ENDOCRINE DISORDER

PPT 3 || NCM 332

ENDOCRINE SYSTEM Calcitonin (Thyrocalcitonin)
• Endocrine system plays a vital • Lowers blood calcium and
role in orchestrating cellular phosphate level
interactions, metabolism, growth, • When calcitonin is high,
reproduction, aging and serum calcium is low
response to adverse conditions. • When calcitonin is low,
• The system uses chemical serum calcium is high
transmitters known as hormones
to regulate and integrate body
functions by acting on local or
distant target sites
Negative feedback mechanism is
deployed to maintain
homeostasis
• Disorders of the endocrine
system are manifested as
hyperfunction or hypofunction of a specific endocrine gland

PARATHYROID GLAND
Parathyroid hormone (PTH)
• Regulates serum calcium
• PTH elevates serum calcium
but LOWERS
PITUITARY GLAD (HYPOPHYSIS) phosphorus level
• Master gland of the • Increase PTH, hypercalcemia
body • Decreased PTH,
• Divided into the hypocalcemia
anterior PG
(adenohypophysis) and
posterior PG
(neurohypophysis)
• Controlled by the
hypothalamus
ANTERIOR PITUITARY
GLAND (ADENOHYPOPHYSIS)
Growth hormone (GH)
• Also known as somatotropin
• Stimulates growth of bone and muscle
• Promotes protein synthesis and fat metabolism
• Decreases carbohydrate metabolism
• Insulin antagonist CALCIUM REGULATION
Arenocorticotropic hormone (ACTH) - Normal Ca++ - 8.5-10.5mg/dL
• Stimulates synthesis and secretion of adrenal
cortical hormones
Thyroid- stimulating hormone (TSH)
• Stimulates synthesis and secretion of thyroid hormones
Follicle Stimulating hormone (FSH)
• Female: stimulates growth of ovarian follicle
• Male: stimulates sperm production
Luteinizing hormone (LH)
• Female: stimulates development of corpus luteum;
release of oocyte
• Male: stimulates secretion of testosterone
Prolactin
• Prepares female breast for breastfeeding
POSTERIOR PITUITARY GLAND (NEUROHYPOPHYSIS) ADNRENAL GLANDS
Antidiuretic Hormone (ADH) • Located atop the
• Increases water reabsorption by kidney kidneys
Oxytocin • Divided into the
• Stimulate contraction of pregnant uterus adrenal cortex and
• Milk ejection adrenal medulla
THROID GLAND • Adrenal cortex=
Thyroid hormones: triiodothyronine (T3) and thyroxine (T4) adrenocortical hormones
• Increase metabolic rate • Adrenal medulla=
adrenomedullary
• Increase responsiveness to catecholamines
hormones
• Stimulate SNS activity
• Necessary for fetal growth and development ADENOCORICAL HORMONES:
- sugar, salt, sex
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ENDOCRINE DISORDER
PPT 3 || NCM 332
GLUCOCORTICOIDS (CORTISOL: SUGAR) DISORDERS OF THE PITUITARY GLAND
• Regulate blood glucose level ANTERIOR PITUITARY GLAND
• Enhance gluconeogenesis • Acromegaly
• Insulin antagonist • Hypopituitarism
• Has anti- inflammatory effect Acromegaly
• Decrease T- lymphocyte participation in cell-mediated • A rare condition characterized by
immunity overproduction of growth hormone
• Increase gastric acid and pepsin production (GH).
MINERALOCORTISOIDS (ALDOSTERONE: SALT) • Prevalence rate: 28-137 cases/million
• Increases sodium retention population (Kamusheva et al., 2020)
• Increases potassium and hydrogen excretion
• “pro- sodium, anti- potassium”
SEX HORMONES (ANDROGEN and ESTROGEN)
• Responsible for some secondary sex characteristics in
females, but works as gonadal steroids in males
EPINEPHERINE and NOREPINEPHRINE
• Serves as neurotransmitters for the SNS
EPHINEPHRINE EFFECT NOREPINEPHRINE EFFECTS
•Increases HR and • Increases BP through
contractility vasoconstriction
• Bronchodilation
• Vasoconstriction
• Increase of blood sugar ACROMEGALY vs GIGANTISM
levels ACROMEGALY GIGANTISM
PANCREAS Hypersecretion of GH Hypersecretion of GH
Endocrine function is performed by the islets of Langerhans Epiphyseal plate is already Epiphyseal plate is still
closed and has become the developing
epiphyseal line
Height will not grow further Person’s height is towering
ACROMEGALY
CAUSE:
• Idiopathic hyperplasia of the APG
• Pituitary tumor (adenoma)- most common

INSULIN
• Secreted by beta cells
• Lowers blood glucose by facilitating glucose transport across
cell membranes of muscle, liver, and adipose tissues
• Promotes glycogenesis

CLINICAL MANIFESTATION
• A- Arthralgia/Arthritis
• B- Blood pressure raised
• C- Carpal Tunnel Syndrome
• D- Diabetes
• E- Enlarged organs, head, hand, face, feet
• F- Field defect (visual impairment)
• G- Gynecomastia
- Prognosis: Shorter than average life span

GLUCAGON
• Secreted by alpha cells
• Increases blood glucose concentration by stimulation of
glycogenolysis and gluconeogenesis

DIAGNOSTIC TEST
Serum Growth Hormone
• Diagnostic Criteria> 0.4 mcg/L
Insulin- like Growth Factor 1 (IGF-1)
• Mediates peripheral action of GH
• Normal: 135-449 ng/mL
• Elevated IGF-1 is diagnostic of acromegaly
Oral Glucose Tolerance Test (OGTT)
• GH secretion is normally inhibited by glucose

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ENDOCRINE DISORDER
PPT 3 || NCM 332
• Baseline GH levels are obtained before ingestion of 75- or • Nausea and vomiting
100- gm oral glucose • Seizures
• GH levels are then measured at 30, 60, 90, and 120 minutes
• Normal: GH <0.4 mcg/L
• Acromegaly: GH > 0.4 mcg/L
MEDICAL MANAGEMENT
Octreotide acetate (Sandostatin)
• Somatostatin analogue
• Reduces GH and IGF-1 to normal
• Given SQ 3x a week
• GH levels are measured every 2 weeks to guide drug dosing,
and then every 6 months until desired response is obtained
SURGICAL MANAGEMENT
Transsphenoidal
hypophysectomy
• Removal of the pituitary MANAGEMENT
gland • Surgical removal of tumor
• Treatment of choice for • Radiation therapy
small pituitary tumors • Lifelong hormone replacement therapy
POST-OP NURSING CARE POSTERIOR PITUITARY GLAND
• Position: Low- fowlers • Diabetes insipidus (DI)
position (30- degrees) at all times to reduce pressure on sella • Syndrome of Inappropriate Antidiuretic
turcica and decrease headaches Hormone (SIADH)
• Provide mouth care q4H to keep surgical area clean and DIABETIS INSIPIDUS
free of debris • Most common disorder of the
• Avoid toothbrushing for at least 10 days to protect suture line neurohypophysis
• Instruct patient to avoid vigorous coughing, sneezing, and • Characterized by a deficiency in
straining at stool to prevent cerebrospinal fluid leakage antidiuretic hormone (ADH)
• WOF: clear nasal discharge, persistent and severe TYPE ETIOLOGY
Central (Neurogenic) DI • Results from an interference with ADH
generalized or supraorbital headache synthesis, transport, or release
• CSF leak usually resolves within 72 hours when treated with • Examples: Brain tumor, head injury,
head elevation and bed rest brain surgery, CNS infections
Nephrogenic DI • Results from inadequate renal
• Report to physician increasing urine output and low specific response to ADH despite presence of
gravity as they may indicate the development of diabetes adequate ADH
insipidus • Examples: Drug therapy (esp. lithium),
renal damage, hereditary renal
• Essential hormones of target organs are replaced disease
postoperatively, as ordered Primary DI • Results from excessive water intake
• Examples Structural lesion in thirst
center, psychological disorder
CLINICAL MANIFESTATIONS
Polyuria: Large urine volume
• UO= 2 to 20L/day
Very dilute urine
• Urine Specific Gravity: 1.001 to 1.005
• Polydipsia, craves cold water (2 to 20 L)
Hypovolemia
• Thirst
• Tachycardia
• Hypotension
URINE OSMOLALITY
• A measure of the number of dissolved particles in a fluid.
RADIATION THERAPHY • Used to evaluate the balance between water and dissolved
• Used when surgery failed to produce a cure or patients are particles in the urine
poor candidates • Measurement of concentration
• Given in combination with medications • Normal: 250-900 mOsm/kg
• May also be used to shrink tumor prior to surgery URINE SPECIFIC GRAVITY
HYPOPITUITARISM • A measure of the concentration of particles in urine and the
• A rare disorder that involves a decrease in one or more of density of urine compared with density of water.
the pituitary hormones. • Provides information on the kidney’s ability to concentrate
TYPES: urine
• Selective hypopituitarism • Normal: 1.010 to 1.020
• Deficiency of one pituitary hormone DIAGNOSTICS
• Panhypopituitarism (Simmond’s disease) Fluid Deprivation Test
• Total failure of the pituitary gland that results to deficiency of • Urine osmolality are measured at the beginning and end of
all pituitary hormones test
• Sheehan’s syndrome • Fluids are withheld for 8 to 12 hours or until 3% to 5% of body
• Hypopituitarism caused by postpartum pituitary necrosis weight is lost
CAUSES • Desmopressin acetate (DDAVP) is given intranasally or SQ
• Pituitary tumor- most common DIAGNOSIS Urine Osmolality Urine Osmolality
(mOsm/kg) After Fluid (mOsm/kg) After
• Autoimmune disease Deprivation Desmopressin
• Infection CENTRAL DI <300 >600
• Pituitary infarction NEPHROGENIC DI <300 <300
• Destruction/Removal of pituitary gland CENTRAL DI: MANAGEMENT
CLINICAL MANIFESTATION Desmopressin (DDAVP)
Early (associated with space- occupying lesion): • A synthetic vasopressin
• Headache • Given intranasally q12 to 24 hours
• Visual changes • Caution: CAD
• Loss of smell Chlorpropamide (Diabinese) and Carbamazepine (Tegretol)
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ENDOCRINE DISORDER
PPT 3 || NCM 332
• Helps decrease thirst associated with central • IV Hypertonic (3%) saline solution (administer slowly), as
DI ordered
During acute episodes: Furosemide (Lasix), as ordered
• Hypotonic IV fluids or D5 Water, as ordered to replace urine • Loop diuretic
output • Promotes diuresis
• Encourage increased oral fluids as tolerated • Used ONLY if serum sodium is at least 125 mEq/L
• Monitor VS, urine output and specific gravity • Fluid restriction of 500mL/day, as ordered
• Monitor level of consciousness and for signs of dehydration • Obtain daily weights
NEPHROGENIC DI: MANAGEMENT Tolvaptan (Samsca)
Low- sodium diet (no more than 3g/day) - helps decrease • Vasopressin V2 receptor antagonists
urine output • It works by increasing the amount of water released from the
Thiazide diuretics, as ordered body as urine. Removing fluid from the body helps to increase
• Hydrochlorothiazide, Chlorothiazide the level of sodium in the blood.
• Reduces flow to the ADH- sensitive distal nephrons • Used to treat euvolemia- hyponatremia in HOSPITALIZED
Indomethacin (Indocin), as ordered patients
• NSAID • Monitor closely to prevent rapid correction of serum sodium
• Helps increase renal responsiveness to ADH MANAGEMENT (CHRONIC SIADH)
SYNDROME of INNAPPROPRIATE ANTIDIURETIC HORMONE Demeclocycline (Declomycin)
(SIADH) • Inhibits ADH- induced water reabsorption and promotes
• Excessive secretion of ADH from the pituitary gland even in water diuresis
the face of subnormal serum osmolality • Typically used when patients find severe fluid restriction
unacceptable and the underlying disorder cannot be
corrected
• Use ice chips or sugarless gum to decrease thirst
• Teach patient to supplement diet with sodium and
potassium, especially when loop diuretics are prescribed

Diabetes Insipidus SIADH

Deficiency of PATHOPHYSIOLOGY Excess ADH
(Neurogenic) or
decreased sensitivity
to (Nephrogenic) ADH
Polyuria Significant Dilutional hyponatremia
Polydipsia Manifestations Oliguria
Low urine specific gravity High urine specific
gravity
DISORDERS OF THE THYROID GLAND
THYROID HORMONES
• Triiodothyronine (T3) • Thyroxine (T4) • Calcitonin
THYROID HORMONE SYNTHESIS

CLINICAL MANIFESTATION
• Dilutional hyponatremia (Na <135 mEq/L)
• Headache- earliest sign
• Serum hypo- osmolality
• Concentrated urine
• Oliguria REGULATION OF THYROID HORMONES
• Weight gain

DIAGNOSTICS
• Serum • Serum Na <135 meq/L
• Serum osmolality <280 mOsm/kg EUTHROID: thyroid hormone level is within normal
• Urine Specific Gravity > 1.025 Na 1.025 GOITER
MANAGEMENT (MILD/MODERATE) • A goiter is an enlarged
• Fluid restriction to 800 to 1000 mL/day, as ordered thyroid gland
• Obtain daily weights CAUSE
• Position HOB flat or elevated no more than 10 degrees (to • Iodine deficiency
enhance venous return to heart and increase left atrial filling • Goitrogens- foods or drugs
pressure, thereby reducing release of ADH) that contain thyroid
• Place on seizure precautions inhibiting agents
• Provide frequent oral care and distractions to decrease • Thyroid cells are stimulated
discomfort r/t thirst from fluid restrictions to grow which may
MANAGEMENT (SEVERE) result to an overactive (hyperthyroidism) or
• Seizure precautions underactive (hypothyroidism) thyroid

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ENDOCRINE DISORDER
PPT 3 || NCM 332
• Decreased TSH, Increase Free T4
• Normal TSH: 0.5 -5.0 mIU/L
• Normal free T4: 0.9 to 1.7 ng/Dl
Radioactive iodine uptake:
• Measures the rate of iodine uptake by the thyroid
• Uses Iodine123 (I123) and a count is made over the thyroid
gland using a scintillation counter
• Scintillation counter detects the gamma rays released from
the breakdown of I123
TYPES: • Hyperthyroidism: HIGH uptake of I123
NONTOXIC GOITER MEDICAL MANAGEMENT
• Diffuse enlargement of the thyroid gland that does not result Radioactive Iodine Therapy
from a malignancy or inflammatory process • Goal: eliminate the hyperthyroid state with the administration
• Thyroid hormones are normal of sufficient radiation in a single dose.
NODULAR GOITER • Agent: Iodine 131 (I131)
• Thyroid- hormone secreting nodules that function • Contraindicated in pregnancy and lactation
independent of TSH stimulation • Mechanism of action:
• Benign nodules • The radioactive isotope of iodine becomes
• May be multinodular goiter (multiple nodules) or solitary concentrated inside the thyroid gland destroying
autonomous nodule (single nodule) ONLY the thyroid cells without jeopardizing other
TOXIC NODULAR GOITER radiosensitive tissues
• Nodular goiters associated with hyperthyroidism Pre- treatment:
PREVENTION Methimazole
• Iodine supplementation • Anti-thyroid
• Use of iodized salt • Started 4 to 6 weeks prior to treatment
• Limit intake of goitrogenic foods • Stopped 3 days before and resumed 3 days after RAI
ASIN law (RA 8172) Therapy
• Act for Salt Iodization Nationwide (ASIN) • Nursing Interventions:
• Requires the addition of iodine to all salt intended for animal • PATIENTS IS RADIOACTIVE and may contaminate others
and human consumption in order to eliminate micronutrient through saliva, urine, or radiation emitting from the body
malnutrition in the country • Isolate patient
MANAGEMENT Anti- thyroid medications
• Thyroid hormone replacement to prevent further • Mechanism of action: prevents formation of thyroid
enlargement hormones by blocking iodine utilization
• Levothyroxine (Synthroid) • DOC:
• Surgery is required to remove large goiters • Propylthiouracil (PTU)
HYPERTHYROIDISM • Methimazole (Tapazole)
• A form of thyrotoxicosis resulting from an excessive synthesis • Nursing Management:
and secretion of endogenous and exogenous thyroid • Instruct to take medication early in the morning on an
hormones by the thyroid empty stomach 30 minutes before eating to avoid decrease in
CAUSES absorption
• Grave’s disease- most common • Advise patient that it may take weeks until symptom relief
• Toxic nodular goiter occurs
• Toxic adenoma • WOF: fever and sore throat
• Thyroiditis Adjunctive therapy
• Excessive ingestion of thyroid hormone • Beta- blockers
CLINICAL MANIFESTATIONS • Propranolol, metoprolol
• Basic concept: Everything is HIGH, FAST, and WET • Decreases HR, systolic blood pressure, and anxiety
• Presenting symptom: nervousness Eye Care for Exophthalmos:
Pathophysiology Clinical Manifestation • Artificial tears to prevent excessive dryness
Activation of SNS and CNS • Restlessness, irritability, agitation • Tinted eyeglasses
function • Fine tremors • Eye shield
• Tachycardia
• Hypertension
SURGICAL MANAGEMENT
• Diaphoresis Indications:
Increased metabolism • Increased appetite • Pregnant women who are allergic to
• Weight loss antithyroid medications
• Heat intolerance • Large goiters
Hypocalcemia • Diarrhea • Patients who are unable to take anti-thyroids
• Fine, silky hair SUBTOTAL THYROIDECTOMY
• Pliable nails
• Surgical removal of
Altered reproductive function • Amenorrhea
about 5/6 of the thyroid
Ophthalmopathy
tissue
• Exophthalmos- protrusion of eyeballs
• Requires a euthyroid
resulting from fluid accumulation at the
state prior to conduct
fatpads behind the eyelids
Pre-medications:
Dalyrimple’s sign (Thyroid stare)- bright-
• Anti-thyroid
eyed stare and infrequent blinking
• Iodine compounds
Von Graafe’s sign (lid lag)- long and
• Potassium iodide (KI), Lugol’s solution, Saturated Solution of
deep palpebral fissure that is still evident Potassium iodide (SSKI)
even when • MOA: reduce the size and vascularity of thyroid gland
looking down • Administer with milk or fruit juice to increase palatability
Jeffrey’s sign- forehead remains smooth • Administer using a straw to prevent staining of teeth
when patient looks up Post operative Care:
Dermopathy - Thickened and hyperpigmened skin at the • POSITION: semi-fowler’s with head, neck, and shoulders erect
pretibial area • Monitor surgical site for bleeding and edema:
ASSESSMENT AND DIAGNOSTICS • Check dressing and back of neck
• Enlarged thyroid; soft and may pulsate
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ENDOCRINE DISORDER
PPT 3 || NCM 332
• WOF: respiratory distress • Altered mental status (initial manifestation)
• Prepare at bedside: tracheostomy set, oxygen, and suction • Respiratory depression
equipment • Hyponatremia, hypoglycemia
THYROTOXICOSIS (THYROID STORM) • Hypotension, bradycardia, hypothermia
• A form of severe, life- threatening hyperthyroidism MEDICAL MANAGEMENT
• Causes: stress (surgery, RAI), infection Goal: restore normal metabolic state
CLINICAL MANIFESTATION Levothyroxine (Synthroid)
• Hyperpyrexia (T >38.5C) • Taken on an empty stomach
• Extreme tachycardia (HR > 130 bpm) • Avoid strawberry, peaches, cabbage
• Exaggerated symptoms of hyperthyroidism • Dose is gradually increased to prevents
• Altered mental status (delirium, psychosis, coma) hyperthyroidism
MANAGEMENT • Caution: may increase oxygen demand which
• Ice packs, paracetamol triggers angina or ACS
• Humidified oxygen • Discontinue immediately if with angina or
• IV fluids with dextrose dysrhythmia
• Propylthiouracil (PTU), Lugol’s solution, dexamethasone T3 and T4 IV replacement for myxedema coma
• Results from suboptimal levels of thyroid hormones DISORDERS OF THE PARATHYROID GLAND
• Affects women > men PARATHYROID
• Commonly occurs between 40 to 70 years old • Embedded in the posterior aspect
TYPES of the thyroid gland
• Primary hypothyroidism- dysfunction of the thyroid gland • Secretes parathormone (PTH)
• Secondary hypothyroidism- the dysfunction originates from • Increases serum calcium level, but
the pituitary gland decreases phosphorus level
• Cretinism- hypothyroidism in children • Vitamin D enhances effects of
CAUSES hormone
• Hashimoto’s thyroiditis (most common): HYPERPARATHYROIDISM
• An autoimmune form of thyroiditis in which the person’s own • Overproduction of parathormone and is characterized by
immune system attacks the thyroid gland bone decalcification and the development of renal calculi
• Atrophy of thyroid gland with aging TYPES:
• RAI therapy, thyroidectomy Primary hyperparathyroidism
• Medications (Lithium, iodine compounds, and anti- thyroids) • Parathyroid adenoma – most common
• Head and neck radiation therapy • Long- term lithium therapy
DIAGNOSTICS Secondary hyperparathyroidism
Primary Hypothyrodism Secondary Hypothyrodism • A compensatory response to conditions that induce
• Increased TSH • Decreased TSH
• Decreased Free T4 • Decreased Free T4
hypocalcemia
• Elevated cholesterol, TG, and • Decreased Free T4 • CKD, vitamin D deficiency
LDL • Elevated cholesterol, TG, and
• Positive thyroid peroxidase LDL
antibodies (Hashimoto’s)
CLINICAL MANIFESTATIONS
• Basic concept: “Everything is low, slow, and dry”
Early:
• Hoarseness of voice
• Extreme fatigue
• Loss of libido
• Amenorrhea
• Skin dryness
Late:
• Cold intolerance CLINICAL MANIFESTATIONS
• Hypothermia • Fatigue
• Expressionless and masklike facie • Muscle weakness
• Weight gain even without increase in food intake • Constipation
• Bradycardia • Nausea and vomiting
• Alopecia • Dysrhythmias
• Constipation • Hypertension
• Apathy • Kidney stones
• Sensitivity to opioids is increased • Pathologic fractures
• Atherosclerosis • Skeletal pain and tenderness
• Myxedema: accumulation of mucopolysaccharides in the • Shortening of body stature
subcutaneous tissue DIAGNOSTICS
Serum calcium level
GRAVE’S DISEASE • Normal: 8.5-10.5 mg/dL
• An autoimmune disorder that results from an excessive • Hyperparathyroidism: elevated
output of thyroid hormones caused by an abnormal Intact PTH
stimulation of the thyroid gland by circulating immunoglobulins • Normal: 14-72 pg/mL
• Affects women> men • Hyperparathyroidism: elevated
• Occurs between 30-40 years old Serum phosphorous level
• May be precipitated by emotional shock, stress, or infection • Normal: 2.5- 4.5 mg/dL
MYXEDEMA COMA • Hyperparathyroidism: decreased
• A rare life- threatening condition BONE MINERAL DENSITY (BMD)
• Decompensated state of severe hypothyroidism BONE DENSITY T-SCORE
• Common among undiagnosed hypothyroidisms NORMAL BONE DENSITY +1.0 – 1.0
• Precipitated by: LOW BONE DENSITY -1.0 - -2.5
AT HIGH RISK FOR OSTEOPOROSIS -2.5 - higher
• Infection
• Opioids Hyperparathyroidism: T score of -2.5 or less at any site or
CLINICAL MANIFESTATIONS previous fragility fracture

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ENDOCRINE DISORDER
PPT 3 || NCM 332
MEDICAL MANAGEMENT • Have a tracheostomy set, oxygen, and suction available at
Hydration therapy bedside
• Increased fluid intake to 2,000mL or more to prevent renal • Provide a high- calcium, low- phosphorus diet
calculi • Broccoli, tomato, banana, kidney beans
• PNSS IV- fluid of choice as sodium enhances excretion of • Avoid cheese, milk and milk products, and egg yolk
calcium • Avoid spinach which contains oxalate that forms insoluble
Mobility calcium substances
• Bones subjected to the normal stress of walking give up less DISORDERS of the ADRENAL GLANDS
calcium. Bed rest increases calcium excretion and the risk of PHEOCHROMOCYTOMA
renal calculi. • A tumor of the chromaffin cells of
Gallium nitrate (Ganite) the adrenal medulla (usually benign;
• Anti- hypercalcemic 10% malignant)
Alendronate (Fosamax) • Peak incidence at 40-50 years old
• Bisphosphonates • Affects men and women equally
• Inhibit osteoclastic bone resorption, normalizing serum • High familial tendency
calcium levels CLINICAL MANIFESTATIONS
SURGICAL MANAGEMENT • Headache
Parathyroidectomy: • Hyperhidrosis
• Removal of one or more of the parathyroid • Hypertension
glands • Hypermetabolism
Postoperative care: • Hyperglycemia
• Position: Semi- Fowler’s DIAGNOSTICS
• WOF respiratory distress, bleeding at post Vanillylmandelic Acid (VMA) Test
operative site • Measures urinary excretion of
• Prepare at bedside: tracheostomy set catecholamine metabolite
HYPERCALCEMIC CRISIS • Specimen: 24- hour urine sample
• Occurs with extreme elevation of calcium levels greater than • Avoid coffee and tea, banana,
13 mg/dL chocolate, vanilla, and aspirin
Cause: dehydration • Normal: 1.4-6.5mg/24 hours
Management: Clonidine suppression test
• Rapid rehydration with large volume of isotonic fluid • Clonidine suppresses release of
• Loop diuretic (e.g., Furosemide) if with edema neurogenically mediated
• Calcitonin- promotes renal excretion of calcium catecholamines
• Corticosteroids- promotes calcium deposition in bone • (+): clonidine does not suppress
• Dialysis catecholamine levels
HYPOPARATHYROIDISM MEDICAL MANAGEMENT (ABC)
• Hyposecretion of parathyroid hormone Alpha- Adrenergic blocker
Cause: • Phenoxybenzamine (Dibenzyline)
• Subtotal thyroidectomy (most common) • Given 10 to 14 days prior to surgery
• Abnormal parathyroid development • S/E: orthostasis, nasal stuffiness, fatigue, retrograde
ejaculation
Beta- Adrenergic blocker
• Propranolol (Inderal)
CLINICAL MANIFESTATIONS • Initiated once alpha- adrenergic control is achieved
Hypocalcemia (Ca++ < 8.5mg/dL) Calcium Channel Blocker
• Tetany: general muscle hypertonia, with • Nifedipine (Adalat)
tremor and spasmodic or uncoordinated • Alternative treatment if blood pressure control is inadequate
contractions occurring with or without or patient is unable to tolerate side effects
efforts to make voluntary movement SURGICAL MANAGEMENT
Latent Tetany: Adrenalectomy
• Numbness, tingling, and cramps in the • Removal of one or both adrenal glands
extremities • Definitive treatment of pheochromocytoma
• Stiffness of hands and feet • Pre-operative preparation: control blood pressure
Overt Tetany: Complication:
• Bronchospasm • Hypertensive crisis (Intra/Post- Op)
• Laryngospasm • Results from the manipulation of
• (+) Trousseau’s sign: carpopedal spasm resulting the tumor during surgical excision
from occlusion of the blood flow to the arm for 3 Mgt:
minutes • Sodium nitroprusside (Nitropress)
• (+) Chvostek’s sign: sharp tapping over the facial • Phentolamine (OraVerse)
nerve causes spasm or twitching of mouth, nose, Nursing Management:
eye • Institute bed rest with HOB elevated to
• Seizures promote orthostatic decrease in BP during
• Dysrhythmias episodes of hypertension or tachycardia
• Photophobia • Monitor vital signs, ECG, fluid and
MEDICAL MANAGEMENT electrolytes, and blood glucose levels
Goal: increase serum calcium to 8.5 to 10.5 mg/dL CUSHING’S SYNDROME
• Vitamin D3 (calciferol) • A clinical condition that results from
• Hydrochlorothiazide (Hydrodiuril)- decreases urinary calcium chronic exposure to excess
excretion corticosteroids, particularly
• Calcium gluconate very slow IVTT – if hypocalcemia is after glucocorticoids
thyroidectomy • Affects women > men
• Aluminum hydroxide gel (Amphojel) after meals to bind CAUSE:
phosphate and promote its excretion through the GI tract • Steroids (most common exogenous)
• Place patient on seizure precaution

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ENDOCRINE DISORDER
PPT 3 || NCM 332
• Cushing’s Disease: Presence of ACTH- secreting pituitary • Dose is tapered to the minimum dosage needed to treat
adenoma (most common endogenous) underlying disease process
• Hyperplasia of adrenal gland (less common)
• Ectopic production of ACTH by malignancies ADDISON’S DISEASE
CLINICAL MANIFESTATIONS • Primary adrenocortical insufficiency
• Moon- face • Occurs when the adrenal glands are damaged and cannot
• Buffalo hump secret adrenocortical hormones
• Virilization (women): CAUSES
appearance of • Autoimmune or idiopathic atrophy
masculine traits and • Abrupt withdrawal of corticosteroids
recession of feminine • Adrenalectomy
traits • Infections (i.e., tuberculosis and histoplasmosis)
• Truncal obesity but CLINICAL MANIFESTATIONS
thin extremities • Muscle weakness
• Purple/Red Striae • Anorexia
• Easy bruising • GI symptoms
• Menstrual disorders • Emaciation
• HTN •Dark pigmentation of knuckles,
• Unexplained hypokalemia knees, and elbows, dehydration
• Sleep disturbances • Hypoglycemia, hyponatremia,
• Hyperglycemia hyperkalemia
• Osteoporosis, Pathologic fractures • Emotional lability
• Bronze pigmentation of skin
MEDICAL MANAGEMENT
• Hydrocortisone (Solu- cortef), as
ordered
• Fludrocortisone (Florinef), as ordered
• Dietary:
• High sodium, low potassium
• Small, frequent feedings if with anorexia
ADDISONIAN CRISIS
• Hypotension, cyanosis, fever, n&v, signs of shock
• Cause: stress, exposure to cold, acute infection, decreased
DIAGNOSTICS salt intake, dehydration
Serum cortisol level • Management:
• Normal: • High-dose hydrocortisone IV
• high in early morning (6 to 8 am) • 5% dextrose in normal saline IV- to reverse hypotension
• 10-20 mcg/dL; • Vasopressors, if with persistent hypotension
• low in the evening (4 to 6 pm) PRIMARY ALDOSTERONISM
• 3-10 mcg/dL • Excessive production of aldosterone
• Abnormal: disruption of normal variation Cause:
Dexamethasone suppression test • Tumor of the adrenal gland (solitary adrenocortical
• Dexamethasone 1mg (low dose) or 8 mg (high dose) PO at adenoma)
bedtime, then plasma cortisol and ACTH levels are obtained CLINICAL MANIFESTATION
at 8am the next morning • Hypertension
PARAMETER NORMAL
Cortisol 5-25 mcg/dL
• Hypokalemia
ACTH 10-60 pg/mL • Muscle weakness
• Fatigue
• Dysrhythmias
DIAGNOSTICS
Captopril Challenge Test (CCT)
• ACE inhibitors normally block the activity of RAAS
Give 25-50 mg captopril PO after sitting/standing for at least 1
hours with blood samples drawn at time zero and after 2 hours
for plasma renin activity (PRC) and plasma aldosterone
measurements
• (+): Plasma aldosterone is >/= 8.5 ng/Dl AND renin remain
suppressed
COLLABORATIVE MANAGEMENT
Transsphenoidal hypophysectomy
• Done if cause is a pituitary tumor
Adrenalectomy (Laparoscopic):
• Done if cause is adrenal hypertrophy
Post operative care:
• Symptoms of adrenal insufficiency may appear 12 to 48
hours after surgery
• Hydrocortisone is given for several months
Adrenal enzyme inhibitor
• Metyrapone (Metopirone), Ketoconazole
COLLABORATIVE MANAGEMENT
(Nizoral)
• Used if cause is an ectopic ACTH production Laparoscopic adrenalectomy:
Dose reduction • Done to achieve total surgical removal of adrenal tumor
• Done if cause of syndrome is the administration • Less complications and shorter hospital stay
of corticosteroids • Spironolactone (Aldactone)
• Potassium- sparing diuretic
• Controls hypertension without causing further hypokalemia

JHTA