1.endocrine System

3/17/2021 Pramila Baral,Smarts Brain Academy 1

Pramila Baral
Lecturer
Adult Nursing (Medical Surgical
Nursing)
SMARTS BRAIN ACADEMY
AREAS I AM GOING TO DEAL
- Endocrine system disorders

- Nervous system disorders
- Cardiovascular system disorders
- Emergency nursing
- MCQ practice of related areas

- BONUS:
Past questions (CEE based MN

entrance,2077) of all subject based on
student’s memory

Date: 2077/12/04 Time: 08:00 to 10:00
Pm
CONTENTS TO DISCUSS TODAY
(Medical Surgical Nursing)
ENDOCRINE DISORDERS
- Endocrine system overview
- Pituitary gland disorders
 Diabetes Insipidus
 Syndrome of inappropriate antidiuretic
hormone
- Thyroid gland disorders
 Hypothyroidism
 Hyperthyroidism

LETS GET STARTED!!!!!!!!

Q.1 The gland that have ducts
are…………gland

Q2. Thyroid stimulating hormone is
produced by
a. Thyroid gland
b. Pituitary gland
c. Hypothalamus
d. Parathyroid gland

Q3. Which of the following gland is
responsible for regulating
immunologic process
a. Pineal gland
b. Thymus
c. Pancreas
d. Thyroid gland

• Exocrine glands – Nonhormonal
substances (sweat, saliva) – Have
ducts to carry secretion to membrane
surface
• Endocrine glands – Produce hormones –

Lack ducts
• [once secreted hormones remains in

body for 4-6 hrs]

• Hormones have specific cellular
targets (target cells).

Endocrine glands

Other Hormone-producing Structures
• Heart – Atrial natriuretic peptide (ANP)

decreases blood Na+ concentration,
therefore blood pressure and blood volume
• Kidneys
– Erythropoietin signals production of red
blood cells
– Renin initiates the renin-angiotensin
aldosterone mechanism
- calcitriol: kidney hormone ; increases
calcium in the blood.
Renin Angiotensin Aldosterone System

Your EFFORT To Review the glands and
their functions
• Thymus:
Mediastinum behind the sternum

Thymosine: T cell maturation
Regulates immunologic process
Atrophies after puberty
• Pineal gland:
 Behind the 3rd ventricle
 Melatonin
 Regulate– sleep awake cycle

Hypothalamus
• CRH
• TRH
• GHRH
• GnRH
• Somatostatin: inhibit growth hormone
and TSH

Control set up via negative feedback systems:
When hormone concentration increases;
further production
3/17/2021
is inhibited and viceversa 18
Pramila Baral,Smarts Brain Academy
• GH
• Hypersecretion: children: gigantism; adult:
acromegaly
• Hypo:
- Dwarfism
- Stunted growth
- Immature facial feature and voice
• Prolactin
Hyper: galactorrhea
- females: amenorrhea
- Male: hypogonadism
Hypo: Postpartum lactation failure
– ACTH:
Excess
- cushing’s syndrome
Low
- Addison’s disease
– TSH
Excess
- Hyperthyroidism
Low
- s/s of secondary Hypothyroidism

Posterior pituitary
• ADH
• Oxytocin

Q4. Diabetes Insipidus is the
disorder of:
a. Anterior pituitary
b. Posterior pituitary
c. Adrenal gland
d. Intermediate pituitary

Q5. Diabetes insipidus is due to
deficiency of……………………..hormone.

Q6. Which outcome indicates that
treatment of a male client with
diabetes insipidus has been
effective?
a. Fluid intake is less than 2,500 ml/day
b. Urine output measures more than 200
ml/hour
c. Blood pressure is 90/50 mm Hg
d. The heart rate is 126 beats/minute
Ans a
Q7. When caring for a male client
with diabetes insipidus, nurse
expects to administer:
a. vasopressin (Pitressin Synthetic)

b. furosemide (Lasix)
c. regular insulin
d. 10% dextrose
Ans a
C/M
• Marked polyuria: daily output 3-20L of
dilute urine
• Polydipsia: intense thirst : 2-20L of fluid
daily, has craving for cold water
• Water like urine
• Urine specific gravity: 1.001-1.005
• Urine osmolality: 50-200 mosm/kg

C/M contd..
• Serum osmolality : (greater than 300
mOsm/kg
• Serum sodium: greater than 147 mEq/L
The high volume fluid loss continues
despite fluid deprivation.

C/M contd..
[Specific gravity (SG) <1.008 is dilute and
>1.020 is concentrated]
[Random urine osmolality should average

300-900 mOsm/kg of water]
The reference range of serum osmolality is

275–295 mosm/kg (mmol/kg).

Assessment
• Water deprivation test (Miller-

moses test):
- If serum osmolality rises to >305
mmol/kg

Management
• The primary treatment: drinking enough
liquid to prevent dehydration.
Pharmacologic
• Desmopressin (drug of choice):
- Synthetic analogue of ADH with potent
antidiuretic activity but no vasopressor
activity.
• Synthetic Vasopressin :
- Vasopressor and ADH activity

TREATMENT contd..
- It increases water resorption at collecting

ducts (ADH effect)
- At high doses, promotes smooth muscle

contraction throughout the vascular bed of
renal tubular epithelium (vasopressor
effects)

Major nursing focus
• Measure I/O and weight
• Hemodynamic status
• Provide patient with ample water to drink
and IV fluids as directed
• Monitor serum and urine osmolality
regularly
• Watch for dehydration and overhydration
• Eliminate coffee and tea: diuretic effect
• Advise to avoid limiting fluid

Lets recall!!
Q8. Diabetes Insipidus is the disorder
of:
a. Anterior pituitary
b. Posterior pituitary
c. Adrenal gland
d. Intermediate pituitary

Q9. Diabetes insipidus is due to
deficiency of……………………..hormone.

Q10. Which outcome indicates that
treatment of a male client with
diabetes insipidus has been
effective?
a. Fluid intake is less than 2,500 ml/day
b. Urine output measures more than 200
ml/hour
c. Blood pressure is 90/50 mm Hg
d. The heart rate is 126 beats/minute
Ans a
Q11. When caring for a male client
with diabetes insipidus, nurse
expects to administer:
a. vasopressin (Pitressin Synthetic)

b. furosemide (Lasix)
c. regular insulin
d. 10% dextrose
Ans a
NURSING MANAGEMENT contd..

BONUS QUESTION
Q12.What to assess after

bronchoscopy? (2071)
Q13. Most Important intracellular

cation?

CEE ,MN,2077
Q14. A patient is undergoing
pulmonary function test. The client
is instructed to breathe normally.
This measures which of the
following?
a. Tidal volume
b. Vital capacity
c. Expiratory reserve volume
d. Inspiratory reserve volume
SYNDROME OF INAPPROPRIATE
ANTIDIURETIC HORMONE

Q15. A male client is admitted for
treatment of the syndrome of
inappropriate antidiuretic hormone
(SIADH). Which nursing intervention is
appropriate?
a. Infusing I.V. fluids rapidly as ordered

b. Encouraging increased oral intake
c. Restricting fluids
d. Administering glucose-containing I.V. fluids
as ordered
Ans c

SIADH
• Antidiuretic hormone (ADH) is produced

by the hypothalamus.
• The hormone is stored in and released

by the pituitary gland.
• ADH controls the mechanism of water

release and conservation.
• SIADH is characterized by excessive
release of antidiuretic hormone
• even in the face of subnormal serum
osmolarity
• water retention and dilutional hyponatrae
mia.

SIADH
• Patient cannot dilute urine
• Often non endocrine origin
• Reduced serum osmolality
• Increased urine osmolality
 Hyponatremia (ie, serum Na+< 135
mmol/L) with concomitant hypo-
osmolality (serum osmolality < 280
mOsm/kg) and high urine osmolality.
Hallmark of SIADH
Drugs
– Demeclocycline can be used in chronic

situations when fluid restrictions are
difficult to maintain; demeclocycline is the
most potent inhibitor of Vasopressin
(ADH/AVP) action.

Surgical management
- If ADH is coming from the ectopic tumor
production, treatment will be aimed at
eliminating the tumor.
Radiotherapy, chemotherapy for malignancy

Q16. A male client is admitted
for treatment of the syndrome
of inappropriate antidiuretic
hormone (SIADH). Which nursing
intervention is appropriate?
a. Infusing I.V. fluids rapidly as

ordered
b. Encouraging increased oral intake
c. Restricting fluids
d. Administering glucose-containing
I.V. fluids as ordered
HYPOTHYROIDISM

 The primary function of the thyroid
is production of the hormones
triiodothyroxine(T3), thyroxine(T4)
and calcitonin (lower blood calcium
and phosphate level)

 The thyroid gland uses iodine (mostly
available from the foods such as
seafood, bread, and salt) to produce
thyroid hormones.
 However, the hormone with the most

biological activity is T3.

REGULATION OF THYROID HORMONE
• The hypothalamus senses low

circulating levels of thyroid
hormone(T3 and T4) and responds by
releasing thyrotropin- releasing
hormone (TRH).
• The TRH stimulates the pituitary to

produce thyroid-stimulating hormone
(TSH).
Q17. In hypothyroidism:
a. T3 is raised, T4 is raised, TSH is raised
b. T3 is reduced, T4 is raised, TSH is
reduced
c. T3 is reduced, T4 is reduced, TSH is
raised
d. T3 is raised, T4 is reduced, TSH is
raised
Ans c

HYPOTHYROIDISM
• Suboptimal levels of thyroid hormone
• Can affect all body functions and can
range from mild, subclinical form to
myxedema an advanced form
• If present at birth: cretinism
• F:M- 10:1

HYPOTHYROIDISM contd..
• Most common cause: autoimmune
thyroiditis ( Hashimotos disease); US
and other areas of adequate iodine
intake
• Worldwide: iodine deficiency remains

foremost cause

Types
• Primary, secondary and tertiary

Primary Hypothyroidism
Primary: dysfunction of the thyroid

gland.
TH level is low and TSH levels are

elevated, indicating to that the pituitary
is attempting to stimulate the secretion
of thyroid hormones but the thyroid is
not responding.
Types
Primary Hypothyroidism contd..
This is the most common form of primary

autoimmunine hypothyroidism known as
Hashimoto’s disease(named after Dr.
Hakaru Hashimoto who described it in
1912).

Contd….
Secondary or Pituitary Hypothyroidism
Due to malfunction of the pituitary gland.
Caused by pituitary injury either during surgery

of the brain or other reason.
Insufficient stimulation of a normal thyroid gland,

resulting in decreased TSH levels.
When this occurs both TSH and TH levels are

low in the serum.

Contd….
Tertiary or Hypothalamic Hypothyroidism
It is due to a disorder of the hypothalamus

resulting in inadequate secretion of thyroid
stimulating hormone from decreased stimulation
by thyrotropin releasing hormone(TRH).
It may be due to a tumor or other destructive

lesion in the hypothalamic region. When this
occurs, both TSH and TH levels are again low in
the serum.

Contd….
Subclinical Hypothyroidism
Subclinical hypothyroidism refers to a state in
which patients do not exhibit the symptoms of
hypothyroidism.
These patient also have a normal amount of

circulating thyroid hormone.
The only abnormality is an increased TSH in

their blood or increased TSH but normal or low
T4 level.

Contd….
This implies that the pituitary gland is working

extra hard to maintain a normal circulating
thyroid hormone level and that the thyroid gland
requires extra stimulation by the pituitary to
produce adequate hormones.

Contd….
The majority of these patients can be

expected to progress to obvious hypothyroidism,
especially if the TSH is above a certain level.
Manifestation resembles those of mild
hypothyroidism with subtle(slight) cardiac
defects.

Cause
• Atrophy
• Therapy for hyperthyroidism
• Thyroidectomy
• Radiation to neck, head
• Medications: lithium, iodine compounds
• Iodine deficiency and excess

Cause contd..
• The Wolff–Chaikoff effect
- autoregulatory phenomenon
- inhibits the formation of thyroid
hormones inside the thyroid follicle,
and the release of thyroid hormones
into the bloodstream.
- This becomes evident secondary to
elevated levels of circulating iodide.

Q18.Nurse should expect a client with
hypothyroidism to report which
health concerns?
a. Increased appetite and weight loss

b. Puffiness of the face and hands
c. Nervousness and tremors
d. Thyroid gland swelling
Ans b
Hypothyroidism (myxedema) causes
facial puffiness, extremity edema, and
weight gain.

• Decreased level of thyroid hormones
leads to
Overall slowing of BMR

Decreased HCL secretion and GI motility
Bradycardia
Slowed neurologic functioning
Decrease heat production
Increase in serum cholesterol and
triglyceride level
Increase atherosclerosis and CAD
Anemia

S/S : Early
• Fatigue
• Sadness
• Weight gain
• Cold intolerance
• Excessive sleepiness
• Dry coarse hair
• Amenorrhea
• Dry skin

Late
• Hoarseness
• Thickening of skin
• Puffy face, hands and feet
• Bradycardia
• Weight gain even without increase in
intake
• Slow speech
• Masklike face
• Dull mental process
Myxedema coma
• Severe form
• Hypothermic
• Unconscoius
• Stupor
• Coma
• [Cause: undiagnosed hypothyroidism,

precipitated by infection or disease, opoid
analgesics]

Management
• Synthetic levothyroxine
• External heat application avoid: this
increase oxygen demand and lead to
vascular collapse
• Protect from exposure to cold
• Concentrated glucose may be given if
hypoglycemia is evident

Q19. For the first 72 hours after
thyroidectomy surgery, nurse would
assess the female client for
Chvostek’s sign and Trousseau’s sign
because they indicate which of the
following?
a. Hypocalcemia
b. Hypercalcemia
c. Hypokalemia
d. Hyperkalemia
• The client who has undergone a
thyroidectomy is at risk for developing
hypocalcemia from inadvertent removal or
damage to the parathyroid gland.
• The client with hypocalcemia will exhibit a

positive Chvostek’s sign (facial muscle
contraction when the facial nerve in front
of the ear is tapped) and a positive
Trousseau’s sign (carpal spasm when a
blood pressure cuff is inflated for a few
minutes).

Q20. An incoherent female client with a history of
hypothyroidism is brought to the emergency
department. Physical and laboratory findings reveal
hypothermia, hypoventilation, respiratory acidosis,
bradycardia, hypotension, and nonpitting edema of
the face and pretibial area. Knowing that these
findings suggest severe hypothyroidism, nurse
prepares to take emergency action to prevent the
potential complication of:
a. Thyroid storm.
b. Cretinism.
c. Myxedema coma.
d. Hashimoto’s thyroiditis.

• Severe hypothyroidism may result in
myxedema coma, in which a drastic drop
in the metabolic rate causes decreased
vital signs, hypoventilation (possibly
leading to respiratory acidosis), and
nonpitting edema.

• Thyroid storm is an acute complication of
hyperthyroidism.
• Cretinism is a form of hypothyroidism

that occurs in infants. Hashimoto’s
thyroiditis is a common chronic
inflammatory disease of the thyroid gland
in which autoimmune factors play a
prominent role.

Q21. A female client with
hypothyroidism (myxedema) is
receiving levothyroxine (Synthroid),
25 mcg P.O. daily. Which finding
should nurse recognize as an adverse
effect of drug?
a. Dysuria
b. Leg cramps
c. Tachycardia
d. Blurred vision
Q22. Early this morning, a female client
had a subtotal thyroidectomy. During
evening rounds, nurse assesses the
client, who now has nausea, a
temperature of 105° F (40.5° C),
tachycardia, and extreme restlessness.
What is the most likely cause of these
signs?
a. Diabetic ketoacidosis
b. Thyroid crisis
c. Hypoglycemia
d. Tetany
.
• Thyroid crisis/thyroid storm usually
occurs in the first 12 hours after
thyroidectomy and causes exaggerated
signs of hyperthyroidism, such as high
fever, tachycardia, and extreme
restlessness.

• Diabetic ketoacidosis is more likely to
produce polyuria, polydipsia, and
polyphagia; hypoglycemia, to produce
weakness, tremors, profuse perspiration,
and hunger.
• Tetany typically causes uncontrollable

muscle spasms, stridor, cyanosis, and
possibly asphyxia

Q.23 Heat intolerance, excessive
perspiration and exopthalmus are
the features of
a. Hyperthyrodism
b. Hypothyroidism
c. Hyperparathyroidism
d. Hypoparathyroidism
Ans a

Hyperthyroidism
• Over secretion of thyroid hormones

associated with enlarged thyroid gland
• Goiter
• 2nd common endocrine disease after DM
• Graves disease most common type of
hyperthyroidism
• Women: 8 times more common than men

Management
• Antithyroid agents: propylthiouracil,
sodium iodide
• Propanolol
• Radioactive iodine
• Surgery

Focus after thyroidectomy
• Patent airway: 1st priority
• Tracheostomy set: bedside
• Semi fowlers position
• Assess for Tetany
• Assess for laryngeal nerve damage:
ask patient to speak

Review
• Myxedema Coma
• Cretinism
• Thyroid crisis
• Features of hypothyroidism and
hyperthyroidism

Q 24. For the first 72 hours after
thyroidectomy surgery, the patient
is at the risk of development of
a. Hypocalcemia
b. Hypercalcemia
c. Hypokalemia
d. Hyperkalemia
Ans a

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3/17/2021 Pramila Baral,Smarts Brain Academy 1

3/17/2021 Pramila Baral,Smarts Brain Academy 2

- Endocrine system disorders

3/17/2021 Pramila Baral,Smarts Brain Academy 4

Past questions (CEE based MN

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3/17/2021 Pramila Baral,Smarts Brain Academy 6

3/17/2021 Pramila Baral,Smarts Brain Academy 7

3/17/2021 Pramila Baral,Smarts Brain Academy 8

3/17/2021 Pramila Baral,Smarts Brain Academy 9

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• Endocrine glands – Produce hormones –

• [once secreted hormones remains in

3/17/2021 Pramila Baral,Smarts Brain Academy 11

3/17/2021 Pramila Baral,Smarts Brain Academy 12

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• Heart – Atrial natriuretic peptide (ANP)

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Mediastinum behind the sternum

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a. vasopressin (Pitressin Synthetic)

3/17/2021 Pramila Baral,Smarts Brain Academy 27

3/17/2021 Pramila Baral,Smarts Brain Academy 28

[Random urine osmolality should average

The reference range of serum osmolality is

3/17/2021 Pramila Baral,Smarts Brain Academy 29

• Water deprivation test (Miller-

3/17/2021 Pramila Baral,Smarts Brain Academy 30

3/17/2021 Pramila Baral,Smarts Brain Academy 31

- It increases water resorption at collecting

- At high doses, promotes smooth muscle

3/17/2021 Pramila Baral,Smarts Brain Academy 32

3/17/2021 Pramila Baral,Smarts Brain Academy 33

3/17/2021 Pramila Baral,Smarts Brain Academy 34

3/17/2021 Pramila Baral,Smarts Brain Academy 35

a. vasopressin (Pitressin Synthetic)

3/17/2021 Pramila Baral,Smarts Brain Academy 38

Q12.What to assess after

Q13. Most Important intracellular

3/17/2021 Pramila Baral,Smarts Brain Academy 39

3/17/2021 Pramila Baral,Smarts Brain Academy 41

a. Infusing I.V. fluids rapidly as ordered

3/17/2021 Pramila Baral,Smarts Brain Academy 42

• Antidiuretic hormone (ADH) is produced

• The hormone is stored in and released

• ADH controls the mechanism of water

3/17/2021 Pramila Baral,Smarts Brain Academy 44

– Demeclocycline can be used in chronic

3/17/2021 Pramila Baral,Smarts Brain Academy 46

Radiotherapy, chemotherapy for malignancy

3/17/2021 Pramila Baral,Smarts Brain Academy 47

a. Infusing I.V. fluids rapidly as