ENDOCRINE SYSTEM

ANATOMY & PHYSIOLOGY

● The foundations of the endocrine system are the hormones (products) and the glands
(ductless)
● Hormones transfer information and instructions from one set of cells to another
○ Exocrine = glands w/ ducts = enzymes

CLASSIFICATION OF HORMONES: (SAP)

● Steroids - lipids derived from cholesterol; they are secreted by the gonads (sex cells),
adrenal cortex (glucocorticoid, mineralocorticoid, aldosterone) and the placenta (human
placental lactogen)
● Peptides - short chains of amino acids; they are secreted by pituitary, parathyroid, heart,
stomach, liver, and kidneys
● Amines - derived from tyrosine and are secreted from the thyroid (T3, T4, calcitonin)
and the adrenal medulla (epinephrine, norepinephrine (sympathetic response))

ANATOMY
● Hypothalamus - link between CNS and Endocrine
○ Produces: corticotropin-releasing hormone (acts in adrenal cortex);
thyrotropin-releasing hormone (acts in the thyroid gland); gonadotropin-releasing
hormone (acts in egg cells and testes)
● Pituitary gland - Also known as “master gland” divided into anterior and posterior
○ Adenohypophysis “Anterior”
■ Secretes GH, ACTH, TSH, FSH & LH, MSH, prolactin (production of milk)
○ Neurohypophysis “posterior”
■ Secretes ADH (aka vasopressin), oxytocin (ejection of milk)
● Endocrine gland
■ Negative feedback control mechanism - control or regulate the amount of
hormones within our body/ blood
■ Primary disorder - target glands are affected
■ Secondary disorder - hypothalamus or pituitary gland are affected

POSTERIOR PITUITARY
● Lack of ADH - “DIABETES INSIPIDUS”
● Excessive ADH - “SIADH or Syndrome of Inappropriate Antidiuretic Hormone”

DIABETES INSIPIDUS:
RISK FACTORS:
● Brain, tumors, trauma, infection, surgery
● Nephrogenic DI (kidney problem)
● Medications: Lithium (commonly used for manic d/o, bipolar) and Demeclocycline
(tetracycline ADH)
DIAGNOSTIC TESTS:
● Urinary Specific gravity (N: 1.010 - 1.025)
○ Depends on the number of particles in a solution
○ In Diabetes Insipidus: Low Urine specific gravity <1.005 (Since daghan tubig ang
mugawas sa lawas = diluted urine)
● Serum osmolality sodium levels:
○ In Diabetes insipidus: High serum osmolality sodium levels (as the body excrete
water, sodium is retained)
● Fluid deprivation test
○ Pt is deprived from drinking water for 8 hours
○ In normal pt: ADH will increase, however in DI, ADH will continue decreasing
● Hypertonic saline test
○ Pt is given a solution with high sodium content “hypertonic solution” like 3-5%
NaCl
○ In normal pt: ADH will increase, however in DI, ADH will continue decreasing as it
does not respond

SIGNS & SYMPTOMS

● Polyuria

⬆️
● Polydipsia

⬆️
● Serum Na

⬇️
● Hct
● Specific gravity:

Objectives of Therapy:
● To replace ADH
○ DDAVP (DOC: Desmopressin)
○ Route: IV, SC, Intranasal
○ EXAMPLE: “Pitressin” Tannate in oil (via IM)
■ Outcome: Decrease urine output
■ Responsibility: Report chest pain
● To ensure adequate fluid replacement
○ Transphenoidal lympophysectomy - nasal packing
■ Position: Semi-fowlers
● To identify and correct the underlying intracranial pathology

SYNDROME OF INAPPROPRIATE ANTIDIURETIC HORMONE (SIADH)

RISK FACTORS:
● Vasopressin overuse
● Malignancy - 80% “small cell CA” lung cancer
● Increase intracranial pressure
● Medications: vincristine, phenothiazines thiazides, TCA
 ⬆️
DIAGNOSTIC TEST:

⬇️
● urine specific gravity “hemodilution” “fluid overload”

⬇️
● serum sodium
● CBC (hct)

Nursing Interventions:

⬇️
● Monitor v/s, I&O, daily weights (N: 2 pounds per week weight gain or loss)
● Monitor for serum electrolytes ( Na)
○ Mgt: Administer IVF = 3-5% nACl
● Client and family teaching
● Replacement IV fluids and electrolytes
● Medications:
○ All diuretics except thiazide
○ Lithium
○ Demeclocycline (monitor for possible nephrotoxicity)
■ Check urine for presence of protein (first to be check), crea, BUN

THYROID GLAND
Produces the thyroid hormones by the thyroid follicles:
● Tri-iodothyronine or T3 = more potent and rapid
● Tetra-iodothyronine or thyroxine or T4
● Thyrocalcitonin = found in C-cells
○ Decreases serum calcium by depositing the calcium to the bone

Functions:
● Regulate growth and development of tissues

Common Laboratory Procedures

● Radioactive iodine uptake (RAI 131 I )
○ Measuring the absorption of I 131 or I12
○ Normal uptake: 5-35%
■ <5% = hypothyroid
■ >35% = hyperthyroid
○ Thyroid antibodies
■ Nursing resp:
● Allergy to seafood and iodine containing meds (cough syrup)
● Ask the pt what foods he had eaten prior to the procedure
● Avoid Medications (BLEP): because it can lead to False UPTAKE
○ Barbiturates
○ Lithium
○ Estrogen
○ Phenothiazine
■ Autoimmune DiSEASES:
● Hashimoto’s thyroiditis
 ● Graves Disease
● Thyroid scan 131 I
○ Used to visualize the thyroid gland when thyroid disease or nodule is suspected
■ Result:
● HOT NODULES: benign tumor
● Cold nodules = malignant tumor
● Thyroid stimulating hormone
○ Best screening test for thyroid problem
○ Normal value : 0.4 - 6.15 mU/L
● Fine needle aspiration biopsy
○ Confirmatory test

DISORDERS OF THYROID GLAND

⬇️ ⬇️
● Hypothyroidism
○ T3 & T4
○ Incidence: women is commonly affected
○ Age: 30 to 60 y/o
○ Etiology and risk factors:
■ Congenital defects: “cretinism” or congenital hypothyroidism
■ Antithyroid drugs: methimazole, propylthiouracil
■ Surgery or radioactive agents
○ Could lead to :
■ Myxedema coma
● Severe form of hypothyroidism
■ Cretinism
● Avoid barbiturates, anesthesia as it could lead to coma
○ Signs and symptoms:

⬇️ ⬆️ ⬆️ ⬆️
■ CNS: Lethargy, Depression, Confused
■ Cardiovascular: HR, BP, Cholesterol, lipids
■ Musculoskeletal: slow movement

⬇️
■ Skin: dry, absences of hair
■ Reproductive: Excessive bleeding/ menorrhagia, impotence, libido
■ Gastro: constipation, absence of hydrochloric acid “achlorhydria”
○ Nursing intervention:
■ Promote independence in self care activities
■ Maintenance of body temp = “pt experience cold intolerance”
● Provide warm blanket
● Extra clothing
● Comfortable environment
● Avoid using heating pads and electric blankets as it may cause
injury to the pt
■ Return of normal bowel function
● High-fiber diet
● Increase fluid intake at least 8 glasses of water per day
 ● Stool softeners like sodium docusate
■ Knowledge and acceptance of the prescribed therapeutic regimen
● Levothyroxine (Synthroid)
○ Taken on an empty stomach, in the morning
○ Report MD: chest pain, palpitations
○ Improved cardiovascular and respiratory status
○ Meticulous skin care

● Hyperthyroidism
○ Women are commonly affected
○ Age: 20 to 40 y/o
○ Etiology and risk factors:
■ Autoimmune = Grave’s disease
■ Medications
■ Thyroid carcinoma
○ Manifestations:
■ Exophthalmos : inflammation and accumulation of fluids behind the
eyeballs
● Can lead to corneal dryness = corneal ulcer = corneal blindness
○ Signs and symptoms:

⬆️ ⬆️ ⬆️
■ CNS: paranoia, restlessness, nervousness, anxiety

⬆️
■ Cardiac: CO, HR, BP = HEART FAILURE
■ GIT: Diarrhea, wt loss, appetite
■ Musculo: tremors,

⬇️
■ Skin: moist
■ Repro: amenorrhea, infertility, libido
○ Nursing interventions:

⬆️ ⬇️ ⬆️
■ Improving nutritional status
● High-calorie, CHO, Fiber, protein diet
■ Enhancing coping measures
● Restful and quiet environment
■ Improving self-esteem
■ Maintaining normal body temp
● Heat intolerance = cool environment, cool bath, and cold drinks
■ Monitor and manage potential complications
○ Medical Management:
■ Anti-thyroid medication therapy
● Propylthiouracil (DOC: for pregnant women)
● Methimazole (tapazole)
○ Taken with food
○ Monitor for agranulocytosis
○ Monitor bleeding & infection
○ These medications lowers WBC & platelets
 ■ Radioiodine therapy
● Contraindicated for pregnant women
● No exposure of children and pregnant
■ Adjunctive therapy “additional”
● Beta-blockers
● Steroids
○ To prevent Addisonian crisis during thyroidectomy
■ Thyroidectomy
○ Major Complications of Grave’s Disease
■ Exophthalmos
● Mgt: cover eyes with eye patch, eyeglasses, artificial tears (14%
methylcellulose)
● Give steroids and diuretics as prescribed
● Restrict salt intake
● Decompression Surgery
■ Heart disease
● To correct palpitation: Give beta-blockers and calcium channel
blockers
● Give PROPRANOLOL
■ Thyroid storm (thyrotoxicosis)
● Severe form of hyperthyroid that can lead to fatality
● Surgery: Thyroidectomy
○ Medications to prevent thyroid storm during thyroidectomy:
■ BETA BLOCKERS - inhibit thyroid hormone
■ IODINE (lugols, potassium iodide)- to make the
thyroid gland less vascular or avascular (to lessen
the bleeding)
■ STEROIDS - to prevent Addisonian crisis
■ ANTITHYROID MEDICATIONS - Propylthiouracil,
methimazole
○ Complications:
■ Bleeding
● Observations:
○ Frequent swallowing may indicate
bleeding
○ Monitor dressing and neck of the pt
■ Laryngeal Nerve Damage
● Observations:
○ Hoarseness of voice
■ Hypocalcemia
● Accidental removal of parathyroid glands
● Can lead to broncho/laryngospasm
■ Thyroid storm
 ○ Position: Semi-flowers; Head: Midline/ Neutral; No flexion
and extension of the head: can use pillow or sandbag in
between of the heads

The Adrenal Glands (location: top of the kidneys)

● Adrenal cortex: 3S
○ Zona glomerulosa (outermost layer) SALT
■ Produces mineralocorticoids
■ Produces aldosterone = for water and sodium reabsorption
● Excretion of Potassium and absorption of sodium
○ Zona fasciculata (middle layer) SUGAR
■ Source of glucocorticoids
○ Zona reticularis (innermost layer) SEX HORMONES
■ Source of sex hormones for both male/female (androgen (mainly),
estrogen)
● Adrenal medulla: Catecholamines
○ Epinephrine
○ Norepinephrine
■ Sympathetic - fight or flight response

ADDISON’S DISEASE ⬇️3S (salt, sugar, sex hormones)

● IDIOPATHIC/Autoimmune - 80%

⬇️
● Signs Symptoms:
○ Hypotension : aldosterone

⬇️
○ Hypoglycemia

⬇️
○ Hyponatremia : aldosterone

⬆️
○ Hyperkalemia: aldosterone
○ Hyperpigmentation : “bronze skin” melanin
■ Generalized skin pigmentation “caucasion” esp in the deposition in the
palmar skin creases, nails, and gums
● Management:
○ Priority: give IV fluid to prevent shock / addisonian crisis
○ Position (when in shock): Trendelenburg 20 degree elevation of the feet
○ Diet: High carbohydrate diet
○ Provide quiet non stressful environment
○ Adequate fluid and electrolyte replacement
■ IVF D5NSS or D5LR
○ Hormonal replacement: solu cortef (hydrocortisone), decadron (Dexamethasone)
and florinef
■ Steroids should be given with food; larger dose should be given in the
morning (⅔); ⅓ of dose is given in the evening because more activities in
the morning than in the evening, and more production of steroids in the
morning than in the evening
 ● Nursing resp: Taper the dose until the pt’s body can adapt to give
time for the adrenal glands to function again to reproduce steroids
to prevent steroid insufficiency/addisonian crisis

CUSHING'S SYNDROME ⬆️
3S (salt, sugar, sex hormones)
● Signs and symptoms:
○ Hyperglycemia
○ Muscle wasting: decrease of muscle mass; skin: purple striae
○ Obesity - abnormal distribution of fats: truncal/ central obesity, moon face, buffalo
hump
○ Hypertension
○ Muscle weakness: loss of muscle mass
○ Virilization: sex hormones “androgenital syndrome”
■ Hypertrophy of clitoris “enlargement”
■ Acne
○ Infection
○ Steroid psychosis (affecting memory and mood)
● Diagnostic test:
○ Serum cortisol
○ Serum glucose and electrolytes
○ Dexamethasone suppression test
■ Dexa 1 mg @ 11 pm
■ 8 am = measure plasma cortisol
■ Normal: suppression of cortisol at least 5 mg/dl
■ If no suppression, means that pt is positive for cushing’s
○ CT scan and MRI
○ Radioimmunoassay
● Management:
○ Improve body image and thought process
○ Decrease risk for injury and infection
■ Side rails up, bed on lowest position
■ Avoid crowded places, aseptic technique
○ Promote skin integrity
○ Administer medications:
■ Mitotane (lysodren)
■ Aminoglutethamide
■ Trilostane
■ Antihypertensive drug
○ Prepare patient for surgery:
■ unilateral adrenalectomy (2 yrs treatment; avoid sudden withdrawal of
steroids
■ bilateral adrenalectomy (lifetime steroid intake)
○ Diet: Low calories and moderate protein
PHEOCHROMOCYTOMA:

● Tumor in Adrenal medulla = catecholamines = urine = VMA vanillylmandelic acid

● 90% = benign; 10% = malignant
● Women are commonly affected
● Signs and symptoms: 5H
○ Hypertension - best indicator: 99% pt has pheochromocytoma
○ Headache
○ Hyperglycemia
○ Hypermetabolism
○ Hyperhidrosis
● Assessment to avoid:
○ Avoid palpating the abdomen to avoid compressing the adrenal glands resulting
to excessive release of catecholamines leading to hypertension
● Diagnostic test:
○ VMA (vanillylmandelic acid) “urinary metabolite” - standard test for urinary
catecholamines
■ 24-hour urine collection
● Discard the first void; do not include the first collection in the 24
hour sample
● Normal value: 7 mg/ 100 ml
● 2 days prior of the test avoid:
○ Aspirin
○ Banana
○ Cheese/ Coffee
○ Vanilla
○ Nuts
○ Clonidine Suppression test:
■ Sublingual antiadrenergic drug
■ Normal response: 40% suppression of the total catecholamines
○ Total PLASMA CATECHOLAMINES CONCENTRATION
■ Epinephrine: 100pg/ml
■ Norepinephrine: 100-55- pg/ml
○ CT SCAN AND MRI
○ I -metaiodobenzylguanidine (MIBG) scintigraphy - detect metastasis
● Management:
○ Diet: Avoid foods with tyramine
○ Monitor v/s and serum glucose level
○ Provide quiet and non stressful environment
○ Medications: phentolamine (Regitine) (initial meds/ first in line - alpha blockers),
phenoxybenzamine, propranolol (2nd in line - beta-blockers), metyrosine
■ Hypertensive crisis: 200/120 mmHg
● Position: High-fowler's position
○ Surgery: Adrenalectomy
DIABETES MELLITUS
● CLASSIFICATION:
○ Type 1 DM
i. Insulin dependent DM
ii. Juvenile onset: < 29 y.o
iii. Autoimmune
iv. Will lead to Diabetic KetoAcidosis
1. Pushing of Potassium outside of the cell = pt will experience
hyperkalemia
○ Type 2 DM
i. Non-insulin dependent DM
ii. HHNK
iii. Relative deficiency of insulin
○ Gestational DM
i. DM diagnosed during pregnancy
ii. Monitor for hypoglycemia for LGA babies after delivery because the
pancreas is hyperstimulated
○ DM associated with other conditions or syndromes
i. Cushing’s syndrome
ii. Pheochromocytoma
iii. Gigantism/ Acromegaly
● Risk factors:
○ Family history of DM
○ Obesity
○ Polycystic ovary syndrome - estrogen
○ Racial predisposition
○ Age: >45 y.o
○ History of gestational diabetes
○ Hypertension (BP >140/90 mmHg
○ HDL level <35 mg/dl or triglyceride level >250 mg/dl
○ In previous testing, impaired glucose tolerance or impaired fasting glucose
● Signs & symptoms:
○ Polyphagia “cell starvation” = fats usage = “ketone bodies”
○ Polyuria = High urine specific gravity (due to sugar content)
○ Polydipsia
○ Kussmaul breathing - to remove excess acid in the blood; common in type 1
DM
● Diagnosis of DM:
○ FBS - NPO for 8 hours
i. Normal values: 70 - 110 mg/dL
ii. Borderline: 110-126 mg/dl
iii. (+) > 126 mg/dl for 2 or 3 separate occasions
○ OGTT (oral glucose tolerance test)
 i. Normal value: <140 mg/dl
ii. Borderline 140 - 200 mg/dl
iii. (+) >200 mg/dl
iv. Controlled diet: 150 mg of CHO per day for 3 days
v. On the 3rd day: fasting for 8 hours
vi. 4th day: lab day
1. Get blood (baseline)
2. Give 75 g of glucose solution
3. Get blood after 30 mins, after 1 hour, and after 2 hours
a. Expected outcome: normal blood sugar after 2 hours
○ RBS (random blood sugar)
i. (+) DM = (+)3Ps and > 200 mg/dl
○ Glycosylated Hemoglobin
i. HbA A1C = determine amount of glucose bound to hemoglobin for 3-4
months/ 120 days (RBC lifespan)
ii. To check for pt compliance of diet and medication
iii. Result:
1. < 7.5% = good control
2. 7.6% - 8.9% = failed
3. >9% = poor
○ Urine test
i. Test for ketones
1. Mgt: CBS >240mg/dl = Increase dose of meds
ii. Acetest, ketodiastix
● Nursing Mgt:
○ Nutritional management:
i. Increase fiber intake
ii. Lower down carbohydrates (Cal 250-500 / day)
iii. Low fat diet
○ Regular exercise
○ Regular glucose monitoring
○ Pharmacological therapy
○ Client education
● Four main areas for insulin injection are:
○ Abdomen
○ Upper arms
○ Thighs
○ Hips
i. ROTATION OF INJECTION SITES to prevent lipodystrophy (1 inch
interval): Interval of 1 -2 wks before using same site again
1. Lipoatrophy - loss of fat tissue “dimpling of skin”
2. Lipohypertrophy - thickening of the fat tissue

● Oral Hypoglycemic agents (Type 2 DM)

○ Sulfonylureas - stimulates the b-cells for production of insulin
i. Example:
1. First generation:
a. Chlorpropamide (diabinase)
i. Do not take with alcohol which can lead to
Disulfiram reaction (nausea, vomiting and
headache)
b. Tolbutamide (orinase)
c. Thiazamide (tolinase)
d. Acetohexamide (dymelor
2. Second generation:
a. Glipizide (Glucotrol)
b. Glyburide diabeta (micronase)
c. Micronized glyburide (glynase, prestab)
○ Meglitinides - stimulates the b-cells for production of insulin
i. Meglitinide
ii. Repaglinide
○ Biguanides - enhance action of insulin in the peripheral receptors
i. Example: Metformin
1. Monitor renal function
○ Thiazolidinediones - enhance action of insulin in the receptors
i. Rosiglitazone
ii. Pioglitazone
1. Monitor for liver function
2. If pt is in family planning, better not to use this drug as it increases
ovulation
○ Alpha glucosidase inhibitor - inhibits alpha-glucosidase enzymes in the small
intestine and alpha amylase in the pancreas
i.
1. Should be given before an intake of food