endocrine system. thyroid gland thyroid hormones affect nearly all body tissues dysfunctions cause...

ENDOCRINE SYSTEMENDOCRINE SYSTEM

THYROID GLANDTHYROID GLAND

Thyroid hormones affect nearly all body Thyroid hormones affect nearly all body tissuestissues

Dysfunctions cause profound effectsDysfunctions cause profound effects Three hormones:Three hormones:

– TT33 ; T ; T44 ; calcitonin ; calcitonin Thyroid hormone’s main component is Thyroid hormone’s main component is

iodineiodine Minimum daily requirement of I= 80 mcg; Minimum daily requirement of I= 80 mcg;

more like 500mcg (contained in bread, more like 500mcg (contained in bread, water, and iodized salt)water, and iodized salt)

THYROIDTHYROID

Thyroid gland can store large Thyroid gland can store large quantities for monthsquantities for months

S/S may not appear for monthsS/S may not appear for months Works on negative feedback system; Works on negative feedback system;

TRH signals TSH which stimulates TRH signals TSH which stimulates thyroid glandthyroid gland

Most hormone is bound to proteinMost hormone is bound to protein

THYROIDTHYROID Functions:Functions:

– Metabolism: increase rate, accelerate food utilization for Metabolism: increase rate, accelerate food utilization for energy, excites mental processesenergy, excites mental processes

– Growth: in children accelerates growthGrowth: in children accelerates growth– Carbohydrate: stimulates metabolism, including insulin Carbohydrate: stimulates metabolism, including insulin

secretionsecretion– Fat: enhances fat metabolismFat: enhances fat metabolism– Body wt: production relates inversely to body wt (does Body wt: production relates inversely to body wt (does

not stimulate appetite)not stimulate appetite)– CV: causes vasodilation, increased cardiac output and CV: causes vasodilation, increased cardiac output and

heart rate, increased systolic B/P by 10-20 mm but heart rate, increased systolic B/P by 10-20 mm but diastolic may drop the samediastolic may drop the same

– Respiration: increases O2 use, rate, and depthRespiration: increases O2 use, rate, and depth– GI: increases appetitie, absorption,motilityGI: increases appetitie, absorption,motility– CNS: speeds mental processesCNS: speeds mental processes

THYROIDTHYROID Assessments:Assessments:

– SwallowingSwallowing– Skin changesSkin changes– Tolerance to heat or coldTolerance to heat or cold– Weight changesWeight changes– PalpitationsPalpitations– DrugsDrugs– Radiation to neck or surgeryRadiation to neck or surgery– Head traumaHead trauma– AlcoholAlcohol– Growth rateGrowth rate– AppetiteAppetite– Menstrual periodsMenstrual periods– BEGIN WITH INSPECTION, LOOKING FOR LUMPS, PUFFINESS, BEGIN WITH INSPECTION, LOOKING FOR LUMPS, PUFFINESS,

FACIAL EXPRESSIONS, ENLARGED TONGUE, VOICE, HAIR, FACIAL EXPRESSIONS, ENLARGED TONGUE, VOICE, HAIR, VISION, NAILS, AND MUSCLE ACHES. VISION, NAILS, AND MUSCLE ACHES.

THYROIDTHYROID

Diagnostic tests:Diagnostic tests:– Thyroid panel: TThyroid panel: T33 & T & T44; free and bound; ; free and bound; – RAIU: radioactive iodine uptake; uses RAIU: radioactive iodine uptake; uses

radioactive iodine and scan thyroid as it uses radioactive iodine and scan thyroid as it uses iodine. Given PO, IV, or liquid; only use small iodine. Given PO, IV, or liquid; only use small amt. no risk, do before scan with contrastamt. no risk, do before scan with contrast

– Stimulation testsStimulation tests– ScansScans– UltasoundUltasound– BiopsyBiopsy

THYROIDTHYROID

Hyperthyroidism:Hyperthyroidism:– Involves excessive hormone productionInvolves excessive hormone production– Leads to hypermetabolismLeads to hypermetabolism– Signs and symptoms: Signs and symptoms: thyrotoxicosisthyrotoxicosis– Stimulates heart, protein synthesis, Stimulates heart, protein synthesis,

breakdown>buildup leading to negative breakdown>buildup leading to negative nitrogen balance (degradation); nitrogen balance (degradation); hyperglycemia; increased fat metabolismhyperglycemia; increased fat metabolism

– Caused by two etiologies:Caused by two etiologies: Increased iodine uptake (Grave’s, goiter, adenomaIncreased iodine uptake (Grave’s, goiter, adenoma Low iodine uptake (subacute and silent)Low iodine uptake (subacute and silent)

THYROIDTHYROID Grave’s diseaseGrave’s disease: toxic diffuse goiter: toxic diffuse goiter Most commonMost common Strikes women, 20-30.Strikes women, 20-30. Multisystem syndrome, affecting eyes, Multisystem syndrome, affecting eyes,

skin, bonesskin, bones Increased thyroid hormone as well as Increased thyroid hormone as well as

goitergoiter No sure cause: autoimmune disorderNo sure cause: autoimmune disorder Generally emotional upset precedes Generally emotional upset precedes

symptomssymptoms Has heredity componentHas heredity component

THYROIDTHYROID Assessment:Assessment:

– Increase appetite but slight wt lossIncrease appetite but slight wt loss– DyspneaDyspnea– Decreased heat toleranceDecreased heat tolerance– Menstruation may decrease or stopMenstruation may decrease or stop– Increased bowel movements or diarrheaIncreased bowel movements or diarrhea– Nervous, irritable, restlessNervous, irritable, restless– Speak rapidly; laugh inappropriatelySpeak rapidly; laugh inappropriately– Exopthalamus (BUG-EYE)Exopthalamus (BUG-EYE)– Moist skin, thinning hair, elbows red; clubbing of nails Moist skin, thinning hair, elbows red; clubbing of nails

(Plummer’s nails), hyperpigmentation (vitiligo- milk-white (Plummer’s nails), hyperpigmentation (vitiligo- milk-white patches)patches)

– Tremors, weaknessTremors, weakness– Tachycardia, atrial fibrillation; widened pulse pressureTachycardia, atrial fibrillation; widened pulse pressure– Fine, soft hair; moist skinFine, soft hair; moist skin– Hyperactive deep tendon reflexes Hyperactive deep tendon reflexes

THYROIDTHYROID

Diagnostic tests:Diagnostic tests:– Elevated TElevated T33, T, T44

– RAIURAIU– No response to TRHNo response to TRH– Below normal TSHBelow normal TSH– Thyroid scanThyroid scan

THYROIDTHYROID Interventions:Interventions:

– Record vital signsRecord vital signs– Rest, frequent linen changes, cool environmentRest, frequent linen changes, cool environment– Drugs to reduce hormone: can cause Drugs to reduce hormone: can cause thyroidthyroid stormstorm

PTUPTU TapezoleTapezole Iodine-radioactive; cells are destroyedIodine-radioactive; cells are destroyed LithiumLithium Inderal: not used on clients with asthma or heart diseaseInderal: not used on clients with asthma or heart disease

– Watch for Watch for agranulocytosisagranulocytosis: fever, sore throat, rash: fever, sore throat, rash– Treatment does not correct infiltrative opthalopathy; use Treatment does not correct infiltrative opthalopathy; use

tears, elevate head, diuretics for edema; prednisonetears, elevate head, diuretics for edema; prednisone

THYROIDTHYROID Surgical intervention:Surgical intervention: May perform total or subtotalMay perform total or subtotal Treat with drugs to return to near normal thyroid Treat with drugs to return to near normal thyroid

function prior to surgeryfunction prior to surgery– Give Lugol’s solution or SSKI (saturated solution of Give Lugol’s solution or SSKI (saturated solution of

potassium iodide) prior to OR to firm thyroid, reduce potassium iodide) prior to OR to firm thyroid, reduce vascularity which can reduce bleedingvascularity which can reduce bleeding

– Give in milk, OJ, sip thru straw so as not to discolor teethGive in milk, OJ, sip thru straw so as not to discolor teeth– Watch for toxicity: buccal mucosal swelling, excessive Watch for toxicity: buccal mucosal swelling, excessive

salivation, skin reactionssalivation, skin reactions– May receive Inderal to reduce cardiac problemsMay receive Inderal to reduce cardiac problems– Teach T,C, & DB; support head, explain about risk for Teach T,C, & DB; support head, explain about risk for

hoarseness and sorenesshoarseness and soreness

THYROIDTHYROID After surgical assess:After surgical assess:

– Vital signsVital signs– Voice-may be hoarse; usually temporaryVoice-may be hoarse; usually temporary– Neuromuscular functioningNeuromuscular functioning– Expect moderate drainage; check back of neckExpect moderate drainage; check back of neck– Respiratory distress- use humidified airRespiratory distress- use humidified air– Laryngeal stridor, paralysis, tetanyLaryngeal stridor, paralysis, tetany– Keep in semi-Fowler’sKeep in semi-Fowler’s– Avoid strain on suture line- avoid neck extensionAvoid strain on suture line- avoid neck extension– Keep emergency drugs:Keep emergency drugs:

O2, suction, trach tray, O2, suction, trach tray, calcium gluconatecalcium gluconate Monitor for transient hypothyroidism, damage to voice, Monitor for transient hypothyroidism, damage to voice,

nerves, hypocalcemia, and tetanynerves, hypocalcemia, and tetany

THYROIDTHYROID

Thyroid stormThyroid storm::– Crisis situation- usually caused by Grave’sCrisis situation- usually caused by Grave’s– Life-threateningLife-threatening– Uncontrolled hyperthyroidismUncontrolled hyperthyroidism– Develops quickly and triggered by stress; over-Develops quickly and triggered by stress; over-

palpation of glandpalpation of gland– Fever, tachycardia, systolic hypertensionFever, tachycardia, systolic hypertension, GI, , GI,

restlessness, confused, psychoticrestlessness, confused, psychotic– Even with treatment, 25% mortality rateEven with treatment, 25% mortality rate

THYROIDTHYROID

Hypothyroidism:Hypothyroidism:– Deficiency in thyroid hormoneDeficiency in thyroid hormone– Leads to low metabolism with build-up of Leads to low metabolism with build-up of

metabolitesmetabolites– Metabolites with water accumulate within cells, Metabolites with water accumulate within cells,

cause edema, called cause edema, called myxedemamyxedema– Myxedema coma: Myxedema coma: rare but can occur; heart rare but can occur; heart

becomes flabby, chambers increase in size, CO becomes flabby, chambers increase in size, CO decreases; life threatening; high mortality ratedecreases; life threatening; high mortality rate

THYROIDTHYROID

3 TYPES:3 TYPES:– HYPOTHYROIDISM:HYPOTHYROIDISM: adult onset; tissue adult onset; tissue

destruction is most probable causedestruction is most probable cause– CRETINISM:CRETINISM:

Profound hypothyroidism in infantsProfound hypothyroidism in infants All developmental aspects are retardedAll developmental aspects are retarded Severe brain damage can occurSevere brain damage can occur If caught early, can prevent retardationIf caught early, can prevent retardation

– JUVENILE HYPOTHYROIDISMJUVENILE HYPOTHYROIDISM:: Begins during childhood, Hashimoto’s disease, Begins during childhood, Hashimoto’s disease,

caused by drugs, autoimmunecaused by drugs, autoimmune Affects growth and sexual maturationAffects growth and sexual maturation

THYROIDTHYROID Assessments:Assessments:

– Changed sleeping habits (increased)Changed sleeping habits (increased)– Lethargy,Lethargy,– HA, wt gainHA, wt gain– Cold intoleranceCold intolerance– DyspneaDyspnea– ConstipationConstipation– MenorrhagiaMenorrhagia– Muscle achesMuscle aches– AnorexiaAnorexia– Lack of expressionLack of expression– Cool, dry, skin, yellow tint, rough, thick, scalyCool, dry, skin, yellow tint, rough, thick, scaly– Dry hair, coarse, lusterlessDry hair, coarse, lusterless– Enlarged tongueEnlarged tongue– Speech slow and deliberate with hoarse voiceSpeech slow and deliberate with hoarse voice– Impotence and infertilityImpotence and infertility– Decreased blood pressure; bradycardia; dysrhythmias; decreased Decreased blood pressure; bradycardia; dysrhythmias; decreased

urinary outputurinary output

THYROIDTHYROID

Diagnostic tests:Diagnostic tests:– Below-normal TBelow-normal T33 & T & T44

– Above-normal TSHAbove-normal TSH– Above-normal TRFAbove-normal TRF– Above-normal creatinine phosphokinaseAbove-normal creatinine phosphokinase– Anemia Anemia

THYROIDTHYROID Interventions:Interventions:

– Requires life-long replacement hormoneRequires life-long replacement hormone– Synthetic usually used TSynthetic usually used T44 (Levothyroid, (Levothyroid,

Synthroid, Noroxine)Synthroid, Noroxine)– Start with lowest dose possible and work way Start with lowest dose possible and work way

up every 1-3 weeksup every 1-3 weeks– With known cardiac problems, always use With known cardiac problems, always use

lowest dose possiblelowest dose possible– TT33 (Cytomel) has more rapid effect. (Cytomel) has more rapid effect.– Euthroid (Liotrix)– combined TEuthroid (Liotrix)– combined T33 & T & T44 – Make sure client knows to continue with meds Make sure client knows to continue with meds

even if he feels bettereven if he feels better– Avoid sedation if possibleAvoid sedation if possible

THYROIDITISTHYROIDITIS Inflammation of thyroidInflammation of thyroid Three types:Three types:

– AcuteAcute: bacterial; pain, malaise, fever, : bacterial; pain, malaise, fever, dysphagia;dysphagia; treat with antibiotics treat with antibiotics

– SubacuteSubacute: viral infection; fever, chills, : viral infection; fever, chills, dysphagia, pain, hard & enlarged gland; treat dysphagia, pain, hard & enlarged gland; treat symptoms; antiviralssymptoms; antivirals

– Chronic:Chronic: (Hashimoto’s)- auto immune, invade (Hashimoto’s)- auto immune, invade thyroid with antibodies and lymphocytes thyroid with antibodies and lymphocytes causing tissue destruction; treat with thyroid causing tissue destruction; treat with thyroid hormonehormone

Administer thyroid hormones; surgery; Administer thyroid hormones; surgery; promote comfort and teachingpromote comfort and teaching

THYROID CANCERTHYROID CANCER

4 types4 types Surgery is treatment- totalSurgery is treatment- total Suppressive doses of thyroid for 3 Suppressive doses of thyroid for 3

months after surgerymonths after surgery Ablation- laser destruction of tissueAblation- laser destruction of tissue chemotherapychemotherapy

PARATHYROIDSPARATHYROIDS Parathyroid hormone corrects calcium deficiency by Parathyroid hormone corrects calcium deficiency by

promoting calcium conservation by kidneys, stimulating promoting calcium conservation by kidneys, stimulating calcium release by bone, enhance calcium absorption from calcium release by bone, enhance calcium absorption from GI, & reduce serum phosphate levels.GI, & reduce serum phosphate levels.

Works on negative feedback controlWorks on negative feedback control In kidneys, causes calcium to be reabsorbed with release of In kidneys, causes calcium to be reabsorbed with release of

phosphorusphosphorus Stimulates kidneys to convert Vit D to a metabolite that Stimulates kidneys to convert Vit D to a metabolite that

allows for PTH to work on boneallows for PTH to work on bone In bone, helps convert osteoblasts to osteoclasts, promoting In bone, helps convert osteoblasts to osteoclasts, promoting

bone breakdown and release of calcium.bone breakdown and release of calcium. Acts on GI to stimulate absorption of calcium (must have Acts on GI to stimulate absorption of calcium (must have

calcitriol). calcitriol). Calcitonin from thyroid causes inhibition of Ca++ release Calcitonin from thyroid causes inhibition of Ca++ release

from bonesfrom bones

PARATHYROIDPARATHYROID

Hyperparathyroidism:Hyperparathyroidism:– Primary:Primary:

Faulty PTH regulation; adenoma, genetics, CA, Faulty PTH regulation; adenoma, genetics, CA, radiation, hyperplasia; occurs more commonly in radiation, hyperplasia; occurs more commonly in women, 35-65women, 35-65

– Secondary:Secondary: Compensatory response to defective homeostasis, Compensatory response to defective homeostasis,

chronic renal failure, malabsorption disorderschronic renal failure, malabsorption disorders

– Tertiary:Tertiary: Compensates for secondary malfunction to primary, Compensates for secondary malfunction to primary,

leading to overgrowth of gland and overproduction leading to overgrowth of gland and overproduction and secretionand secretion


All three lead to increased calcium All three lead to increased calcium and decreased phosphorusand decreased phosphorus

PARATHYROIDPARATHYROID Assessments:Assessments:

– Urine calcium increase and kidneys fail to Urine calcium increase and kidneys fail to concentrate urineconcentrate urine

– Phosphorus excretion increasesPhosphorus excretion increases– Enhances sodium, potassium, amino acids, Enhances sodium, potassium, amino acids,

bicarbonate (acidosis leading to excretion of bicarbonate (acidosis leading to excretion of CaCa++++

– PolyuriaPolyuria– Renal calculiRenal calculi– Bone demineralization (breakdown):Bone demineralization (breakdown):

Bone painBone pain Pathologic fracturesPathologic fractures Cystic bone diseaseCystic bone disease

PARATHYROIDPARATHYROID Other assessments:Other assessments:

– Weakness, wt. loss, fatigueWeakness, wt. loss, fatigue– HA, depressionHA, depression– Renal colic pain, back pain, Renal colic pain, back pain, – Hematuria, renal calculi, cholelithiasisHematuria, renal calculi, cholelithiasis– Anorexia, vomiting, constipationAnorexia, vomiting, constipation– Peptic ulcer (stimulates gastric HCL)Peptic ulcer (stimulates gastric HCL)– Increase heart contractility; decreased automaticityIncrease heart contractility; decreased automaticity– Increased sensitivity to digitalisIncreased sensitivity to digitalis– HypertensionHypertension– Depressed reflexes- hyporeflexiaDepressed reflexes- hyporeflexia– Confusion, irritability, mood swingsConfusion, irritability, mood swings

PARATHYROIDPARATHYROID Diagnostic tests:Diagnostic tests:

– Serum PTH: elevatedSerum PTH: elevated– Calcium: elevated (>10.5mg/dl; 5.2mEq/LCalcium: elevated (>10.5mg/dl; 5.2mEq/L– Kidney stonesKidney stones– Phosphorus: decreasedPhosphorus: decreased– X-rays; CT; MRI: look at bone density and X-rays; CT; MRI: look at bone density and

demineralizationdemineralization– PTH infusion test: (Ellsworth-Howard excretion PTH infusion test: (Ellsworth-Howard excretion

test); give IV PTH, hourly urine samples looking test); give IV PTH, hourly urine samples looking for phosphorusfor phosphorus

– Calcitonin stimulation test: if cancer Calcitonin stimulation test: if cancer suspected; use calcium gluconate suspected; use calcium gluconate

PARATHYROIDPARATHYROID Interventions:Interventions:

– Surgery (usually remove only three)Surgery (usually remove only three)– Stabilize calcium levels prior to surgeryStabilize calcium levels prior to surgery

HemorrhageHemorrhage Laryngeal paralysisLaryngeal paralysis Difficulty swallowingDifficulty swallowing Respiratory distressRespiratory distress Transient hypoparathyroidismTransient hypoparathyroidism TetanyTetany Muscle crampsMuscle cramps Hyperactive tendon reflexesHyperactive tendon reflexes Prolonged QT on EKGProlonged QT on EKG Positive Chvostek’s and Trousseau’s signsPositive Chvostek’s and Trousseau’s signs


– Medical treatment:Medical treatment: Rehydration with isotonic fluidsRehydration with isotonic fluids DiuresisDiuresis MobilizationMobilization Restrict intake of calcium (thyazides and Vit D.Restrict intake of calcium (thyazides and Vit D. Monitor EKGMonitor EKG Drugs:Drugs:

– Phosphates: Neutra-phosPhosphates: Neutra-phos– Calcitonin: IV; IM- decrease release from skeletal areas; Calcitonin: IV; IM- decrease release from skeletal areas;

increased excretion by kidneysincreased excretion by kidneys– Calcium chelators ( bind calcium) Plicamycin: mithramycin; Calcium chelators ( bind calcium) Plicamycin: mithramycin;

cytotoxic agents; watch for thrombocytopeniacytotoxic agents; watch for thrombocytopenia– Steroids: inhibit Vit DSteroids: inhibit Vit D– EstrogenEstrogen– Alpha & beta blockersAlpha & beta blockers– cimetidinecimetidine


HypoparathyroidismHypoparathyroidism– Too little PTH leading to decreased calcium and Too little PTH leading to decreased calcium and

increase phosphorusincrease phosphorus– 3 types3 types

Iatrogenic:Iatrogenic:– Most common, resulting from surgery of neck removing Most common, resulting from surgery of neck removing

glands, radiation, or other traumaglands, radiation, or other trauma Idiopathic: Idiopathic:

– Early onset and late onset; autoimmune; genetic Early onset and late onset; autoimmune; genetic causes of absent glands, pernicious anemia, ovarian causes of absent glands, pernicious anemia, ovarian failurefailure

Functional:Functional:– Long term hypomagnesemia causes this (alcohol, Long term hypomagnesemia causes this (alcohol,

malabsorption)malabsorption)

PARATHYROIDPARATHYROID Assessments:Assessments:

– Neuromuscular problems, increased excitability, tetany, Neuromuscular problems, increased excitability, tetany, muscle cramps, tingling, numbness, hyperreflexiamuscle cramps, tingling, numbness, hyperreflexia

– Tetany leads to anxiety; leads to hyperventilation; leads Tetany leads to anxiety; leads to hyperventilation; leads to hypocapnia and alkalosis, which worsens to hypocapnia and alkalosis, which worsens hypocalcemiahypocalcemia

– Seizures, laryngeal spasmsSeizures, laryngeal spasms– Personality changesPersonality changes– Increased ICPIncreased ICP– Nausea, vomitingNausea, vomiting– Dysrhythmias, decreased contractility, reduced CODysrhythmias, decreased contractility, reduced CO– Cataracts, dry skin, scaly, coarseCataracts, dry skin, scaly, coarse– AlopeciaAlopecia– Bands or pits on teethBands or pits on teeth


Diagnostic tests:Diagnostic tests:– Serum calcium: lowSerum calcium: low– Serum phosphorus: highSerum phosphorus: high– Serum magnesium: normal to lowSerum magnesium: normal to low– Serum PTH: lowSerum PTH: low– Urinary creatinine: lowUrinary creatinine: low– Urinary excretion of calcium: highUrinary excretion of calcium: high– X-ray; MRI; CAT scansX-ray; MRI; CAT scans


– Treatment focuses on preventing tetany and Treatment focuses on preventing tetany and correcting hypocalcemiacorrecting hypocalcemia

IV calcium gluconate or calcium gluconateIV calcium gluconate or calcium gluconate– Do not use saline, promotes calcium and sodium Do not use saline, promotes calcium and sodium

excretionexcretion– Avoid bicarbonate, cause precipitationAvoid bicarbonate, cause precipitation

Vit D and calcium supplementsVit D and calcium supplements– Ergocalciferol (Vit DErgocalciferol (Vit D2 2 ); Rocaltrol; may use combined ); Rocaltrol; may use combined

therapy of oral and IV initiallytherapy of oral and IV initially– Need 1 gram of calcium daily if using Vit DNeed 1 gram of calcium daily if using Vit D– Life-long therapyLife-long therapy– Emergency airway if laryngeal spasms occurEmergency airway if laryngeal spasms occur– Foods high in calcium but low in phosphorus- milk, Foods high in calcium but low in phosphorus- milk,

yogurt, processed cheese.yogurt, processed cheese.

ADRENAL GLANDSADRENAL GLANDS

Widespread effects, confusing clinical Widespread effects, confusing clinical picturepicture

S/S mimic many other disordersS/S mimic many other disorders Survival depends upon prompt Survival depends upon prompt

diagnosis and treatmentdiagnosis and treatment

ADRENAL GLANDSADRENAL GLANDS Cortex secretes glucocorticoids and Cortex secretes glucocorticoids and

mineralocorticoidsmineralocorticoids ACTH from anterior pituitary is controlled by CRFACTH from anterior pituitary is controlled by CRF Other factors controlling release include stress, Other factors controlling release include stress,

circadian rhythmscircadian rhythms ACTH peaks at 6am, Cortisol at 8am; lowest level ACTH peaks at 6am, Cortisol at 8am; lowest level

at midnightat midnight With decreasing cortisol, ACTH is stimulated and With decreasing cortisol, ACTH is stimulated and

releasedreleased Stress prompts release of glucocorticoids to Stress prompts release of glucocorticoids to

promote metabolism of proteins, amino acids, promote metabolism of proteins, amino acids, fatty acids, and glucosefatty acids, and glucose

ADRENAL GLANDSADRENAL GLANDS Mineralocorticoids, aldosterone, is controlled by Mineralocorticoids, aldosterone, is controlled by

renin-agiontension systemrenin-agiontension system Renin is increased by blood volume, blood Renin is increased by blood volume, blood

pressure, and Napressure, and Na++

Renin lead to angiotension II production and Renin lead to angiotension II production and aldosterone formationaldosterone formation

KK+ + & Na& Na++ directly affect aldosterone release directly affect aldosterone release Increased KIncreased K++ increases aldosterone and Na increases aldosterone and Na++

decreases aldosteronedecreases aldosterone Epinephrine and norephinephrine are produced, Epinephrine and norephinephrine are produced,

but because brain produces we can survive but because brain produces we can survive without adrenal medullawithout adrenal medulla

ADRENAL GLANDADRENAL GLAND

Assessments:Assessments:– Most disorders have slow, gradual onset and Most disorders have slow, gradual onset and

progressionprogression– Changes early are subtle, hard to detectChanges early are subtle, hard to detect– Weight changesWeight changes– FatigueFatigue– ApathyApathy– Depressed or neuroticDepressed or neurotic– Worsens with increased stressWorsens with increased stress– Physical appearance may be a cluePhysical appearance may be a clue

ADRENAL GLANDADRENAL GLAND Physical assessment:Physical assessment:

– Responds appropriately, but facial expressions Responds appropriately, but facial expressions do not matchdo not match

– Normal weightNormal weight– Increased secondary sex characteristicsIncreased secondary sex characteristics– Fat distribution abnormalFat distribution abnormal– Poor skin turgorPoor skin turgor– Purplish striae on abdomenPurplish striae on abdomen– Pitting edemaPitting edema– HyperpigmentationHyperpigmentation– Hair distribution is abnormalHair distribution is abnormal– Muscle weaknessMuscle weakness

ADRENAL GLANDSADRENAL GLANDS

Diagnostic tests:Diagnostic tests:– Secreted in minute amounts, therefore Secreted in minute amounts, therefore

most sensitive tests are RAImost sensitive tests are RAI– Remember: if anxious, will affect results Remember: if anxious, will affect results

of some tests of some tests– Samples must be timed!!Samples must be timed!!

ADRENAL GLANDSADRENAL GLANDS Cushing’s syndrome: hypercortisolismCushing’s syndrome: hypercortisolism Cortisol excessCortisol excess Affects more women than menAffects more women than men Primary:Primary:

– Usually a neoplasmUsually a neoplasm Secondary:Secondary:

– Pituitary or hypothalamus disorder causing increased Pituitary or hypothalamus disorder causing increased ACTH; adrenal hyperplasiaACTH; adrenal hyperplasia

Iatrogenic:Iatrogenic:– Excessive use of steroids (prednisone)Excessive use of steroids (prednisone)– Artifically increases cortisol, suppresses ACTH, causing Artifically increases cortisol, suppresses ACTH, causing

adrenal atropyadrenal atropy– S/S are of hyperfunctionS/S are of hyperfunction

ADRENAL GLAND Cushing’sADRENAL GLAND Cushing’s Assessments:Assessments:

– Fatigue, muscle wastingFatigue, muscle wasting– Frequent infections, slow wound healingFrequent infections, slow wound healing– Suppressed immune response ( can mask S/S); kill Suppressed immune response ( can mask S/S); kill

lymphocyteslymphocytes– Truncal obesity, buffalo hump, moon-shaped face, scrawny Truncal obesity, buffalo hump, moon-shaped face, scrawny

arms and legs (PICKLE WITH LEGS)arms and legs (PICKLE WITH LEGS)– Fragile skin, purplish striae on abdomen, buttocks, breasts, Fragile skin, purplish striae on abdomen, buttocks, breasts,

bruisesbruises– Masculinization in women, hirsutism (increased hair growth), Masculinization in women, hirsutism (increased hair growth),

acneacne– HypertensionHypertension– OsteoporosisOsteoporosis– Labile emotionsLabile emotions– Abnormal sleep patternsAbnormal sleep patterns– Nitrogen, carbohydrate, and mineral metabolismNitrogen, carbohydrate, and mineral metabolism– Elevated blood glucoseElevated blood glucose

ADRENAL GLANDS CUSHING’SADRENAL GLANDS CUSHING’S

Diagnostic tests:Diagnostic tests:– Cortisol: high with no circadian variationCortisol: high with no circadian variation– Urinary levels of steroid metabolites: Urinary levels of steroid metabolites:

highhigh– RBC and granulocytes: highRBC and granulocytes: high– X-rays, MRI, CAT scansX-rays, MRI, CAT scans– Dexamethasone suppression test: give 1 Dexamethasone suppression test: give 1

mg at night, test at 8am; high levelmg at night, test at 8am; high level

ADRENAL GLAND CUSHING’SADRENAL GLAND CUSHING’S

Interventions:Interventions:– Treat underlying cause; stop steroidsTreat underlying cause; stop steroids– Remove tumors of pituitary or Remove tumors of pituitary or

adrenalectomy ( uni or bi lateral)adrenalectomy ( uni or bi lateral)– Drugs: Drugs:

Mitotane to inhibit cortisol synthesis ( watch Mitotane to inhibit cortisol synthesis ( watch for adrenal crisis!!for adrenal crisis!!

Cyproheptadine: ACTH inhibitorCyproheptadine: ACTH inhibitorAldactone: mineralocorticoid antagonist to Aldactone: mineralocorticoid antagonist to

relieve hypertension and hypokalemiarelieve hypertension and hypokalemia

ADRENAL GLAND CUSHING’SADRENAL GLAND CUSHING’S

Complications:Complications:– Fluid and e-lyte imbalancesFluid and e-lyte imbalances– Hypertension: NaHypertension: Na++ and water retention and water retention– CHF: excess volume in compromised heartCHF: excess volume in compromised heart– HypokalemiaHypokalemia– Ventricular dysrhythmias: due to CHF and Ventricular dysrhythmias: due to CHF and

hypokalemiahypokalemia– Increased risk for infections & fracturesIncreased risk for infections & fractures– Skin breakdownSkin breakdown

ADRENAL GLAND ADRENAL GLAND INSUFFICIENCY: ADDISON’SINSUFFICIENCY: ADDISON’S

Suppressed adrenocortical function and Suppressed adrenocortical function and hormoneshormones

May precipitate “adrenal crisis”: life-threateningMay precipitate “adrenal crisis”: life-threatening Primary: Primary:

– Addison’s- rare, chronic disorderAddison’s- rare, chronic disorder– 90% gland usually destroyed before symptoms appear90% gland usually destroyed before symptoms appear

Secondary:Secondary:– Reduced ACTH secretion caused by pituitary disease or Reduced ACTH secretion caused by pituitary disease or

exogenous steroid administration; more commonexogenous steroid administration; more common Impairs stress response by reducing cortisol, Impairs stress response by reducing cortisol,

aldosterone, and androgensaldosterone, and androgens

ADRENAL GLAND ADDISON’SADRENAL GLAND ADDISON’S

Assessments:Assessments:– Muscle weakness and fatigue (especially during stress)Muscle weakness and fatigue (especially during stress)– Nausea, vomiting, diarrhea, abdominal painNausea, vomiting, diarrhea, abdominal pain– Salt cravingSalt craving– Anxiety, restlessness, irritability, and confusionAnxiety, restlessness, irritability, and confusion– Orthostatic hypotensionOrthostatic hypotension– HYPOGLYCEMIA & HYPOGLYCEMIA & HYPERKALEMIAHYPERKALEMIA– Hyperpigmentation Hyperpigmentation (ONLY PRIMARY DISEASE HAS (ONLY PRIMARY DISEASE HAS

THIS) THIS) Knees, elbows, nipples, palm creases, scars( bronzed, “dirty Knees, elbows, nipples, palm creases, scars( bronzed, “dirty

tan”)tan”) Small black freckles on neck, face; bluish splotches on Small black freckles on neck, face; bluish splotches on

mucous membranesmucous membranes

ADRENAL GLANDS ADDISON’SADRENAL GLANDS ADDISON’S

Diagnostic tests:Diagnostic tests:– Serum cortisol: lowSerum cortisol: low– Urinary metabolites: lowUrinary metabolites: low– ACTH:ACTH:– ACTH stimulation: elevated cortisol=Addision’s; ACTH stimulation: elevated cortisol=Addision’s;

low cortisol=secondary diseaselow cortisol=secondary disease– HyperkalemiaHyperkalemia– HyponatremiaHyponatremia– HpochloremiaHpochloremia– Fasting hypoglycemiaFasting hypoglycemia– BUN elevated; hematocrit HCT elevatedBUN elevated; hematocrit HCT elevated

ADRENAL GLANDS ADDISON’SADRENAL GLANDS ADDISON’S

Interventions:Interventions:– Lifelong therapy with replacementLifelong therapy with replacement– Drugs:Drugs:

Cortisone: twice daily, increase dose for stressful timesCortisone: twice daily, increase dose for stressful times Florinef: aldosterone replacementFlorinef: aldosterone replacement

– Salt food liberallySalt food liberally– Avoid fastingAvoid fasting– Eat high carbs and proteinsEat high carbs and proteins– Always wear medic alert identificationAlways wear medic alert identification– Carry emergency kit with 100mg hydrocortisone for Carry emergency kit with 100mg hydrocortisone for

injectioninjection– Prevent acute exacerbationsPrevent acute exacerbations– Avoid salt and fluid restriction with diuretics; may lead to Avoid salt and fluid restriction with diuretics; may lead to

crisiscrisis

ADRENAL GLANDS ADRENAL GLANDS

Complications:Complications:– Adrenal crisis: due to insufficiency; can occur Adrenal crisis: due to insufficiency; can occur

gradually or abruptly (acute adrenal gradually or abruptly (acute adrenal insufficiency)insufficiency)

– Potentially lethalPotentially lethal– Occurs in individuals who don’t respond to Occurs in individuals who don’t respond to

therapy; increased stress without increased therapy; increased stress without increased meds; abrupt corticosteroid withdrawalmeds; abrupt corticosteroid withdrawal

– ALWAYS WITHDRAW STEROIDS THERAPY ALWAYS WITHDRAW STEROIDS THERAPY GRADUALLYGRADUALLY

ADRENAL GLANDS ADRENAL ADRENAL GLANDS ADRENAL CRISISCRISIS

Treatment:Treatment:– Restore volume with DRestore volume with D55NSNS

– Be sure to assess fluid status frequentlyBe sure to assess fluid status frequently– Cortisol q 6 hr. (Solu-Cortef IV): if given Cortisol q 6 hr. (Solu-Cortef IV): if given

with saline, proves adequate to replace with saline, proves adequate to replace AldosteroneAldosterone

– Do not give methyleprednisolone (Solu-Do not give methyleprednisolone (Solu-Medrol: lack mineralocorticoid effects)Medrol: lack mineralocorticoid effects)

– Reduce anxietyReduce anxiety

ADRENAL GLANDSADRENAL GLANDSPHEOCHROMOCYTOMAPHEOCHROMOCYTOMA

Rare, benign tumor; arises in medullaRare, benign tumor; arises in medulla Results in hypersecretion of Results in hypersecretion of

epinephrine and norepinephrineepinephrine and norepinephrine Tumors appear more commonly on Tumors appear more commonly on

right side; middle-aged womenright side; middle-aged women Can occur with thyroidal cancer and Can occur with thyroidal cancer and

hyperparathyroidism-Sipple’s hyperparathyroidism-Sipple’s syndromesyndrome

PHEOCHROMOCYTOMAPHEOCHROMOCYTOMA Assessment:Assessment:

– Exaggerated flight or fight reactionExaggerated flight or fight reaction– High blood pressure (Hallmark sign) 200/150High blood pressure (Hallmark sign) 200/150– End-organ damage; CVA, heart disease, kidney End-organ damage; CVA, heart disease, kidney

damagedamage– Orthostatic hypotensionOrthostatic hypotension– Attack occurs with sporadic release of Attack occurs with sporadic release of

catecholaminescatecholamines– Pounding heart beat, deep breathing, HAPounding heart beat, deep breathing, HA– Peripheral vasoconstrictionPeripheral vasoconstriction– HyperglycemiaHyperglycemia– anxietyanxiety

PHEOCHROMOCYTOMAPHEOCHROMOCYTOMA

Attacks may occur frequently or Attacks may occur frequently or seldomseldom

May last minutes to hoursMay last minutes to hours May result from exercise, lifting, May result from exercise, lifting,

emotional distress, exposure to cold, emotional distress, exposure to cold, food, alcohol, sex, etc.food, alcohol, sex, etc.


Diagnostic tests:Diagnostic tests:– Must rule out all other disordersMust rule out all other disorders– HyperglycemiaHyperglycemia– Elevated hematocritElevated hematocrit– 242400 urine for catecholamines and their urine for catecholamines and their

metabolites (metanephrine(catecholamine) is metabolites (metanephrine(catecholamine) is more conclusive than vanillylmandelic more conclusive than vanillylmandelic acid(epinephrine)acid(epinephrine)

– EKG changesEKG changes– CAT scan shows tumorCAT scan shows tumor– Diagnostic tests may precipitate a Diagnostic tests may precipitate a

crisis!!!crisis!!!

PHEOCHROMOCYTOMAPHEOCHROMOCYTOMA Interventions:Interventions:

– Surgical removalSurgical removal– Prior to surgery, drugs to reduce the excessive Prior to surgery, drugs to reduce the excessive

adrenergic action (2 weeks)adrenergic action (2 weeks)– Receive plasma volume expandersReceive plasma volume expanders– During surgery, receive Regitine, alpha-adrenergic During surgery, receive Regitine, alpha-adrenergic

blocker to prevent hypertensive crisisblocker to prevent hypertensive crisis– If unable to have surgery, may order drug, Demser, If unable to have surgery, may order drug, Demser,

inhibits an enzyme promoting norepinephrine synthesisinhibits an enzyme promoting norepinephrine synthesis– Avoid drugs like opiates, histamines, OTC cold Avoid drugs like opiates, histamines, OTC cold

medicationsmedications– During attack, maintain bedrest, HOB elevated to at 30During attack, maintain bedrest, HOB elevated to at 3000

to reduce orthostatic hypotensionto reduce orthostatic hypotension


Complications:Complications:– Severe hypotensionSevere hypotension– CVACVA– Heart problemsHeart problems– If left untreated, always leads to If left untreated, always leads to

deathdeath

ALDOSTERONISMALDOSTERONISM

Excessive secretion of mineralocorticoids, Excessive secretion of mineralocorticoids, especially aldosteroneespecially aldosterone

Primary: Primary: – Called Conn’s syndrome, usually benign Called Conn’s syndrome, usually benign

Aldosterone producing adenomaAldosterone producing adenoma Secondary:Secondary:

– Excess renin-angiotension stimulation; Excess renin-angiotension stimulation; stimulation occurs with conditions involving stimulation occurs with conditions involving low circulating blood volume: pregnancy, low circulating blood volume: pregnancy, hypvolemia, CHF, cirrhosis, oral contraceptives, hypvolemia, CHF, cirrhosis, oral contraceptives, chronic renal failurechronic renal failure


Assessment:Assessment:– Sodium and water retention, increased Sodium and water retention, increased

fluid volume, hypertensionfluid volume, hypertension– HA, visual disturbancesHA, visual disturbances– HypokalemiaHypokalemia– Metabolic alkalosis: finger tingling and Metabolic alkalosis: finger tingling and

paresthesiaparesthesia– Increased urine outputIncreased urine output


Diagnostic tests:Diagnostic tests:– Decreased potassiumDecreased potassium– Elevated aldosteroneElevated aldosterone– Urinary potassium elevated >30mEq/LUrinary potassium elevated >30mEq/L– X-rays, CAT scans, MRIX-rays, CAT scans, MRI


Interventions:Interventions:– Reduce B/P, correct hypokalemiaReduce B/P, correct hypokalemia– Surgical removal of tumorSurgical removal of tumor– Administer AldactoneAdminister Aldactone– Potassium supplementsPotassium supplements– Sodium restrictionSodium restriction


Complications:Complications:– Hypertension and hypokalemia possibly Hypertension and hypokalemia possibly

leading to neurologic impairmentleading to neurologic impairment– CHFCHF– Lethal dysrhythmiasLethal dysrhythmias– Profound muscle weaknessProfound muscle weakness

endocrine system. thyroid gland thyroid hormones affect nearly all body tissues dysfunctions cause...

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