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
• 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
• Inspection
• Palpation
• Percussion (not utilized)
• Auscultation
• Vital signs
 Laboratory Studies
• 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.
– 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
• 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
• 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
• 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
• 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
• 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
• 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
• Irritability
• Nervousness
• Insomnia
• Fatigue
• Palpitations
• Heat intolerance
• Emotionally labile
 Test
• 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
• 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
• Risk for decrease cardiac output
• Sensory-perceptual alteration
• Risk for altered nutrition
• Body image disturbance
• Hyperthermia
• Activity Intolerance
• Anxiety
• 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
• 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) anti-
thyroid medication, thyroiditis
(Hashimoto’s disease) or iodine
deficiency.
• Secondary: Pituitary Thyroid stimulating
hormone deficiency
 Incidence
• 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
• Apathy, listlessness, tiredness
• Sensitivity to cold
• Loss of libido
• Loss of appetite
 Signs and Symptoms
• 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
• 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
• 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
• 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
• Pigmentation of the skin
• Weight loss
• Hypotension
• Diarrhea/constipation
• Syncope
 Clinical Presentation
• 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
• Diagnosis
• Measurement of adrenal reserves
• Plasma cortisol
• 17 keto steroids
• Restoration of fluid and electrolyte balance
• Prevention of circulatory collapse
 Nursing Management
• 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
• 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
– Thiazide diuretics
– Glucocorticords
– Sympathometics
– Phenytoin
– Chlorpromazine
– Cimetidine
– Calcium channel blockers
– Immunosuppressive agents
– Beta blockers
– Diazoxide
 Incidence
• 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
• Dry skin and mucus membranes
• Fever
• Tachypnea
• Tachycardia
• Hypotension
• glycosuria
 Clinical Presentation
• Lethargy to stuporous
• Polyuria
• Polydipsia (if thirst mechanism is working)
• Weight loss
• Decrease urinary output
• Nausea and vomiting
• Hypernatremia
• Hyperglycemia (600-2400)
• High serum osmolality
• Soft eyeballs
• Shock
• Acute tubular necrosis
• Mortality rate 50%
 Medical Management
• Airway
• Control hyperglycemia
• Restore hydration
• Correct metabolic acidosis
 Nursing Management
• Establish and maintain airway
• Insert naso-gastric tube
• Neurological checks and management
• Cardiac monitoring, vital signs
• Physical assessment
• Diagnostic study interpretation
 Nursing Diagnosis
• Alterations in breathing pattern
• Alteration in fluid volume deficit
• Risk for injury
• Alteration in sensorium