Endocrine Test 8

Chapter 52
Random points she said:
 Most common cause of something to be in a hyper state- tumor, either fixed by
antihormone or surgery

 70 yo pt wife monitoring BS- HA1C- to see how well pt’s BS has been controlled
over last 3 months

 Assess shellfish allergies for a thyroid scan- explain to pt that we are looking for
tumor and if you get a HOT spot= GOOD not cancer its absorbing the iodine…
COLD spot=BAD pt will go to biopsy bc probably cancer

 What would you expect to see with a tumor that is stressing the medulla- nervous
system will be affected, catecholamines are being pushed out causing flight or
fight= tachy, decreased peristalsis, hyper, ^ BP, decreased urine output

 Hypophysectomy- removing pituitary gland

 Cushing’s syndrome, although hyper, steroid IV prior to surgery- give steroids,

cannot abruptly stop steroids, surgery removal will immediately stop steroids
therefore needs IV

 Negative feedback

 S/S tetany- cramping, twitching, periorbital numbness and tingling and around
fingertips-> tap cheek instead of drawing labs first

 IV calcium gluconate to treat hypocalcemia- low calcium= tetany

 Levothyroxine- know signs of hypothyroid and hyperthyroid

 65 questions 11 SATA

Types of disorders:
 Primary- problem with the actual gland
 Secondary- problem with area where stimulating hormone comes from
 Tertiary- problem in the hypothalamus
Glands of the Endocrine System
 1. Hypothalamus
2. Pituitary
3. Thyroid
4. Parathyroid
5. Thymus
6. Adrenal
7. Pancreas islet cells
8. Gonads
 secrete hormones directly into the bloodstream and affects target cells with
specific hormone receptor
 works with nervous system to maintain homeostasis by controlling overall body
func. and regulation of: metabolism, nutrition, elimination, temperature, fluid &
electrolyte balance, growth, and reproduction SATA
Hypothalamus
 releases hormones that control hunger, thirst, body temp, and anger
 closed circulatory system w/ anterior pituitary so only small amounts in blood
(hypothalamic-hypophysial portal system)
 releasing hormones regulate the secretion of other hormones in pituitary gland
 inhibiting hormones turns off the secretion of some hormones released from the
pituitary
 produces 2 hormones- antidiuretic hormone (ADH) and oxytocin and is stored in
the posterior pituitary gland
 ADHD given IV= vasopressin short term
7 Anterior Pituitary Hormones SATA
1. Thyrotropin, Thyroid Stimulating Hormone (TSH)- stimulates to excrete thyroid
hormone
2. Prolactin- stimulates milk in mammary glands in females, in males it may make
the testes more sensitive to LH (only definition)
3. Adrenocorticotropic (ACTH)- stimulates adrenal cortex to secrete corticosteroids
4. Growth hormone or somatotropin- promotes protein synthesis, lipid and carb
metabolism, and bone and skeletal muscle growth
5. Luteinizing hormone- a gonadotropin- and stimulates ovulation and estrogen and
progesterone synthesis in females and the secretion of testosterone by the tests
in males (only definition)
6. Follicle stimulating hormone (FSH)- one of the gonadotropins- stimulates the
production of eggs in the ovaries of females and sperm in the testes of males
(only definition)
7. Melanocyte- stimulating hormone (MSH)- targets melanocytes to promote
pigmentation of skin
2 Posterior Pituitary Hormones (STORED IN PPH, produced by HYPOTHALAMUS)
 1. Oxytocin- stimulates contraction of the uterus during childbirth and triggers the
release of milk from the breasts during lactation
2. ADH- acts on the kidneys to reduce urine volume and prevent dehydration, AKA
vasopressin
Functions of Adrenal Glands-> inner region=medulla-> outer region= cortex
 Works w/ hypothalamus and pituitary in following processes:
o Hypothalamus produces corticotropin- releasing hormones, which
stimulate the pituitary gland
o The pituitary gland produces corticotropin hormones, which stimulate the
adrenal glands to produce corticosteroid hormones
Adrenal Cortex-> 3 steroid hormones
1. Mineralocorticoids- aldosterone is most abundant!!! Targets kidneys to control
F&E imbalance and maintains ECF volume
2. Glucocorticoids- Cortisol is most abundant!!! Belly fat->symptom of metabolic
syndrome
3. Gonadcorticoids- contributes to libido
Adrenal Medulla-> secretes 2 catecholamines
1. Epi- adrenaline
2. Norepi- noradrenaline
Thyroid Gland
 ***Only palpable gland***if enlarged do not touch-> send to thyroid storm
 ***Only gland that can store hormones for later use***
 Isthmus
 Euthyroid= as normal as possible
 Antithyroid drugs- Methimazole, PTU- will use to get pt to a euthyroid state prior
to surgery
 Three hormones: T3, T4, and Calcitonin
 Regulates the body’s metabolism and calcium balance
 Calcitonin hormone works together with parathyroid hormone to regulate calcium
levels in the blood
 T3 and T4 are commonly called the thyroid hormones
o T3 and T4 are high - TSH will be low
Parathyroid Glands
 Regulates calcium and phosphorus metabolism by acting on bones, kidneys, GI
tract
 PTF increases bone resorption (release of calcium by bones into the
bloodstream)
 Purpose is to raise blood calcium levels and lower phosphate levels
  Function-> produce PTH which plays a role in the regulation of calcium levels in
the blood by increasing absorption by the kidneys
Pancreas (3 hormones-> insulin, glucagon, somatostatin)
 Exocrine tissue- secretes digestive enzymes
 Endocrine tissue- secretes hormones into bloodstream, islets of Langerhans
(pancreatic islets) produce glucagon and insulin which aids in control of blood
sugars and somatostatin which inhibits secretion of both insulin and glucagon
 3 cell types:
1. Alfa- secretes glucagon-> increases blood glucose levels
2. Beta- secretes insulin-> promotes movement and storage of carbs, protein, and
fat
3. Delta- secretes somatostatin-> inhibits release of glucagon and insulin from
pancreas
Pineal Gland-> secretes the hormone melatonin
Aging & Endocrine
 Endocrine glands will reduce some function, but they still continue to function
 Decrease in energy and increase risk for dehydration
 Adipsia- lack of thirst-> teach to drink if mouth feels dry
 Decrease in ADH: leads to more diluted urine-> risk for dehydration
 Decrease in growth hormone: decrease in muscle mass, increase in fat storage->
decrease energy
 Decrease in TSH and thyroid hormone: decrease in basal metabolic rate->
decrease in energy
 Decrease in insulin: decrease in glucose tolerance-> decrease in energy
 More frequent blood sugar levels need to be drawn, yearly TSH drawn
Assessment
 Thyroid only palpable gland- only the MD can palpate, RN observes and hands
pt water when needed to swallow for MD
 Assessing hyper condition- suppression test
 Assessing hypo condition- stimulation (provocative) test
Dx Tests for Endocrine
1. Hormone Tests
 Serum hormone levels: blood specimen
 Suppression tests: substance injected to suppress a hormone’s release->
if a steroid hormone is injected, cortisol release from the adrenal cortex is
expected to be suppressed. If cortisol level is not suppressed, a problem
in the adrenal cortex is suspected.
 Stimulation Tests: substance is injected to stimulate a gland, the hormone
secreted by the gland is then measured in the blood to determine how well
it responded to stimulation-> TRH stimulation test, TRH injected, if
 pituitary responds appropriately TSH is secreted. If thyroid responds, T3
and T4 rise. Failure of TRH to stimulate TSH or thyroid hormone indicates
a pituitary of thyroid condition.
2. Other lab tests
 Serum calcium indicates calcitonin secretion- calcium good test for
hyperthyroid.
 Blood glucose indicates insulin secretion
3. Urine Tests
 24 hour urine
 Best method for measuring a hormone level
4. Nuclear Scanning
 Thyroid scan-> will show hot spots or cold spots
 Hot spot= not malignant
 Cold spot= malignancy, does not take up iodine
Common Lab tests- what would be an appropriate test to asses…
 Thyroid Tests
o TSH
o T3
o T4
 Parathyroid Tests
o PTH
o Calcium
o Phosphorus
 Pituitary Tests
o GH
o ADH
o Urine Specific Gravity
o ACTH
 Adrenal Tests
o Aldosterone
o Cortisol – blood and urine
o 24-Hour Urine for VMA (Vanillylmandelic acid)
 Pancreatic Function Tests (Diabetes)
o Fasting Plasma Glucose
o Ketones – blood and urine
o Oral Glucose Tolerance
o Glycosylated Hemoglobin
ANTERIOR PITUITARY: ACTH, GROWTH HORMONE, & TSH
Don’t worry about the other 4- per Chavis

POSTERIOR PITUITARY: ADH & OXYTOCIN

Pituitary
Hypopituitarism
 Panhypopituitarism—Decreased production of all anterior pituitary hormones-
Post partum women
 Pituitary tumor most common cause
 Avoid therapy in patients w prostate cancer, gynecomstia
 Estrogens and progesterone
 Growth hormone subq injections
 Side effect is gynecomastia (male breast tissue development),
acne, baldness, and prostate enlargement
Hyperpituitarism
 Caused mainly by pituitary adenoma (benign tumor)
 Symptoms
 Visual disturbances
 Ha
 ICP
 Prolactin (PRL) secreting tumor is most common and see breast
milk secretion, infertility and amenorrhea
 Suppression test can help - Serum growth hormone (give 100g oral
glucose to see if GH suppressed, if don’t fall below 5ng/mL = + Dx)

Acromegaly
 Adult’s bones increase in size- face, hands and feet. (irreversible)
 The long bones get wider but not longer (permanent).
 Treatment Bromocriptine)

Pituitary Tumors
First sign of pituitary tumor is VISUAL CHANGES
Hypophysectomy-
 The nasal pack stays in for about four days and stays in place unless removal
ordered by physician.
o If you see clear drainage on the mustache dressing- test for glucose-
positive cerebral spinal fluid- CALL DOCTOR, negative its snot

Pre Op & Post Op

  Baseline neuro
 Avoid anything that causes straining
 Watch for clear drainage
 ^ Intracranial pressure-clear with light yellow “halo sign” on mustache
dressing test for glucose
 Nasal packing
 No scar, minimally invasive
 Check for urine gravity diabetes insipidus
 Avoid bending
 Avoid straining at stool
 Avoid coughing

Give Education:
 Expect a small amount of bloody or mucous drainage from nose.
 Do not blow nose, can injure surgical site and cause bleeding or CSF
leakage.
 If an upper lip incision was used, do not brush teeth. Floss and mouth
rinses only.
 Take medications as prescribed.
 Call physician if fever develops, increased bloody drainage from
incision, if clear drainage develops, or develop increased thirst or
urination (DI).
Diabetes Insipidus- CAN’T STOP PEEING- SYMPTOMS OF DEHYDRATION
 Caused by deficiency in ADH Urine osmolarity difference between DI
and Fluid Volume Deficit ADH – responsible for reabsorption of water
by distal tubules and collecting ducts of kidneys.

Treatments:
 VASOPRESSIN
 Lithium and demeclocycline because interfere with kidney’s
response to ADH
 Oral chloropropramide- ^ ADH secretion will lower BS, avoid
sun exposure
 Hypotonic IV fluids (0.45% normal saline to replace
intravascular volume without adding much sodium).
S &S:
 URINATION OVER 4 L PER DAY
 LOW SPECIFIC GRAVITIY AND LOW
OSMOLARITY/OMOLALITY- BUT HIGH SERUM OSMALAITY
 PT. IS IMPROVING WHEN URINE SPECIFIC GRAVITY BEGIN
TO RISE
 PT’S ALREADY HAVE A HIGH SODIUM
 Medical Treatment involves replacement of ADH
  Acute cases require Vasopressin (synthetic ADH) given IV or SC
along with IV fluid replacement.
 For long-term therapy – Synthetic ADH (desmopressin acetate
or DDAVP) in nasal spray form is given twice daily.
 Avoid lemon, caffeine, and watermelon- they are natural diuretics

SIADH: Too little ADH- Fluid Volume Excess Symptoms

Usually causes by cancer
Pathophysiology:
 Results from too much ADH in the body.
 Causes excess water to be reabsorbed by the kidney tubules and collecting
ducts resulting in decreased urine output and fluid overload.
 Fluid builds up in the bloodstream causing osmolality to decrease and the blood
to become diluted.
 Normally, a decreased serum osmolality inhibits the release of ADH, but in
SIADH, ADH continues to be released causing fluid overload.
 ADH normally controls amounts of water in the body so urine is very
concentrated but blood is very diluted causing low sodium levels

S&S:
 Weight gain usually without edema
 Dilutional Hyponatremia (actual blood Na may be normal,but may appear
to be low due to the diluting effect of the retained fluid).
 (H/A, Nausea, bounding pulse, muscle weakness, personality changes,
diarrhea, convulsions, coma)
 Low urine output with very concentrated Urine.
 Serum osmolality is less than 275 mOsm/kg (Normal serum osmolality =
278–300 milliosmoles per kilogram (mOsm/kg) of water)
Which of these fluids should you question?
Treatments:
 If due to an inoperable cancer, Lasix and Declomycin may be indicated to
block the action of ADH in the kidney .
 IV Hypertonic Saline Solutions.
 Oral Salt.
 Monitor for fluid overload at least q 2 hours
 Drug therapy (tolvaptan or conivaptin,

Adrenal Gland Hypofunction:

 Keep simple carb snacks at all times
 See loss of aldosterone and cortisol
  Low cortisol leads to hypoglycemia, decreased gastric acid prod
and glomerular filtration rate which leads to elevated BUN causing
anorexia and wgt loss
 Low aldosterone leads to hyperkalemia which causes acidosis,
hyponatremia and hypovolemia

Addison’s Disease: LOW CORTISOL

Pathophysiology:
 Primary adrenocortical insufficiency, (not enough steroid)
S&S:
 Hypotension, Hypoglycemia, Weakness, Fatigue, Bronze Skin,
Nausea and Vomiting, vitiligo, decreased body hair, hyperkalemia,
hyponatremia
Complications:
 Adrenal Crisis (Addison’s Crisis)
 Profound Dehydration, Hypotension, Hypoglycemia, cardiac
arrhythmia, Shock, Coma, Death
 Treatment of adrenal crisis involves rapid fluid volume and cortisol
level restoration with IVF and glucocorticoids and electrolytes, need
to treat cause
 NEVER ABRUPTLY DISCONTINUE STEROIDS!
 Avoid Adrenal Crisis

Diagnosis & Interventions:

 ACTH Stimulation Test is most definitive test!!
 Fluid balance, Hormone management, hyperkalemia management, and
hypoglycemia management
‒ Glucocorticoids (hydrocortisone) and Mineralocorticoids (fludrocortisone)
Daily for Life
 Two-thirds in AM, One-third in PM
 Double or Triple in Times of Stress
 May inject IM with emergency injection kit
‒ High Sodium Diet especially during hot weather
‒ Assess cardiac func due to high K+