Transcript Pituitary and Adrenal Disorders

Endocrine abnormalities
PN4
Winter 2008
Common Key Features of
Hormones
• All hormones exert their effect at low blood
concentrations
• Receptors on or within target tissues are needed for
all hormones to exert an effect
• Most hormones (except for thyroid and adrenal
medullary hormones) are not stored to any great
extent and must be produced as needed
• Hormones in the blood are bound to plasma proteins
• Only free hormones can bind to their receptor sites
Common Key Features of
Hormones
• Most hormones cause target tissues to increase
or decrease their activity
• The activity of hormones is of short duration
• Continued hormone activity requires continued
production and secretion
• Clearance of secreted hormones occurs through
cellular uptake, enzymatic breakdown, GI
excretion or urinary excretion
General Assessment
Often present as problems associated with:
• Nutrition-metabolic
• Elimination
• Sleep-rest
• Sexuality-reproduction
Review assessment questions from sem 2
and Iggy pg1452
Physical Assessment
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Inspection
Palpation
Auscultation
Psycho-social
Diagnostic Test
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Stimulation/suppression tests
Assays
Urine tests
Test for glucose (look up Hgb A1C)
CAT scan; MRI
Needle biopsy
Hypopituitarism
• Deficiency in one or more hormone
• Rarely all of the hormones
• Results in metabolic abnormalities and
sexual dysfunction
• Deficiencies of ACTH and TSH are life
threatening because they result in
decrease of secretions from adrenal and
thyroid glands
Deficiencies of Gonadotropins
• LH and FSH causes ?????
• GH causes ?????
Etiology
• Benign or malignant pituitary tumor
• Malnutrition or rapid loss of body fat, i.e.
AN
• Idiopathic cause
• Postpartum hemorrhage
• Infection
• trauma
Disorder of the Anterior Pituitary
• Can be primary or secondary
• One or more hormones are under or over
secreted
Treatment
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Testosterone
Hormone therapy combinations e + p
Clomid for pregnancy
GH therapy
Hyperpituitarism
• Often caused by hormone secreting tumor
• Causes gigantism or acromegaly
Figure 63-1
The clinical features of GH excess
Figure 63-2
The progression of acromegaly
Pathophysiology
• Often caused by a benign tumor
• As tumor gets larger, in addition to extra
hormone, client suffers from visual
disturbances, headache, increased IP
• Usually prolactin (PRL) and GH
hypersecretion
Nursing Diagnosis
• Disturbed body image r/t altered physical
appearance
• Sexual dysfunction r/t actual limitation
imposed by disease ( loss of libido,
infertility, impotence)
Addition ND
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Acute/chronic pain
Fear
Anxiety
Activity intolerance
Disturbed sensory perception
Knowledge deficit
Treatment
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Non-surgical
Drugs
Radiation
Surgical
Figure 63-3
The transsphenoidal surgical approach to the pituitary gland
Disorders of the posterior pituitary
gland
• Also called neurohypophysis
• Deficiency or excess of vasopressin (ADH)
• Results in either diabetes insipidus or
SIADH (syndrome of inappropriate
antidiuretic hormone)
Diabetes Insipidus
• Disorder of water metabolism caused by a
deficiency of ADH
• Results in the excretion of large volumes
of dilute urine. Kidneys do not concentrate
• Polyuria
• Dehydration causes thirst
• Either insufficient production or kidneys
inability to respond to ADH
DI
• Can be caused by Lithium or
demeclocycline (Declomycin)
• Key symptoms are excessive urination
and thirst
• Cardiovascular Sx
• Renal/urinary Sx
• Integumentary Sx
• Neurologic Sx
Treatment
• Meds: Diabinese, Nova-Propamide which
increase the action of existing ADH
• Nrs Care: early detection, I = O,
• Administer vasopressin transnasally
• Medic alert
SIADH
• Increased ADH causes water retention
resulting in dilution hyponatremia and fluid
volume overload
• Causes: malignancies, pulmonary causes,
CNS disorders, medications
• Diagnosis: blood and urine tests that
relate to osmolarity and concentration
Interventions
• Fluid restriction
• Drug therapy: diuretics, hypertonic IV,
Adrenal Gland hypofunction
• Acute adrenal insufficiency is called
Addisonian Crisis and is life threatening
• Affects electrolytes Na low, K+ high; and
glucose levels
• Tx: replacement therapy
Adrenal hypersecretion
• Cushings Syndrome (hyper cortisolism)
• Increase in body fat, “buffalo hump”,
“moon face”, decreased muscle mass,
atrophic skin and bone density, hirsutism,
oligomenorrhea
Figure 63-6
Appearance of a client with Cushing’s disease or syndrome
Endocrine System Problems:
Thyroid and Para-thyroid
PN 1V
Overview
• Hormones from the thyroid and para
thyroid affect general metabolism,
electrolyte balance and excitable
membrane activity.
• Disturbances usually have widespread
clinical symptoms
• Sometimes life threatening
Hormonal Pathway
Figure 62-6
Anatomic location of the thyroid gland
Figure 62-9
Palpation of the thyroid gland
Hyperthyroidism
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Called thyroidtoxicosis
State of hypermetabolism
Increased heart rate
Elevated protein, carb and lipid
metabolism
• Glucose tolerance is
decreased=hyperglyciemic
• Fat metabolism increased = fat loss
Hyperthyroidism
• Over secretion of thyroid changes the
secretions of hormones from the
hypothalamus and anterior pituitary glands
• Influence sex hormone production
Etiology
• Graves’ Disease or Goiter (auto immune)
• Sx of GD: Exophthalmos, pretibial
myxedema,
• Can also be caused by overmedication of
thyroid hormone
• Thyroid Storm, Thyroid Crisis
Figure 64-2
Exophthalmos
Figure 64-3
Goiter
Symptoms
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Wt. loss
Heat intolerance, diaphoresis
Palpitations, chest pain, dyspnea
Changes in vision, look of eyes
Change of energy, weakness, insomnia, F
Irritable or depressed
Menstrual changes, increase libido
Diagnostic and Lab findings
• Elevated T3, T4, free T4, decreased TSH,
positive RAI uptake scan and thyroid scan
Interventions
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Monitor cardiovascular sytem
Environmental
Drugs: Tapazole, iodine, Atenolol
Surgery: total or subtotal thyriodectomy
– Pre op
– Post op
– Post discharge
Hypothyroidism
• Decreased metabolism due to low levels
of the thyroid hormone
• Can occur at any age/stage
• Sx depend on length of time of disease
Symptoms
• Goiter
• Lethargy, diminished reflexes, periorbital
edema, bradycardia, dysrhythmia,
hypotension, reproductive problems,
coarse dry hair that falls out, coarse dry
skin, signs of slowed metabolism, anemia,
elevated serum lipids
Symptoms
• Assess for myxedema
• Decreased T4 , free T4, normal T3,
increased TSH
• Managed by giving T4 replacement
(Synthroid, Cytomel)
Nsg Diagnosis
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Decreased cardiac output
Constipation
r/f impaired skin integrity
R/f activity intolerance
r/f sexual dysfunction
Disturbed body image
Hypothermia
Knowledge deficit
Nsg Interventions
• Meds given in a.m. before or after meals
(taken for life) Must use same brand
• Adjust environment
• Pace activities
• Encourage fluid intake and fibre
• Medic alert
• What to report to MD?
Thyroiditis
• Inflammation of the thyroid gland
• Acute, chronic, subacute
• Chronic more common (Hasimotos’s
disease)
Thyroiditis
Acute: bacterial, uncommon
– Pain, neck tenderness, malaise, increase Temp;
Sub acute: viral, sometimes follows URI
- fever, chills, difficulty swallowing, muscle and
joint pain, pain that radiates to jaw and ears
- lymph nodes hard and enlarged
- thyroid function is normal, but may go up or
down
TX: rest fluids ASA, sometimes c-steroids
Thyroiditis
Chronic: low thyroidism, males more than
females, 30’s to 50’s
Autoimmune
• Thyroid gland is invaded with antibodies
and lymphocytes and gland is destroyed
• The more tissue destroyed the more hypo
they become and the more TSH increases
Chronic con’t
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DX: blood test
Needle bx
Scan
RAIU
• TX: thyroid hormone to decrease TSH which will
decrease size of gland
• Surgery
• Life long meds
Thyroid CA
4 types:
• Papillary
• Follidular
• Medulllary
• Anaplastic
Types
Papillary: most common, females under 40,
slow growing, progresses for years before
spreading to LN’s. Good cure if confined
to gland
Follicular: 25% over age 50yrs, invades
blood vessels and spreads to bone and
lung, rarely spreads to lymph G, prognosis
fair
Types
Medullary: 5-10 % over age 50 yrs, mets
via lymphatic
Anaplastic: rapid, aggressive tumor
invades, poor prognosis, die within 1 yr,
surgery palliative
Hyperparathyroidism
• Occurs in older adults; 2x’s more common
in women
Etiology:
– Primary: hyperplasia or tumor of one of the PT
glands, increasing the absorption of calcium
from GI tack
– Secondary: enlargement d/t chronic
hypocalcemia in the presence of elevated
PTH
– Tertiary; PT glands are enlarged and do not
respond to changes in serum C+ usually
associated with CRF
Assessment findings
• Polyuria and renal calculi, anorexia,
constipation, nausea, vomiting, abdominal
pain, generalized bone pain, pathologic
fractures, muscle weakness and atrophy,
CNS depression
Diagnostic findings & Tx
• Elevated serum levels of total calcium;
increased PTH; decreased phosphate;
possible bone changes on xray and CT
• Treatment: decrease serum calcium with
NS diuretics and phosphate replacement,
surgery to remove involved PT glands
Nsg Diagnosis
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Risk for injury
Pain
Impaired physical mobility
r/f altered urinary elimination
r/f constipation
Knowledge deficit
Nsg Interventions
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Comfort and safety; pace activity etc
Strain all urine
2 to 3 lts of fluid and fiber in diet
Daily wt, nutrition,
Chvostec and Trousseau signs, tetany
(post surgery of aggressive tx)
• Client education and assess their
understanding
Hypoparathyroidism
• Low PTH levels causing hypocalcemia,
usually caused by surgical removal of all
or part of gland
• Hypocalcemia raises the threshold for
excitability in nerve and muscle fibers
causing the fibers to be easily stimulated;
could lead to life threatening tetany.
Manifestations
• GI symptoms (pain, n, v, d, anorexia)
• Signs of hypocalcemia (anxiety, headache,
paresthesia, neuromuscular irritability with
tremors and muscle spasm)
• Difficulty swallowing, (possibly
laryngospasms!) hoarse voice, sensation
of tightness in throat, dry hair, patch hair
loss, ridged finger nails
Diagnostic findings & Tx
• Decreased PTH, total calcium, free
calcium, increased serum phosphate
• Tx: supplemental calcium and Vit D.
Nursing education
• Instruct ct. about diet high in calcium and
Vit D,
• identify minimum daily intake,
• foods high in calcium such as cheese,
milk, turnip greens, almonds, collard
greens, beans, peanuts, frankfurters and
bologna