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7endocrine System Disorders
7endocrine System Disorders
7endocrine System Disorders
DISORDERS OF THE
ENDOCRINE SYSTEM
02/28/2023
Anatomy and physiology
2
Insulin
is one of the polypeptide hormones.
it is a powerful hypoglycemic agent i.e.it acts to lower
blood glucose level by promoting the passage of glucose
in to cells.
it is the only hormone in the body that decreases blood
glucose level.
Plays a key role in the metabolism of CHO, fat & protein
It is an anabolic (storage) hormone.
Medical Surgical Nursing by Selamu Amanuel 02/28/2023
Function of Insulin
9
Antagonists of insulin.
Epinephrine
Corticosteroid
Growth hormone
Glucagon
Glucagon
Is a potent hyperglycemic agent which rises blood sugar by
promoting the conversion of glycogen [the principal form
in which CHO are stored] to glucose with in the liver.
Medical Surgical Nursing by Selamu Amanuel 02/28/2023
Pituitary gland
14
Regulation of TH
The secretion of T3 and T4 by the thyroid gland is
controlled by TSH or thyrotropin. It controls the
release of thyroid hormone. In turn the level of TH
in the blood determines the release of TSH.
If thyroid hormone concentration in the blood
decreases, the release of TSH increases which
causes increased out put of T3 and T4. This is an
example of negative feed back.
Function of T3 and T4
The primary function of the thyroid hormone is to
control the cellular metabolic activity.
T4, a relatively weak hormone, maintains body
metabolism in a steady state.
T3 is about 5 times as potent as T4 and has a more rapid
metabolic action.
The THs, influences cell replication and are important in
brain development.
TH is also necessary for normal growth
Medical Surgical Nursing by Selamu Amanuel 02/28/2023
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CALCITONIN (THYROCALCITONIN)
It is secreted in response to high plasma levels of
calcium, and it reduces the plasma level of Ca++
by increasing its deposition in bone.
PARATHORMONE
It is the protein hormone from the parathyroid glands
regulates calcium and Phosphorus metabolism.
Increased secretion of parathormone results in
increased ca absorption from the kidney, intestine, &
bones there by raising the blood ca++ level.
Excess Parathormone can result in markedly elevated
levels of serum ca++ a potentially life threatening
situations
28
Adrenal medulla
Function as part of the ANS
Stimulation of preganglionic sympathetic nerve
fibers, which travel directly to the cells of the
adrenal medulla, causes release of the
catecholamine hormones i.e. Epinephrine and
Nor epinephrine
About 90% the secretion of the human adrenal
medulla is epinephrine (also called adrenaline).
Medical Surgical Nursing by Selamu Amanuel 02/28/2023
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Adrenal cortex
The three types of steroid hormones produced by
the adrenal cortex are:-
Glucocorticoids, the prototype of which is
hydrocortisone
Mineralocorticoids, mainly aldosterone and
Androgens, sex hormone (male)
Glucocorticoids
Are so named because they have an important influence on
glucose metabolism.
Increased hydrocortisone secretion results in elevated blood
glucose levels. How ever, the Glucocorticoids has major
effects on the metabolism of almost all organs of the body.
The presence of Glucocorticoids in the blood inhibits the
release of corticotropin-releasing factor from the
hypothamlus and also inhibits ACTH secretion from the
pituitary.
Mineralocorticoids
Exert their major effects on electrolyte metabolism.
They act principally on the renal tubular and GI
epithelium to cause increased Na+ ion absorption
in exchange for excretion of K+ and OH-.
ACTH only minimally influences aldosterone
secretion.
It is primarily secreted in response to the presence
of Angiotensin II in the blood stream.
Medical Surgical Nursing by Selamu Amanuel 02/28/2023
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41
urine
A) Blood Tests
1. Fasting blood sugar (FBS)
2. Random Blood sugar(RBS)
3. Oral Glucose tolerance test (OGTT)
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B ) Urine tests
Applying urine to a reagent strip or tablet matching colors
+ve result)
Does not indicate hypoglycemia
65
The aim of Rx of DM
to control the patients symptoms & maintain a sense of well
being
to normalize insulin activity and achieve normal blood glucose
level (euglycemia) with out hypoglycemia
To maintain normal weight in adult & normal growth &
development in children
To prevent acute metabolic complications such as ketoacidosis,
hypoglycemia.
To prevent or deter the long-term complications of DM.
Medical Surgical Nursing by Selamu Amanuel 02/28/2023
Cont--
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Aim
to control total calorie intake
to attain /maintain a reasonable body weight
to control blood glucose levels
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73
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Aim:
to reduce the blood glucose level
to improve insulin utilization
to improve circulation & muscle tone as well as to
decrease weight
79
Exercise recommendations
People with diabetes should exercise at the same time
(preferably when blood glucose levels are at their peak) and in
the same amount each day
Regular daily exercise, rather than sporadic exercise should be
encouraged
In general, a slow, gradual increase in the exercise periods is
encouraged
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85
Insulin therapy
Because the body loses the ability to produce insulin in type
1 diabetes, exogenous insulin must be administered for life.
In type 2 diabetes, insulin may be necessary on a long term
basis to control glucose level if diet and oral agents fail.
In addition, some patients in whom type 2 diabetes is usually
controlled by diet alone or by diet and an oral hypoglycemic
agent may require insulin temporarily during illness,
infection, pregnancy, surgery, or some other stressful event.
89
short acing / semilente clear cloudy 1/2 -1 2-4hr 6-8 hr All insulin
preparations
concentration
Insulin dosage is always prescribed in units
All type of insulin are prepared in 10 ml vials w/h contain either 40,
80 or 100U/ml
e.g. U-100 means there is 100 units of insulin per 1 ml and U-80
insulin is 2x as concentrated as U-40 insulin
species /sources
Insulin is obtained from beef/cow pig/pork's pancreas & from human.
Human insulin is now widely available
Human insulin preparations have a shorter duration of action than
insulin from animal sources
Medical Surgical Nursing by Selamu Amanuel 02/28/2023
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91
Insulin syringes
Insulin syringes must match with insulin
concentration in the vial.
Most insulin syringes have 27 to 29 gauge needle
that is approximately 1/2 inch in the length.
Currently, three size of insulin needle are available -
1 ml/cc syringe- hold 100U.
1/2 ml/cc syringe hold 50 U
3/10 ml/cc syringe hold 30 U
Medical Surgical Nursing by Selamu Amanuel 02/28/2023
Fig. insulin syringes
92
N.B:
Don't shake insulin but roll b/n hands.
Don't administer cold (extremely freezed) insulin
In mixing regular insulin with long acting insulin, first draw the
regular insulin in order not to contaminate the regular insulin
(1st from the cloudy vial & then from the clear vial)
Don't give insulin to NPO patient
Always check the label on the insulin bottle the appearance of
insulin (color)
Prepare insulin at room temperature don't allow insulin to
freeze extreme To
Medical Surgical Nursing by Selamu Amanuel 02/28/2023
Complications of Insulin Therapy
100
B) Insulin Lipodystrophy
Lipodystrophy refers to a localized disturbances of
fat metabolism.
It may be lipoatrophy or lipohypertrophy.
C) Insulin Resistance
~ is need of more insulin for the control of diabetes
caused by
Specific insulin antagonists with in blood
insulin
Obesity
- over exercise
E) Hyperglycemia - occurs when the blood glucose
concentration is too high (> 180 mg/dl).
106
A) Sulfonylureas
Stimulate the release of insulin from the β- cells of the
pancreas, also reduce the glucose output from the liver &
improve insulin sensitivity.
Examples
B) Biguanides
Inhibit gluconeogenesis there by leading to lowered
111
The overall overview of education in DM patient’s has a
broad ,generally it includes
Teaching patients to self-administer insulin
Routes of insulin administration
Systematic rotation of injection sites
Avoid use of alcohol to cleanse the skin
How to keep the foot clean, wear shoe
To have diabetic ID card or bracelet
Signs of hypoglycemia
About diet , medication and exercises
The natures of the diseases etc
Medical Surgical Nursing by Selamu Amanuel 02/28/2023
Complications of Diabetes
112
A) Acute complication
There are three major acute complication of
diabetes related to short-term imbalance in blood
glucose levels.
Includes
Hypoglycemia [insulin reaction/ insulin shock]
Diabetic ketoacidosis [DKA]
Hyperglycemia hyperosmolar non ketotic coma
[HHNK]
Medical Surgical Nursing by Selamu Amanuel 02/28/2023
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1) Hypoglycemia
When blood glucose level falls below 50-60 mg/dl
metabolism.
Cause
Three main causes of DKA are
A decrease or missed dose of insulin /insulin
withdrawal
An illness or infection such as skin , UTI, lung etc
The initial manifestation of undiagnosed &
untreated diabetes
C/M
The three main problems /clinical features of DKA
are
Dehydration
Electrolyte loss
Acidosis
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LAB-VALUES
Blood glucose level from 300mg -800 mg/dl (may be
lower or higher)
Low serum bicarbonate 0-15 meg/L
Low pH (6.8-7.3) low Pco2 (10-30 mm Hg)
Na & K levels may be low, normal or high depending on
the amount of water loss (dehydration).
Elevated creatinine.
123
MANAGEMENT OF DHN
a patient may need up to 6-10 liters of IV fluid to replace the
fluid loss.
Initially 0.9% Ns is administered at a high rate of 0.5 -1 lit/hr
for 2-3hrs (0.45% Ns may be used for HTN, CH for
hypernatremia)
0.45 % Ns is fluid of choice after the 1st few hours provided
that BP is stable & sodium level is not low
Monitor fluid volume status intake & out put . Initial urine out
put will lag behind IV fluid intake due to DHN.
Medical Surgical Nursing by Selamu Amanuel 02/28/2023
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MANAGEMENT OF ACIDOSIS
Infuse insulin at slow continuous rate e.g. 5u/hr.
Monitor blood glucose values hourly
Add dextrose to IV when blood glucose reaches 250-300
mg/dl to avoid too rapid drop in blood glucose
insulin must be infused continuously until SC
administration of insulin is resumed.
Iv insulin must be continued until the serum bicarbonate
improves & patient can eat.
Medical Surgical Nursing by Selamu Amanuel 02/28/2023
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Clinical Manifestation
polyuria & polydipsia for days to weeks
weight loss
hypotension, tachycardia
profound DHN ( dry mucus membranes, poor skin turgor)
altered mental status (confusion lethargy or coma)
Management
similar to DKA
fluid replacement
Correction of electrolyte imbalances
Insulin administration to prevent hyperglycemia
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DKA HHNK
Age All ages Usually over 50 years
Duration of DM Variable Recent onset
Precipitating factors Infection. Stress Infection, steroids. Diuretics
Mortality 5% 50%
Acute complication
Hypoglycemia
DKA
HHNS
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137
139
It can be :-
Peripheral neuropathy
Autonomic neuropathy
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Others
Sexual dysfunction
Sexual dysfunction, especially impotence in men, is a
complication of diabetes
It occurs with greater frequency in diabetic men than in non
diabetic men of the same age
The effect on female sexual functioning are no well documented.
Foot and Leg Problems
From 5% to 75% of lower extremity amputations are performed
on people with diabetes
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143
HYPOTHYROIDISM
It results from suboptimal levels of thyroid hormone.
Thyroid deficiency can affect all body functions and can range
mild, sub clinical forms to myxedema, an advanced form.
Hashimoto’s disease, autoimmune thyroiditis is the most
common cause of hypothyroidism in adults, in which the
immune system attacks the thyroid gland.
Hypothyroidism also commonly occurs in patients with
previous hyperthyroidism who have been treated with
radioiodine or antithyroid medications or who have had a
surgery
Medical Surgical Nursing by Selamu Amanuel 02/28/2023
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extreme fatigue
Hair loss, brittle nails, and dry skin are common
numbness and tingling of the finger may occur.
On occasion, patient may complain of hoarseness of
sound
Menstrual disturbance such as menorrhagia or amenorrhea
occur
Severe hypothyroidism results in a subnormal temperature
(being cold even in warm env’t) & pulse rate
Medical Surgical Nursing by Selamu Amanuel 02/28/2023
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148
149
Nursing interventions
Modifying activity
promoting physical comfort
Monitoring physical status
providing emotional support etc
150
C/M
Nervousness, patients are often emotionally hyper
excitable, irritable, and apprehensive; they can not sit
quietly;
they suffer from palpitation; and their pulse is abnormally
rapid at rest as well as on exertion.
They tolerate heat poorly
The skin is flushed continuously, and is likely to be warm,
soft and moist
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Dxtic findings
The thyroid gland invariably is enlarged to some extent
Medical management
Rx is directed toward reducing thyroid hyperactivity to relieve
symptoms and remove the cause of important complications
Pharmacologic therapy: two forms are available for treating
hyperthyroidism and controlling excessive thyroid activity:
use if irradiation by administration of the radioisotopes 123I
or 131I for destructive effects on the thyroid gland
anti thyroid medications that interfere with the synthesis of
thyroid hormone and other agents that control manifestation of
hyperthyroidism
Antithyroid medications
It block the utilization of iodine by interfering with the
iodination of thyrosine and the coupling of iodothyrosines in
the synthesis of thyroid hormone; this prevent the synthesis
of thyroid hormone
The most commonly used medications are propylthiouracil
(propacil, PTU) or methimazole (Tapazole) until the
patient is euthyroid
They are contraindicated in late pregnancy because they may
produce goiter and cretinism in the fetus
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C/M
High fever above 38.5oC
Extreme tachycardia (more than 130 beats/min)
Exaggerated symptoms of hyperthyroidism,
GI (wt loss, diarrhea, abdominal pain) or
CVS (edema, chest pain, dyspnea, palpitations)
CNS (Altered neurologic or mental state)
THYROID TUMORS
They are classified on the basis of benign or malignant, the
presence or absence of associated thyrotoxicosis and the diffuse or
irregular quality of the glandular enlargement
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167
HYPOPARATHYROIDISM
The most common cause is
surgical removal of parathyroid gland tissue or
during thyroidectomy or
inadequate secretion of parathyroid hormone after interruption
of the blood supply
The symptoms are caused by a deficiency of
parathormone that results in: elevated blood phosphate
(Hyperphosphatemia) and decreased blood calcium
(Hypocalcaemia)
Medical Surgical Nursing by Selamu Amanuel 02/28/2023
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C/M
hypocalcaemia causes irritability of the neuromuscular system &
contributes to the chief symptom of hypothyroidism Tetany
Tetany is a general muscle hypertonia, with tremor and spasmodic or
uncoordinated contractions occurring with or without efforts to make
voluntary movements
Symptoms of latent tetany are:
Numbness
Tingling
Cramps in the extremities
The patient complains of stiffness in the hand and feet
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Dxtic findings
A positive Trousseau’s sign or a positive Chvostek’s sign
suggests latent tetany
Management
The goals of therapy are to raise the serum calcium level to 9 to 10
mg/dl (2.2 to 2.5mmol/l) and to eliminate the symptoms of
hypoparathyroidism and hypocalcaemia
Hyper parathyroidism
is a condition of excessive secretion of parathyroid hormone by
parathyroid gland
Clinical manifestations
It has different characteristics and is not always associated
with bone disease
Some patients are asymptomatic and show only an increased
serum calcium,
Psychological irritability and neurosis to psychoses
[Delirium, confusion, incoordination]
Hyperactive deep tendon reflexes
Renal colic, renal stones, urinary tract infections & polyuria
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Urine tests
calcium and phosphate [increased]
Radiologic studies
Demineralization of bones
Complications:-
Hypercalcemic crisis
Calcification of kidney parenchyma, renal failure &
uremia
Collapse of vertebral bodies and rib fractures
Medical management
To minimize the formation of calcium renal stones can be
managed by
Forcing fluid intake to dilute the excess calcium
Avoiding immobilization
Surgical management
Surgical removal of parathyroid tumors
Nursing intervention (management)
If surgery is performed close monitoring of the client’s
vital sign is required
Prevent the major postoperative complications: Tetany and
fluid and electrolyte imbalances/disturbances
Limit ambulation to short walks because the client
problem is fatigue and weakness
Medical Surgical Nursing by Selamu Amanuel 02/28/2023
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DIABETES INSPIDUS
It is a disorder of the posterior lobe of the pituitary gland
characterized by a deficiency of ADH, or vasopressin
C/M
Polyuria: an enormous daily out put of very dilute, water-like
urine with a specific gravity of 1.00 to 1.0005 occurs
Because of the intense thirst, the patient tends to drink 2 to 20
liters of fluid/day
The disease can not be controlled by limiting fluid intake; because
the high volume loss of urine continuous even with out fluid
replacement
Restriction of fluids causes the patient to experience an insatiable
craving for fluid and to develop hypernatremia and severe
dehydration
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C/M
Muscle weakness
Anorexia
GI symptoms
Fatigue
Emaciation
Dark pigmentation of the skin, knuckles, elbow’
Hypotension
Low blood glucose, Na+ level
High K+ levels
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Dxtic findings
The diagnosis is confirmed by lab test result:-
Decreased blood glucose, hyponatremia, increase K+
(hyperkalemia)
level, and increased WBC count (Leukocytosis)
Management
Immediate Rx is directed towards combating circulatory
shock: Restoring blood circulation, administering fluids
and corticosteroids, monitoring V/S and placing the patients
with legs elevated
Hydrocortisone is administered intravenously followed
with 5% dextrose in normal saline; oral intake may be
initiated as soon as tolerated
Additionally, the patient is assessed closely to identify other
factors, stressors or illness that led to the acute episode
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CUSHING’S SYNDROME
It results from excessive, rather than deficient, adrenocortical
activity.
It may results from excessive administration of
corticosteroids or ACTH or from hyperplasia of the adrenal
cortex
Over production of endogenous corticosteroids may be caused
by several mechanisms including a tumor of the pituitary gland
that produces ACTH and stimulates the adrenal cortex to
increase its hormone secretion despite adequate amounts being
produced
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C/M
The S/S of Cushing syndrome are primarily a result of
over secretion of glucocorticoids and androgens, although
mineralocorticoid secretion also may be affected
Arrest of growth, obesity and musculoskeletal changes
occur along with glucose intolerance
The classic picture of Cushing’s syndrome in the adult is
that of central- type obesity, with a fatty “buffalo hump”
in the neck and supraclavicular areas, a heavy trunk, and
relatively thin extremities
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Management
If it is caused by pituitary tumors rather than tumors of the
adrenal cortex, Rx is directed at the pituitary gland.
Corticosteroids therapy
Cortisterioids are used extensively for:-
Adrenal insufficiency
Suppressing inflammation and autoimmune reactions
Controlling allergic reactions
Reducing the rejection process in transplantation
Their anti-inflammatory and antiallergy actions make them
effective in treating rheumatic or connective tissue disease,
such as rheumatoid arthritis and SLE (Systemic Lupus
Erymatosis)
Medical Surgical Nursing by Selamu Amanuel 02/28/2023
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