Rotsen J.

Jambongana, RN, MN (CSE, PHICNA)

Professor III, University of St. La Salle – Bacolod
Course/Subject Leader – INA1 and INA2 for BSN4, USLS Bacolod
NCLEX-RN & NLE National Lecturer, RGO Review Systems
Former Local NLE Lecturer, PRN/Millennium Review Center
Former Midwifery Board Exam Lecturer, NONESCOST Sagay
Former Supervisor, Riverside Medical Center – Infection Control Section
COURSE OUTLINE & EXPECTATIONS

1. MIDTERM: Medical Surgical Nursing Addendum

a. 3 to 4 quizzes – TBA and will compose Midterm Exam
b. Critical Thinking/Retention check: Graded Oral revalida
2. FINALS A: Prof Adjustment, Nursing Leadership,
Nursing Management, Ethics, Nursing Research
a. 2 to 3 quizzes – TBA and included in Endterm Exams
3. FINALS B: Psychiatric Nursing
a. 2 to 3 quizzes – TBA and included in Endterm Exams
 PHYSIOLOGY BASICS: Normal vs Abnormal

HEALTH - ILLNESS CONTINUUM – a predictive grid that

displays the likelihood of a person to participate in preventive
health care

The process of achieving high levels of wellness or the

consequences of unhealthy lifestyle.
(A) – Awareness, (E) – Education, and (G) Growth. Otherwise, an individual
who continuously live an unhealthy lifestyle, will be on the other side of the
grid, and would develop the following: (S) – signs and symptoms (S) –
syndromes, and (D) – Disorder or disability which may lead disease or
premature death.
DEFINITIONS

1. ILLNESS
▪ subjective state in which the person’s functional faculties are thought
to be diminished
2. DISEASE
▪ alteration in body’s physiology which reduces one’s capacities and
shortens the normal life span.
3. ETIOLOGY
▪ the cause of the disease
4. Acute illness
▪ severe symptoms but short duration which may or may not require
medical interventions.
5. Chronic illness
▪ longer duration with periods of remission and exacerbation.
NURSING PROCESS IN ILLNESS STATE
 VITAL SIGNS - BASIC M/S BASELINE

Variations in Vital Signs By Age

Purpose of taking V/S:

• To obtain baseline measurement of the patient’s vital signs
• To assess patient’s response to treatment or medication
• To monitor patient’s condition after invasive procedures
VITAL SIGNS - BASIC M/S BASELINE

FACTORS INFLUENCING VITAL SIGNS

The body system responsible for
your response, mood and temper?
Endocrine System

• What is the endocrine system?

The endocrine system is made up of
glands and the hormones they secrete.
Although the endocrine glands are the
primary hormone producers, the brain,
heart, lungs, liver, skin, thymus,
gastrointestinal mucosa, and placenta
also produce and release hormones.
Fxn: production and regulation of
chemical substances called hormones
Let’s watch a short video…
 Endocrine System - Anatomy

• Like the nervous

system, the endocrine
system is a regulatory
system. However,
instead of using
electrical impulses for
signaling, it produces
and uses chemical
signals called
hormones, which
travel through the
bloodstream and
control the actions of
cells and organs.
Relation to Nervous System

• The CNS is made

of the brain and
spinal cord.
• Commands to the
body originate in
the brain and the
spinal cord
connects the brain
with the rest of the
nerves in the body.
Relation to Nervous System

• The Peripheral NS can be broken down into two parts:

• The somatic nervous system (SNS) regulates
voluntary activities such as muscular movement. It also
controls reflexes, such as pulling your hand away from
the hot surface of a stove.
• The autonomic nervous system (ANS) regulates
activities that are not under conscious control and has
two divisions that are opposite of one another: the
sympathetic and parasympathetic nervous systems.
The sympathetic nervous system prepares the body for
“fight-or-flight” responses, while the parasympathetic
nervous system is active during restful periods.
Relation to Nervous System
• Neurons: These structures are important for transmitting
neural impulses, electrical signals that allow neurons to
communicate with one another.
• Neurons are specialized, depending on their functions:
❖ Sensory neurons carry impulses from sense organs, such as the
eyes or ears.
❖ Motor neurons carry impulses to muscles and glands.
❖ Interneurons transfer signals between sensory and motor neurons,
as well as in between other interneurons.
Hormones (ES) vs Nerve impulses (CNS)
Endocrine vs Exocrine glands
Key Terms
Common Hormones
 Classification /
Composition of
Hormones

• Proteins
• Protein Peptides
• Lipids
• Cholesterols
• Amino Acids /
Amines
• Steroid hormones
Source Gland Hormone(s) secreted Hormone function
Antidiuretic hormone Affects water retention in kidneys;
Pituitary gland
(vasopressin) controls blood pressure
Controls production of sex hormones
Adrenocorticotropic (estrogen in women and testosterone in
Pituitary gland
hormone (ACTH) men) and the production of eggs in
women and sperm in men.
Affects growth and development;
Pituitary gland Growth hormone (GH) stimulates protein production; affects fat
distribution

Luteinizing hormone (LH) Controls production of sex hormones

Pituitary gland and follicle-stimulating (estrogen in women and testosterone in
hormone (FSH) men) and the production of eggs in
women and sperm in men

Pituitary gland Oxytocin Stimulates contraction of uterus and

milk ducts in the breast

Pituitary gland Prolactin Initiates and maintains milk production

in breasts; impacts sex hormone levels
Thyroid-stimulating Stimulates the production and secretion
Pituitary gland
hormone (TSH) of thyroid hormones
 Hormone function
Source Gland Hormone(s) secreted
Parathyroid hormone Most important regulator of blood
Parathyroid glands
(PTH) calcium levels

Thyroid gland Thyroid hormone Controls metabolism; also affects

growth, maturation, nervous system
activity, and metabolism
Growth hormone
Hypothalamus releasing hormone Regulates growth hormone release in
(GHRH) the pituitary gland
Thyrotropin releasing
Hypothalamus Regulates thyroid stimulating hormone
hormone (TRH)
release in the pituitary gland
Gonadotropin releasing
Hypothalamus Regulates LH/FSH production in the
hormone (GnRH)
pituitary gland
Corticotropin releasing
Hypothalamus Regulates adrenocorticotropin release
hormone (CRH)
in the pituitary gland
Thymus Humoral factors Helps develop the lymphoid system
Source Gland Hormone(s) secreted Hormone function
Adrenal glands Aldosterone Regulates salt, water balance, and
blood pressure

Controls key functions in the body; acts

Adrenal glands Corticosteroid as an anti-inflammatory; maintains
blood sugar levels, blood pressure, and
muscle strength; regulates salt and
water balance
Adrenal glands Epinephrine Increases heart rate, oxygen intake,
and blood flow
Adrenal glands Norepinephrine Maintains blood pressure
Pancreas Glucagon Raises blood sugar levels

Pancreas Insulin Lowers blood sugar levels; stimulates

metabolism of glucose, protein, and fat

Kidneys Renin and angiotensin Controls blood pressure, both directly

and also by regulating aldosterone
production from the adrenal glands
Kidneys Erythropoietin
Affects red blood cell (RBC) production
Source Gland Hormone(s) secreted Hormone function

Affects development of female sexual

Ovaries Estrogen characteristics and reproductive
development, important for functioning
of uterus and breasts; also protects
bone health

Ovaries Progesterone Stimulates the lining of the uterus for

fertilization; prepares the breasts for
milk production

Testes (testicles) Testosterone Develop and maintain male sexual

characteristics and maturation

Pineal gland Melatonin Releases melatonin during night hours

to help with sleep
Endocrine System

• Primary endocrine glands

• Hypothalamus
• Pineal body
• Pituitary
• Thyroid and
parathyroid
• Thymus
• Adrenal gland
• Pancreas
• Ovary
• Testis
Endocrine System

• Hormones
A hormone is a chemical transmitter. It is
released in small amounts from glands, and
is transported in the bloodstream to target
organs or other cells. Hormones are
chemical messengers, transferring
information and instructions from one set
of cells to another. Hormones regulate
growth, development, mood, tissue function,
metabolism, and sexual function.
Endocrine System

• The “Master Gland”

Pituitary Gland – primary or main
gland of the ES
• Just the size of a pea, it is
the main endocrine gland
that controls the rest of the
ES glands and acts as the
“band master of the
orchestra”. It has Anterior
and Posterior parts.
• However, deep dive of ‘who
controls’ the pituitary gland
shows that hypothalamus
(lies above the pituitary
gland) is the ‘true master
gland’.
To better understand hormones..
CAUSES OF
ENDOCRINE
DISORDERS:
hormonal imbalance
caused by:
> A problem with the
endocrine feedback
system that controls
the amount of
hormone secreted in
the bloodstream.
> The disease of the
endocrine gland.
> Genetic disorder.
> Infection of the
gland.
Injury to the gland.
> Development of
nodules or tumors in
the glands
Secretions from the anterior pituitary
gland…

Growth Hormone
(GH): essential for
the growth and
development of
bones, muscles, and
other organs. It also
enhances protein
synthesis,
decreases the use of
glucose, and
promotes fat
destruction.
Secretions from the anterior pituitary
gland…

Adrenocorticotropin
(ACTH): essential
for the growth of the
adrenal cortex.

Thyroid-Stimulating
Hormone (TSH):
essential for the growth
and development of the
thyroid gland.
Secretions from the anterior pituitary
gland…

Follicle-Stimulating
Hormone (FSH): is a
gonadotropic hormone.

It stimulates the
growth ovarian
follicles in the female
and the production of
sperm in the male.
Secretions from the anterior pituitary
gland…
Luteinizing
Hormone (LH): is a
gonadotropic
hormone
stimulating the
development of
corpus luteum in
the female ovarian
follicles and the
The yellow corpus luteum production of
remains after ovulation; it testosterone in the
produces estrogen and male.
progesterone.
Secretions from the anterior pituitary
gland…

Prolactin (PRL):
stimulates the
development and
growth of the
mammary glands
and milk production
during pregnancy.

The sucking motion of the

baby stimulates prolactin
secretion.
Secretions from the anterior pituitary
gland…

Melanocyte-stimulating hormone (MSH):

regulates skin pigmentation and promotes
the deposit of melanin in the skin after
exposure to sunlight
Secretions from the posterior lobe of the
pituitary gland…

Antidiuretic Hormone
(ADH): stimulates the
reabsorption of water
by the renal tubules
(water retention in
kidneys; thus less
water excreted in
urine). Hyposecretion
of this hormone can
result in diabetes
insipidus.
Secretions from the posterior lobe of the
pituitary gland…

Oxytocin: stimulates
the uterus to contract
during labor, delivery,
and parturition. A
synthetic version of
this hormone, used
to induce labor, is
called Pitocin. It also
stimulates the
mammary glands to
release milk.
Secretions from the PINEAL gland

The pineal gland is pine-

cone-shaped and only
Melatonin: communicates about 1 cm in diameter.
information about
environmental lighting
to various parts of the
body. Has some effect
on sleep/awake cycles
and other biological
events connected to
them, such as a lower
production of gastric
secretions at night.
Secretions from the PINEAL gland

Serotonin: a
neurotransmitter that
regulates intestinal
movements and affects
appetite, mood, sleep, anger,
and metabolism.
Secretions from the THYROID gland

The thyroid gland plays a

vital role in metabolism
and regulates the body’s
metabolic processes.

Calcitonin:
influences bone and
calcium metabolism;
maintains a
homeostasis of
calcium in the blood
plasma
Secretions from the THYROID gland
Thyroxine (T4) and
triodothyronine (T3): essential
to BMR – basal metabolic rate
(the rate at which a person’s
body burns calories while at
rest); influences
physical/mental development
and growth
Hyposecretion of T3 and T4 = cretinism,
myxedema, Hashimoto’s disease

Hypersecretion of T3 and T4 = Grave’s disease,

goiter, Basedow’s disease
Secretions from the PARATHYROID gland

The two pairs of

parathyroid glands are
located on the dorsal or
back side of the thyroid
gland. They secrete
parathyroid (PTH) which
plays a role in the
metabolism of phosphorus.
Too little results in
cramping; too much
results in osteoporosis or
kidney stones.
The islets of Langerhans…

The islets of Langerhans are small clusters of

cells located in the pancreas.
Secretions from the islets of Langerhans…

Beta cells secrete the

Alpha cells hormone insulin, which is
facilitate the essential for the maintenance
breakdown of of normal blood sugar levels.
glycogen to Inadequate levels result in
glucose. This diabetes mellitus.
elevates the blood
sugar.

Delta cells suppress

the release of
glucagon and
insulin.
The adrenal glands…
The triangular-
shaped adrenal
glands are
located on the
top of each
kidney. The
inside is called
the medulla and
the outside layer
is called the
cortex.
Secretions from the adrenal
cortex…
Cortisol: regulates
carbohydrate, protein, and
fat metabolism; has an anti-
inflammatory effect; helps
the body cope during times
of stress
Hyposecretion
results in Corticosterone: like
Addison’s disease; cortisol, it is a
hypersecretion steroid; influences
results in potassium and
Cushing’s disease sodium metabolism
Secretions from the adrenal cortex…
Aldosterone: essential in regulating
electrolyte and water balance by
promoting sodium and chloride
retention and potassium excretion.

Androgens: several
hormones including
testosterone; they
promote the
development of
secondary sex
characteristics in
the male.
Secretions from the
adrenal medulla…

Dopamine is used to
treat shock. It dilates
the arteries, elevates
systolic blood
pressure, increases
cardiac output, and
increases urinary
output.
Secretions from the
adrenal medulla…

Epinephrine is also called

adrenalin. It elevates systolic
blood pressure, increases heart
rate and cardiac output, speeds
up the release of glucose from
the liver… giving a spurt of
energy, dilates the bronchial
tubes and relaxes airways, and
dilates the pupils to see more
clearly. It is often used to
counteract an allergic reaction.
Secretions from the
adrenal medulla…

Norepinephrine, like epinephrine, is released when

the body is under stress. It creates the underlying
influence in the fight or flight response. As a drug,
however, it actually triggers a drop in heart rate.
Secretions from the ovary…
The ovaries produce
several estrogen hormones
and progesterone. These
hormones prepare the
uterus for pregnancy,
promote the development
of mammary glands, play a
role in sex drive, and
develop secondary sex
characteristics in the
female.
Estrogen is essential for the growth, development,
and maintenance of female sex organs.
Secretions from the testes…
The testes produce
the male sex
hormone called
testosterone. It is
essential for normal
growth and
development of the
male sex organs.
Testosterone is
responsible for the
erection of the
penis.
Secretions of the placenta…
During pregnancy, the
placenta serves as an
endocrine gland.

It produces
chorionic
gonadotropin
hormone,
estrogen, and
progesterone.
Secretions of the gastrointestinal
mucosa…

The mucosa
of the pyloric
area of the
stomach
secretes the
hormone
gastrin, which
stimulates the
production of
gastric acid
for digestion.
Secretions of the gastrointestinal
mucosa…

The mucosa of
the duodenum
and jejunum
secretes the
hormone
secretin, which
stimulates
pancreatic juice,
bile, and
intestinal
secretion.
 Secretions of the
thymus…

The thymus gland has

two lobes, and is part
of the lymphatic
system. It is a
ductless gland, and
secretes thymosin.
This is necessary for
the Thymus’ normal
production of T cells
for the immune
system.
Summary: Endocrine Glands

• Primary endocrine glands

• Hypothalamus. This is located at the base
of the brain, near the optic chiasm where
the optic nerves behind each eye cross and
meet. The hypothalamus secretes
hormones that stimulate or suppress the
release of hormones in the pituitary gland,
in addition to controlling water balance,
sleep, temperature, appetite, and blood
pressure.
Summary: Endocrine Glands

• Primary endocrine glands

• Pineal body. This is located below the
corpus callosum, in the middle of the
brain. It produces the hormone
melatonin, which helps the body know
when it's time to sleep.
Summary: Endocrine Glands

• Primary endocrine glands

• Pituitary gland. This is located below
the brain. Usually no larger than a pea,
the gland controls many functions of
the other endocrine glands.
Summary: Endocrine Glands

• Primary endocrine glands

• Thyroid and parathyroid. These are
located in front of the neck, below the
larynx (voice box). The thyroid plays an
important role in the body's metabolism.
The parathyroid glands play an
important role in the regulation of the
body's calcium balance.
Summary: Endocrine Glands

• Primary endocrine glands

• Thymus. This is located in the upper
part of the chest and produces white
blood cells that fight infections and
destroy abnormal cells.
Summary: Endocrine Glands

• Primary endocrine glands

• Adrenal gland. This is located on top of
each kidney. Like many glands, the
adrenal glands work hand-in-hand with
the hypothalamus and pituitary gland.
The adrenal glands make and release
corticosteroid hormones and
epinephrine that maintain blood
pressure and regulate metabolism.
Summary: Endocrine Glands

• Primary endocrine glands

• Pancreas. This is located across the
back of the abdomen, behind the
stomach. The pancreas plays a role in
digestion, as well as hormone
production. Hormones produced by the
pancreas include insulin and glucagon,
which regulate levels of blood sugar.
Summary: Endocrine Glands

• Primary endocrine glands

• Ovary. These are located on both sides
of the uterus, below the opening of the
fallopian tubes (tubes that extend from
the uterus to the ovaries). In addition to
containing the egg cells necessary for
reproduction, the ovaries also produce
estrogen and progesterone.
Summary: Endocrine Glands

• Primary endocrine glands

• Testis. These are located in a pouch
that hangs suspended outside the male
body. This produces testosterone and
sperm.
 DIAGNOSTICS: Endocrine Focus

1. Radioactive iodine reuptake

▪ A thyroid function test that measures the absorption of
the iodine isotope to determine how the thyroid gland
is functioning.
▪ Administration of I-123 or I-131 orally followed in 24
hrs. by a scan of the thyroid for the amount of
radioactivity emitted.
▪ Normal value is 5-35% in 24 hours
▪ Increased: hyperthyroidism , thyrotoxicosis
▪ Decreased: hypothyroidism, thyroiditis
 DIAGNOSTICS: Endocrine Focus

2. T3 and T4 resin
▪ Blood test for diagnosis of thyroid disorders
▪ Normal Value : T3: 80-230 ng/dL
▪ T4: 5-12 ng/dL
▪ increase in hyperthyroidism
▪ decreased in hypothyroidism
DIAGNOSTICS: Endocrine Focus

3. Thyroid Stimulating Hormone Test

▪ Blood test used to differentiate the diagnosis of primary
hypothyroidism from secondary hypothyroidism
▪ Normal value is 0.2 to 5.4 uU/ml
▪ Elevated in primary hypothyroidism
▪ Decreased in hyperthyroidism or secondary
hypothyroidism
 DIAGNOSTICS: Endocrine Focus

4. Thyroid Scan
▪ Performed to identify nodules or growths in the
thyroid glands Discontinue medications
containing iodine 14 days prior to test and
discontinue thyroid meds 4-6 weeks prior to test.
▪ NPO post MN
▪ If iodine is used client will fast an additional 45
minutes after ingestion of radioactive isotope &
scan is done after 24 hours.
▪ A radio isotope of iodine or technetium is
administered prior to the scanning of the thyroid
gland.
 DIAGNOSTICS: Endocrine Focus

5. Needle Aspiration of Thyroid Tissue

▪ Aspiration of thyroid tissue for cytological exam,
▪ No preparation needed
▪ Light pressure applied to aspiration site after the
procedure
DIAGNOSTICS: Endocrine Focus

6. Eight-hour intravenous ACTH Test

▪ Used to determine function of adrenal cortex
▪ Administration of 25 units of ACTH (Adenocorticotrophine
Hormone) 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
 DIAGNOSTICS: Endocrine Focus

7. Glucose Tolerance Test

Pre test:
▪ eat a high-carbohydrate (200 to 300 g) diet for 3 days
before the test
▪ avoid alcohol, coffee & smoking 36 hours before testing
▪ fast midnight before test
▪ fasting blood glucose & urine glucose specimens
obtained.
▪ avoid strenuous exercise 8 hours before & after test
▪ client ingests 100g glucose; blood sugar drawn at 30 & 60
mins, then hourly for 3-5 hrs.
▪ urine specimens may also be collected
DIAGNOSTICS: Endocrine Focus

8. Glycosylated Hemoglobin
▪ Is a reflection of how well blood glucose levels
have been controlled for up to the prior 4 months
▪ Fasting is not needed
▪ Most accurate
▪ Test for treatment compliance
▪ 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
DIAGNOSTICS: Endocrine Focus

9A. BLOOD CHEMISTRY- Blood Glucose

▪ Glucose measurement is performed by either :
▪ Skin puncture or venipuncture
▪ fasting blood sugar (FBS)
✓ normal fasting value is 70 to 115 mg/dl
▪ non-fasting (usually 2-hours postprandial)
✓ less than 120 mg/dl
▪ 2-hour postprandial - This test is used to screen
for diabetes mellitus; if the results are abnormal,
the practitioner may order a glucose tolerance
test
DIAGNOSTICS: Endocrine Focus

9B. BLOOD CHEMISTRY- Glucose Tolerance Test

A glucose tolerance test is the most accurate test
for diagnosing hypoglycemia and hyperglycemia
(diabetes mellitus).
▪ Requires fasting
▪ The test is conducted as follows:
❖ Initial blood and urine specimens are obtained.
❖ An oral loading dose of glucose is administered.
❖ Blood and urine specimens are obtained at 30
minutes, 1 hour, 2 hours, 3 hours, & sometimes 4
hours after loading dose.
DIAGNOSTICS: Endocrine Focus

10. MRI (Magnetic Resonance Imaging)

▪ Noninvasive, usually painless medical test
▪ Useful in detecting Abdominal Aortic Anuersyms and
deep vein thrombosis and organ related diseases,
malignancies or physiologic alterations
▪ Some MRI examinations may require the patient to
swallow contrast material or receive an injection of
contrast into the bloodstream.
▪ the contrast material used for an MRI exam, called
gadolinium, does not contain iodine and is less likely
to cause an allergic reaction.
▪ metal and electronic objects are not allowed in the
exam room.
DIAGNOSTICS: Endocrine Focus

11. PET Scan (positron emission tomography)

▪ A PET scan can measure such vital functions as blood flow,
oxygen use, and glucose metabolism, which helps doctors
identify abnormal from normal functioning of organs and
tissues.
▪ The test involves injecting a very small dose of a radioactive
chemical, called a radiotracer, into the vein of the arm
▪ Pretest: Generally, most patients are told not to eat anything
for a minimum of 6 hours before the scan.
▪ Heart patients are also told to not take any product with
caffeine for at least 24 hours
▪ Intratest: The client will be asked to lie down on a flat
examination table that is moved into the center of a PET
scanner
 DIAGNOSTICS: Endocrine Focus

12. Blood Enzymes

Enzymes are globular proteins produced in the body that
catalyze chemical reactions within the cells by promoting the
oxidative reactions and synthesis of various chemicals, such as
lipids, glycogen, and adenosine triphosphate (ATP).
CPK Isoenzymes
DIAGNOSTICS: Endocrine Focus

13. Digestive Enzymes

Retention Check - ENDOCRINE SYSTEM:
COMMON
ENDOCRINE
DISEASES
 Assessment

• Health history —energy level, hand and

foot size changes, headaches, urinary
changes, heat and cold intolerance,
changes in sexual characteristics,
personality changes, others
• Physical assessment—appearance
including hair distribution, fat distribution,
quality of skin, appearance of eyes, size of
feet and hands, peripheral edema, facial
puffiness, vital signs
Congenital Hypothyroidism- CH

• Clinical condition associated with

decreased function of the thyroid gland
and a decrease in the circulating level of
thyroid hormones

• 1:3500 to 1:4000 newborns

• One of most common preventable causes
of mental retardation
Causes of CH

• The most common cause of congenital

hypothyroidism is iodine deficiency.
• Most commonly due to defect of development of the
thyroid gland itself, resulting in an absent (athyreosis) or
underdeveloped (hypoplastic) gland.
– A hypoplastic gland may develop higher in the
neck or even in the back of the tongue.
– A gland in the wrong place is referred to as
ectopic, and an ectopic gland at the base or
back of the tongue is a lingual thyroid.
 Causes of CH
• Some of these cases of developmentally abnormal
glands result from genetic defects, and some has no
identifiable cause.
• Genetic defects of thyroxine or
triiodothyronine synthesis within a structurally
normal gland.

• Among specific defects are:

1. thyrotropin (TSH) resistance
2. organification defect
3. iodine trapping defect

• The defect sometimes might be due to a deficiency of

thyroid stimulating hormone, either isolated or as part of
congenital hypopituitarism.
Iodine Deficiency Disorders (IDD)

• Endemic goiter
• Endemic cretinism (CH)
• Intellectual disability
• Growth retardation
• Neonatal hypothyroidism
• Increased early and late pregnancy loss
• Increased perinatal and infant mortality
CH – Signs and Symptoms

• Anemia due to decreased oxygen carrying

requirement
• Retardation of mental development and growth
manifest in later infancy and largely irreversible
• Feeding problems, failure to thrive, constipation
Protuberance of abdomen, dry skin, poor growth of
hair and nails, delayed eruption of deciduous teeth,
umbilical hernia
• Delay in holding up the head, sitting, walking and
talking
• Limb disproportionately short in relation to the trunk
• Severe mental deficiency, and low IQ
CH Screening

• Highly sensitive immunoassay methods

• Direct measurement of serum thyroxine
and TSH
• Filter paper blood spots (DNA analysis)
• Guarantee detection and treatment from
the first weeks of life
Diagnosis of CH

• Diagnosis of primary hypothyroidism is

confirmed by decreased levels of:
– serum thyroid hormone (total or free T4)
– elevated levels of TSH.
Treatment of CH

• thyroid hormone replacement.

• Most important treatment variables are
the dose and timing of thyroxine therapy
(Levothyroxine).
• Endemic cretinism (CH) can be
prevented by appropriate iodine
supplementation.
• Iodization of salt is the usual method.
• Calcium supplements may be useful,
Vitamin D therapy is necessary, and IV
calcium gluconate
Nursing care

• Patients who have been treated for

hyperthyroidism need to be followed
closely because they may develop
Hypothyroidism, signs of seizures, or
tetany.
• Follow up care includes:
– Check thyroid function test every 4-6 weeks
– Follow up on medications and dose
adjustment
 Disorders of the Pituitary

Pituitary Tumors
 Eosinophilic tumors may result in gigantism
or in acromegaly. May suffer from severe
headaches, visual disturbances,
decalcification of the bone, endocrine
disturbances
 Basophilic tumors may cause Cushing’s
syndrome w/features of hyperadrenalism,
truncal obesity, amenorrhea, osteoporosis
 Chromophobic tumors—90% of pituitary
tumors. Present with obesity, somnolence,
scant hair, low body temp, headaches, visual
changes
Dwarfism

• Growth hormone deficiency in

childhood will result in primary
dwarfism.
• Dwarfism is generally defined as an
adult height of 4 feet 10 inches
• Human growth hormone has no place
in its management, as the condition is
not caused by a lack of growth
hormone
 Pituitary Tumors—Assessment and
Diagnostic Findings

• Vision tests
• CT scan
• MRI
• Serum levels of pituitary hormones
 Diabetes Insipidus
• Deficiency of ADH
• Excessive thirst, large volumes of dilute
urine
• Can occur secondary to brain tumors,
head trauma, infections of the CNS, and
surgical ablation or radiation
• Nephrogenic DI—relates to failure of the
renal tubules to respond to ADH. Can be
related to hypokalemia, hypercalcemia and
to medications (lithium demeocycline)
Assessment and Diagnostic Findings

• Fluid deprivation test—withhold fluids for

8-12 hours. Weigh patient frequently.
Inability to slow down the urinary output
and fail to concentrate urine are
diagnostic. Stop test if patient is
tachycardic or hypotensive
• Monitor serum and urine osmolality and
ADH levels
 Pharmacologic Tx and Nursing
Management

• DDAVP (Desmopressin) —intranasal bid

• Can be given IM if necessary.
• Can also use Diabenese and thiazide
diuretics in mild disease as they potentiate
the action of ADH
• If renal in origin—thiazide diuretics, NSAIDs
(prostaglandin inhibition) and salt depletion
may help
• Educate patient about actions of
medications, how to administer meds
 SIADH

 Excessive ADH secretion

 Retain fluids and develop a dilutional
hyponatremia
 Often non-endocrine in origin—such as bronchogenic
carcinoma
 Causes: Disorders of the CNS like head injury, brain
surgery, tumors, infections or medications like
vincristine, phenothiazines, TCAs or thiazide diuretics
 Meds can either affect the pituitary or increase
sensitivity to renal tubules to ADH
 Management: eliminate cause, give diuretics (Lasix),
fluid restriction, I&O, daily wt., lab chemistries
 SIADH

• Restoration of electrolytes must be

gradual
• May use 3% NaCl in conjunction with
Lasix
 Thyroid
• T3 and T4
• Need iodine for synthesis of hormones—
excess will result in adaptive decline in
utilization called the Wolf-Chaikoff mechanism
• Thyroid is controlled by TSH
• Cellular metabolism, brain development,
normal growth, affect every organ in the body
• T3 is five times as potent as T4
• Calcitonin—secreted in response to high
levels of serum calcium, increases deposition
in the bone
 Thyroid

• Radioactive iodine uptake test measures

rate of iodine uptake. Patients with
hyperthyroidism exhibit a high uptake,
hypothyroidism will have low uptake
• Thyroid scan —helps determine the
location, size, shape and size of gland. “Hot”
areas (increased function) and “cold” areas
(decreased function) can assist in diagnosis.
• Graves’s Disease
manifestations
 Nursing Implications

• Be aware of meds patient is taking (see

list in text) that can affect accuracy of
testing
• Also be aware if patient is taking
multivitamins and food supplements
 Hypothyroidism

 Most common cause is Hashimoto’s thyroiditis

 Common in those previously treated for
hyperthyroidism
 Atrophy of gland with aging
 Medications like lithium, iodine compounds,
antithyroid meds can cause
 Radiation treatments to head and neck
 Infiltrative diseases like amyloidosis,
scleroderma
 Iodine deficiency and excess
 Hypothalamic or pituitary abnormality
 More common in women, especially over age 50
Hashimoto’s thyroiditis
 Manifestations

• From mild symptoms to myxedema

• Myxedema –accumulation of
mucopolysaccharides in sc and interstitial
tissues. Is the extreme form of
hypothyroidism. Can progress to shock.
• S/S—fatigue, hair loss, dry skin, brittle nails,
numbness and tingling of the fingers,
amenorrhea, weight gain, decreased heart
rate and temperature, lassitude, cognitive
changes, elevated cholesterol levels,
constipation, hypotension
Myxedema

• Extreme form of hypothyroidism;

accumulation of mucopolysaccharides in sc
 Pharmacologic Management of
hypothyroidism

• Levothyroxine is preferred agent

• Dosage is based on TSH
• Desiccated thyroid used infrequently due to
inconsistent dosing
• Angina can occur when thyroid replacement is
initiated as it enhances effects of
cardiovascular catecholamines (in pt. w/pre-
existent CAD). Start at low dose.
• Hypnotics and sedatives may have profound
effects on sensorium
 Management in Myxedema

• Cautious fluid replacement

• Glucose to restore to normal glycemic levels
• Avoid rapid overheating due to increased
oxygen demands but keep warm
• May give levothyroxine intravenously
With recovery,
• Modify activity
• High fiber foods
• Home health for follow-up
 Hyperthyroidism

• Extreme form is Grave’s disease

• Caused by thyroiditis, excessive amount
thyroid hormone, abnormal output by
immunoglobulins
• Is more common in women
Manifestations of hyperthyroidism

• Thyrotoxicosis—nervousness,
irritable, apprehensive, palpitations,
heat intolerance, skin flushing, tremors,
possibly exophthalmos
• Have an increased sensitivity to
catecholamines
• Can occur after irradiation or presence
of a tumor
 Assessment and Diagnosis

• Thyroid thrill and or bruit may be

present
• Thyroid may be enlarged
• Decreased TSH, increased free T4 and
an increased radioactive iodine uptake
 Management

• Reduce thyroid hyperactivity—

usually use radioactive iodine,
antithyroid meds or surgery)
• Beta blockers (lower stress on the
heart and blood vessels)
– Atenolol
– metropolol
• Can be relapse with antithyroid meds
– Tapazole
 Pharmacologic Therapy

 Irradiation with administration of radioisotope

iodine 131 —initially may cause an acute release of
thyroid hormones. Should monitor for thyroid storm
 S/S of thyroid storm—high fever. Tachycardia,
delirium, chest pain, dyspnea, palpitations, weight
loss, diarrhea, abdominal pain
 Management of thyroid storm—oxygen, IV fluids
with dextrose, hypothermic measures, steroids to
treat shock or adrenal deficiency, iodine to decrease
output of T4, beta blockers, Tapazole impedes
formation of thyroid hormone and blocks conversion
of T4 to T3
 Antithyroid Medications

• Tapazole (methimazole)—blocks synthesis

of hormones.
• Sodium Iodide -suppresses release of
thyroid hormone
• SSKI (saturated solution of potassium
chloride)– suppresses release of hormones
and decreases vascularity of thyroid. Can
stain teeth
• Dexamethazone —suppresses release of
thyroid hormones
 Surgical Management

• Reserved for special circumstances, e.g.

large goiters, those who cannot take
antithyroid meds, or who need rapid
normalization
• Subtotal thyroidectomy
• Before surgery, give PTU (Propylthiouracil)
until s/s of hyperthyroidism have
disappeared
• Iodine may be used to decrease vascularity
 Nursing Management

• Reassurance r/t the emotional reactions

experienced
• May need eye care if has exophthalmos
• Maintain normal body temperature
• Adequate caloric intake
• Managing potential complications such as
dysrhythmias and tachycardias
• Educate about potential s/s of
hypothyroidism following any antithyroid tx.
ASYNC TIME on next topics
 Parathyroid Glands

 Parathormone maintains sufficient serum calcium

levels
 Excess calcium can bind with phosphate and
precipitate in various organs, can cause
pancreatitis
 Hyperparathyroidism will cause bone
decalcification and development of renal calculi
 More common in women
 Secondary hyperparathyroidism occurs in those
with chronic renal failure and renal rickets
secondary to excess phosphorus retention (and
increased parathormone secretion)
Manifestations of Hyperparathyroidism

• fatigue, muscle weakness, nausea, vomiting,

constipation, hypertension and cardiac
dysrhythmias
• Excess calcium in the brain can lead to
psychoses
• Renal lithiasis can lead to renal damage and
even failure
• Demineralization of bones with back and
joint pain, pain on weight bearing, fractures
• Peptic ulcers and pancreatitis can also occur
 Assessment and Diagnostic Findings

• Persistent elevated calcium levels

• Elevated serum parathormone level
• Bone studies will reveal decreased density
• Double antibody parathyroid hormone test is
used to distinguish between primary
hyperparathyroidism and malignancy
• Ultrasound, MRI, thallium scan, fine needle
biopsy also can be used to localize cysts,
adenomas, or hyperplasia
 Management

 Recommended Tx for hyperparathyroidism is surgical

removal
 Hydration therapy necessary to prevent renal calculi
 Avoid thiazide diuretics (Furosemide- Lasix) as they
decrease renal excretion of calcium
 Increase mobility to promote bone retention of calcium
 Avoid restricted or excess calcium in the diet
 Fluids, prune juice and stool softeners to prevent
constipation
 Watch for s/s of tetany postsurgically (numbness, tingling,
carpopedal spasms) as well as cardiac dysrhythmias and
hypotension
 Hypercalcemic crisis

• Seen with levels greater than 15mg/dL

• Can result in life-threatening neurologic,
cardiovascular and renal symptoms
• Treatments include: hydration, loop diuretics
to promote excretion of calcium,
phosphate therapy to promote calcium
deposition in bone and reducing GI
absorption of calcium
• Give calcitonin or mithramycin to decrease
serum calcium levels quickly
 Hypoparathyroidism
• Seen most often following removal of thyroid
gland, parathyroid glands or following radical
neck surgery
• Deficiency of parathormone results in
increased bone phosphate and decreased
blood calcium levels
• In absence of parathormone, there is
decreased intestinal absorption of dietary
calcium and decreased resorption of
calcium from bone and through kidney
tubules
 Clinical Manifestations of
Hypoparathyroidism

• Irritability of neuromuscular system

• Tetany —hypertonic muscle
contractions , numbnes, tingling,
cramps in extremities, laryngeal spasm,
bronchospasm, carpopedal spasm (
flexion of the elbows and wrists,
dorsiflexion of the feet), seizures
 Assessment and Diagnostic Findings

• Trousseau’s sign —can check with a

BP cuff (carpopedal spasm)
• Chvostek’s sign —tapping over facial
nerve causes spasm of the mouth,
nose and eye
• Lab studies may reveal calcium levels
of 5-6 mg/dL or lower
• Serum phosphate levels will be
decreased
 Management of Hypoparathyroidism

• Restore calcium level to 9-10 mg/dL

• May need to give IV calcium gluconate for
immediate treatment
• Use of parathormone IV reserved for extreme
situations due to the probability of allergic reactions
• Monitor calcium levels
• May need bronchodilators and even ventilator
assistance
• Diet high in calcium and low in phosphorus; thus,
avoid milk products, egg yolk and spinach.
Management of Hypoparathyroidism

• Keep calcium gluconate at bedside

• Ensure has IV access
• Cardiac monitoring
• Care of postoperative patients who
have undergone thyroid surgery,
parathyroidectomy or radical neck
surgery. Be watchful for signs of
tetany, seizures, and respiratory
difficulties
 Adrenals--Pheochromocytoma

• Usually benign tumor

• Originates from the chromaffin cells of
the adrenal medulla
• Any age but usu. Between 40-50 years
old
• Can be familial
• 10% are malignant
• May be associated with thyroid
carcinoma or parathyroid hyperplasia or
tumor
 Clinical Manifestations

• Headache, diaphoresis, palpitations,

hypertension
• May have hyperglycemia related to
excess epinephrine secretion
• Tremors, flushing and anxiety as well
• Blurring of vision
• Feeling of impending doom
• BPs exceeding 250/150 have occurred
Assessment and Diagnostic Findings

 Associated with the 5 H’s—hypertension,

headache, hyperhidrosis, hypermetabolism and
hyperglycemia
 Urinary catecholamines and metanephrine are
direct and conclusive tests
 Serum epinephrine and norepinephrine levels will
be elevated
 Must avoid coffee, tea, bananas, chocolate, vanilla
and ASA, nicotine, amphetamines, decongestants
before 24h urine testing
 Imaging studies
 Management

• Bedrest
• Elevated HOB
• ICU
• Nipride (Na nitroprusside, to lower BP)
• Calcium channel blockers and Beta blockers
• Surgical management (manipulation of the tumor
can cause excessive release of catecholamines)
• Steroid therapy if adrenalectomy performed
• Hypotension and hypoglycemia can occur post-op
 Addison’s Disease

• Adrenocortical insufficiency
• Autoimmune or idiopathic atrophy
• Can be caused by inadequate ACTH
from pituitary
– hormone your pituitary gland releases that
plays a large role in how your body
responds to stress
• Therapeutic use of steroids
Addison’s Disease
 Manifestations

• Muscle weakness
• Anorexia
• Dark pigmentation
• Hypotension
• Hypoglycemia
• Low sodium levels
• High potassium levels
• Can result in Addisonian crisis
 Addisonian crisis

• Circulatory shock
• Pallor, apprehension, weak&rapid
pulse, rapid respirations and low blood
pressure
• Headache, nausea, abdominal pain
and diarrhea
• Can be brought on by overexertion,
exposure to cold, acute infection,
decrease in salt intake
 Assessment and Diagnostic Findings

• Early morning serum cortisol and plasma

ACTH are performed. Will distinguish
between primary and secondary adrenal
insufficiency. In primary, will have elevated
ACTH levels and below normal cortisol
levels.
• If the adrenal cortex is not stimulated by the
pituitary, a normal response to doses of
exogenous ACTH (see text)
• Blood sugar levels and electrolyte values
 Management
• Restore circulatory status—fluids, steroids
• May need antibiotics if infection precipitated crisis
• May need lifelong steroid therapy and
mineralocorticoid therapy
• May need additional salt intake
• Check orthostatics
• Daily weights
• Aware that stressors can precipitate crises
• Medic alert bracelet or similar identification of
history
 Cushing’s Syndrome

• Results from excessive adrenocortical

activity
• May be related to excessive use of
corticosteroid medications or due to
hyperplasia of the adrenal cortex
• Oversecretion of corticosteroids can
also be caused by pituitary tumor
• Can be caused by bronchogenic
carcinoma or other malignancy
 Manifestations of Cushing’s syndrome

 Cataracts, glaucoma
 Hypertension, heart failure
 Truncal obesity, moon face, buffalo hump, sodium
retention, hypokalemia, hyperglycemia, negative
nitrogen balance, altered calcium metabolism
 Decreased inflammatory responses, impaired wound
healing, increased susceptibility to infections
 Osteoporosis, compression fractures
 Peptic ulcers, pancreatitis
 Thinning of skin, striae, acne
 Mood alterations
 Assessment and Diagnostic Findings

 Overnight dexamethasone suppression test

frequently used for diagnosis
 Administered at 11pm and cortisol level
checked at 8am
 Suppression of cortisol to less than 5mg/dL
indicates normal functioning
 Measurement of plasma ACTH
(radioimmunoassay) in conjunction with
dexamethasone suppression test helps
distinguish pituitary vs. ectopic sites of ACTH.
 MRI, CT and CT also help detect tumors of
adrenal or pituitary
 Medical Management

 If pituitary source, may warrant

transphenoidal hypophysectomy
 Radiation of pituitary also appropriate
 Adrenalectomy may be needed in case of
adrenal hypertrophy
 Temporary replacement therapy with
hydrocortisone or Florinef
 Adrenal enzyme reducers may be indicated if
source if ectopic and inoperable. Examples
include: ketoconazole, mitotane and
metyrapone.
 If cause is r/t excessive steroid therapy,
tapering slowly to a minimum dosage may be
appropriate.
 Primary Aldosteronism or Conn’s
Syndrome
• Excessive aldosterone secondary to adrenal
tumor
• retain sodium and excrete potassium
• Results in alkalosis
• Hypertension—universal sign of
hyperaldosteronism
• Inability of kidneys to concentrate the urine
• Serum becomes concentrated
• Excessive thirst
• Hypokalemia interferes with insulin secretion
thus will have glucose intolerance as well
 Assessment and Diagnostic Findings

• High sodium
• Low potassium level
• High serum aldosterone level
• Low renin level
• Aldosterone excretion rate after salt
loading is diagnostic for primary
aldosteronism
• Renin-aldosterone stimulation test
 Management

• Surgical removal of tumor

• Correct hypokalemia
• Usual postoperative care with
abdominal surgery
• Administer steroids
• Fluids
• Monitoring of blood sugar
• Control of hypertension with
spironolactone
 Corticosteroid Therapy

• Hydrocortisone--Cortisol
• Cortisone--Cortate
• Prednisone--Deltasone
• Prednisolone-Prelone
• Triamcinolone--Kenalog
• Betamethasone--Celestone
• Fludrocortisone (contains both
mineralocorticoid and glucocorticoid)
Florinef
 Indications

• RA
• Asthma
• MS
• COPD exacerbations
• Lupus
• Other autoimmune disorders
• Dermatologic disorders
 Dosing

• Lowest dose
• Limited duration
• Best time to give dose is in early
morning between 7-8 am
• Need to taper off med to allow normal
return of renal function
 Side Effects of Steroids

• Hypertension, thrombophlebitis,
accelerated atherosclerosis
• Increased risk of infection
• Glaucoma and corneal lesions
• Muscle wasting, poor wound healing,
osteoporosis, pathologic fractures
• Hyperglycemia, steroid withdrawal
syndrome
• Moon face, weight gain, acne
Diabetes Mellitus (DM)

• Diabetes mellitus refers to a group of

diseases that affect how the body uses
blood sugar (glucose). Glucose is an
important source of energy for the cells
that make up the muscles and tissues. It's
also the brain's main source of fuel. The
main cause of diabetes varies by type.
– Type I – Insulin dependent (usually, children)
– Type II – Non Insulin Dependent (40 above)
Usual S/Sx of Diabetes Mellitus (DM)
• Feeling more thirsty than usual.
• Urinating often.
• Unusual hunger or crave for (sweet) foods.
• Losing weight without trying.
• Presence of ketones in the urine. Ketones are a
byproduct of the breakdown of muscle and fat that
happens when there's not enough available insulin.
• Feeling tired and weak.
• Feeling irritable or having other mood changes.
• Having blurry vision.
• Having slow-healing sores.
• Getting a lot of infections, such as gum, skin and vaginal
infections.
Complications of Diabetes Mellitus (DM)

• Heart and blood vessel (cardiovascular) disease

• Nerve damage from diabetes (diabetic
neuropathy)
• Kidney damage from diabetes (diabetic
nephropathy)
• Eye damage from diabetes (diabetic retinopathy)
• Foot damage
• Skin and mouth conditions
• Hearing impairment
• Depression 20 DM
Pathophysiology of Diabetes Mellitus

• defective insulin secretion by pancreatic β-cells and

the inability of insulin-sensitive tissues to respond
appropriately to insulin.
• People with DM-1 do not produce insulin, and as a
result sugar builds up in the blood instead of going
into the cells, where it's needed for energy.
• With DM-2, the body continues to produce insulin,
although insulin production by the body may
significantly decrease over time. The pancreas
produces either not enough insulin, or the body is
unable to recognize insulin and use it properly.
Common Rx for Diabetes Mellitus-I
• Short-acting (regular Ins, onset 30 mins SQ)
– Humulin R
– Novolin R
• Rapid-acting (given 15 mins ac; onset 15 mins)
– Lispro (Humalog)
– Aspart (Novolog)
• Intermediate-acting (onset 1hr, lasts 24hrs)
– Novolin N
– Humulin N
• Long- and ultra-long-acting (covers 14-40 hrs)
– Glargine (Lantus)
– detemir (Levemir)
Common Rx for Diabetes Mellitus-II
• Sulfonylureas (Trigger the release of insulin)
– Glipizide
– Glimepiride
• Dipeptidyl-peptidase 4 (DPP-4) inhibitors
(release insulin when sugar is high)
– Sitagliptin
– Linagliptin
• Biguanides (Improve cells' sensitivity to insulin)
– Metformin
• Thiazolidinediones (limit liver to release sugar)
– Rosiglitazone
– Pioglitazone
Nugget of wisdom before we end…

Be informed. Be a critical thinker.

Thank you for listening.

Ready for the NLE?

Rotsen Jambongana, RN, MN

Professor III – USLS Bacolod
Course Leader – USLS INA Internal for BSN4

0998-4299939
rotsenrn@gmail.com
r.jambongana@usls.edu.ph
Rotsen.Jambongana@concentrix.com