Transcript Lesson 9A - Pathophysiology

THE ENDOCRINE SYSTEM
ENDOCRINE METABOLIC
ALTERATIONS
M.DUBOIS FENNAL, PHD, RN, CNS
RELATIONSHIP OF THE
ENDOCRINE SYSTEM TO OTHER
PARTS OF THE BODY
• Endocrine disorders can affect all body
systems. Such disorders are usually
caused by overproduction or
underproduction of hormones
Definition
• Ductless glands that release secretions
(hormones) directly into the blood stream.
The Organs of the Endocrine
System
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Pituitary
Pineal
Thyroid
Para-thyroids
Thymus
Adrenals
Pancreas
Gonads
Adrenals
Major Hormone Secreting Glands
of the Endocrine System
Hypophysis/Pituitary
• Located at the base of the brain, has two
separate divisions, anterior and posterior.
Regulates or controls
Pituitary Gland and Its Hormones
Thyroid Gland
• Located at the level of the thyroid cartilage
of the trachea, connected by the isthmus,
blood supply, the carotids
Thyroid Gland (cont.)
Parathyroids
• Located on the surface of the thyroid (may
be in other areas) 4 to 8 in number,
circulation, carotids
Parathyroid Gland (cont.)
Adrenals
• Located on top of the kidneys, blood
supply, aorta and the renal artery, secretes
glucocorticoids and
• mineralocorticoids, catecholamines
Adrenal Glands (cont.)
Pancreas
• Has a head, a body and a tail, located
between the spleen and the duodenum,
has exocrine and endocrine function,
circulation, celiac artery, splenic artery,
pancreatic artery
Pineal Gland
• Shape like a pine cone, located posteriorly
to the hypopsis, secretes melatonin,
inhibited by sunlight
Examination of the metabolic
system
• History
– Medical problems (current and significant
past)
– Symptoms
– Medication history (current)
Physical Examination
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Inspection
Palpation
Percussion (not utilized)
Auscultation
Vital signs
Laboratory Studies
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Blood work
Urine
Basal metabolic rate
Radiological examination
Electrocardiogram
Disorders of the Endocrine Glands
• Primary
• Secondary
• Tertiary
Pituitary Tumors
• Primary
• Secondary
Alteration of the Pituitary Gland
• Hypopituitarism: Definition, a disorder of
the amount of hormones secreted.
Panhypopituitarism is the term used
because of the insufficiency of all
hormones released from the pituitary
gland
Etiology
• Pituitary tumors, vascular thrombosis,
granulomas, idiopathic or autoimmune
destruction of the pituitary cells.
Incidence
• Affects children and adults, with a different
pathology for each.
Pathophysiology
• Decrease in the production, release or
stimulation of the hormones of the Anterior
pituitary gland.
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ACTH
MSH
LH (MEN)
FSH (MEN)
LH (WOMEN)
FSH (WOMEN)
PROLACTIN
GROWTH HORMONE
CLINICAL MANIFESTATIONS
• Children: short stature, failure of sex
organs to develop, fatigue, weakness,
anorexia, cold intolerance, impaired sexual
function, pale skin.
• Adults: hypogonadism, amenorrhea,
insulin sensitivity, breast atrophy, pale skin
Medical Management
• Administration of deficient hormones
• Medication route by intramuscular route
only
Hyperpituitarism
• Definition: over secretion of the growth
hormone.
– Gigantism in children
– Acromegaly in adults
Etiology
• Results from a pituitary tumor that
secretes growth hormone or from a
hypothalamic abnormality that leads to
increase growth hormone release
Incidence
• Research is limited, few known individuals
around the world have been studied
– Andrea the giant
– Gentleman in Africa
– Woman (American?)
Pathophysiology
• Gigantism: (child) rapid longitudinal growth
• Acromegaly: (adult) enlargement of bone
structure
Medical Management
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CT scan
Irradiation of the pituitary gland
Resection of tumors
Suppression of GH using the somatostatin
analog
Diabetes Insipidus
• Definition: a clinical syndrome characterized by
excessive amounts of dilute urine. Urine in
excess of 50 ml/kg in a 24 hour period. Specific
gravity of less than 1.010 and osmolality of less
than 300 mOsm/kg.
• A defect in the chain of events by which
vasopressin is released from the
neurohypophysis and acts on the renal system.
Etiology
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Tumors of the hypothalmus
Surgery injury of the pituitary gland
Intracerebral Vascular occlusions
Grandulomas
Renal disease
Multiple myleoma
Sickle cell anemia
Hypercalcemia & hyperkalemia
Sarcardosis, CVA,
Incidence
• Occurs most often in clients with head
injury accidental or caused and in
neurogenic patients
• Occurs frequently in clients with conditions
that affect the renal tubules, that prevent
sensitivity to ADH
Pathophysiology
• Impairment of renal conservation of water.
(polyuria, > 3L in 24 hrs) May be partial or
complete, temporary or permanent. ADH
deficiency (neurogenic ) and/or ADH insensitivity
(nephrogenic) or excessive water intake
(secondary to KI)
• Deficiency of the antidiuretic hormone arginine
vasopressin
• Destruction of cells that produce arginine
vasopressin
Clinical Manifestations
• 12 to 24 hour onset after trauma
• Dehydration, dry skin, constipation,
confusion
• Polyuria: 15-29 liters per day and
polydipsia
• Intense, nearly insatiable thirst
• Specific gravity < 1.010
• Serum Osmolality >295 mOsm/kg
Medical Management
• Skull and chest x-ray, looking for
metastatic disease
• EEG
• Spinal Fluid study
• Serology for syphilis
• Serum protein level
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Check visual fields
Bone marrow aspirate (multiple myeloma)
Urinalysis, BUN, Creatinine
Determine the cause
Treat the underlying cause
Replace the fluid (1/2 NS)
Vasopressin therapy
Nursing Management
• Maintain fluid replacement for urine output
• Prevent dehydration and hypovolemic
shock
• Accurate intake and output
• Management of vasopressin therapy warm
the solution)
• Correction of underlying cranial problems
i.e. increase intercranial pressure
Complications
• Vasomotor Collapse
• Dilatation and hypertrophy of the bladder
with megaloureter
• Vasopressin resistance
Syndrome of Inappropriate ADH
• Definition: Inappropriate secretion of
Antidiuretic hormone, characterized by
hyponatremia, impaired water secretion in
the absence of hypovolemia or a
deficiency in cardiac, renal, or adrenal
function
Etiology
• Endogenous secretion of arginine
vasopressin
• Pulmonary disease,(hypercapnia &
hypoxia)
• Malignant tumors
• Disorders of the central nervous system
• Surgery
Incidence
• More common in acutely ill hospitalized
patients
Pathophysiology
• Hyperosmolar syndrome, excessive and
inappropriate water retention, severe
hyponatremia, producing neurological
irritability
Treatment
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Fluid Restriction
Administration of 3%-5% sodium chloride
Lasix therapy
Demeclocycline
Hyperthyroidism/Thyrotoxicosis
• Definition: a biochemical and physiological
complex that results when tissues are
presented with excessive quantities of
thyroid hormone
Etiology
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Graves disease
Goiter
Hyperfunction of thyroid tissue
Ingestion of large quantities of exogenous
hormone
• Familial traits
• Stress
• Trauma
Incidence
• Higher in females
• High in individuals with other autoimmune
disorders
• More frequent in puberty, during
menstruation and pregnancy
Pathophysiology
• Increase level of circulating TH, increase
metabolic rate, heighten sympathetic
nervous system physiology. Increase
cardiac rate and stroke volume, increase
cardiac output and peripheral blood flow.
Decrease lipids, decrease glucose
tolerance, degradation of protein, negative
nitrogen balance.
Signs and Symptoms
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Exaggerated alertness
Flushed face, warm skin, diaphoretic
Palmar erythema
Increase pigmentation of the skin
Bulging eyes, thin fine hair
Enlarged thyroid, weight loss, tremors
Elevated blood pressure, tachycardia
Left ventricular failure, amenorrhea
Clinical Presentation
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Irritability
Nervousness
Insomnia
Fatigue
Palpitations
Heat intolerance
Emotionally labile
Test
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TA Test
TSH Test
T4 Test
T3 Test
T3 Uptake Test
RAI uptake Test
Thyroid Suppression Test
Medical Management
• Pharmacology
– Iodine potassium/sodium
– Tapazole
– PTU
– Radioactive therapy
– Surgery
Nursing Management
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Provide a cool, quiet environment
Eye drops and coverings
Between meal snacks
Monitor for and treat dysrhythmias
Interpret laboratory data
Monitor results of medication
administration
• Provide un-interrupted rest periods
Nursing Diagnosis
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Risk for decrease cardiac output
Sensory-perceptual alteration
Risk for altered nutrition
Body image disturbance
Hyperthermia
Activity Intolerance
Anxiety
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Fluid Volume Deficit
Altered thought processes
Risk for Injury
Altered urinary elimination
Sleep pattern disturbances
Risk for altered health maintenance
Thyrotoxic Storm
• Usually occurs with Graves Disease, but
sometimes with toxic goiter
• Occurs with pre-existing thyrotoxicosis or goiter,
or exophthalmos or all three, trauma, emotional
upset, infection, surgical emergencies, abrupt
withdrawal of anti-thyroid drugs
• Less common causes include radiation
thyroiditis, diabetic acidosis, and toxemia of
pregnancy
Clinical Presentation
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Fever
Profuse Sweating
Marked tachycardia
Congestive heart failure/pulmonary edema
Restlessness, delirium, psychosis
Hypothyroidism/Myxedema
• Definition: Insufficient production of thyroid
hormone
Etiology
• Primary: Congenital defect or surgery,
radiation (loss of thyroid tissue) antithyroid medication, thyroiditis
(Hashimoto’s disease) or iodine deficiency.
• Secondary: Pituitary Thyroid stimulating
hormone deficiency
Incidence
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More common in women age 30-60 years
Older adults
With coma, 50% mortality
Occurs more frequently in winter
Pathophysiology
• Acceleration of metabolism and clearance
of thyroid hormone in the body
• Increase hormone utilization without
hormone production or decrease thyroid
production
• Development of a hypo-metabolic state
Clinical Presentation
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Apathy, listlessness, tiredness
Sensitivity to cold
Loss of libido
Loss of appetite
Signs and Symptoms
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Slowing of intellectual and motor ability
Constipation
Weight gain
Laryngitis
Periorbital edema
Enlarged tongue
Non pitting edema
Menstrual disturbances
Diagnosis
• Protein bound iodine (PBI) below 3.5
mg/100mL plasma
• Radioiodine (I 131)
• Thyroid scan
• Basal metabolic rate (-15% to 40%)
• Serum cholesterol above 300 mg.
Medical Management
• Medication to increase thyroid hormone
activity
– Desiccated thyroid extract
– L-thyroxin (synthroid)
– Cytomel
– Treat the underlying cause
– Restore fluid and electrolyte balance
Nursing Management
• Administer meds and monitor reaction.
Report untoward symptoms
• Protect the patient from cold and drafts
• Assess for cardiac complications
• Watch for signs of overdose of thyroid
hormone
• Patient and family teaching
Nursing Diagnosis
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Fluid volume deficit
Potential for decrease cardiac output
Alteration in sensorium
Risk for ineffective breathing pattern
Risk for injury, skin integrity
Impaired communication
Myxedema Coma
• Occurs with long standing untreated
hypothyroidism
• Occurs in the winter months mostly due to
exposure to cold, trauma, infection, CNS
depression, alveolar hypoventilation
Physical Signs
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Mental obtundation to coma
Subnormal temperature
Bradycardia
Hypotension
Ventilatory failure
Seizures
Disorders of the Adrenal Glands
• Congenital Adrenal Hyperplasia
• Adrenal Cortical Insufficiency
• Cushing Syndrome
Addison’s Disease
• Definition: Disordered function of the
adrenal glands resulting in lack of adrenal
output. i. e. cortisol and aldosterone
Etiology
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Adrenocortical destruction
Tuberculosis
Idiopathic atrophy of the adrenals
Bilateral adrenal tumor with metastasis
Amyloidosis
Incidence
• More common in adults under sixty years
of age
• More common in women
• High in individuals withdrawing from
steroid therapy
• Clients with AIDS
• Clients on anti-coagulants
Pathophysiology
• Hypo-function of the adrenal glands from
primary or secondary mechanisms that
suppress corticosteroid secretion. In
Addison’s disease there is a deficiency of
mineralocorticoids and glucocorticoids
• Autoimmune diseases, infection,
hemorrhagic destruction
Signs and Symptoms
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Pigmentation of the skin
Weight loss
Hypotension
Diarrhea/constipation
Syncope
Clinical Presentation
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Inability to conserve sodium
Weight loss
Hypovolemia/hypotension
Decrease cardiac size and output
Decrease renal blood flow
Pre-renal azotemia
Increase rennin production
Shock, electrolyte imbalance
Medical Management
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Diagnosis
Measurement of adrenal reserves
Plasma cortisol
17 keto steroids
Restoration of fluid and electrolyte balance
Prevention of circulatory collapse
Nursing Management
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Administration of fluid
Intake and output maintenance
Monitoring electrolytes
Safety
Emotional support
Protection from infection
Vital signs, lab work, positioning,
conservation of energy
Nursing Diagnosis
• Fluid volume deficit
• Risk for ineffective management of
therapeutic regimen
• Ineffective individual coping
• Activity intolerance
• Altered tissue perfusion
Hyperosmolar Coma (HHNC)
• Definition: Profound hyperglycemia,
hyperosmolality and severe dehydration,
associated with minimal ketosis resulting
from insulin deficiency
• Serum glucose >600
Etiology
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Debilitation
Diminished thirst
Inadequate intake
Newly diagnosed Type II diabetes
Major illness
High calorie parenteral and enteral nutrition
Sepsis, pancreatitis, uremia, burns, GI
hemorrhage, stress and medication, as well as
dialysis
• Medication
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Thiazide diuretics
Glucocorticords
Sympathometics
Phenytoin
Chlorpromazine
Cimetidine
Calcium channel blockers
Immunosuppressive agents
Beta blockers
Diazoxide
Incidence
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More common in the elderly
In patients receiving TPN or PPN
High in clients with diminished thirst
Inadequate fluid intake
High in individuals with history of stroke or
coronary disease
Pathophysiology
• Hyperglycemia
• Deficiency of insulin to handle large
quantities of glucose
• Hypernatremia
• Inadequate renal excretion of solute
leading to azotemia
• Severe cellular dehydration
Signs and Symptoms
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Dry skin and mucus membranes
Fever
Tachypnea
Tachycardia
Hypotension
glycosuria
Clinical Presentation
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Lethargy to stuporous
Polyuria
Polydipsia (if thirst mechanism is working)
Weight loss
Decrease urinary output
Nausea and vomiting
Hypernatremia
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Hyperglycemia (600-2400)
High serum osmolality
Soft eyeballs
Shock
Acute tubular necrosis
Mortality rate 50%
Medical Management
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Airway
Control hyperglycemia
Restore hydration
Correct metabolic acidosis
Nursing Management
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Establish and maintain airway
Insert naso-gastric tube
Neurological checks and management
Cardiac monitoring, vital signs
Physical assessment
Diagnostic study interpretation
Nursing Diagnosis
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Alterations in breathing pattern
Alteration in fluid volume deficit
Risk for injury
Alteration in sensorium