PRE-INTENSIVE

MEDICAL SURGICAL
MR. RISKY VANGUARDIA | AUGUST 4, 2025

ENDOCRINE DISORDER

OUTLINE: - Poor skin turgor

I. ANTIDIURETIC DISORDERS - Sunken eyeballs
A. Syndrome Of Inappropriate Antidiuretic Hormone - Cravings for water (extreme thirst)
(SIADH) • Urine specific gravity:
B. Diabetes Insipidus (DI) - Normal SG: 1.010 - 1.030
II. T3-T4 - DI: Diluted urine
A. Hyperthyroidism
B. Hypothyroidsim MANAGEMENT
III. PARATHORMONE DISORDERS • ↑ Oral fluids
A. Hyperparathyroidism • IVF - hypotonic solutions (swelling); Volume
B. Hypoparathyroidism replacement
IV. ADRENAL/SUPRARENAL DISORDERS • Medications
A. Pheochromocytoma - Antidiuretics
B. Cushing’s syndrome
o Vasopressin (IM/V)
C. Addison’s disease
o Desmopressin (Intranasal)
V. DIABETES MELLITUS (DM)
o Action: water retention
A. Type 1
o Effect: Normal urine output & specific
B. Type 2
C. Insulin
gravity
VI. REFERENCES o Principle in endo (all hypo): Give
VII. ABBREVIATIONS medications lifetime
VIII. APPENDIX • Avoid caffeine & alcohol
LEGEND: T3 AND T4
Black for PowerPoint, red for audio lecture, blue for book
• Metabolism = Body heat

ANTIDIURETIC HORMONE/DISORDERS HYPERTHYROIDISM

• ↑ ADH = SIADH (Si inday and devoing H20) • ↑ T3 Т4 = ↑ BMR = ↑ metabolism = ↑ body heat
• ↓ ADH = DM (Dami lhi) • HYPER = SNS = ↑ VS
• Very hot and wet
SYNDROME OF INAPPROPRIATE ANTIDIURETUIC
HORMONE (SIADH) FACTORS
• ↑ ADH = ↑ Water retention • Thyroiditis
- ↑ Blood vol = ↑ Cardiac Output = ↑ BP • Tumor/ nodes
• Hypervolemia: • ↑ Intake of T3T4
- Edema • Autoimmune (Grave's disease)
- Dilutional hyponatremia
- Altered LOC (confusion & irritability) SIGNS AND SYMPTOMS
• Urine specific gravity: • All are increase except weight (weight loss) &
- Normal SG: 1.010 - 1.030 menses (amenorrhea)
- SIADH: Concentrated urine (oliguria/ anuria) • Inc Body heat (Heat intolerance)
o Oliguria: <500 mL/day • Diarrhea
o Anuria: <50 mL/day • ↑ VS (BP. RR, HR, Temp)
• Danger: Water intoxication (early sign: Vomiting) • Hypermetabolism
• Insomnia
MANAGEMENT
• CNS changes: irritable, restless, tremors
• Limit/ Restrict Fluid intake (<1L/day)
• Perspiration
• Diet: ↑ Sodium
• Weight client daily DIAGNOSTIC TEST
• Skin care (meticulous) - because of edema; • ↑ T3 T4
repositioning every 2 hours
• ↓ TSH
• Medications • Thyroid Scan
- Diuretics: - Enlarged thyroid gland
o Furosemide (Lasix) - loop diuretic - Palpate behind the patient & palpate below
o Mannitol
• Radioactive Iodine (RAIU)
- Measures thyroid activity
DIABETES INSIPIDUS (DI)
- Direct testing iodine
• ↓ ADH = ↑ water excretion
• Iodine 131 (PO)
• ↑ Urine output = marked polyuria (5 - 20 U/day) - Result:
- Weight client daily
o Normal: 3-10% uptake (euthyroid)
• Dehydration (severe)
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PRE-INTENSIVE
MEDICAL SURGICAL
MR. RISKY VANGUARDIA | AUGUST 4, 2025

ENDOCRINE DISORDER
o Abnormal: <10% (hyperactive overactive § Laryngeal damage
thyroid) - (+) Hoarseness (normal until 5
o Early sign: Exophthalmos Hyperactive days)
thyroid) - No voice (aphonia)
§ Accidental removal of parathyroid
MANAGEMENT gland
• Medications: ⁃ Early sign: ↓ Tetany & spasm
- Thionarides. ⁃ Late sign: Chvostek & trousseau
o Propylthiouracil (PTU) – preferred sign
§ Side effect: Agranulocytosis ⁃ Priority: Airway
o Methimazole ⁃ Medications: Calcium gluconate
§ More potent
⁃ Bedside: Trachea set
§ Used as maintenance dose
• Environment
o Thioamides MOA
§ Blocks T3/T4 ⁃ Provide cold environment because client is heat
§ Effect: adequate sleep intolerant
§ Immunosuppressants ⁃ Light clothing
o Iodine solution • Oral fluids
§ Lugol's solution • Diet:
⁃ ↓ Vascularity of thyroid gland ⁃ ↑ Caloric intake (4000-5000 kcal) day
⁃ ↓ Thyroid state o Normal: Caloric intake of a person 1800-
⁃ ↓ Bleeding 2000 kcal/day (under normal condition)
o Pregnant: + 300
⁃ Given: Before Thyroidectomy
(around 10 - 14 days before o Lactating: + 500
surgery) ⁃ ↑ Protein
o Radioactive iodine ⁃ ↓ Fiber (residue)
§ Teratogenic • Avoid caffeinated/ decaffeinated beverages, energy
§ In all trimester in pregnancy drinks
§ No pregnancy for the next 6 mos. • Exophthalmos (Bulging eyes)
§ Oral iodine 131 ⁃ Problem: Corneal drying
⁃ Destroys overactive cells ⁃ Advice patient to wear shades or sunglasses
(thyroid) ⁃ Artificial tears to promote moisture
⁃ Action: To destroy overactive • Uncontrolled/undiagnosed hyperthyroidism
cells (malignant) - Danger: Thyroid storm/crisis
⁃ Low dose: No special - Severe, life threatening, fatal
precaution - Factors: ↑ Stress, (+) infection, trauma,
⁃ High dose: Contact Precaution surgery, dental work, pregnancy
⁃ Risk: Hypothyroidism - High temp (>40 degree Celsius)
- HPN/HTN
⁃ Avoid: Seafoods, cabbage, †
- Drug of choice: PTU
iodine foods (2 - 4 weeks)
o 48 - 96 hours contact precaution
PARATHYROID GLAND
§ Sleep alone (use separate
towels/linens) • Will produce parathormone (PTH)
§ ↑ Fluid intake • ↑ PTH
§ No direct contact (kissing, sex & - Hypercalcemia
sitting close) - ↑ Calcium in bones: Risk for fracture
§ Flush toilet twice - ↑ Calcium in blood: Risk for renal stones
o Beta - blockers ("glol") • ↓ PTH
§ Controls palpitations - Hypocalcemia
• Surgery - ↓ Calcium in blood
⁃ Thyroidectomy - (+) Spasm (bronchospasm, laryngeal spasm,
pharyngeal spasms)
⁃ Post-thyroidectomy:
- (+) Tetany
o Priority: Airway
o Position: Semi-fowlers
HYPERPARATHYROIDISM
o Complications:
• ↑ in PTH (hypercalcemia)
§ Hemorrhage (Assess for):
• ↑ Excretion of phosphate (hypophosphatemia)
⁃ Dressing
⁃ Neck/ back of the neck • ↑ in CA = ↓ Muscle excise (constipation, weakness,
fatigue)
⁃ Avoid neck hyperextension
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PRE-INTENSIVE
MEDICAL SURGICAL
MR. RISKY VANGUARDIA | AUGUST 4, 2025

ENDOCRINE DISORDER
• ↑ Risk for renal stones • Priority
• ↑ Risk for fracture ( ↓ Ca in bones) - During seizure: Safety
• If taking calcium supplements, should do weight - After seizure: Airway
bearing exercise. If will not do exercise, prone to - Patient in seizure avoid all kind of strains
fracture because it can cause fractures/ injury
• Arrhythmias/ dysrhythmias - Side rails up always and bed on lowest position
to the floor
DIAGNOSTIC • Diet: Inc calcium diet (milk, dairy products, salmon,
• ↑ Calcium serum anchovies)
• ↓ serum phosphate • At bedside: Tracheo set
• Monitor cardiac rhythms (ECG)
MANAGEMENT
• Medication ADRENAL GLANDS
- Calcitonin • Medulla
o Prevents bone resorption - Pheochromocytoma
o Resorption: destruction of tissues on • Cortex (GMA)
bones that could lead to fracture - Cushing’s
- Atendronate - Addison’s
o Oral biphosphate
o Management and prevention of PHEOCHROMOCYTOMA
osteoporosis • (+) Tumor at chromaffin cells
o Taken upon arising/ 30 mins. before meals - Benign
o After taking, advice patient to sit upright or • ↑ catecholamine production (Epinephrine/
stand for 30 minutes (to prevent Norepinephrine) = ↑ SNS effect
esophageal ulceration - because it is irritant
to GI lining) SIGNS AND SYMPTOMS
• ↑ fluid intake • Hypertension (sustained hypertension)
• Strain all urine • headache
• Diet: ↓ calcium in diet • Hyperhidrosis (excessive perspiration)
• Ambulation and exercise (it will increase calcium in • Hypermetabolism (Inc body heat and weight loss)
bone the calcium in blood will decrease) • Hyperglycemia
• Surgery: Parathyroidectomy
DIAGNOSTIC
HYPORPARATHYROIDISM • Vanillylmandelic Acid Test (VMA)
• ↓ PTH (hypocalcemia) - Specimen: 24hr. urine collection
- Result:
SIGNS AND SYMPTOMS o (N) Plasma Epi: 100 pg/mL
• Spasm o (N) Plasma Norepi: 100-500 pg/mL
• Tetany o + Pheochromocytoma: Abnormal when
• ECG changes already x4 from normal range
• Tingling sensation
• Paresthesia MANAGEMENT
• (+) Laryngospasm, (+) bronchospasm, (+) • Goal: Control hypertension
esophageal spasm • Ultimate Mgt: Adrenalectomy
• (+) Chvostek’s (muscle twitching on face) • Medications
• (+) Trousseau’s sign (carpopedal spasm) - Anti-hypertensive medications
• Risk for seizure activity o Phenoxybenzamine
o Doxazosin
MANAGEMENT o Given: 10-14 days before surgery
- Betablockers
• Medication
o Propranolol, Metoprolol
- Calcium Gluconate
- Calcium Channel Blockers
- Vitamin D supplements
o Nifedipine
- Oral calcium supplements
• Bed rest
• Avoid precipitating stimulus (seizure)
• ↑ fluids
- Avoid:
o Glaring lights • Monitor blood glucose level
o Loud noises • Surgery: Adrenalectomy
o Banging - WOF: Hypotension, hypoglycemia
• Private room (semi-dark/ dim light room) - If + Bilateral adrenalectomy: Corticosteroid
replacement for life
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PRE-INTENSIVE
MEDICAL SURGICAL
MR. RISKY VANGUARDIA | AUGUST 4, 2025

ENDOCRINE DISORDER
CUSHING’S DISEASE • Mineralocorticoids: Aldosterone
• Common in women of 20-40 years old - ↑ of Na, H2O
• ↑ GMA - Hypovolemia (dec CO, dec BP) = dehydration
- Glucocorticoids - Hyperkalemia (irritability, dysrhythmia)
- Mineralocorticoids - Weight loss
- Androgens - ↑ in ACTH
• Androgens: Sex hormone
SIGNS AND SYMPTOMS - Hyperpigmentation of skin
• Glucocorticoids: Sugar - Bronze-skin pigmentation (knuckles, kinase,
- Hyperglycemia skin folds)
- Immunosuppression (↑ risk for infection) - Loss of pubic hair, axillary hair
• Mineralocorticoids: Aldosterone
- Sodium and water retention MANAGEMENT
- Signs of hypernatremia • Medication
- ↑ blood volume = ↑ Cardiac output = ↑ BP - Corticosteroids
- Edema o Immunosuppressants, gastric irritant
- Weight gain o Long term use: Will cause Cushingoid
- Hypocalcemia: Muscle weakness and ECG effects
changes o At risk for fracture because steroids
- Moon face decrease bone in density
- Truncal obesity - Fludrocortisone
- Buffalo hump o Mineralocorticoids
- Pendulous abdomen o IV hydrocortisone
- Thin extremities - Vasopressor
• Androgens: Sex hormones o (+) hypotension
- Virilization/ virilism • ↑ Fluid intake
- Masculinization • ↑ Na intake
- Absence of menstruation (amenorrhea) • Avoid unnecessary/ strenuous activity
- Hirsutism • Diet: High carbs, high protein, high sodium, low
- Deepening of voice potassium diet
- Clitoris enlargement • Prevent: Addisonian Crisis
- Acne, striae (stretch marks) - Causes: Stress, infection, cold exposure,
- Impotence decrease sodium
- Signs and symptoms
DIAGNOSTIC TEST o Severe hypotension
• ↑ in blood glucose o Severe Hypokalemia
• ↑ Na o Severe Hyponatremia
• ↓K - Management:
o IV hydrocortisone
MANAGEMENT o Fluid replacement
• Medication
- Diuretics (K-Sparing) ADRENAL GLANDS
- Mitotane (Adrenal enzyme inhibitor)
• Restrict fluids TYPE 1 DM
• Weight client daily • Juvenile onset (childhood)
• Skin care (edema) • Insulin dependent
• Diet: Low sodium, low carbs, high protein, high • Cause: Destruction of beta cells (autoimmune)
potassium
• Surgery: Adrenalectomy SIGNS AND SYMPTOMS
• 3P’s: Polydipsia, Polyuria, Polyphagia
ADDISON’S DISEASE • Weight loss
• Primary adrenal insufficiency
• ↓ GMA MANAGEMENT
o Glucocorticoids • Diet
o Mineralocorticoids • Most important MGT: Insulin
o Androgens • Exercise

SIGNS AND SYMPTOMS COMPLICATION: DIABETIC KETOACIDOSIS (DKA)

• Glucocorticoids: Sugar • Absence/ inadequate of insulin
- Hypoglycemia
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PRE-INTENSIVE
MEDICAL SURGICAL
MR. RISKY VANGUARDIA | AUGUST 4, 2025

ENDOCRINE DISORDER
• Main feature: Hyperglycemia, dehydration, and loss o Sulfonylureas
of electrolytes, acidosis § Action: Increase insulin secretion
• Cause: Missed insulin dose, illness/infection, § Tolbutamide, glyburide, glipizide
undiagnosed/untreated DM § Taken with food
• Onset: Abrupt/ sudden o Meglitinide
• RBS: >250 mg/dL § Action: Increase insulin
• Breathing: Kussmaul’s breathing § Repaglinide, Neteglinide
• Urine: Ketonuria § Taken 30 mins, before meals
• Management: o Biguanides
- Hydrate (0.9 NSS at rapid rate) § Action: Insulin sensitizers
- Major electrolyte concern: Potassium § Metformin
(Hypokalemia) § Taken with foods
- Give: Insulin (treats acidosis) and Potassium o Glitazones
supplements § Action: Insulin sensitizer
§ Progligazone, Rosiglitazone
TYPE 2 DM § Taken anytime
o Alpha-glucosidase inhibitor
• Non-insulin dependent
§ Action: Delays digestion and reduce
• Insulin problem:
absorption of the carbohydrates
- Abnormal insulin production
§ Acarbose
- Insulin resistance
§ Bite the food first before taking the
• Glucose problem: ↑ GAlucose intake (diet) medication
• Effect of Insulin: Hypoglycemia and hypokalemia • Diet: Balanced diet
- Carbohydrates: 50-60%
SIGNS AND SYMPTOMS - Protein: 20-30%
• Early: 3 P’s + weight gain - Fats: 10%
- Polyuria • Exercise
o Hyperglycemia (osmotic diuresis) - ↑ Insulin sensitivity
- Polydipsia - Best exercise: Walking
o Increased viscosity of blood
- Polyphagia COMPLICATION: HYPERGLYCEMIC HYPEROSMOLAR
o Potassium allows glucose to enter the cells NONKETOTIC SYNDROME (HHNS)
o Without insulin, potassium is unable to
• Causes: Infection, acute illness
attach the cell and glucose can’t enter the
• Onset: Slow/gradual
cell
o Thus, cell starvation happens • RBS: >600 mg/dL
• Late: Sweet urine (presence black ants) • Main problem: Severe dehydration
• Sudden weight loss (at least 5 kls.) • Management: hydration

DIAGNOSTIC TEST INSULIN

• Use gauge 30 – 0.5 inch long (NCLEX: 27-29
• Fasting Blood Sugar (FBS)
gauge)
- Patient on NPO
- Normal: 70-110 mg/dL • Timing: 30 mins before meals
- + DM: >125 mg/dL • Speed: Slowly administer insulin
• Oral Glucose Tolerance Test (OGTT) • Temperature:
- Patient on NPO (10hrs) - Giving: Room temperature
- Patient receives 75 mg carbohydrates in AM - Storage: Cold temperature around 5-8 Degree
- Check blood sugar (2 hours after carbohydrates Celsius
intake and it must not be >200 mg/dL) • Site: Abdomen, upper arms, thighs
- Normal: <200 mg/dL • Greatest absorption: Abdomen
- + DM: >200 mg/dL • Angle: 90 degree (45 degree if thin)
• Glycosylated Hemoglobin (HbAIC) • Aspiration: NO
- Most important dx test • Caution: Do not exercise/ use the part (it will
- This will assess glucose utilization for the last 3 increase absorption)
months • Discard expired insulin
- Normal: <7% (good management) • Use insulin map:
- + DM: >9% (bad management) ⁃ To avoid giving same site
⁃ To rotate the site
MANAGEMENT ⁃ Attached on the bed frame
• Medications ⁃ Distance: 1 inch away
- Oral Hypoglycemic Agent (OHA)
⁃ Same site of injection: Lipodystrophy
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PRE-INTENSIVE
MEDICAL SURGICAL
MR. RISKY VANGUARDIA | AUGUST 4, 2025

ENDOCRINE DISORDER
⁃ Too fast administer: Hardening of site
• Monitor: Hypoglycemia (<50 mg/dL)
- Signs and symptoms:
o Shakiness, sweating, nervousness,
hunger, weakness
- Cause:
o Too much insulin
o Too much exercise
o No food
- Management:
o 15 g concentrated CHO
o 1/2 juice
o 1/2 sandwich
o Crackers
o 2-3 glucose tablet

TYPES OF APPEARANCE ROLL SQ IV

INSULIN GENTLY
Rapid Acting Clear ✕ ✓ ✕
(Humulog
Lispro)
Short Acting Clear ✕ ✓ ✓
(Humulin R)
Intermediate Cloudy ✓ ✓ ✕
Acting (Humulin
NPH, Lente)
Long Acting Cloudy ✓ ✓ ✕
(Ultralente/
Glargin – Lantus)

TYPES OF ONSET PEAK DURATION

INSULIN
Rapid Acting 10 – 15 mins. 30 mins. – 3 hrs. 3 – 5 hrs.
(Humulog
Lispro)
Short Acting 30 mins. – hr. 2 – 5 hrs. 5 – 8 hrs.
(Humulin R)
Intermediate 1.5 – 4 hrs. 4 – 12 hrs. 12 – 18 hrs.
Acting (Humulin
NPH, Lente)
Long Acting 1 – 4 hrs. Steady >24 hrs.
(Ultralente/ (peak less/
Glargin – prolonged
Lantus) hypoglycemic
effect)

END OF TRANSCRIPTION

REFERENCES
• Sir Ricky’s lecture

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