Endocrine Anatomy and physiology by acrc213

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									                                                                      MEDSURG NURSING                                                                            ENDOCRINE SYSTEM

ANATOMY AND PHYSIOLOGY                                                                                  OVARY: Estrogen and Progesterone
    Hormones are natural chemicals that exert their effects on specific tissues known as          ADRENAL GLANDS
     target tissues; which are located distant from and without any direct connection                   Tent-shaped organs on the top of each kidney
     with the endocrine gland.                                                                          ADRENAL CORTEX (outer portion)
    Endocrine glands are known as “ductless glands” and must use the blood to                            1. Mineralocorticoids or Aldosterone (produced in the zona glomerulosa)-
     transport secreted hormones to the target tissues.                                                       maintains extracellular fluid volume by prmoting sodium and water
    The endocrine system works with the nervous system to regulate overall body                              reabsoprtion and potassium excretion in the kidney tubules; secretion is
     function and maintain homeostasis known as neuroendocrine regulation.                                    regulated by the renin-angiotensin system, serum potassium ion
    Hormone-receptor actions work in a lock-and-key manner in that only the correct                          concentration, and ACTH
     hormone can bind to and activate the receptor site.                                                  2. Glucocorticoids or Cortisol (produced in the zona fasciculata and zona
    The control of cellular function by any hormone depends on a series of reactions                         reticularis)- affects carbohydrate(gluconeogenesis and perpiheral
     working through negative feedback control mechanisms.                                                    glucose use), protein (protein catabolism), and fat (lipolysis)
    HYPOTHALAMUS                                                                                             metabolism, body’s response to stress (anti-inflammatory), emotional
          Located beneath the thalamus on each side of the third ventricle of the brain                      stability, and immune function (polymorphonuclear leukocytes); peaks
          Shares a closed circulatory system with the anterior pituitary gland known                         in the morning and reaches its lowest level 12 hours after each peak
              as the hypothalamic-hypophysial portal system, which allows hormones                        3. Androgens and Estrogens (produced in the zona fasciculata and zona
              produced in the hypothalamus to travel directly to the anterior pituitary                       reticularis)
              gland                                                                                     ADRENAL MEDULLA (inner portion)
          Nerve fibers in the hypophysial stalk connect the hypothalamus to the                          1. Catecholamines (Epinephrine and Norepinephrine)- not essential for life
              posterior pituitary gland                                                                       but play a role in the physiologic stress response (fight or flight)
          FUNCTION: To produce regulatory hormones (releasing hormones)                           THYROID GLAND
    PITUITARY GLAND                                                                                    Located in the anterior neck and directly below the cricoids cartilage
          Located at the base of the brain in the valley of the sphenoid known as the                    1. Thyroxine (T4) and Triiodothyronine (T3-most active form) (produced by
             sella turcica                                                                                    the follicular cells)- increase metabolism (BMR) which causes an increase
          ANTERIOR LOBE (ADENOHYPOPHYSIS)                                                                    in oxygen use and heat production in all tissues; release is stimulated by
             1. Thyroid-stimulating hormone (TSH)- stimulates synthesis and release of                        cold and stress; act as insulin antagonist
                  thyroid hormone                                                                         2. Thyrocalcitonin (TCT) (produced by the parafollicular cells)- lowers serum
             2. Adrenocorticotropic hormone (ACTH)- stimulates synthesis and release of                       calcium and serum phosphorous levels by reducing bone resorption or
                  corticosteroids and adrenocortical growth                                                   breakdown
             3. Luteinizing hormone (LH)- stimulates ovulation, progesterone, and                  PARATHYROID GLAND
                  testosterone secretion                                                                Consist of four small glands located close to, embedded in, or attached to the
             4. Follicle-stimulating hormone (FSH)- stimulates estrogen secretion, follicle               back surface of the thyroid gland
                  maturation, and spermatogenesis                                                         1. Parathyroid hormone (PTH)- regulates calcium and phosphorous
             5. Prolactin (PRL)- stimulates breast milk production                                            metabolism by acting on bone (bone resoprtion) , kidney (activates
             6. Somatotropin or Growth hormone (GH)- promotes growth through                                  vitamin D and calcium reabsorbtion), and the intestinal tract
                  lypolysis, protein anabolism, and insulin antagonism                             PANCREAS
             7. Melanocyte-stimulating hormone (MSH)- promotes pigmentation                             Lies behind the stomach and has endocrine (islets of Langerhans) and
          POSTERIOR LOBE (NEUROHYPOPHYSIS)                                                               exocrine functions
             1. Vasopressin or Antidiuretic hormone (ADH)- promotes water                                 1. Glucagon (alpha cells)- increases blood glucose levels by causing
                  reabsorption                                                                                glycogenolysis, gluconeogenesis, lipolysis, and ketone formation
             2. Oxytocin- stimulates uterine contractions and ejection of milk                            2. Insulin (beta cells)- promotes movement and storage of carbohydrate,
    GONADS                                                                                                   protein, and fat therefore lowering blood glucose levels
          Male (testes) and female (ovaries) reproductive endocrine glands                               3. Somatostatin (delta cells)- inhibits release of glucagon, insulin, and GI
          Although these glands are present at birth, their function does not begin                          peptides
             until puberty
          TESTES: Testosterone

                                                                                 ENDOCRINE DIRSORDERS
                       DISORDERS                                        MANIFESTATIONS                                                       MANAGEMENT
Hypopituitarism                     Gonadotropin          Testicular failure: testosterone and          Neurologic Assessment:
                                                            sterility                                           Peripheral vision: diplopia (double vision)
*Sheehan’s Syndrome: post-                                 Ovarian failure: amenorrhea, dyspareunia            Temporal headaches
partum hemorrhage                                          and infertility                                     Muscular paralysis
hypotensionischemia                GH (Dwarfism)         somatomedins                                       Limiting eye movement
pituitary infarction (necrosis)                           decreased bone density (osteoporosis)               Hypometabolism
                                                           pathologic fractures                                Hemianopsia
*Simmond’s Disease or                                      muscle strength                               Laboratory Findings:
Panhypopituitarism (total absence                          serum cholesterol levels                           Stimulation tests (injecting agents that are known to stimulate secretion of
of all pituitary secretions)        TSH (Secondary        circulating thyroid hormone levels                    specific pituitary hormones and then measuring the response)
                                    Hypopituitarism)       weight gain                                                 insulinGH or ACTH
*Primary Hypopituitarism                                   cold intolerance                                            TRHTSH
(problems arising within the                               scalp alopecia                                              GnRHLH and FSH
anterior pituitary itself)                                 hirsutism                                      Diagnostics:
                                                           menstrual abnormalities                             Skull x-rays
*Secondary Hypopituitarism                                 libido                                             CT scan
(problems in the hypothalamus                              slowed cognition                                    MRI
that change anterior pituitary                             lethargy                                            Angiogram
function)                           ACTH (Addison’s       serum cholestrerol                            Interventions:
                                    Disorder)              pale, sallow complexion                             Androgen therapy (SE: gynecomastia, acne, baldness, prostate enlargement)
                                                           malaise and lethargy                                Estrogen and Progesterone therapy (SE: hypertension, thrombosis)
                                                           anorexia                                            Clomiphene citrate (to induce ovulation)
                                                           postural hypotension                                GH injections
                                                           headache                                            Surgical removal of tumor
                                                           hypoglycemia                                        Radiation
                                                           hyponateremia
                                                           axillary and pubic hair (women)
Hyperpituitarism                    PRL                   galactorrhea                                   Assessment:
                                                           amenorrhea                                          Change on hat, shoe, ring, or glove size
*most common cause: pituitary                              infertility                                         Fatigue or lethargy
adenoma                             GH (Gigantism or      Gigantism (before puberty): rapid                   Backache and athralgia
                                    Acromegaly)             proportional growth in the length of the            Headaches
                                                            bones                                               Changes on vision
                                                           Acromegaly (after puberty): increased               Menstrual changes
                                                            skeletal thickness, hypertrophy of the skin,        Decreased libido
                                                            enlargement of visceral organs (liver and           Dyspareunia
                                                            heart)                                              Difficulty in chewing and dentures that no longer fit
                                                           hyperglycemia                                       Arthritic changes causing joint pain and mobility
                                                           in lip and nose sizes, and a prominent             Fingers and toes with arrow-head shape at tips
                                                            brow ridge, and head, hand and foot sizes          Metabolism and strength
                                                           prognathism (projection of the jaw beyond           Lethargy and weakness
                                                            the facial features)                                Perspiration and oil secretion in the skin
                                                           organomegaly                                   Laboratory Findings:
                                                           hypertension                                        Hormone elevation
                                                           dysphagia (enlarged tongue)                    Diagnostics:
                                                           deepening of the voice (hypertrophy of              Skull x-rays
                                                            larynx)                                             CT scan
                                                                                                                MRI
                                                                                                                Angiogram
       Suppression test (giving the agents that induce a suppressed response from
        the pituitary gland, and they can determine whether the normal feedback
        control mechanisms for hormonal regulation are intact)
     Encourage the client to express concerns and fears about his or her altered
        physical appearance
     Drug Therapy:
        -   Dopamine agonists: bromcriptine mesylate (Parlodel), cabergoline
            (Dostinex) SE: orthostatic hypotension, gastric irritation, nausea,
            headache, abdominal cramps, constipation
        -    Somatostatin analogues: octreotide (Sandostatin)
        -   GH receptor blocker: pegvisomant (Somavert) SE: gallbladder disease
            and tumor size
      Radiation
      Surgery: Transsphenoidal Hypophysectomy (incision above the upper lip
         and reaches the pituitary gland through the sphenoid sinus)
          -  nasal and oral mucous membrane swab specimens for bacterial C&S
             before surgery because the surgery can move microorganisms from
             these areas into the blood and cause systemic infection
          -  monitor neurologic response and document changes in vision, mental
             status, altered LOC, or strength of extremities
          -  observe for transient diabetes insipidus (monitor I&O, urine specific
             gravity, vasopressin as indicated, F/C and daily weight)
          -  teach client to report postnasal drip (check if CSF through Halo sign or
             glucose test)
          -  teach the client to avoid coughing early after surgery because it ICP
             and may lead to CSF leak
          -  deep breathing exercises to prevent pulmonary problems
          -  frequent mouth rinses, dental floss, and apply petroleum jelly to dry
          -  assess for meningitis (fever, headache, nuchal rigidity)
          -  antibiotics, analgesics, antipyretics as ordered
          -  monitor neurological status q1 for the first 24 hours then q4
          -  instruct client to avoid bending at the waist because it ICP
          -  monitor nasal drip pad for type and amount of drainage
          -  monitor bowel movements to prevent constipation and straining
          -  teach self-administration of hormones
Diabetes Insipidus (ADH)                                      polyuria                      Assessment:
                                                               dehydration                        Measure 24 hour fluid I&O
*distal kidney tubules and collecting ducts remain             urine SG                          Do not restrict food and fluids
impermeable to water                                           plasma osmolarity                 UO 4-30L/day
                                                               polydipsia                            Urine SG <1.005
*the client who is deprived of fluids or who cannot            hypotension                        Dehydration (obtain baseline VS and monitor q1; deprive client of fluid;
increase oral fluid intake may develop shock from fluid        pulse pressure                       measure UO, SG, osmolarity, and weight q1; give 5 units vasopressin SQ
loss                                                           tachycardia                           and continue urine monitoring) and hypertonic saline (administer normal
                                                               weak peripheral pulses                water load followed by hypertonic saline; measure UO q1) tests
*Nephrogenic DI (inherited disorder wherein renal tubules      hemoconcentration             Interventions:
does not respond to existing ADH)                              poor skin turgor                   Drug Therapy:
                                                               dry mucous membranes                   -   mild: Chlorpropamide (Diabinese, Novo-Propamide) per orem
*Primary DI (defect in the hypothalamus or pituitary           hyperthermia                           -   drug of choice: Desmopressin acetate (DDVAP) per nasal spray SE:
gland resulting to lack of ADH)                                ataxia                                     ulceration of the mucous membranes, allergy, sensation of chest
                                                               lethargy to coma                           tightness, pulmonary inhalation of spray
*Secondary DI (result from tumors within or adjacent to        irritability                           -   short acting: Lypressin (Diapid) per nasal spray or SQ
the hypothalamus or pituitary gland, head trauma,                                                      -   ADH per IV or IM
infection, hypophysectomy, metatstaic tumors,                                                          -   Encourage client to drink fluids equal to UO
hemorrhage)                                                                                            -   Ensure IV patency
                                                                                                       -   Instruct client to blow nose gently prior to administration of nasal
*Drug-related DI (caused y lithium carbonate and                                                           medication
demeclocycline)                                                                                        -   Instruct to remain upright and not to tilt head back when spraying and
                                                                                                           not to blow nose for several minutes after administration
Syndrome of Inappropriate ADH or Schwartz-Bartter              dilutional hyponatremia       Diagnostics:
Syndrome (ADH)                                                expansion of ECF                   Sodium <110mEq/L
                                                               UO                                Radioimmunoassay
*inhibits the release of renin and aldosterone                 urine SG                     Interventions:
                                                               plasma osmolarity                 Restrict fluid intake
                                                               glomerular filtration rate        Measure I&O and daily assess weight (1kg=1L)
                                                               loss of appetite                   Keep mucous membranes moist by offering frequent oral rinsing
                                                               nausea and vomiting                Drug Therapy:
                                                               weight gain                            -   Hypertonic saline per IV
                                                               dependent edema not present            -   Lithium carbonate (Eskalith, Lithobid, Carbolith)
                                                               lethargy                               -   Demeclocycline (Declomycin)
                                                               headaches                           Observe and document changes in neurologic status and muscle twitching
                                                               hostility                           Check orientation q2
                                                               disorientation                      Reduce environmental noise and lighting to prevent overstimulation
                                                               change in LOC                       Basic safety measures and siderails secured in place
                                                               seizures and come
                                                               DTR
                                                               tachycardia
                                                               hypothermia
                                                               hypertension
Addisonian Crisis or Adrenal Insufficiency                     glomerular filtration rate   Assessment:
                                                               gastric acid production           History of radiation to the head or abdomen, medical problems, and past
*impaired cortisol secretiongluconeogenesis and              urea nitrogen excretion             and current drugs
depletion of liver and muscle glycogenhypoglycemia            anorexia and weight loss           Observe patient and check orientation
                                                               hypotension                   Diagnostics:
* impaired aldosterone secretionpotassium excretion          lethargy                           serum cortisol
(hyperkalemia), sodium and water excretion                    fatigue and muscle weakness        FBS
(hyponatremia and hypovolemia)reabsoprtion of                salt craving                                            sodium
hydrogen ions (acidosis)                                      nausea and vomiting                                     potassium
                                                              diarrhea                                                BUN
*Primary Addison’s Disease (caused by autoimmune              abdominal pain                                          eosinophil count
disease, metastatic cancer, hemorrhage, adrenalectomy,        menstrual changes and impotence                         Skull x-ray
radiation, and drugs)                                         hyperpigmentation                                       CT scan
                                                              body hair                                              MRI
*Secondary Addison’s Disease (caused by pituitary             hypoglycemia (sweating, headaches,                      Arteriography
tumors, Sheehan’s syndrome, hypophysectomy)                    tachycardia, tremors)                                   most definitive test: ACTH Stimulation Test (ACTH 0.25-1mg per IV and
                                                              hypovolemia (postural hypotension and                    plasma cortisol level obtained at 30 minute and 1 hour interval; primary
                                                               dehydration)                                             and secondary)
                                                              hyperkalemia (dysrhythmias)                      Interventions:
                                                              hypercalcemia                                         Weigh client daily and record I&O
                                                              energy level and mood swings                         Asses VS q1-4
                                                              Anemia                                                Monitor for presence of Dysrhythmias and postural hypotension
                                                              vitiligo                                              Hydrocortisone or Prednisone (corrects glucocorticoid deficiency)
                                                                                                                     Fludrocortisone (maintain electrolyte balance)
                                                                                                                     Take medications with meals
                                                                                                                     Monitor BP (hypertension is a potential side effect)
                                                                                                                     Monitor for signs and treat hypoglycemia
                                                                                                                     Salt restriction or diuretic therapy should not be started without
                                                                                                                        considering whether it may lead to an adrenal crisis
                                                                                                                     Emergency: rapid infusion D5NSS+hydrocortisone or dexamethasone,
                                                                                                                        administer IV glucose, use loop or thiazide diuretics, ECG, KVO
Cushing’s Disease or Hypercortisolism                         abnormal sleep patterns (due to excessive        Assessment:
                                                               glucocorticoids)                                      History of fractures (due to osteoporosis)
*breakdown of tissue proteinnitrogen                       fatigue                                               Frequent infections and easy bruising
excretionmuscle mass, thin skin, bone density loss          muscle weakness                                       Cessation of memses
                                                              bone pain                                             GI problems (ulcer formation due to HCl secretion and production of
*slow turnover of plasma fatty acidstotal body fatfat      wasting                                                  protective gastric mucus)
redistribution: 1. truncal obesity 2. buffalo hump 3.         blood vessel fragility (bruises, thin or             Steroid or alcohol abuse
moon face                                                      translucent skin, non-healing wounds)            Diagnostics:
                                                              reddish purple striae or stretch marks at             cortisol levels (cortisol assays obtained same time of the day)
*corticosteroidskill lymphocytes and shrink                  abdpmen, thighs, and upper arms (due to               ectopic syndromes (ACTH-producing): ACTH
lymphocyte-containing organs (liver, spleen, lymph             degenerative effects of cortisol on collagen)         Cushing’s: ACTH
nodes)eosinophils and                                       acne                                                  blood glucose level
macrophagescytokinesneutrophil activity and               thinning of the skin (paperlike appearance            lymphocyte count
antibody synthesis immune and inflammatory                   at back of hands)                                     sodium level
response                                                      fine hair covering the face and body                  serum calcium level
                                                              male pattern balding                                  serum potassium level
*androgenacne, hirsutism, clitoral hypertrophy,             hyperglycemia
                                                                                                                     Save all urine for 24 hours (free cortisol, metabolite of cortisol and
estrogen and progesterone production, oligomenorrhea         hypertension (due to water and sodium
                                                                                                                        androgens, calcium, potassium, glucose)
                                                                                                                     X-ray
*Endogenous or Cushing’s Disease (caused by excess of         immunosuppressed
                                                                                                                     CT scan
cortisol secreted by the adrenal cortex due to                risk for infection (fever, purulent exudates,
                                                                                                                     MRI
malignancies)                                                  redness at affected area)
                                                                                                                     Arteriography
                                                              emotional lability (mood swings, irritability,
                                                                                                                     Overnight Dexamethasone Suppression Test (initial screening test for
*Exogenous or Iatrogenic or Cushing’s Syndrome                 confusion, depression)
                                                                                                                        Cushing’s Disease): instruct client not to take drugs, especially phenytoin
(caused by therapeutic use of ACTH or glucocorticoids)        neurotic or psychotic behavior
                                                                                                                        (Dilantin) or phenobarbital, for at least 2 days before the test; if cortisol
                                                                                                                        levels >5mg/dL (normal value) needs further testing
       3-Day Low Dose Dexamethasone Suppression Test: instruct client not to
        take drugs for at least 2 days before the test and no stressful procedures
        (barium enema, myelogram, intense physical therapy); day1: baseline 24-
        hour urine sample; days 2&3: dexamethasone 0.5mg q6 then 24 hour urine
        testing; if cortisol levels needs further testing (normal: urinary 17-
        hydroxycorticosteroid excretion and cortisol levels suppressed by
     High-Dose Dexamethasoe Suppression Test (distinguishes between bilateral
        adrenocortical hyperplasia and adrenocortical neoplasm): overnight or 2-day
        test injection of 8mg dexamethasone; if plasma cortisol that is 50% less
        than baselineCushing’s disease
      Weigh client daily and monitor I&O to assess hydration status
      Fluid restriction as indicated
      Drug Therapy:
         -    Mitotane (Lysodren): adrenal cytotoxic agent used for inoperable
         -    Aminogluthethimide (Epliten, Cytadren)
         -    Metyrapone (Metopirone)
         -    Cyproheptadine (Periactin): interferes with ACTH production
      Radiation (assess for neurologic status, headache. BP or PR,
         disorientation, changes in pupillari size or reaction, skin dryness, redness,
         flushing, or alopecia)
      Surgery:
         -    Removal of pituitary adenoma
         -    Total hypophysectomy
         -    Adrenalectomy
     Correct electrolyte imbalances before surgery (sodium, potassium, chloride)
     Carding monitoring for dysrhythmias
     Control hyperglycemia before surgery
     Prevent infection with handwashing and aseptic technique
     Decrease risk of falls by raising side rails and encouraging client to ask for
        assistance when getting out of bed
     High calorie and high protein diet before surgery
     Glucocorticoids before and during surgery to prevent adrenal crisis
     CCU: assess client q15minutes for shock (BP, rapid and weak pulse, UO)
     Monitor VS, hemodynamic variables, I&O, daily weight, and serum
        electrolytes post-op
     Lifelong glucocorticoid replacement after bilateral adrenalectomy
     Assess skin for reddened areas, excoriation, breakdown, and edema
     If mobility decreased, turn client q2 and pad bony prominences
     Avoid activities that may result to skin trauma
     Use soft toothbrush and electric shaver
     Keep skin clean and dry after washing
     Moisturizing lotion for excessive skin dryness
     Use tape sparingly and use caution when removing
     Exert pressure over site of puncture longer than normal to prevent bleeding
        and bruising
     When moving client in bed, use lift sheet instead of grasping
     Ambulatory aids
                                                                                                                   High calorie, calcium, and vitamin D diet
                                                                                                                   Avoid caffeine and alcohol which promote GI ulcers and bone density loss
                                                                                                                   Antacids and H2-blockers on regular schedule
                                                                                                                   Avoid aspirin
Hyperaldosteronism                                              hypernatremia (BP and suppress renin        Diagnostics:
                                                                 production)                                       Laboratory studies
*Primary Hyperaldosteronism or Conn’s Syndrome                  hypokalemia                                       X-rays
(results from excessive secretion of aldosterone from one       metabolic alkalosis                               CT scan
or both of the adrenal glands caused by adrenal                 rare peripheral edema due to “renal escape        MRI
adenoma)                                                         mechanism” (kidney decrease sodium                plasma renin
                                                                 reabsorption)                                     potassium, sodium
*Secondary Hyperaldosteronism (high levels of                   headache                                          aldosterone
angiotensinII that are stimulated by high plasma levels of      fatigue                                           H+ loss, blood pH
renin caused by renal hypoxemia or thiazide diuretics)          muscle weakness                                   USG
                                                                nocturia                                     Interventions:
                                                                polydispsia                                       Surgery: Adrenalectomy
                                                                polyuria                                          Drug Therapy:
                                                                paresthsias                                           -   Spirinolactone: potassium diuretic (avoid potassium supplements and
                                                                visual changes                                            rich foods and increase dietary sodium) SE: hyponatremia, dryness of
                                                                                                                           the mouth, thirst, lethargy, drowsiness
                                                                                                                       -   Potassium supplements
                                                                                                                   Low sodium diet before surgery
                                                                                                                   Glucocortcoid replacement
Pheochromocytoma                                                intermittent episodes of hypertension or     Diagnostics:
                                                                 attacks                                           24 hour urine collection for Vanillylmandelic acid (VMA-product of
*catecholamine producing and storing tumor that arises           *tricyclic antidepressants, droperidol,              cathecholamine metabolism), metanephrine, and cathecholamine
in chromaffin cells                                              glucagon, metoclopramide,                            *restrict caffeine, citrus fruits, bananas, vanilla-containing foods, licorice,
                                                                 phenothiazenes, naloxaone, tyramine rich             aspirin, and antihypertensive drugs
*epinephrine and norepinephrinealpha and beta                 foods can induce hypertensive crisis              Plasma cathecholamines are elevated after the client has rested for 30
receptor activitymimic SNS effects                             severe headaches                                     minutes
                                                                palpitations                                      Clonidine Suppression Test: for inconsistent results; cathecholamines
*hallmark: HPN                                                  profuse disphoresis                                  remain elevated
                                                                flushing                                          Cathecholamine Stimulation Test
                                                                apprehension                                      MRI
                                                                sense of impending doom                           CTscan
                                                                chest or abdominal pain                      Interventions:
                                                                nausea and vomiting                               Surgery: Adrenalectomy
                                                                IAP                                              Monitor BP regularly and place cuff consistently on the same arms with the
                                                                urinary frequency                                    client in standing and lying positions
                                                                heat intolerance                                  Identify and avoid stressors
                                                                weight loss                                       Do not smoke, drink caffeine, or change positions suddenly
                                                                tremors                                           DO NOT PALPATE ABDOMEN: sudden release of cathecholamines and sever
                                                                                                                   Calorie, vitamin, and mineral rich diet
                                                                                                                   Maintain hydration status
                                                                                                                   Calm, resting environment for client with severe headache
                                                                                                                   Limit activity
                                                                                                                   Provide darkened, private room to promote rest (avoid interruptions)
                                                                                                                   Drug Therapy:
                                                                                                                           - alpha-adrenergic blockers for HPN, tachycardia, and dysrhythmias:
                                                                                                                                   Phenooxybenzamine (Dibenzyline), Propranolol (Inderal, Detensol),
                                                                                                                                   Labetalol (Trandate)
                                                                                                                              - calcium channel blockers: Nicardipine (Cardene)
                                                                                                                              - agents to cathecholamine synthesis: Metyrosine (Demser)
                                                                                                                      Avoid beta-adrenergic blockers to prevent rebound HPN
                                                                                                                      Closely monitor for hypotension and hypovolemia post-op (hemorrhage and
                                                                                                                      Monitor VS, I&O
Hyperthyroidism                                                unusual diaphoresis (wears lighter clothing      Assessment:
                                                                in cold weather)                                      Record age, gender, and usual appetite
*the manifestations of hyperthyroidism are called              palpitations or chest pain                            Client may report weight loss, increased appetite, and increased number of
thyrotoxicosis                                                 dyspnea with or without exertion                         bowel movements per day
                                                               earliest problem the client notices: visual           Change in energy level or in the ability to perform ADLs
*causes hypermetabolism and SNS activity                       changes due to opthalmopathy (abnormal                Past thyroid surgery or neck radiation therapy
*protein degradation > protein synthesisnegative               eye appearance or function)                           Ask present antithyroid drugs of thyroid hormones
nitrogen balance                                                    -eyelid retraction (eyelid lag): occurs in        Ask client to look up and down and document responses
*glucose tolerancehyperglycemia                               all forms of thyrotoxicosis, the upper eyelid    Laboratory Findings: T3, T4, T3 resin uptake, TSH, TSH-antibodies
*fat metabolismbody fat                                      fails to descend when the client gazes           Diagnostics:
*increased appetite but energy demand > food                    slowly downward                                       Thyroid scan: evaluates the position, size, and functioning of the thyroid by
intakeweight losschronic nutritional deficiency                   -globe lag (eyeball lag): upper eyelid               giving radioactive iodine per orem and measuring RAIU *discontinue iodine
                                                                pulls back faster when the client gazes                  containing drugs 1 week before and procedures using iodine containing dye
*NOT ALL CLIENTS WITH GOITER HAVE                               upward                                                   4 weeks before the scan
HYPERTHYROIDISM                                                fatigue                                               Ultrasonography: determine size and composition of masses and nodules
                                                               weakness                                              ECG
*CAUSES:                                                       insomnia                                         Interventions:
        -Grave’s Disease (toxic diffuse goiter):               changes in menses: amenorrhea or                      Monitor apical pulse, BP, temperature at least q4
autoimmune disorder in which antibodies (TSIs) are made         menstrual flow                                       Instruct client to report palpitations, dyspnea, vertigo, or chest pain
and attach to TSH receptor sites causing the thyroid           libido                                                  immediately
gland to increase in size and overproduce thyroid              exopthalmos (wide-eyed or startled look):             Encourage rest
hormones (hyperthyroidism, exopthalmos, pretibial               due to edema in the extraocular muscles               Keep environment quiet as possible
myxedema)                                                       and fatty tissue behind the eye which                Frequent bed line changes, sponge baths, and cool environment
        -Toxic Mulitnodular Goiter: hyperthyroidism             pushes the eyeball forward and pressure               Drug Therapy:
caused by multiple thyroid nodules; absence of                  on the optic nerve                                            - Antithyroid drug (block thyroid hormone production): thioamides,
exopthalmos and pretibial myxedema                             corneal ulcers or infection                                        PTU, methimazole (Tapazole), and carbimazole (Neo-Mercazole)
        -Exogenous Hyperthyroidism: hyperthyroidism            excessive tearing and bloodshot                               - Iodine (thyroid size, vascularity and blood flow to the thyroid
caused by excessive use of thyroid replacement hormones         appearance                                                         which reduces hormone production and release)
                                                               photophobia                                                   - Lithium carbonate (inhibits thyroid hormone release) SE:
*thyroid storm or crisis is a life-threatening condition       bruits (turbulence from increased blood                            depression, DI, tremors, N/V
that can occur when hyperthyroidism is left untreated or        flow)                                                         - Beta blockers (Propranolol):relieve diaphoresis, anxiety,
poorly controlled or when the client is severely stressed      systolic BP                                                       tachycardia, palpitations
                                                               tachycardia                                            Radioactive Iodine Therapy (not used in pregnant women because it crosses
*hallmark: heat intolerance                                    dysrhythmias                                               the placenta and can damage the fetal thyroid gland)
                                                               diastolic BP                                          Surgery: Total/Subtotal Thyroidectomy (collar incision with parathyroid left
*GOITER CLASSIFICATION:                                        widened pulse pressure                                     behind)lifetime thyroid hormone replacement (total)
0-no palpable or visible goiter                                fine, soft, silky hair and smooth, moist skin          Return client to euthyroid before surgery
1-mass not visible with head in normal position but            muscle weakness                                        High-protein and high –carbohydrate diet
palpated and moves up when swallowing                          hyperactive DTR                                        Coughing and deep breathing exercises (support neck when coughing and
2-massvisually asymmetric and easily palpated                  tremors                                                    moving with both hands behind neck to reduce tension on suture line)
                                                               restless and irritable                                 Explain hoarseness of voice post-op
                                                               mood swings and attention span                        Monitor VS q15minutes post-op until stable and then q30minutes
                                                                                                                  Use sandbags or pillows to support head and neck
                                                                                                                  Semi-Fowler’s position
                                                                                                                  Avoid neck extension
                                                                                                                  Analgesics as needed
                                                                                                                  Elevate HOB at night and use artificial tears
                                                                                                                  Dark glasses or eye patches for photophobia
                                                                                                                  Tape lids with non-allergic tape
                                                                                                                  Prednisone, diuretics, or orbital decompression for infiltrative
                                                                                                                 Hemorrhage: during first 24 hours after surgery; inspect neck dressing and
                                                                                                                     behind the client’s neck for blood
                                                                                                                 Respiratory Distress: stridor is heard in acute respiratory obstruction; keep
                                                                                                                     emergency tracheostomy, oxygen, suction at bedside
                                                                                                                 Hypocalcemia and Tetany: due to PTH; assess for tingling around mouth,
                                                                                                                     toes, fingers and muscle twitching; ready calcium gluconate or calcium
                                                                                                                     chloride per IV at bedside
                                                                                                                 Laryngeal Nerve Damage: temporary hoarseness and weak voice; assess
                                                                                                                     voice at 2-hour interval and document changes
                                                                                                                 Thyroid Storm: triggered by stressors (trauma, infection, diabetic
                                                                                                                     ketoacidosis, pregnancy), exposure to iodine, vigorous palpation of the
                                                                                                                     goiter, RAI; KEY MANIFESTATIONS: fever, tachycardia, systolic HPN, GI
                                                                                                                     distress, restlessness; INTERVENTIONS: maintain airway, give antithyroid
                                                                                                                     drug, propranolol, sodium iodide solution glucocorticoids, and
                                                                                                                     antipyretics as prescribed, monitor VS q30minutes, PNSS, cooling blanket
                                                                                                                     and ice packs

Hypothyroidism                                               time spent sleeping (14-16 hours)            Laboratory Findings: T3, T4; primary:TSH; secondary:TSH
                                                             generalized weakness                          Interventions:
*dysfunctional thyroid or insufficient iodine or             anorexia                                            Respiratory Monitoring:
tyrosineTHmetabolic rateTSH by hypothalamus            muscle aches                                               - Monitor rate, rhythm, depth, and effort of respirations
and anterior pituitary gland TSH binds to thyroid           paresthesias                                               - Note chest movement, symmetry, and retractions
cellsgoiter                                                 constipation                                               - Check for bradypnea, dyspnea and paradoxical motion
                                                             cold intolerance (more blankets at night or                - Note changes in SaO2 and ABG
*cellular energy and metabolites build up inside cells       sweater and extra clothing in warm                         - Monitor client’s ability to cough effectively
(glycoaminoglycans)mucous and water                         weather)                                            Shock Prevention: BP, UO, change in mental status
(myxedema)non-pitting cellular edema (around the            libido                                                    - Monitor temperature and respiratory status
eyes, hands and feet, between shoulder blades, tongue        difficulty in becoming pregnant and                        - Monitor BP, skin color, heart sounds and rhythm, peripheral
and larynx)change in organ texture                           changes in menses (heavy, prolonged                           pulses, and capillary refill
                                                              bleeding or amenorrhea)                                    - Monitor signs of inadequate tissue oxygenation (restlessness and
*myxedema coma is a rare, serious complication of            impotence and infertility                                     apprehension)
untreated or poorly treated hypothyroidism which causes      edema around the eyes and face                             -  Monitor I&O
heart muscles to be flabby and chamber size to               blank expression                                           - Administer oxygen or mechvent as needed
increaseCO and perfusion to the brain and other           thick tongue                                               - Administer antiarryhthmic agents as ordered
vital organsorgan failure                                   slow muscle movement                                Hypothermia Treatment:
                                                             most common reason for seeking medical                     - Monitor temperature and VS, and skin color
*most common cause: RAI                                       attention: depression                                      - Place cardiac monitor as appropriate
                                                             lethargy, apathy, drowsy, withdrawn                        - Cover with warm blankets and adequate clothing
*CAUSES: thyroidectomy, radiation, autoimmune thyroid        impaired memory and attention span                         - Administer heated oxygen
destruction, thryroid cancer, iodine deficiency, excessive                                                                 - Avoid giving IM or SQ medications during hypothermia
exposure to iodine, lithium, phenylbutazone, PTU,                                                                          - Give client warm oral fluids and consume adequate caloric intake
sodium or potassium perchlorate, aminiglutethimide,                                                                  Lifelong thyroid hormone replacement (lowest dose and gradual increase to
thiocyanates, cobalt                                                                                                   prevent HPN. heart failure, and MI)
                                                                                                                     Instruct client to report episodes of chest pain or discomfort immediately
*hallmark: cold intolerance                                                                                          Orient client and assess mental status
                                                                                                                     Provide safe environment
Acute Thyroiditis (bacterial invasionneck tenderness,                                                               Emergency Care for Myxedema Coma:
fever, dysphagia)                                                                                                          - Maintain patent airway
                                                                                                                           - Replace fluids with IV normal or hypertonic saline
Subacute or Granulomatous Thyroiditis (viral                                                                               - Give levothyroxine sodium, glucose IV, corticosteroids as prescribed
infectionfever, dysphagia, joint pain)                                                                                    - Check temperature q1
                                                                                                                           - Cover with warm blankets
Chronic Thyroiditis or Hashimoto’s Disease                                                                                 - Monitor changes in mental status
(autoimmune disorder which destroys thyroid tissue)                                                                        - Turn q2
                                                                                                                           - Institute aspiration precautions
Thyroid Cancer (papillary, follicular, medullary,                                                                    Adequate fluid and fiber to prevent constipation
anaplastic)                                                                                                          Adequate rest
                                                                                                                     Encourage family to voice out concerns

Hyperparathyroidism                                             waxy pallor of the skin                      Assessment:
                                                                bone deformities in the extremities and           Ask about bone fractures, recent weight loss, arthritis, or psychological
*PTHkidney reabsorption of calcium and phosphate             back                                                 distress
excretionhypercalcemia and hypophosphatemia                    renal calculi and calcium deposits at soft        Past neck or head radiation
*PTHosteoblast and osteoclastbone resoprtion or            tissues of the kidney                        Laboratory Findings: serum PTH, calcium and phosphate levels, urine cAMP
bone losscalcium deposited in soft tissues                     bone lesions (pathologic fractures, bone     Diagnostics:
                                                                 cysts, osteoporosis)                              x-ray (kidney stones and bone lesions)
*most common cause: beneign tumor in parathyroid                anorexia                                          Arteriography
(hypocalcemia and vitamin D deficiency)                         nausea and vomiting                               CT scan
                                                                epigastric pain                                   Venous catheterization of thyroid veins
                                                                constipation                                      Ultrasonography
                                                                weight loss                                  Interventions:
                                                                serum gastrinpeptic ulcer disease               Hydration (IV saline) and furosemide (Lasix): a diuretic which calcium
                                                                fatigue and lethargy                                 excretion
                                                                psychosis and mental confusion                    Monitor cardiac function and I&O q2-4
                                                                 (>12mg/dL)                                        Report precipitous drop of serum calcium which may cause tingling and
                                                                damage of laryngeal nerve may cause voice            numbness
                                                                 hoarseness                                        Drug Therapy:
                                                                                                                           - Oral phosphates (inhibit bone resoprtion and interfere with calcium
                                                                                                                           - Calcitonin and glucocorticoids (release of skeletal calcium and
                                                                                                                               excretion of calcium)
                                                                                                                           - Calcium chelators: Mithramycin (SE: thrombocytopenia and kidney
                                                                                                                               liver toxicity; monitor liver function) and Penicillamine (Cuprimine,
                                                                                                                   Surgery: Parathyroidectomy
                                                                                                                   Stabilize calcium levels before surgery
                                                                                                                   Coughing and deep breathing exercises
                                                                                                                   Talking may be painful 2 days post-op
                                                                                                                   Neck support by placing both ahnds behind the neck to assist in elevating
                                                                                                                        the head
                                                                                                                       Observe for respiratory distress which may occur from compression of
                                                                                                                        trachea by hemorrhage or neck swelling
                                                                                                                     Keep suction, oxygen, and tracheostomy at bedside
                                                                                                                     Monitor VS and bleeding
                                                                                                                     Check for hypocalcemic crisis (Trousseau’s and Chvostek’s signs)
                                                                                                                     Lifelong treatment of calcium and vitamin D post-op
Hypoparathyroidism                                               tingling and numbness around the mouth        Assessment:
                                                                  or in the hands and feet                           Ask about mild tingling and numbness
*Iatrogenic Hypoparathyroidism (due to total                     severe muscle cramps                               Past neck or head radiation
parathyroidectomy)                                               carpopedal spasms                             Laboratory Findings: serum PTH, calcium and phosphate levels, urine cAMP
*Idiopathic Hypoparathyroidism (due to unknown cause             seizures (without loss of consciousness or    Diagnostics:
or autoimmune)                                                    incontinence)                                      X-ray (kidney stones and bone lesions)
                                                                 irritability or psychosis                          Arteriography
*hypomagnesemia (alcoholic or malabsoprtion) interfere           bands or pits may encircle the crowns of           CT scan
with PTH effect on kidneys and bones                              the teeth (loss of calcium and enamel loss)        ECG
                                                                                                                     Blood test
                                                                                                                      IV calcium as 10% solution of calcium chloride or calcium gluconate over
                                                                                                                         10-15 minutes
                                                                                                                      Calcitrol (Rocaltrol) 0.5-2mg daily for acute vitamin D deficiency
                                                                                                                      50% magnesium sulfate 2mL doses per IM or IV to correct hypomagnesemia
                                                                                                                      Calcium intake 0.5-2g daily
                                                                                                                      50,000-400,000 units ergocalciferol daily for long tern therapy
                                                                                                                      Instruct to eat foods high in calcium but low in phosphorous (avoid milk,
                                                                                                                         yogurt, and processed chees)
                                                                                                                      Stress lifelong therapy for hypocalcemia to prevent hypocalcemic crisis
Diabetes Mellitus (Chronic Hypergycemia)                         Polyuria (osmotic dieresis caused by excess   Laboratory Findings:
                                                                  glucose in the urinesodium, potassium,            Blood glucose values
*Type1 (insulin deficiency): autoimmune disorder in               chloride, water)                                    Fasting Blood Glucose Test (do not eat any food or drink any liquid for at
which beta cells are destroyed in a genetically susceptible      Polydipsia (due to dehydration)                        least 8 hours; water is permitted)
person                                                           Polyphagia (because cells receive no                Oral Glucose Tolerance Test (most sensitive test for diagnosing DM;
*Type2 (insulin resistance): progressive disorder in which        glucosecell starvation)                               carbohydrate restrictions or bed rest alters results; client drinks a beverage
the pancreas makes less insulin over time)                       ketone bodiesmetabolic acidosis                       containing glucose load of 75g and blood samples are collected at 30
*GDM (pregnancy)                                                 dehydrationhemoconcentration,                         minute intervals for 2 hours; DM=200mg/dL at 120 minutes)
                                                                  hypovolemia, hypoperfusion,                         Glycosylated Hgb Assays (shows the average blood glucose level during the
*METABOLIC SYNDROME (SYNDROME X): group of                        hypoxiablock Kreb’s cyclelactic acid                previous 120 days)
disorders with insulin resistance or obesity as a main           H+ and CO2Kussmaul respiration                   Glycosylated Serum Proteins and Albumin (viable for 14 days)
feature                                                          fruity (acetone) breath or odor                     Urine Testing for Ketones
                                                                 Macrovascular Complications:                        Urine Testing for Renal Function
*liver is the first organ to be reached by insulin in the         - Coronary heart disease (most common               Urine Testing for Glucose
bloodglycogenesis, gluconeogenesis, glycogenolysis,                complication of DM; MI is the leading          ICAs
ketogenesis                                                           cause of death in clients with DM)             C-peptide levels
                                                                  - Cerebrovascular disease (                   Interventions:
*basal insulin secretion (low levels during fasting)              - Peripheral vascular disease                       Drug Therapy
*prandial insulin secretion (high levels during eating)          Microvascular Complications:                               - Oral: sulfonylurea, meglitinide, biguanide, alpha-glucosidase,,
                                                                  - Nephropathy (DM is the leading cause                         thiazolidenidione, combination agents) *antidiabetic drug is not a
*blood glucoseglucagon glycogenesis,                              of ESRD; microalbunimemai is the                          substitute for dietary modification and exercise
gluconeogenesis (lipolysis and proteolysis) and                       earliest sign                                         - Insulin Therapy (1.abdomen[2 inch radius from the navel] 2. deltoid
glycogenolysis                                                    - Neuropathy(excess                                            3. thigh 4. buttocks) *rotate sites to prvent lipohypertrophy or
                                                                    glucosesorbitolimpaired motor                        lipoatrophy
*THREE THEORIES FOR DIABETIC VASCULAR                               function; constipation is the most           Diet and Exercise
COMPLICATIONS:                                                      common GI symptom, gastroparesis is          Surgery: Pancreas Transplantation
1. chronic hyperglycemia causes irreversible structural             a cause of hypoglycemia)                     Wound and Foot Care: foot injury is the most common complication of Dm
changes resulting in basement membrane thickening and          -   Retinopathy (NPDR, PDR or                      leading to hospitalization
organ damage                                                        neovascularization, microaneurysms,          HYPOGLYCEMIA
2. glucose toxicity directly or indirectly affect functional        venous beading)                       Causes:
cell integrity                                                                                                -   Omission of meals
3. chronic ischemia in microcirculatory branches causes                                                       -   Overdose of Insulin
connective tissue hypoxia and microischemia                                                                   -   Strenuous exercise
                                                                                                              -   GI upset
*Dawn Phenomenon: night time release of GH that                                                           Assessment
causes blood glucose elevations at about 5-6AM (treated                                                       -   Restlessness
by providing more insulin for the overnight period)                                                           -   Hunger pangs
*Somagyi’s Phenomenon: morning hyperglycemia from                                                             -   Yawning
the effective counter-regulatory response to night time                                                       -   Weakness
hypoglycemia (treated by ensuring adequate dietary                                                            -   Tremors
intake at bedtime and evaluating insulin dose and                                                             -   Pallor
exercise program)                                                                                             -   Diaphoresis
                                                                                                              -   Cold, clammy skin
                                                                                                              -   Headache
                                                                                                              -   Dizziness
                                                                                                              -   Faintness
                                                                                                              -   Tachycardia
                                                                                                              -   Abdominal pain
                                                                                                              -   Blurred vision
                                                                                                              -   Slurred speech
                                                                                                              -   Urine (-) CHO
                                                                                                              -   Altered LOC
                                                                                                              -   Simple sugars per orem
                                                                                                                      o 3-4 oz. regular softdrink
                                                                                                                      o 8oz. fruit juice
                                                                                                                      o 5-7 pcs. Lifesaver’s candies
                                                                                                                      o 3-4 pcs. hard candies
                                                                                                                      o 1 tbsp. sugar
                                                                                                                      o 5 ml. pure honey / Karo syrup
                                                                                                                      o 10-15 gms. CHO
                                                                                                              -   D50 W 20-50 ml/IV push
                                                                                                              -   Monitor blood sugar
                                                                                                              -   Patient teaching
                                                                                                               DIABETIC KETOACIDOSIS (sudden): insulingluconeogenesis and
                                                                                                                  glycogenolysislipolysis and proteolysisketone formation and
                                                                                                                  BUNhyperglycemiaosmotic diuresisdehydration and acidosis
                                                                                                              -   First assess airway, LOC< hydration status, electrolytes and glucose level
                                                                                                              -   Closely assess client’s fluid status (IVF PNSS and D5 0.45%
                                                                                                              -   Watch for signs of hypokalemia, including fatigue, malisise, confusion,
                                                                                                                  muscle weakness, shallow respirations, abdominal distention or paralytic
                                                                                                                  ileus, hypotension, and weak pulse
                                                                                                              -   Before giving IV potassium, make sure that the client produces at least
    30mL/hour urine
-   Bicarbonate for severe acidosis
    (gradual): insulingluconeogenesis and
    glycogenolysishyperglycemiaosmotic diuresisextracellualr
    dehydrationrenal insufficiency and hypokalemiashocktissue
-   Rehydrate and restore normal glucose level within 36-72 hours\assess q1
    for signs of cerebral edema; abrupt changes in mental status, abnormal
    neurologic signs, and coma
-   Immediately report changes in LOC, changes in papillary size, shape,
    reaction, or seizure
-   IV isulin at 10units/hour

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