ENDOCRINE SYSTEM

➢ The endocrine system plays a vital role in growth and development, the metabolism of energy, muscle and adipose,
tissue distribution, sexual development, fluid and electrolyte imbalance, and inflammation and immune responses.
➢ The endocrine system involves the release of chemical substances known as hormones to regulate and integrate body
functions.
➢ Disorders of the endocrine system are common and are manifested as hyperfunction and hypofunction.
Glands of the Endocrine System
1. PITUITARY
2. ADRENAL
3. PARATHYROID
4. PANCREAS
5. OVARIES
6. TESTES
7. THYROID

I- PITUITARY GLAND
➢ Located at the base of the brain.
➢ Directly affects the function of the other endocrine glands.
➢ Promotes growth of body tissues.
➢ Influences water absorption by the kidney.
➢ Controls sexual development and function.
1. Anterior pituitary gland (APG)
a. FSH – stimulates graafian follicle growth and estrogen secretion.
b. LH – induces ovulation & development of corpus luteum and stimulates testosterone secretion in men.
c. ACTH – stimulates secretion of hormones from adrenal cortex.
d. TSH – regulates secretory activity of thyroid gland.
e. GH – stimulates growth of cells, bones, muscles and soft tissue.
f. Prolactin – development of mammary glands & lactation
g. MSH- melanocyte stimulating hormone
2. Posterior Pituitary Gland (PPG)
a. ADH (Vasopressin) - regulates water metabolism, helps body to retain water.
b. Oxytocin- stimulates uterine contractions during labor milk secretion in lactating mothers.
II- ADRENAL GLAND
✓ Two small glands, one above each kidney.
✓ Regulates sodium and water retention.
✓ Affects CHO, fat and CHON metabolism.
✓ Influences development of sexual characteristics.
✓ The adrenal cortex synthesizes glucocorticoids and mineralocorticoids.
✓ The adrenal medulla produces epinephrine and norepinephrine.
Adrenal cortex
a. Glucocorticoids - (Cortisol, Cortisone, Cortecosterone)
✓ Increase blood glucose levels by increasing rate of glyconeogenesis
✓ Increases CHON catabolism
✓ Increase mobilization of fatty acids
✓ Promote sodium & water retention
✓ Anti-inflammatory effect
 ✓ Aid the body in coping stress.
b. Mineralocorticoids - (Aldosterone, Deoxycortisone)
✓ Regulate F/E balance
✓ Stimulate reabsorption of sodium chloride & water
✓ Stimulate potassium excretion.
2. Adrenal medulla- secretes catecholamine epinephrine and norepinephrine
✓ Function in acute stress
✓ Increase heart rate & BP
✓ Dilate bronchiole
✓ Convert glycogen to glucose when needed by muscles for energy.
III- THYROID GLAND- secretes T3 & T4, Thyrocalcitonin
✓ Regulate metabolic rate, CHO, fat and CHON metabolism
✓ Aid in regulating physical and mental growth & development.
✓ Lowers serum calcium by increasing bone deposition.
IV- PARATHYROID GLAND- PTH (parathormone)
✓ Located near the thyroid.
✓ Controls calcium and phosphorus metabolism.
✓ Produces parathyroid hormone
V- PANCREAS
✓ Located posterior of liver.
✓ Influences CHO metabolism.
✓ Indirectly influences fat and CHON metabolism.
✓ Produces insulin and glucagon.
❖ Insulin- allows glucose, potassium and magnesium to diffuse across cell membrane converts glucose to glycogen.
❖ Glucagon- Increases blood glucose by causing gluconeogenesis in the liver secreted in response to blood sugar.
VI- OVARIES
✓ Located in the pelvic cavity.
✓ Produce estrogen and progesterone.
VII- TESTES
✓ Located in the scrotum.
✓ Contributes to the development of secondary sex characteristics.
✓ Produce testosterone.
Diagnostic Tests
1. RADIOACTIVE IODINE UPTAKE (RAIU)
✓ A thyroid function test that measures the absorption of the iodine isotope to determine how the thyroid gland is
functioning.
✓ Administration of I123 or I131 orally followed in 24 hours by a scan of the thyroid for the amount of radioactivity
emitted.
✓ Normal value is 10-35% in 24 hours
Elevated values indicates:
a. Hyperthyroidism
b. Thyrotoxicosis
c. Decreased iodine intake
d. increased iodine excretion
Decreased values indicates:
a. Hypothyroidism
b. Thyroiditis
c. Low T4
d. Use of anti-thyroid meds.
➢ Thyroid medication must be discontinued 7-10 days prior to test.
➢ No radiation precautions necessary.
2. T3 & T4 RESIN UPTAKE TEST
✓ T3 & T4 regulate thyroid-stimulating hormone
✓ Normal Value of: T3: 80-230 ng/dL T4: 5-12 ng/dL
✓ Increase in hyperthyroidism
✓ Decreased in hypothyroidism
3. THYROID-STIMULATING HORMONE (TSH)
✓ Blood test used to differentiate the diagnosis of primary hypothyroidism from secondary hypothyroidism.
 ✓ Normal value is 0.2 to 5.4 IU/ml
✓ Increased in primary hypothyroidism
✓ Decreased in hyperthyroidism or secondary hypothyroidism
4. THYROID SCAN
✓ Performed to identify nodules or growths in the thyroid glands
✓ A radio isotope of iodine or technetium is administered prior to the scanning of the thyroid gland.
✓ Level of radioisotope is not dangerous to self or others.
Nursing considerations:
1. Discontinue medications containing iodine 14 days prior to test
2. Discontinue thyroid meds 4-6 weeks prior to test.
3. NPO post MN- if iodine is used client will fast an additional 45 minutes after ingestion of radioactive isotope
4. Scan is done after 24 hours.
5. NEEDLE ASPIRATION OF THYROID TISSUE
✓ Aspiration of thyroid tissue for cytological exam
✓ Diagnostic test for thyroid cancer
a. Invasive, Informed consent
b. No preparation needed
c. Check PT, Vit. K at bedside
d. Strict asepsis
e. Local anesthetics
f. Light pressure applied to aspiration site after the procedure
6. Eight-hour intravenous ACTH Test
✓ Used to determine function of adrenal cortex.
✓ Administration of 25 units of ACTH in 500 ml of saline over an 8-hr period.
✓ 24-hr urine specimens are collected before & after administration for measurement of 17-ketosteroids and 17-
hydrocorticosteroids.
✓ In Addison’s disease
➢ urinary output of steroids does not increase following administration of ACTH
✓ Normally steroid excretion increases threefold to fivefold ff. ACTH administration.
✓ In Cushing’s syndrome
✓ Hyperactivity of the adrenal cortex increases the urine output of steroids in the second urine specimen tenfold.
7. GLUCOSE TOLERANCE TEST (GTT)
✓ Aids in the diagnosis of diabetes mellitus
✓ If the glucose level peaks at higher than normal at 1 to 2 hours after injection or ingestion of glucose, and are slower
than normal to return to normal levels, DM is diagnosed
Preparation:
a. Eat a high-carbohydrate (200 to 300 g) diet for 3 days before the test
b. Avoid alcohol, coffee & smoking 36 hours before testing
c. Fast midnight before test
d. Fasting blood glucose & urine glucose specimens obtained.
e. Avoid strenuous exercise 8 hours before & after test
f. Client ingests 100g glucose; blood sugar drawn at 30 & 60 minutes, then hourly for 3-5 hrs.; urine specimens
may also be collected.
8. GLYCOSYLATED HEMOGLOBIN
✓ Glycosylated hemoglobin is blood glucose bound to hemoglobin
✓ Is a reflection of how well blood glucose levels have been controlled for up to the prior 4 months
✓ Hyperglycemia in clients with DM causes increase in glycosylated hemoglobin
Fasting is not needed
Values:
Diabetics with good control: 7.5% or less
Diabetics with fair control: 7.6% to 8.9%
Diabetics with poor control: 9% or greater
Disorders of Pituitary Gland
1. ANTERIOR PITUITARY
✓ Hypopituitarism
✓ Hyperpituitarism
2. POSTERIOR PITUITARY
✓ Diabetes Insipidus
✓ SIADH (Syndrome of Inappropriate Antidiuretic Hormone)
A. HYPOPITUITARISM - Hyposecretion of growth hormone by the anterior pituitary gland.
S/Sx:
1. Retarded physical growth
2. Premature aging
3. Low intellectual development
4. Poor development of secondary sex characteristics
Medical management
1. Given human growth hormone
2. Offer emotional support to client & family

B. HYPERPITUITARISM
✓ Hypersecretion of GH by anterior pituitary gland which results in gigantism or acromegaly
✓ Gigantism occurs in childhood before the closure of epiphyses of the long bones
✓ Acromegaly which occurs after the closure of epiphyses of the long bones
S/Sx:
1. Large hands & feet
2. Thickening & protrusion of jaw
3. Arthritic changes
4. Visual disturbances
5. Diaphoresis, oily & rough skin
6. Organomegaly
7. Hypertension
8. Dysphagia
9. deepening of voice

Nursing Management
1. Emotional support
2. Frequent skin care
3. Pharmacologic & non- pharmacologic
4. Interventions for joint pains
 5. Prepare for radiation of pituitary gland
Surgical Intervention
Hypophysectomy
✓ Removal of pituitary gland
✓ Post-operative care:
✓ Monitor V/S, neurological status & LOC
✓ Elevate head of bed
✓ Monitor for increased intracranial pressure & any postnasal drip which might be CSF
✓ Avoid sneezing, coughing & blowing nose
✓ Monitor for temporary diabetes insipidus
✓ Monitor I & O & water intoxication
✓ Administer antibiotics, analgesics, antipyretics hormones & glucocorticoids if entire gland is removed

C. DIABETES INSIPIDUS
✓ Hyposecretion of ADH & deficiency of vasopressin
S/Sx:
1. Polyuria of 4-24 liters/day
2. Signs of dehydrations- decreased skin turgor, dry mucus membranes
3. fatigue, headache, postural hypotension
4. Polydipsia
5. Inability to concentrate urine - low urine specific gravity of 1.004 or less

Nursing Management
1. Provision of safe environment especially with decreasing LOC
2. Monitoring I & O with specific gravity
3. Wear Medic-Alert bracelet
4. Meds:
✓ Vasopressin tannate (Pitressin Tannate)
✓ Desmopressin acetate (DDAVP, Stimate) lypressin (Diapid)
▪ Enhances reabsorption of water in the kidney promoting antidiuretic effect & regulates fluid balance
A/R: hypertension; nasal congestion
D. SYNDROME OF INAPPROPRIATE ANTIDIUREDIC HORMONE (SIADH)
✓ Hypersecretion of ADH
S/Sx:
1. Signs of fluid overload- weight gain, hypertension, tachycardia
2. Changes in LOC & mental status
3. Hyponatremia
Nursing Management
1. Monitor I & O and daily weight
2. Monitor fluid & electrolyte balance
3. Restrict fluids as prescribed
4. Administer diuretics
5. Monitor IV fluids carefully
6. Demeclocycline (Declomycin)- inhibits ADH-induced water reabsorption & produces water diuresis
Disorders of the Adrenal Gland
1. ADRENAL CORTEX
✓ Addison’s disease
✓ Cushing’s syndrome
✓ Aldosteronism (Conn’s Syndrome)
2. ADRENAL MEDULLA
✓ Pheochromocytoma
A. ADDISON’S DISEASE- Hyposecretion of the adrenal cortex hormones.
Assessment:
Subjective:
1. Muscle weakness, fatigue, lethargy, dizziness, fainting
2. Nausea, anorexia
3. Abdominal pain/cramps.
Objective:
1. Decreased BP, orthostatic hypotension
2. Pulse: increased, collapsing, irregular
3. Subnormal temp
4. Vomiting, diarrhea, weight loss
5. Tremors
6. Skin: poor turgor, excessive pigmentation (bronze tone)
7. Hyponatremia, hypoglycemia, hyperkalemia

NURSING MANAGEMENT:
1. Decrease stress- Provide quiet environment, non-demanding schedule.
2. Promote adequate nutrition:
✓ acute phase- high sodium, low potassium
✓ non-acute phase- increase CHO and CHON
✓ Fluids: force to balance fluid
3. Monitor I&O
4. Daily weight monitoring
3. Administer lifelong exogenous replacement therapy as ordered
1. Glucocorticoids- prednisone, hydrocortisone
2. Mineralocorticoids- fludrocortisone (Florinef)
4. Health teaching:
a. Take meds with food or milk.
b. Avoid stress
5. Monitor for s/sx of addisonian crisis
ADDISONIAN CRISIS
✓ Life-threatening disorder caused by acute adrenal insufficiency precipitated by stress, infection, trauma or surgery.
✓ May cause:
a. Hyponatremia, hypoglycemia, hyperkalemia & shock.
b. Severe, generalized muscle weakness
c. Severe hypotension, hypovolemia shock (vascular collapse)
Management
1. Given glucocorticoids IV - hydrocortisone Na succinate (Solu-Cortef)
2. Mineralocorticoids e.g. fludrocortisone (Florinef).
3. Check BP & electrolyte levels.
4. Strict bed rest in quiet environment
5. Protect from infection.
B. CUSHING’S SYNDROME- Hypersecretion of corticoids.
ASSESSEMENT:
Subjective:
1. Headache, backache
2. Weakness, decreased work capacity
Objective:
1. Hypertension, weight gain, pitting edema
2. Characteristic fat deposits- truncal & cervical obesity (buffalo hump), pendulous abdomen
3. Purple striae, easy bruising
4. Moon face, Acne, hyperpigmentation,
5. Impotence
6. Virilization in women: hirsutism, breast atrophy, Amenorrhea
7. Pathologic fractures, reduced height
8. Slow wound healing
9. Hypernatremia, hyperglycemia, hypokalemia

NURSING MANAGEMENT:
1. Promote comfort- protect from trauma.
2. Prevent complications- monitor fluid balance, glucose metabolism, Hypertension, infection.
3. Health teachings:
4. Diet:
✓ increased protein, Increased potassium, decreased calories, decreased sodium
5. Meds:
1. Cytoxic agents:
✓ aminoglutethimide (Cytadren)
✓ trilostane (Modrastane)
✓ mitotane (Lysodren)- to decrease cortisol production.
6. Replacement hormones as needed.
7. Monitor for progression of disease.
8. Prepare client for adrenalectomy.
C. HYPERALDOSTERONISM (CONN’S SYNDROME)
✓ Hypersecretion of aldosterone from the adrenal cortex of the adrenal gland commonly caused by adenoma.
ASSESSMENT
1. Hypertension, headache
2. Hypokalemia
3. polydipsia
4. Polyuria, low urine specific gravity
5. Hypernatremia
Management
1. Monitor I & O
2. Administer spironolactone (Aldactone)
3. K supplements
4. Maintain Na restriction
5. Administer antihypertensives
6. Wear Medic-Alert bracelet
7. Usually will be undergoing adrenalectomy- administer glucocorticoids pre & post-op.
D. PHEOCHROMOCYTOMA
✓ Catecholamine-producing tumor usually found in the adrenal gland.
✓ Causes hypersecretion of epinephrine & norepinephrine by the adrenal medulla
ASSESSMENT
1. HPN, severe headache, tachycardia, palpitations
2. Pain in chest or abdomen
3. Hyperglycemia & glucosuria
4. Profuse sweating
5. Nausea and vomiting
6. Dilated pupils

Complications :
1. Hypertensive retinopathy
2. CVA
3. CHF
Nursing Management
1. Monitor for hypertensive crisis & avoid stimuli which triggers it
Such as:
✓ increased abdominal pressure
✓ vigorous abdominal palpation and micturation
2. Instruct patient not to smoke, drink cola, coffee or tea
3. Monitor blood glucose & urine for glucose & acetone.
ADRENALECTOMY
✓ Surgical removal of one or more of the adrenal gland because of tumors or overactivity
✓ For unilateral adrenalectomy, up to 2 years of glucocorticoid therapy needed
✓ For bilateral…lifelong replacement

Pre-op:
1. Reduce risk of post-op complications:
a. Prescribed steroid therapy, given 1 wk. before surgery
b. Discontinue antihypertensive drugs
c. Sedation as ordered
During surgery:
a. Monitor for hypotension, hemorrhage
Post-op:
1. Promote hormonal balance, administer hydrocortisone
2. Monitor for signs of Addisonian crisis
3. Observe for hemorrhage and shock.
4. Prevent infection.
5. Administer cortisone or hydrocortisone as prescribed.
a. Bethamethasone (Celestone), cortisone (Cortone)
b. Dexamethasone (Decadron), prednisone (Orasone)
c. Stimulate the adrenal cortex to secrete cortisol
d. Produces an anti-inflammatory effect.
A/R- Increased appetite, mood swings, water & Na retention, hypocalcemia, Hypokalemia, cushing-like symptoms
7. Check I & O
8. Weight and for edema (decrease Na intake)
9. Monitor for infection
10. Monitor electrolyte & calcium levels
11. Monitor for poor wound healing, menstrual irregularities, decrease in growth & edema
12. Dose must be tapered & not stopped abruptly
13. Advise to wear Medic-Alert bracelet
ADRENOCORTOCOTROPIC HORMONE (Glucocorticoid, Minirralocorticoid)
✓ Produce metabolic effects, alters normal immune response suppress inflammation, promote Na & H2O retention, K+
excretion
✓ Produce anti-inflammatory, Anti-allergic, anti-stress effects, replacement for adrenocortical insufficiency.
A/R:
1. Increase appetite
2. Mood swing
3. Water and sodium retention
4. Hyperglycemia, hypokalemia
5. Edema & masks signs & symptoms of infection
6. Cushing’s-like symptoms
✓ Check I & O, weight and for edema (decrease Na intake)
✓ Monitor for infection
✓ Monitor electrolyte & calcium levels
 ✓ Monitor for poor wound healing, menstrual irregularities,
✓ Dose must be tapered & not stopped abruptly
✓ Advise to wear Medic-Alert bracelet
7. Contraindicated in client with DM
8. Increases effect of anticoagulants & oral anti-diabetic agents
9. Increases potency of aspirins & NSAIDS & K-sparing diuretics
10. Check for overdose or signs of Cushing’s syndrome
11. Additional doses during stress or surgery.
THYROID DISORDERS
A. HYPOTHYROIDISM (MYXEDEMA)-hyposecretion of the thyroid hormone characterized by decreased rate of body
metabolism.
ASSESSMENT:
Subjective data:
✓ Weakness, fatigue, lethargy, headache
✓ Slow memory
✓ Loss of interest in sexual activity.
Objective data:
✓ Depressed BMR
✓ Intolerance to cold
✓ Cardiomegaly, Bradycardia, Hypotension
✓ Anemia
✓ Menorrhagia, Amenorrhea, infertility
✓ Dry skin, brittle nails, coarse hair, hair loss
✓ Slow speech, hoarseness, thickened tongue
✓ Weight gain, edema, periorbital puffiness

Lab data:
✓ Elevated TRH, TSH normal-low serum T4 & T3 decreased
NURSING MANAGEMENT
1. Provide for comfort and safety: provide warmth, prevent heat loss & vascular collapse
2. Monitor HR including rhythm.
3. Instruct on low-calorie, low-cholesterol, low-saturated fat diet.
4. Assess for constipation & provide roughage.
5. Monitor for infection or trauma
6. Administer thyroid meds as ordered.
7. Monitor for overdose of thyroid meds.
8. Stress-management techniques
 9. Exercise program
Myxedema coma
✓ Rare but serious d/o which result from persistently low thyroid hormone precipitated by:
1. acute illness
2. rapid withdrawal of thyroid meds
3. use of sedatives & narcotics
S/Sx:
1. Hypotension, bradycardia
2. Hypothermia
3. Hyponatremia
4. Hypoglycemia
5. Respiratory failure & death
Nursing Interventions
1. Patent airway
2. Keep patient warm & check V/S frequently
3. Administer IV fluids & levothyroxine Na (Synthroid)
4. Give IV glucose & corticosteroids
B. HYPERTHYROIDISM (GRAVES DISEASE)
✓ Hypermetabolic condition is characterized by excessive amounts of thyroid hormone in the bloodstream.

Clinical Manifestations
1. Nervousness, emotional lability, irritability, apprehension.
2. Difficulty sitting quietly.
3. Rapid pulse at rest and on exertion (ranges between 90 and 160); palpitations.
4. Heat intolerance; profuse perspiration; flushed skin (eg, hands may be warm, soft, moist).
5. Fine tremor of hands; change in bowel habits—constipation or diarrhea.
6. Increased appetite and progressive weight loss; frequent stools.
7. Muscle fatigability and weakness; amenorrhea.
8. Atrial fibrillation possible (cardiac decompensation common in older patients).
9. Bulging eyes (exophthalmos)—seen only in Graves’ disease.
10. Thyroid gland may be palpable and a bruit may be auscultated over gland.
11. Course may be mild, characterized by remissions and exacerbations.
12. It may progress to emaciation, extreme nervousness, delirium, disorientation, thyroid storm or crisis, and death.
Diagnostic Evaluation
✓ Elevated T3 and T4.
✓ Elevated serum T3 resin uptake and free thyroid index (FTI).
✓ Low TSH levels.
✓ Presence of TSI antibodies (if Graves’ disease is the cause).
✓ 131I uptake scan may be elevated or below normal depending on the underlying cause of the hyperthyroidism.
MEDICAL MANAGEMENT:
1. Propylthiouracil (PTU) - blocks thyroid synthesis
2. Methimazole (Tapazole) - to inhibit synthesis of thyroid hormone
3. Iodine preparations (SSKI, Lugol’s Solution)
✓ Decrease size & vascularity of the thyroid gland
✓ Palatable if diluted with water, milk or juice
✓ Give through straw to prevent staining of teeth
✓ Takes 2-4 weeks before results are evident
4. Radioactive Iodine- (I 131) - limits secretion of thyroid hormone by destroying thyroid tissue.
5. Beta blockers: Propranolol (Inderal), atenolol (Tenormin), metoprolol (Lopressor)
✓ Given to counteract the increased metabolic effect of thyroid hormones
✓ Relieve symptoms of tachycardia, tremors & anxiety
NURSING MANAGEMENT:
a. Protect from stress: private room, restrict visitors, quiet environment.
b. Promote physical & emotional equilibrium: cool, quiet, cool well ventilated environment.
c. Eye care: sunglasses to protect from photophobia, protective drops (methylcellulose) to soothe cornea
d. Diet high calorie, protein, vit. B
e. Obtain daily weight
f. Avoid stimulants
g. Prevent complications: give medications as ordered.
h. Monitor for thyroid storm.
i. Health teaching:
✓ stress reduction techniques
✓ importance of medications
✓ methods to protect eyes from environment
✓ s/sx of thyroid storm.
THYROID STORM
✓ Acute & life threatening condition in uncontrolled hyperthyroidism.
Risk factors:
1. Infection, surgery
2. Beginning labor to give birth
3. Taking inadequate antithyroid medications before thyroidectomy.
Clinical manifestations
1. Fever
2. Tachycardia, hypotension
3. Marked respiratory distress, pulmonary edema
4. Irritability, apprehension, agitation, restlessness, confusion, seizures
Medical Management
1. Meds: PTU or Tapazole; Sodium iodide IV or Lugol’s solution orally; Propranolol (Inderal); Aspirin, Steroids, Diuretics
2. Removal of thyroid gland & performed for persistent hyperthyroidism
THYROIDECTOMY
✓ Removal of thyroid gland & performed for persistent hyperthyroidism
PRE-OPERATIVE CARE:
1. Assess V/S, weight, electrolyte & glucose level
2. Teach DBE & coughing as well as how to support neck in post-op period when coughing & moving
3. Administer antithyroid meds etc. to prevent thyroid storm
POST-OP CARE:
1. Monitor for respiratory distress
2. Have tracheostomy set O2 & suction machine at bed side
3. Maintain semi-Fowler’s position to reduce edema
4. Immobilize head with pillows/sandbags; prevent flexion & hyperextension of neck
5. Check surgical site for edema & bleeding
6. Limit client talking & assess for hoarseness
7. Assess for laryngeal nerve damage…high-pitched voice, stridor, dysphagia, dysphonia & restlessness
8. Monitor for signs of hypocalcemia & tetany & have calcium gluconate at bedside
THYROID HORMONES
1. Levothyroxine (Synthroid, Levothroid, Levoxyl)
2. Thyroglobulin (Proloid)
 a. Controls the metabolic rate of tissues & accelerates heat production & oxygen consumption
b. For hypothyroidism, myxedema & cretinism
c. A/R: cramps, diarrhea, nervousness, tremors, hypertension, tachycardia, insomnia, sweating & heat intolerance
d. Taken same time every day preferably in the a.m. with food
e. Teach client to how to take HR
f. Avoid foods that will inhibit thyroid secretions such as:
✓ strawberries, peaches, pears, cabbage, turnips, spinach,
✓ Brussels sprouts, cauliflower, peas & radish
PARATHYROID DISORDER
A. HYPOPARATHYROIDISM
➢ Hypoparathyroidism results from a deficiency of PTH and is characterized by hypocalcemia and neuromuscular
hyperexcitability.
Clinical Manifestations
1. Tetany—general muscular hypertonia; attempts at voluntary movement result in tremors and spasmodic or uncoordinated
movements; fingers assume classic tetanic position.

✓ Chvostek’s sign—a spasm of facial muscles that occurs when muscles or branches of facial nerve are tapped.
✓ Trousseau’s sign—carpopedal spasm within 3 minutes after a BP cuff is inflated 20 mm Hg above patient’s systolic
pressure.
✓ Laryngeal spasm.
2. Severe anxiety and apprehension.
3. Renal colic is usually present if patient has history of calculi; preexisting calculi loosen and migrate into the ureter.

Diagnostic Evaluation
1. Phosphorus level in blood is elevated.
2. Decrease in serum calcium
MEDICAL MANAGEMENT
1. Monitor for hypocalcemia & institute seizure precautions
2. Place a tracheostomy set, O2 & suction machine at bed side
3. Prepare for calcuim gluconate/chloride IV
4. Provide high-calcium/low-phosphorus diet
5. Give vitamin D to enhance calcium absorption at the GIT
6. Given phosphate binders
PARATHYROIDECTOMY- Removal of 1 or more parathyroid gland
PRE-OPERATIVE CARE:
1. Monitor calcium, phosphate & magnesium level
2. Ensure that calcium is near normal
3. Explain to patient that talking may be painful 2 days post-op
POST-OPERATIVE CARE:
1. Monitor for respiratory distress & have a tracheostomy set, O2 & suction machine at bed side
2. Semi-Fowler’s position
3. Check for bleeding
4. Check for hypocalcemic crisis, Trousseau’s or Chvostek’s sign
 5. Assess changes in voice pattern & for laryngeal nerve damage
6. Administer calcium & vitamin D supplements as prescribed.
SIGNS OF TETANY
a. Positive Chvostek’s Sign
b. Positive Trousseau’s Sign
c. Wheezing & dyspnea (bronchospasm, laryngospasm)
d. Numbness & tingling of face & extremities
e. Carpopedal spasm
f. Visual disturbances (photophobia)
g. Muscle & abdominal cramps
h. Cardiac dysrhythmias
i. Seizures
B. HYPERPARATHYROIDISM- hypersecretion of PTH
Clinical Manifestations
1. Decalcification of bones.
✓ Skeletal pain, backache, pain on weight-bearing, pathologic fractures, deformities, formation of bony cysts.
✓ Formation of bone tumors—overgrowth of osteoclasts.
✓ Formation of calcium-containing renal calculi.
2. Depression of neuromuscular function.
✓ The patient may trip, drop objects, show general fatigue, loss memory for recent events, experience emotional
instability, have changes in level of consciousness, with stupor and coma.
✓ Cardiac arrhythmias, hypertension, cardiac standstill.

Medical Management
Treatment of Hypercalcemia
1. Hydration (I.V. saline) and diuretics-furosemide (Lasix) and ethacrynic acid (Edecrin)—to increase urinary excretion of
calcium in patients not in renal failure.
2. Oral phosphate may be used as an antihypercalcemic agent.
3. Pamidronate (Aredia), calcitonin (Cibacalcin), or etidronate disodium (Didronel) are effective in treating hypercalcemia
by inhibiting bone resorption.
4. Dietary calcium is restricted, and all drugs that might cause hypercalcemia (thiazides, vitamin D) are discontinued.
5. Dialysis may be necessary in patients with resistant hypercalcemia or those with renal failure.
6. Digoxin is reduced because patient with hypercalcemia is more sensitive to toxic effects of this drug.
7. Monitoring of daily serum calcium, blood urea nitrogen (BUN), potassium, and magnesium levels.
8. Removal of underlying cause.
Nursing Interventions
1. Achieving Fluid and Electrolyte Balance
✓ Monitor fluid intake and output.
✓ Provide adequate hydration—administer water, glucose and electrolytes orally or I.V. as prescribed.
✓ Prevent or promptly treat dehydration by reporting vomiting or other sources of fluid loss promptly.
✓ Help patient understand why and how to avoid dietary sources of calcium—dairy products, broccoli, calcium containing
antacids.
2. Promoting Urinary Elimination
✓ Strain all urine to observe for calculi.
✓ Increase fluid intake to 3,000 mL/day to maintain hydration and prevent precipitation of calcium and formation of
calculi.
✓ Instruct patient about dietary recommendations for restriction of calcium.
✓ Observe for signs of urinary tract infection (UTI), hematuria, and renal colic.
✓ Assess renal function through serum creatinine and BUN levels.
3. Increasing Physical Mobility
✓ Assist patient in hygiene and activities if bone pain is severe or if patient experiences musculoskeletal weakness.
✓ Protect patient from falls or injury.
✓ Turn patient cautiously and handle extremities gently to avoid fractures.
✓ Administer analgesia as prescribed.
✓ Assess level of pain and patient’s response to analgesia.
✓ Encourage patient to participate in mild exercise gradually as symptoms subside.
✓ Instruct and demonstrate correct body mechanics to reduce strain, backache, and injury.
CALCIUM SUPPLEMENTS
1. calcium carbonate (Tums)
2. calcium gluconate
3. calcium lactate
VITAMIN D SUPPLEMENTS
✓ calcifediol (Calderol)
CALCIUM REGULATORS
✓ calcitonin human (Cibacalcin)
ANTIHYPERCALCEMICS
✓ edetate disodium (Disotate)
PARATHYROID HORMONES- regulates serum calcium levels, Low serum calcium level stimulate parathyroid hormone release
➢ Hyperparathyroidis- given antihypercalcemics
➢ Hypoparathyroidis1d- Given calcium & Vit. D
PANCREASE
DIABETES MELLITUS
✓ Diabetes mellitus is a metabolic disorder characterized by hyperglycemia and results from defective insulin production,
secretion, or utilization.
1. INSULIN-DEPENDENT DIABETES (type 1)
a. Characterized by an acute onset, usually before 30 years of age.
b. Destruction of the pancreatic beta cells. Combined genetic, immunologic, and possibly environmental (eg, viral) factors
are thought to contribute to beta cell destruction.
c. The destruction of the beta cells results in decreased insulin production, unchecked glucose production by the liver, and
fasting hyperglycemia.
d. Insulin normally inhibits glycogenolysis (breakdown of stored glucose) and gluconeogenesis (production of new glucose
from amino acids and other substrates), these processes occur in an unrestrained fashion in people with insulin
deficiency and contribute further to hyperglycemia.
e. Fat breakdown occurs, resulting in an increased production of ketone bodies, which are the byproducts of fat
breakdown.
Clinical manifestations
1. Polydipsia,
2. Polyphagia
3. Polyuria
4. Weight loss.
5. Hyperglycemia
6. Blurring of vision
7. Slow wound healing
8. Vaginal infection
9. Weakness and paresthesia
10. Signs of inadequate feet circulation
DIAGNOSTIC TEST
Blood Glucose
a. Fasting blood sugar (FBS) - drawn after at least an 8-hour fast, to evaluate circulating amounts of glucose
b. Postprandial test- drawn usually 2 hours after a well-balanced meal, to evaluate glucose metabolism;
c. Glycated Hemoglobin (Glycohemoglobin, HbA1c)- Measures glycemic control over a 60- to 120-day period by
measuring the irreversible reaction of glucose to hemoglobin through freely permeable erythrocytes during their 120-
day life cycle.
d. Capillary blood glucose
✓ Helps evaluate effectiveness of medication
✓ Reflects glucose excursion after meals
✓ Assesses glucose response to exercise regimen
✓ Assists in the evaluation of episodes of hypoglycemia and hyperglycemia to determine appropriate treatment.
Medical Management
1. Diet
2. Exercise
3. Insulin
✓ Insulin increases glucose transport into cells & promotes conversion of glucose to glycogen, decreasing serum glucose
levels
✓ Primarily acts in the liver, muscle, adipose tissue by attaching to receptors on cellular membranes & facilitating
transport o glucose, potassium & magnesium.
4. Glucagon
✓ Hormone secreted by the alpha cells of the islets of Langerhans in the pancreas
✓ Increase blood glucose by stimulating glycogenolysis in the liver
✓ Given SC, IM or IV routes
✓ Used to treat insulin-induced hypoglycemia when semiconscious/unconscious
INSULIN THERAPY
✓ The goal of all but the simplest, one-injection insulin regimens is to mimic this normal pattern of insulin secretion in
response to food intake and activity patterns.

Type Onset Peak Duration

1. Rapid-acting 10-15 mins 1 hour 3 hours
Lispro (Humalog)
2. Short-acting 30 min -1 hour 2-3 hours 4-6hours
Humulin Regular
Semi-lente
3. Intermidiate- acting 3-4 hours 6-12 hours 16-20 hours
Humulin NPH
Humulin Lente
4. LONG-ACTING INSULIN 6-8 hours 12-16 hours 20-30 hours
Humulin Ultralente
5. PREMIXED INSULIN 30 min -1 hour 2-12 hours 18-24 hours
70% NPH-30% Regular

Note:
✓ Lantus and Levemir insulins must never be mixed with any other insulin.
✓ NPH only for type 2 DM
2. NON-INSULIN DEPENDENT DIABETES
 ✓ The two main problems related to insulin in type 2 diabetes are insulin resistance and impaired insulin secretion.
✓ To overcome insulin resistance and to prevent the buildup of glucose in the blood, increased amounts of
insulin must be secreted to maintain the glucose level at a normal or slightly elevated level.
Clinical Manifestations
1. Fatigue
2. Irritability,
3. Polyuria
4. Polydipsia
5. Polyphagia
6. Poorly healing skin wounds
7. Vaginal infections
8. Blurred vision (if glucose levels are very high).

Medical Management
1. Nutritional Therapy
a. 50% to 60% of calories carbohydrates
✓ Sucrose (concentrated sweets)10% of total calories
✓ At least 25 g of fiber should be ingested daily.
✓ 1 unit of insulin for 15 g of carbohydrate.
✓ Carbohydrate budget” per meal (eg, 45 to 60 g).
b. 20% to 30% from fat
✓ Cholesterol to less than 300 mg/day.
c. 10% to 20% from protein.
d. Exchange Lists.
✓ Six main exchange lists: bread/starch, vegetable, milk, meat, fruit, fat.
✓ Foods within one group (in the portion amounts specified) contain equal numbers of calories and are approximately
equal in grams of protein, fat, and carbohydrate.
✓ Foods on one list may be interchanged with one another, allowing for variety while maintaining as much
consistency as possible in the nutrient content of foods eaten.
2. Exercise
✓ Lowers blood glucose levels by increasing the uptake of glucose by body muscles and by improving insulin utilization.
✓ Improves circulation and muscle tone.
✓ Alters blood lipid concentrations, increasing levels of high-density lipoproteins and decreasing total cholesterol and
triglyceride levels.
✓ Diabetes should exercise at the same time (preferably when blood glucose levels are at their peak) and in the same
amount each day.
✓ Slow, gradual increase in the exercise period is encouraged.
✓ Patients who have blood glucose levels exceeding 250 mg/dL (14 mmol/L) and who have ketones in their urine should
not begin exercising until the urine test results are negative for ketones and the blood glucose level is closer to normal.
Exercising with elevated blood glucose levels increases the secretion of glucagon, growth hormone, and catecholamines.
The liver then releases more glucose, and the result is an increase in the blood glucose level.
 ✓ Patients who require insulin should be taught to eat a 15-g carbohydrate snack (a fruit exchange) or a snack of complex
carbohydrates with a protein before engaging in moderate exercise to prevent unexpected hypoglycemia.
3. Oral anti-diabetic drugs
A. First-Generation Sulfonylureas- Stimulate beta cells of the pancreas to secrete insulin.
a. Acetohexamide (Dymelor)
b. Chlorpropamide (Diabinese)
c. Tolazamide (Tolinase
d. Tolbutamide (Orinase)
B. Second-Generation Sulfonylureas- Stimulate beta cells of the pancreas to secrete insulin; more potent than the first
generation.
a. Glipizide (Glucotrol, Glucotrol XL)
b. Glyburide (Micronase, Glynase, Dia-Beta)
c. Glimepiride (Amaryl)
C. Biguanides- Inhibit production of glucose by the liver ; increase tissue sensitivity to insulin. Monitor for lactic asidosis.
a. Metformin (GlucophageGlucophage XL, Fortamet)
b. Metformin with glyburide (Glucovance)
D. Alpha-Glucosidase Inhibitors- Delay absorption of complex carbohydrates in the intestine and slow entry of glucose in the
blood stream.
c. Acarbose (Precose)
d. Miglitol (Glyset)
E. Non-Sulfonylurea Insulin Secretagogues
a. Repaglinide (Prandin)
b. Nateglinide (Starlix)
Complications of Diabetes Mellitus
1. Hypoglycemia (Insulin reaction)- Blood glucose less than 50 to 60 mg/dL (2.7 to 3.3 mmol/L)
a. MILD- Sweating, tremor, tachycardia, palpitation, nervousness, hunger.
b. MODERATE- Inability to concentrate, headache, lightheadedness, confusion, memory lapses, numbness of the lips and
tongue, slurred speech, impaired coordination, emotional changes, irrational or combative behavior, double vision, and
drowsiness.
c. SEVERE- Symptoms may include disoriented behavior, seizures, difficulty arousing from sleep, or loss of consciousness.
Management
1. 15 g of a fast-acting concentrated source of carbohydrate
✓ Three or four commercially prepared glucose tablets
✓ 4 to 6 oz of fruit juice or regular soda
✓ 6 to 10 hard candies
✓ 2 to 3 teaspoons of sugar or honey
2. Glucagon 1 mg for unconscious and cannot swallow, can be administered either subcutaneously
2. Diabetes ketoacidosis (DKA)- Blood glucose levels between 300 and 800 mg/dL (16.6 to 44.4 mmol/L).
Three main clinical features of DKA
✓ Hyperglycemia
✓ Dehydration and electrolyte loss
✓ Acidosis
Three main causes of DKA
✓ Decreased or missed dose of insulin, error dose if insulin
✓ Illness or infection
✓ Undiagnosed and untreated diabetes
Pathophysiology
Without insulin, the amount of glucose entering the cells is reduced, and production and release of glucose by the liver
(gluconeogenesis) is increased, leading to 1. hyperglycemia.
↓
Kidneys excrete the glucose along with water and electrolytes (eg, sodium, potassium) causing osmotic diuresis,
which is characterized by excessive urination (polyuria) leads to 2. dehydration and marked electrolyte loss.
↓
Insulin deficiency or deficit is the breakdown of fat (lipolysis) into free fatty acids and glycerol. The free fatty acids are converted
into ketone bodies by the liver leads to 3. metabolic acidosis

Clinical Manifestations
1. Orthostatic hypotension
2. Weak, rapid pulse.
 3. Polyuria, polydipsia
4. Blurring of vision, weakness, headache
5. Anorexia, nausea, vomiting, abdominal pain.
6. Acetone breath (a fruity odor)
7. Kussmaul respirations- very deep but not labored
8. BUN/creatinine- increased
9. Electrolytes- decreased
Medical Management
1. Rehydration- to maintain tissue perfusion
✓ 0.9% sodium chloride (normal saline) solution; 0.45% if with hypertension
2. Electrolyte replacement- especially potassium
3. Insulin
3. Hyperglycemic hyperormolar non-ketotic coma (HHNC) -blood glucose level 600 to 1200 mg/dL,
✓ Is a serious condition in which hyperosmolarity and hyperglycemia predominate, with alterations of the sensorium
(sense of awareness).
✓ The basic biochemical defect is lack of effective insulin (i.e., insulin resistance).
✓ Most often in older people (50 to 70 years of age) who have no known history of diabetes or who have type 2 diabetes.
✓ Precipitating event such as an acute illness (e.g., pneumonia, cerebrovascular accident [CVA]), medications that
exacerbate hyperglycemia (e.g., thiazides), or treatments such as dialysis.
✓ No ketosis- no acetone breath, no kussmaul respiration
Clinical Manifestations
1. Orthostatic hypotension
2. Weak, rapid pulse.
3. Polyuria, polydipsia
4. Profound dehydration (dry mucous membranes, poor skin turgor)
5. Neurologic signs (e.g., alteration of sensorium, seizures, hemiparesis).
6. BUN/creatinine- increased
7. Electrolytes- decreased
Medical Management
1. Rehydration- to maintain tissue perfusion
✓ 0.9% sodium chloride (normal saline) solution; 0.45% if with hypertension
2. Electrolyte replacement- especially potassium
3. Insulin
Long term complications
1. DIABETIC RETINOPATHY
✓ Blurry vision secondary to macular edema
✓ Hemorrhage if severe
2. NEPHROPATHY
3. PERIPHERAL NEUROPATHY
Preventive foot care
1. Inspect feet daily & monitor feet for redness, swelling or break in skin integrity
2. Prevent moisture from accumulating between toes.
3. Apply moisturizing lotion to feet but not between toes
4. Wear loose socks & well-fitting (not tight) shoes & instruct client not to go barefoot
5. Change into clean cotton socks daily
6. Wear socks to keep feet warm
7. Do not wear the same shoes 2 days in a row
8. Do not wear open toed shoes or shoes with strap that goes between toes
9. Check shoes for tears or cracks in lining & for foreign objects before putting them on
10. Break in new shoes gradually
11. Cut toenails straight across & smooth nails with an emery board
12. Do not smoke
13. Avoid thermal injuries from hot water, heating pads & baths
14. Wash feet with warm (not hot) water & dry thoroughly (avoid foot soaks)
15. Do not soak feet
16. Do not treat corns, blisters or ingrown nails
17. Do not cross legs or wear tight garments that may constrict blood flow