endocrine system. endocrine system maintains homeostasis: –growth, maturation, reproduction,...

ENDOCRINE SYSTEMENDOCRINE SYSTEM

ENDOCRINE SYSTEMENDOCRINE SYSTEM Endocrine system maintains homeostasis:Endocrine system maintains homeostasis:

– Growth, maturation, reproduction, energy, Growth, maturation, reproduction, energy, metabolism (metabolism (physical and chemical changes physical and chemical changes that takes place w/i an organism),that takes place w/i an organism), behavior behavior

Composed of glands or glandular tissue:Composed of glands or glandular tissue:– Synthesize, store, and secrete hormonesSynthesize, store, and secrete hormones

Exocrine- secretions passed along ducts Exocrine- secretions passed along ducts that empty outside body or lumen of that empty outside body or lumen of organorgan

Endocrine- glands &/or cells are ductless Endocrine- glands &/or cells are ductless but highly vascular; secretion hormones but highly vascular; secretion hormones into bloodstreaminto bloodstream

HORMONESHORMONES

Hormones: natural chemical Hormones: natural chemical substances secretedsubstances secreted

Carried in bloodstream to “target” Carried in bloodstream to “target” cells/tissuescells/tissues

Effects are direct or indirectEffects are direct or indirect– Trophic/tropic- stimulate another Trophic/tropic- stimulate another

endocrine glandendocrine gland Cells response to hormone depends Cells response to hormone depends

on genetic make-upon genetic make-up

HORMONESHORMONES

Characteristics:Characteristics:– Circulate in blood at low concentrationsCirculate in blood at low concentrations– Secreted in minute amounts at variable Secreted in minute amounts at variable

ratesrates– Bind to specific receptors/cellsBind to specific receptors/cells– Variable effects on rates of responsesVariable effects on rates of responses– Most not stored, must be produced as Most not stored, must be produced as

neededneeded– Activity is of short durationActivity is of short duration

HORMONESHORMONES

Classifications:Classifications:– Polypeptides: proteins with genetic code; Polypeptides: proteins with genetic code;

bind at cell membrane; stimulates cellular bind at cell membrane; stimulates cellular adenyl cyclase (AMP); adenyl cyclase (AMP); FASTFAST CHANGECHANGE (anterior/posterior pituitary)(anterior/posterior pituitary)

– Steroids: derived from cholesterol; diffuse Steroids: derived from cholesterol; diffuse thru cell membrane; enzyme synthesis; thru cell membrane; enzyme synthesis; SLOW CHANGESLOW CHANGE (aldosterone, sex hormones) (aldosterone, sex hormones)

– Amino acids: derived from tyrosine; act on Amino acids: derived from tyrosine; act on cell membrane; ( thyroid, dopamine, cell membrane; ( thyroid, dopamine, epinephrine)epinephrine)

HORMONESHORMONES

Steroid and thyroid hormones are not Steroid and thyroid hormones are not water soluble; bound to protein, but water soluble; bound to protein, but only unbound portion is activated only unbound portion is activated and can be used.and can be used.

Peptides and catecholamine are Peptides and catecholamine are water soluble; not bound to protein water soluble; not bound to protein and can circulate freely in bloodand can circulate freely in blood

Lab tests measure both bound and Lab tests measure both bound and unbound (free) hormonesunbound (free) hormones

SECRETIONSECRETION

Pituitary-target gland axisPituitary-target gland axis: pituitary : pituitary gland regulates endocrine glands gland regulates endocrine glands thru tropic hormones. Tropic thru tropic hormones. Tropic hormones get feedback about hormones get feedback about specific target glands by constant specific target glands by constant monitoring of levels of hormone.monitoring of levels of hormone.

Works by stimulation or inhibition of Works by stimulation or inhibition of hormoneshormones

SECRETIONSECRETION

Hypothalamic-pituitary-target-gland axisHypothalamic-pituitary-target-gland axis: : hypothalamus in brain’s di-encephalon hypothalamus in brain’s di-encephalon produces tropic hormones; in particular produces tropic hormones; in particular the pituitary gland. In turn, pituitary the pituitary gland. In turn, pituitary controls other target glands to produce controls other target glands to produce hormones. Therefore works hormones. Therefore works indirectlyindirectly

Hypothalamus secretes releasing factors Hypothalamus secretes releasing factors and inhibiting factorsand inhibiting factors

FEEDBACK MECHANISMSFEEDBACK MECHANISMS NegativeNegative- increased levels of substance inhibit - increased levels of substance inhibit

hormone synthesis and secretion; decreased hormone synthesis and secretion; decreased levels stimulate production and release (heat levels stimulate production and release (heat thermostat)thermostat)

PositivePositive-- increased levels stimulate hormone increased levels stimulate hormone production and release; decreased levels inhibit production and release; decreased levels inhibit synthesis and secretionsynthesis and secretion

ComplexComplex- - thyroid stimulating hormone (TSH) in thyroid stimulating hormone (TSH) in pituitary is activated by thyroid releasing pituitary is activated by thyroid releasing hormone (TRH) and inhibited by somatostatin (in hormone (TRH) and inhibited by somatostatin (in hypothalamus). Decreased Thypothalamus). Decreased T3 3 & T& T4 4 leads to leads to increased TSH release. Increased levels lead to increased TSH release. Increased levels lead to inhibit TSH secretion inhibit TSH secretion

OTHER REGULATORY OTHER REGULATORY MECHANISMSMECHANISMS

Nervous system- central nervous system Nervous system- central nervous system innervates hypothalamusinnervates hypothalamus

Hypoxia, pain, stress, RX affect ADH and Hypoxia, pain, stress, RX affect ADH and oxytocin levelsoxytocin levels

Hypothalamus helps to control autonomic Hypothalamus helps to control autonomic nervous systemnervous system

Can be used to modify other hormonesCan be used to modify other hormones If secreted and transported by blood- If secreted and transported by blood-

HORMONEHORMONE If secreted across synaptic junction- If secreted across synaptic junction-

NEUROTRANSMITTERNEUROTRANSMITTER

REGULATORY MECHANISMSREGULATORY MECHANISMS

RHYTHMS- hormonal levels fluctuate RHYTHMS- hormonal levels fluctuate in a 24 hour periodin a 24 hour period

Related to sleep-wake periods; dark-Related to sleep-wake periods; dark-lightlight– Diurnal- cortisol rises early in day, falls Diurnal- cortisol rises early in day, falls

toward eveningtoward evening– Circadian- growth hormone, prolactin Circadian- growth hormone, prolactin

peak during sleeppeak during sleep– Ultradian- menstrual cycleUltradian- menstrual cycle

DYSFUNCTIONSDYSFUNCTIONSDEFINITIONSDEFINITIONS

HYPERFUNCTIONHYPERFUNCTION:: excessive hormone excessive hormone production/functionproduction/function

HYPOFUNCTIONHYPOFUNCTION:: deficient hormone deficient hormone function/productionfunction/production

HYPERTROPHYHYPERTROPHY: increase in size of organ, : increase in size of organ, in bulk not in # of cells or tissue elements in bulk not in # of cells or tissue elements as a result of increased functionas a result of increased function

HYPERPLASIAHYPERPLASIA:: excessive proliferation of excessive proliferation of normal cells in normal tissue arrangement normal cells in normal tissue arrangement of an organof an organ

DYSFUNCTIONSDYSFUNCTIONSCLASSIFICATIONSCLASSIFICATIONS

PRIMARYPRIMARY:: disease within endocrine disease within endocrine glandgland

FUNCTIONALFUNCTIONAL: hormonal imbalances : hormonal imbalances resulting from disease in an organ or resulting from disease in an organ or tissue other than endocrine glandtissue other than endocrine gland

SECONDARYSECONDARY:: disease in a target disease in a target glandgland

GLANDSGLANDS

HYPOTHALAMUS:HYPOTHALAMUS:– Size of sugar cubeSize of sugar cube– Autonomic NS and endocrine functionsAutonomic NS and endocrine functions– Works thru releasing/inhibiting factorsWorks thru releasing/inhibiting factors– Hypothalamic-hypophysial portal systemHypothalamic-hypophysial portal system– Functions are visceral, somatic, Functions are visceral, somatic,

behavioral/emotional; temp. regulation, behavioral/emotional; temp. regulation, perspiration, GI secretion/motility, appetite, perspiration, GI secretion/motility, appetite, thirst, B/P, respiration, sexual behavior, thirst, B/P, respiration, sexual behavior, fear, rage, sleep,& menstrual cyclesfear, rage, sleep,& menstrual cycles

GLANDSGLANDS

PITUITARY:PITUITARY:– Size of pea (hypophysis); 1 cm diameterSize of pea (hypophysis); 1 cm diameter– Located in sella turcicaLocated in sella turcica– AnteriorAnterior- largest lobe; growth hormone, - largest lobe; growth hormone,

thyroid stimulating, thyroid stimulating, adrenocorticortrophic, follicle stimulating, adrenocorticortrophic, follicle stimulating, leutinizing, prolactin leutinizing, prolactin

– PosteriorPosterior- lies behind anterior; anti-- lies behind anterior; anti-diuretic, oxytocindiuretic, oxytocin

– Connected to hypothalamus by Connected to hypothalamus by hypophyseal stalkhypophyseal stalk

GLANDSGLANDS

THYROID:THYROID:– Located in front of trachea; two lobes Located in front of trachea; two lobes

connected by isthmus (“H” shaped)connected by isthmus (“H” shaped)– HIGHLY VASCULARHIGHLY VASCULAR– Secretes thyroxine (TSecretes thyroxine (T44); triiodothyronine ); triiodothyronine

(T(T33); thyrocalcitonin (calcitonin)); thyrocalcitonin (calcitonin)– Can store large quantities of hormonesCan store large quantities of hormones– 99%+ is bound to protein; INACTIVE99%+ is bound to protein; INACTIVE

THYROIDTHYROID

Increase in oxygen use and heat Increase in oxygen use and heat productionproduction

Requires iodine and protein to Requires iodine and protein to produce hormoneproduce hormone

Is able to store some hormoneIs able to store some hormone

GLANDSGLANDS

PARATHYROID:PARATHYROID:– Oval shaped arranged in pairs behind Oval shaped arranged in pairs behind

thyroid (4 total glands)thyroid (4 total glands)– Regulates blood levels of calcium and Regulates blood levels of calcium and

phosphorusphosphorus– Free from pituitary and hypothalamus Free from pituitary and hypothalamus

controlcontrol

GLANDSGLANDS

ADRENAL GLANDS:ADRENAL GLANDS:– Flat, pyramid-shaped structures lying on top of Flat, pyramid-shaped structures lying on top of

kidneys, surrounded by thick capsule; crucial kidneys, surrounded by thick capsule; crucial to metabolism, stress response, and fluid & e-to metabolism, stress response, and fluid & e-lytes balancelytes balance

– Cortex- firm, yellow, outer portion; 3 specific Cortex- firm, yellow, outer portion; 3 specific layerslayers

Outer layer secretes Outer layer secretes mineralocorticoidsmineralocorticoids Middle layer secretes Middle layer secretes glucocorticoidsglucocorticoids Inner layer secretes Inner layer secretes androgensandrogens

– Medulla- reddish brown; produces and secretes Medulla- reddish brown; produces and secretes catecholaminescatecholamines

ADRENAL GLANDADRENAL GLAND

MINERALOCORTICOIDS- MINERALOCORTICOIDS- aldosterone, aldosterone, maintains extracellular fluid volume; maintains extracellular fluid volume; acts on renal tubule to promote renal acts on renal tubule to promote renal re-absorption of Na+ & excretion of re-absorption of Na+ & excretion of K+; stimulated by angiotension II, K+; stimulated by angiotension II, hyponatremia, hyperkalemiahyponatremia, hyperkalemia


GLUCOCORTICOIDS- cortisolGLUCOCORTICOIDS- cortisol,,– most abundant,most abundant,– is necessary to maintain life;is necessary to maintain life;– secreted in diurnal pattern;secreted in diurnal pattern;– facilitates hepatic gluconeogenesis; converts facilitates hepatic gluconeogenesis; converts

protein to glucose, decrease glucose use in protein to glucose, decrease glucose use in fasting statefasting state

– critical in body’s response to stress;critical in body’s response to stress;– anti-inflammatory response;anti-inflammatory response;– maintains vascular integritymaintains vascular integrity


ANDROGENS:ANDROGENS:– Steroids secreted in small amountsSteroids secreted in small amounts– Stimulate pubic and axillary hair growthStimulate pubic and axillary hair growth– Stimulate sex drive in femalesStimulate sex drive in females– In post-menopausal women, primary In post-menopausal women, primary

source of estrogensource of estrogen

Easily remembered Easily remembered 3 S’s: 3 S’s: SALT, SUGAR, SEXSALT, SUGAR, SEX

EFFECTS OF AGINGEFFECTS OF AGING

General changes include:General changes include:– Increased connective tissue in glandsIncreased connective tissue in glands– Decreased blood supplyDecreased blood supply– Decreased metabolism resulting in increased Decreased metabolism resulting in increased

half-life of medicationshalf-life of medications– Changed:Changed:

basal levelbasal level response to stimuliresponse to stimuli TransportTransport Target organ responsivenessTarget organ responsiveness catabolismcatabolism

ASSESSMENTSASSESSMENTS Hormones affect Hormones affect ALLALL body tissues body tissues Great diversity in sign/symptomsGreat diversity in sign/symptoms s/s are often s/s are often vaguevague

– FatigueFatigue– DepressionDepression– Energy levelEnergy level– AlertnessAlertness– Sleep patternsSleep patterns– MoodMood– AffectAffect– WeightWeight– SkinSkin– HairHair– Personal appearancePersonal appearance– Sexual functionSexual function

PHYSICAL ASSESSMENTPHYSICAL ASSESSMENT

INSPECTIONINSPECTION: use head to toe approach: use head to toe approach PALPATION:PALPATION: only thyroid and testes can only thyroid and testes can

be palpatedbe palpated AUSCULTATION:AUSCULTATION: cardiac baseline; bruits cardiac baseline; bruits PSYCHOSOCIAL:PSYCHOSOCIAL: coping skills, support coping skills, support

systems; health-related beliefs; perception systems; health-related beliefs; perception of self; need for social servicesof self; need for social services

DYSFUNCTIONSDYSFUNCTIONS

Hypo-functioning:Hypo-functioning: requires hormone requires hormone replacement daily; transplants??, diet, etc.replacement daily; transplants??, diet, etc.– Purified vs. synthetic: Purified vs. synthetic: synthetic is a moresynthetic is a more

precise dosageprecise dosage Hyper-functioningHyper-functioning: generally harder to : generally harder to

treat; usually tumors removed by surgery, treat; usually tumors removed by surgery, radiation, or hormone antagonistradiation, or hormone antagonist– Inhibits action of hormone; Inhibits action of hormone; propylthiouricil propylthiouricil

(PTU)(PTU) and methimazole (Tapezole) to treat and methimazole (Tapezole) to treat hyperthyroidismhyperthyroidism

AdjunctiveAdjunctive:: patient education patient education

QUESTIONS TO ASK??QUESTIONS TO ASK?? General state of health: any noticeable changesGeneral state of health: any noticeable changes Past historyPast history MedicationsMedications Past surgeriesPast surgeries Growth and developmentGrowth and development Trauma (head/neck)Trauma (head/neck) Size of extremitiesSize of extremities Secondary sex characteristicsSecondary sex characteristics Visual changesVisual changes MenstruationMenstruation Changes in: hair, skin, nails, weight, appetite, memory, sleep, Changes in: hair, skin, nails, weight, appetite, memory, sleep,

nervous systemnervous system Family historyFamily history Stressors and coping patternsStressors and coping patterns System reviews: only endocrine gland that can be palpated is System reviews: only endocrine gland that can be palpated is

THYROID;THYROID; must be experienced to do this must be experienced to do this

DIAGNOSTIC TESTSDIAGNOSTIC TESTS

Specific for each hormoneSpecific for each hormone Measure absolute levels, estimate Measure absolute levels, estimate

production, transport, production, transport, catabolism-complex catabolism-complex substances converted to simpler substances converted to simpler substances- energy releasesubstances- energy release

May need multiple samplesMay need multiple samples Time of sample must always be includedTime of sample must always be included Patient should be fasting, free from Patient should be fasting, free from

stressors, no smoking, NPOstressors, no smoking, NPO Some samples need preservativesSome samples need preservatives


DIRECT:DIRECT:– Most common; measures as hormone Most common; measures as hormone

appears in blood or urineappears in blood or urine– Since minute amounts, special Since minute amounts, special

techniquestechniques– May due 24-hour testing (24May due 24-hour testing (2400 urine) urine)– Radioimmunoassay RIA: radioactively Radioimmunoassay RIA: radioactively

labeled hormones compete with labeled hormones compete with unlabeled hormones to binding sites, etcunlabeled hormones to binding sites, etc


INDIRECT:INDIRECT:– Measures the substance the hormone Measures the substance the hormone

controls not the hormone itselfcontrols not the hormone itself– Less costlyLess costly– Easier to administerEasier to administer– EX: glucose measures insulin; calcium EX: glucose measures insulin; calcium

measures PTHmeasures PTH


PROVACATIVE:PROVACATIVE:– Helps to determine endocrine gland’s reserve Helps to determine endocrine gland’s reserve

function with tests that show borderline resultsfunction with tests that show borderline results– Stimulate an under-active gland or suppress Stimulate an under-active gland or suppress

over-active glandover-active gland– StimulationStimulation confirms hypofunction; hormone confirms hypofunction; hormone

given to stimulate target glandgiven to stimulate target gland Stimulus that increases secretion- hypofunctionStimulus that increases secretion- hypofunction If does not increase despite stimulus- hypofunctionIf does not increase despite stimulus- hypofunction

– Suppression Suppression Hormone secretion continues despite suppression Hormone secretion continues despite suppression

confirms hyperfunctionconfirms hyperfunction


RADIOGRAPHIC:RADIOGRAPHIC:– Routine x-raysRoutine x-rays

Evaluates dysfunction and effect on body Evaluates dysfunction and effect on body tissuetissue

– CAT scansCAT scansAssesses endocrine gland structureAssesses endocrine gland structure

– MRIMRIHelps to diagnose thyroid disordersHelps to diagnose thyroid disorders

DEFINITIONSDEFINITIONS

SYNTHESIZE = PRODUCESYNTHESIZE = PRODUCE INHIBIT = BLOCK= SUPPRESSINHIBIT = BLOCK= SUPPRESS ANTAGONIZE= goe against; oppositeANTAGONIZE= goe against; opposite SECRETESECRETE STIMULATESTIMULATE ANTAGONIST= substance that inhibitsANTAGONIST= substance that inhibits AGONIST= Support; help stimulate or AGONIST= Support; help stimulate or

produceproduce

GLANDULAR DYSFUNCTIONSGLANDULAR DYSFUNCTIONS

PITUITARY: gland is divided into 2 PITUITARY: gland is divided into 2 lobes, anterior and posterior. lobes, anterior and posterior. Dysfunctions of these hormones can Dysfunctions of these hormones can alter growth, metabolism, or sexual alter growth, metabolism, or sexual problemsproblems

ANTERIOR PITUITARYANTERIOR PITUITARY HYPOPITUITARYISM: caused by deficiency of one HYPOPITUITARYISM: caused by deficiency of one

or more of hormones. Decreased production of or more of hormones. Decreased production of all hormones is rare, but referred to as all hormones is rare, but referred to as panhypopituitarismpanhypopituitarism

More commonly, one or two deficiencies are More commonly, one or two deficiencies are presentpresent– ACTHACTH: adrenocorticotropic hormone*: adrenocorticotropic hormone*– TSH:TSH: thyroid stimulating hormone* thyroid stimulating hormone*– **Most life-threatening**Most life-threatening– Deficiencies of gonadotropins (LH,FSH) change sexual Deficiencies of gonadotropins (LH,FSH) change sexual

function in men and womenfunction in men and women– Testicular failure in men, ovarian failure in womenTesticular failure in men, ovarian failure in women– Lags in puberty, amenorrhea, and infertilityLags in puberty, amenorrhea, and infertility

ETIOLOGYETIOLOGY

TumorsTumors Postpartum hemorrhage: Sheehan’s Postpartum hemorrhage: Sheehan’s

syndrome, pituitary enlarges during syndrome, pituitary enlarges during pregnancy and if hypotension occurs pregnancy and if hypotension occurs may lead to ischemia and infarction may lead to ischemia and infarction (necrosis) of pituitary gland leading (necrosis) of pituitary gland leading to hypofunctionto hypofunction

GROWTH HORMONEGROWTH HORMONE GROWTH HORMONE: changes tissue growth GROWTH HORMONE: changes tissue growth

indirectlyindirectly GH stimulates liver to produce somatomedins, GH stimulates liver to produce somatomedins,

which enhances growth in cells and tissueswhich enhances growth in cells and tissues May lead to dwarfism (growth retardation), May lead to dwarfism (growth retardation),

hypoglycemia, and delayed wound healinghypoglycemia, and delayed wound healing May give somatrem (Protropin) to help with linear May give somatrem (Protropin) to help with linear

growthgrowth In adults, leads to decreased bone density,In adults, leads to decreased bone density,

(osteoporosis) pathologic fractures, decreased (osteoporosis) pathologic fractures, decreased muscle strength, and increased cholesterolmuscle strength, and increased cholesterol

GROWTH HORMONEGROWTH HORMONE

ASSESSMENT: ASSESSMENT: – Changes in secondary sex characteristics, Changes in secondary sex characteristics,

libidolibido– Visual changes; diplopiaVisual changes; diplopia– HeadacheHeadache– Weakness, fatigue, apathyWeakness, fatigue, apathy– Mental slowness, poor stress toleranceMental slowness, poor stress tolerance– Dry, sallow skinDry, sallow skin– InfectionInfection– Orthostatic hypotensionOrthostatic hypotension


Diagnostic tests:Diagnostic tests:– TT3 3 & T& T4 4

– FSHFSH– TSHTSH– ACTHACTH– CT scan or x-ray: changes in structureCT scan or x-ray: changes in structure– Stimulation tests- insulin increases GH & Stimulation tests- insulin increases GH &

ACTHACTH


INTERVENTIONS: INTERVENTIONS: – Replace deficient hormonesReplace deficient hormones– TestosteroneTestosterone– EstrogenEstrogen– Surgical removal of tumorSurgical removal of tumor

HYPERPITUITARYISMHYPERPITUITARYISM

HYPERPITUITARISM: oversecretion of HYPERPITUITARISM: oversecretion of hormones (same hormones as hypo)hormones (same hormones as hypo)

ETIOLOGYETIOLOGY

Tumors: compresses brain tissue; Tumors: compresses brain tissue; occur between 40-50 yearsoccur between 40-50 years

Congenital defectsCongenital defects HemorrhageHemorrhage InfarctionInfarction Inflammation from TBInflammation from TB SyphilisSyphilis Prolonged mechanical ventilationProlonged mechanical ventilation

GROWTH HORMONEGROWTH HORMONE GROWTH HORMONE: produce gigantism or GROWTH HORMONE: produce gigantism or

acromegalyacromegaly– Gigantism:Gigantism: excess hormone occurs before puberty excess hormone occurs before puberty

causing rapid proportional growth in bone length. Height causing rapid proportional growth in bone length. Height >6’6”>6’6”

– Most die early with infection or trauma.Most die early with infection or trauma.– Acromegaly:Acromegaly: occurs after puberty producing skeletal occurs after puberty producing skeletal

thickness, hypertrophy of skin, enlarged visceral organ thickness, hypertrophy of skin, enlarged visceral organ like liver and heart.like liver and heart.

Enlarged hands, feet, paranasal and frontal sinuses, Enlarged hands, feet, paranasal and frontal sinuses, deformities of spin and mandilble, enlarged tongue, speech deformities of spin and mandilble, enlarged tongue, speech difficulties, hoarseness, hypertension, oily skin, and joint difficulties, hoarseness, hypertension, oily skin, and joint painpain

Cardiomegaly leads to CHFCardiomegaly leads to CHF GH is an insulin antagonist leading to hyperglycemiaGH is an insulin antagonist leading to hyperglycemia Stimulate adrenal cortex- Cushing’s DiseaseStimulate adrenal cortex- Cushing’s Disease


DIAGNOSTIC TESTS:DIAGNOSTIC TESTS:– SAME AS FOR HYPOSAME AS FOR HYPO– Suppression testsSuppression tests


INTERVENTIONS:INTERVENTIONS:– Surgical removal of tumorSurgical removal of tumor– RadiationRadiation– DrugsDrugs

Bromocriptine (Parlodel)- dopamine agonistsBromocriptine (Parlodel)- dopamine agonists Cabergoline (Dostinex)- dopamine agonists Cabergoline (Dostinex)- dopamine agonists Octrotide- somatostatin analog that reduces GH w/I 2 Octrotide- somatostatin analog that reduces GH w/I 2

weeks(given IM and can cause gallbladder disease)weeks(given IM and can cause gallbladder disease)

– Combination therapyCombination therapy– Prognosis depends on age of onset, age Prognosis depends on age of onset, age

treatment is started, and tumor sizetreatment is started, and tumor size– No reversal of bone growth, only soft tissueNo reversal of bone growth, only soft tissue

SURGICAL PROCEDURE: SURGICAL PROCEDURE: HYPOPHYSECTOMYHYPOPHYSECTOMY

Procedure to remove all or part of Procedure to remove all or part of hypophysis; hypophysis;

Uses transphenoidal approachUses transphenoidal approach 70-90% successful70-90% successful Reduces risk of complicatons and deathReduces risk of complicatons and death No visible scar or loss of hairNo visible scar or loss of hair Incision made in inner aspect of upper lip Incision made in inner aspect of upper lip

and gingivaand gingiva Enter sella turcica through floor of Enter sella turcica through floor of

sphenoid sinussphenoid sinus

HYPOPHYSECTOMYHYPOPHYSECTOMY Teach mouth breathing, mouth care, ambulation, pain control, Teach mouth breathing, mouth care, ambulation, pain control,

activity, and hormone replacement prior to ORactivity, and hormone replacement prior to OR Nasal packing for 2-3 daysNasal packing for 2-3 days Dressing applied to upper lip: “mustache dressing”Dressing applied to upper lip: “mustache dressing” Avoid coughing, sneezing, straining at stool to prevent CSF leak Avoid coughing, sneezing, straining at stool to prevent CSF leak

(cerebrospinal fluid leak)(cerebrospinal fluid leak) HOB elevated 30HOB elevated 3000 to avoid pressure on sella turcica and reduce HA to avoid pressure on sella turcica and reduce HA Tooth brushing avoided to prevent disruption of suture lineTooth brushing avoided to prevent disruption of suture line Nasal drainage assessed for CSF (risk for meningitis) c/o HA, Nasal drainage assessed for CSF (risk for meningitis) c/o HA,

yellow halo on pillow, tests + for sugar; usually resolved w/I 72yellow halo on pillow, tests + for sugar; usually resolved w/I 7200; ; may need patchmay need patch

S/S of meningitis-HA, nuchal rigidity, temperature, photosensitivityS/S of meningitis-HA, nuchal rigidity, temperature, photosensitivity Antibiotics startedAntibiotics started Hormone replacement startedHormone replacement started May develop diabetes insipidus which is usually transientMay develop diabetes insipidus which is usually transient

POSTERIOR PITUITARYPOSTERIOR PITUITARY

HYPOFUNCTION: responsible for ADH HYPOFUNCTION: responsible for ADH and oxytocinand oxytocin

Deficiency of ADHDeficiency of ADH


ETIOLOGY:ETIOLOGY:– TumorsTumors– Trauma; head injuryTrauma; head injury– RadiationRadiation– DrugsDrugs– InfectionInfection– IschemiaIschemia

DIABETES INSIPIDUS DIDIABETES INSIPIDUS DI

Disorder of water metabolismDisorder of water metabolism ADH is produced by hypothalamus; stored ADH is produced by hypothalamus; stored

and released by post. Pituitaryand released by post. Pituitary Decreased ADH leads to distal renal Decreased ADH leads to distal renal

tubules not retaining watertubules not retaining water Large volumes of urine excreted (polyuriaLarge volumes of urine excreted (polyuria)) Massive dehydrationMassive dehydration Increased plasma osmolarity/osmolalityIncreased plasma osmolarity/osmolality Stimulates thirst response (if intact)Stimulates thirst response (if intact)

CLASSIFICATIONS OF DICLASSIFICATIONS OF DI NEPHROGENIC:NEPHROGENIC:

– Inherited disorder where kidneys do not respond to ADH; no Inherited disorder where kidneys do not respond to ADH; no deficiency in hormonedeficiency in hormone

PRIMARY:PRIMARY:– Defect in pituitary or hypothalamus; lack of ADH production or Defect in pituitary or hypothalamus; lack of ADH production or

secretionsecretion SECONDARY:SECONDARY:

– Tumors of pituitary or hypothalamus; trauma, infection, Tumors of pituitary or hypothalamus; trauma, infection, surgery, metastasis of oat cell cancer in lung or breastsurgery, metastasis of oat cell cancer in lung or breast

DRUGS:DRUGS:– Any drug that might interfere with kidney’s response to ADH; Any drug that might interfere with kidney’s response to ADH;

lithium carbonate (psych- manic/depressive)lithium carbonate (psych- manic/depressive) PSYCHOGENIC:PSYCHOGENIC:

– Client ingests large quantities of water, usually 5 liters or more Client ingests large quantities of water, usually 5 liters or more which in turn depresses ADH production/secretionwhich in turn depresses ADH production/secretion

DIDI

ASSESSMENTS:ASSESSMENTS:– Water loss (free water)Water loss (free water)– Plasma osmolality increasesPlasma osmolality increases– Serum sodium increasesSerum sodium increases– Urine osmolality decreasesUrine osmolality decreases– ThirstThirst– Frequent voiding (4 liters/24Frequent voiding (4 liters/2400); 200ml/hr with ); 200ml/hr with

specific gravity<1.005specific gravity<1.005– Abrupt onset (1-2 days after injury)Abrupt onset (1-2 days after injury)– Weight loss, fatigue, constipation, anorexiaWeight loss, fatigue, constipation, anorexia

DIDI DIAGNOSTIC TESTS:DIAGNOSTIC TESTS:

– Serum sodium- increaseSerum sodium- increase– Plasma osmolality- increasePlasma osmolality- increase– Specific gravity of urine- decreasedSpecific gravity of urine- decreased– Water deprivation test- withhold food and water at 6am. Water deprivation test- withhold food and water at 6am.

Measure urine volume, osmolality, specific gravity hourly Measure urine volume, osmolality, specific gravity hourly until osmolality is constant. Measure serum osmolality, until osmolality is constant. Measure serum osmolality, give Vasopressin, and take measurements again. Urine give Vasopressin, and take measurements again. Urine osmolality >serum before and after test.osmolality >serum before and after test.

– Vasopressin test – used less frequentlyVasopressin test – used less frequently– Hypertonic saline test- NS followed by 3% saline- sudden Hypertonic saline test- NS followed by 3% saline- sudden

decrease in urine output is sign of ADH releasedecrease in urine output is sign of ADH release

DIDI INTERVENTIONS:INTERVENTIONS:

– Maintain fluid and e-lyte balanceMaintain fluid and e-lyte balance– Identify and correct causeIdentify and correct cause– IV fluids (hypotonic)IV fluids (hypotonic)– Unrestricted access to fluidsUnrestricted access to fluids– Administer VasopressinAdminister Vasopressin

Aqueous for short-acting needsAqueous for short-acting needs Tannate in oil for long-acting needsTannate in oil for long-acting needs

– Diabenese- only used if partial reduction in ADH; Diabenese- only used if partial reduction in ADH; increases action of ADHincreases action of ADH

– Severe cases administer desmopressin acetate DDAVP- Severe cases administer desmopressin acetate DDAVP- synthetic form of ADH (metered dose inhaler) irritate synthetic form of ADH (metered dose inhaler) irritate nasal mucosanasal mucosa

– Daily weights are a must!!Daily weights are a must!!


HYPERFUNCTIONHYPERFUNCTION Oversecretion of ADH even with low Oversecretion of ADH even with low

osmolalities (Schwartz-Bartter osmolalities (Schwartz-Bartter Syndrome)Syndrome)

SYNDROME OF INAPPROPRIATE SYNDROME OF INAPPROPRIATE ADH SIADHADH SIADH

Water is retained but no edemaWater is retained but no edema Dilutional HyponatremiaDilutional Hyponatremia Sodium loss from kidneys further Sodium loss from kidneys further

leads to hyponatremia leads to hyponatremia Positive feedback- elevated ADH Positive feedback- elevated ADH

release persists even with increased release persists even with increased plasma volume and decreased plasma volume and decreased osmolalityosmolality

SIADHSIADH

ETIOLOGY:ETIOLOGY:– CancerCancer– Cerebrovascular accident- CVACerebrovascular accident- CVA– Tuberculosis -TBTuberculosis -TB

SIADHSIADH ASSESSMENTS:ASSESSMENTS:

– Changes in LOC: Changes in LOC: Malaise, nausea, HA, irritabilityMalaise, nausea, HA, irritability

– TachycardiaTachycardia– Increased B/PIncreased B/P– Water intoxicationWater intoxication– Fluid shifts especially in brain lead to LOC Fluid shifts especially in brain lead to LOC

changeschanges– No dependent edema initiallyNo dependent edema initially– Na+ < 130; dilutional hypocalcemia; normal Na+ < 130; dilutional hypocalcemia; normal

BUN, creatinineBUN, creatinine– Symptoms depend on rate of onsetSymptoms depend on rate of onset

SIADHSIADH

DIAGNOSTIC TESTS:DIAGNOSTIC TESTS:– Serum sodium- decreasedSerum sodium- decreased– Serum calcium- decreasedSerum calcium- decreased– BUN and creatinine- normalBUN and creatinine- normal– Plasma osmolality- decreasedPlasma osmolality- decreased– Urine osmolality- elevatedUrine osmolality- elevated

SIADHSIADH

INTERVENTIONS:INTERVENTIONS:– Restrict fluids to 500-600cc/24Restrict fluids to 500-600cc/2400

– I & OI & O– Daily weightsDaily weights– DiureticsDiuretics– Hypertonic saline (3%) use with cautionHypertonic saline (3%) use with caution– Drugs:Drugs:

Lithium carbonate- can cause toxicityLithium carbonate- can cause toxicityDeclomycin**- more commonly used Declomycin**- more commonly used