PITUITARY GLAND

 HYPOPITUITARISM
 decreased secretion of one or more of the eight hormones produced by the pituitary gland  Panhypopituitarism – most hormones  ETIOLOGIC CAUSES:  disease of the pituitary gland itself  disease of the hypothalamus  can result from radiation therapy (head and neck area)  total destruction from trauma, tumor/vascular lesion which removes all stimuli  DWARFISM  GENERALIZED LIMITED GROWTH  CATEGORIES:  Disproportionate  small body but other parts are of average size or above average size  example: Dagul  Proportionate  everything is proportionate but small in nature  example: Mahal and Mura  TYPES:  Genetic or Mid-parental height  boy’s height: (+ 5in to mother’s height) + father’s height = total / 2  girl’s height: ( - 5in from father’s height) + mother’s height = total / 2  Constitutional Stature  short in nature  Psychosocial Dwarfism  due to an emotional problem  Catch-up Growth  present during puberty stage  CLINICAL MANIFESTATIONS:  approximately 4ft in height  average size trunk  short arms and legs  short fingers  limited mobility  progressive development of bowed legs  progressive development of swayed lower back (Kyphotic)  NURSING INTERVENTION:  provide emotional support to the family  encourage client and family to express feelings  administer prescribed GH  DIABETES INSIPIDUS  HYPOSECRETION OF ADH  DISORDER OF WATER

 ETIOLOGIC FACTORS:  Primary  idiopathic

 Secondary

METABOLISM

CAUSED DI)

BY

DEFICIENCY OF ADH SECRETED BY PPG OR INABILITY OF THE KIDNEY TO RESPOND TO ADH

(NEPHROGENIC

 

DEFICIENCY ADH MAY BE PARTIAL /COMPLETE DI MAY BE PERMANENT / TRANSIENT

tumor), aneurysms, conditions that ↑ ICP, surgical removal of posterior pituitary tumor, CNS infections  Nephrotic Diabetes Insipidus  failure of renal tubules to respond to ADH  longstanding renal disease (r/t hypokalemia, hypercalcemia) and other meds  DIAGNOSTIC TESTS:  Fluid deprivation test  withholding fluid for 8-12 hours/until 3-5% body weight is lost  Plasma and urine osmolality studie  inability to ↑ SG and osmolality = DI  ↑ Na level  Plasma levels, desmopressin (synthetic vasopressin), IV infusion (hypertonic)  CLINICAL MANIFESTATION:  marked polyuria (4L/day)  USG: 1.001 - 1.005  polydipsia (2-20L), craves cold water  dehydration  muscle pain and weakness  postural hypotension and tachycardia  urine is like water  MEDICAL MANAGEMENT:  GOALS: replace ADH, adequate fluid replacement, correct underlying intracranial pathology  Desmopressin  without vascular effects of natural ADH = fewer adverse effects  administered intranasally via calibrated plastic tube  Vasopressin causes vasoconstriction; used cautiously with CAD  IM administration of ADH  if intranasal route is not possible  done every 24 – 96 hours  vial of med should be shaken  rotation of injection to prevent lipodystrophy  Clofibrate (Atromid-S)  hypolipidemic agent with antidiuretic effect on px with DI  Chlorpropamide (Diabinese) and thiazide diuretics  used in mild forms as it potentiate the actions of Vasopressin  Tx for nephrogenic DI  thiazide diuretics  mild salt depletion  prostaglandin inhibitors and indomethacin

 head trauma, neurosurgery (brain

 NURSING MANAGEMENT:  demonstrate correct med administration  provide s/sx of hyponatremia  instruct px to wear medical bracelet

 HYPERPITUITARISM
 ETIOLOGIC CAUSES:  Sheehan’s syndrome  Postpartum pituitary necrosis  severe blood loss, hypovolemia, HPN  ACROMEGALY  AFTER CLOSURE OF THE EPIPHYSEAL PLATE  CLINICAL MANIFESTATION:  local or systemic effects  ↑ growth  large and thick hands  visual disturbances  HTN  hyperglycemia  organomegaly  LAB ASST:  CT scan  MRI  MEDICAL MANAGEMENT:  Transphenoidal Hypophysectomy  removal of pituitary gland  post-op: avoid sneezing  watch out for bleeding (racoon’s eyes, hematoma under ear). CSF leak, infection, hypopituitarism  Bromocriptine (Parlodel)  SE: drowsiness  AE: fainting, depression  NURSING MANAGEMENT:  emotional support  skin care  prepare patient for surgery  GIGANTISM  BEFORE CLOSURE OF THE EPIPHYSEAL  MEDICAL MANAGEMENT:  Octreotide  Lanreotide  Parlodel  Radiation therapy  Surgery  SYNDROME

ADRENAL GLANDS
 HYPOFUNCTION

 CNS disorders (head injury, brain surgery/tumor, infection)  CLINICAL MANIFESTATION:  hypervolemia  mental status change  abnormal weight gain  MEDICAL MANAGEMENT:  GOAL: eliminate underlying cause  NURSING MANAGEMENT:  monitor VS, neuro status, I&O, daily weight, provide safe environment  restrict fluid intake  administer diuretics (Furosemide) and IVF carefully  with fluid restriction to treat severe hyponatremia  administer prescribed Demeclemycin

OF ADRENAL GLANDS

PLATE

OF

INCREASED

ADH

(SIADH)
 HYPERSECRETION OF ADH  ETIOLOGIC CAUSES:  nonendocrine origin: bronchogenic carcinoma  malignant lung cells synthesize and release ADH  severe pneumonia, pneumothorax, and other lung disorders  direct stimulation of pituitary gland

 ADDISON’S DISEASE  HYPERCOTISOLISM  HYPOFUNCTION OF ADRENAL GLANDS  ETIOLOGIC FACTORS:  idiopathic  surgical removal of both adrenal glands  infection of adrenal glands  TB, histoplasmosis  inadequate secretion of ACTH  therapeutic use of corticosteroids  sudden cessation of ACTH therapy  CLINICAL MANIFESTATIONS:  muscle weakness  fatigue  weight loss  ↓ appetite  GI disturbances  hyponatremia  hypoglycemia  dehydration and hypovolemia  ↑ /dark skin pigmentation  anorexia  emaciation (too thin)  hypotension  hyperkalemia  mental status changes (apathy, confusion)  NURSING MANAGEMENT:  less stress  fluid  monitor VS, especially BP  monitor weight  monitor blood glucose level and potassium level  administer hormone agents as prescribed (glucocorticoids)  ADDISONIAN’S/HYPOTENSIVE CRISIS  LIFE-THREATENING DISORDER CAUSED BY ACUTESEVERE ADRENAL INSUFFICIENCY

 CAUSES:  severe stress  infection  trauma/surgery  CLINICAL MANAGEMENT:

severe headache severe abdominal pain severe weakness severe hypotension signs of shock  pallor  apprehension  rapid and weak pulse  rapid respiration  hypotension  other signs:  nausea  diarrhea  cyanosis
     

 NURSING MANAGEMENT:  administer hydrocortisone  monitor VS frequently  monitor I&O, neuro status, electrolyte imbalance and blood glucose  administer IVF  maintain bed rest  maintain antibiotics

adrenal hypertrophy  PHARMACOLOGICAL MANAGEMENT:  Metyrapone  test function of pituitary glands  Mitotane  ↓ ability to stress  NURSING MANAGEMENT:  ↓risk for injury  ↓risk for infection  prepare patient for surgery  encouraging rest and activity  promoting skin integrity (meticulous)  improving body image  use ketonazole for ↓ production of excess cortisol  improving thought process (for emotional instability)  monitor lab values (glucose, Na, K, Ca)  administer aminoglutamide  provide ↓CHO, ↓ Na, ↑CHON  CONN’S DISEASE  HYPERALDOSTEROIDISM  ↑ MINERALOCORTICOIDS  DIAGNOSTIC TEST:  ↓USG  very ↓ serum K  ↑serum Na  ↑urinary aldosterone  NURSING MANAGEMENT:  monitor VS, I&O, USG  monitor serum, K, Na  provide K-rich foods  administer diuretics (Spironolactone)  maintain sodium-restricted diet  PHEOCHROMOCYTOMA

 radiation of pituitary gland  adrenalectomy of primary

 HYPERFUNCTION

OF ADRENAL

GLANDS  CUSHING’S DISEASE
 DIURNAL PATTERN OF CORTISOL IS LOST  EXCESSIVE ADRENOCORTICAL ACTIVITY  HYPERSECRETION OF GLUCOCORTICOIDS
ADRENAL CORTEX

FROM

 ETIOLOGIC FACTORS:  adrenal tumor  overuse of corticosteroids  pituitary tumor  ectopic production of ACTH by malignancies  abuse of steroids  DIAGNOSTIC TEST:  ↑ serum cortisol  CLINICAL MANIFESTATIONS:  arrest of growth  obesity, musculoskeletal changes, central-type obesitya  buffalo hump in neck, heavy trunk w/ thin extremities  thin and fragile skin  development of bruises and striae (ecchymoses)  moon-faced  kyphosis, compression fractures  backache  osteoporosis, muscle wasting  hypertension, heart failure  hyperglycemia/overt DM  oiliness of skin/acne  disturbed sleep  lost libido  mood changes  visual disturbances d/t pituitary tumor  slow healing of wounds  weight gain  MEDICAL MANAGEMENT:  surgical removal of tumor by transphenoidal hypophysectomy

 ↑ ACTH  ↑ SECRETION
MEDULLA

OF EPINEPHRINE AND NOREPINEPHRINE BY

 ↑ ADRENERGIC

HORMONES

 CLINICAL MANIFESTATIONS:  hypertension  severe headache  palpitation  tachycardia  profuse sweating  sweating and flushing  weight loss, tremors  hyperglycemia, glycosurics  NURSING MANAGEMENT:  monitor BP  monitor hypertensive crisis (TOP priority)  avoid stimulation (regulate BP)  administer antihypertensive (check BP)  prepare phentolamine  monitor blood glucose  provide adequate rest  ↑ caloric food  prepare surgery (adrenalectomy)  depletion of water in body  monitor s/sx of shock

 IVF  lifelong replacement

glucocorticoids

 Fine-needle Aspiration Biopsy

THYROID GLANDS
 ASSESSMENT
AND

DIAGNOSTIC FINDINGS

 inspection and palpation

 swelling and asymmetry: extend neck
slightly and swallow  size, consistency, shape, symmetry, and presence of tenderness  hands encircle patient’s neck  soft texture = Grave’s disease, firmness = Hashimoto’s, tenderness = thyroiditis auscultation  localized audible vibration of a bruit = ↑ blood flow through thyroid gland (hyperthyroidism) Serum Thyroid-Stimulating Hormone  used for monitoring thyroid hormone replacement therapy  distinguishing disorders of thyroid and pituitary/hypothalamus Serum Free T4  to confirm abnormal TSH  direct measurement of free thyroxine  N: 0.9 – 1.7ng/dL (11.5 – 21.8 pmol/L) Serum T3 and T4  includes protein bond and free hormone levels that occur in response to TSH secretion  CI: serious systemic illnesses, meds (oral contraceptives, corticosteroids, phenytoin, salicylates), protein wasting (result of nephrosis), androgen use  N (T4): 4.5 – 11.5 ug/dL (58.5 – 150 nmol/L)  N (T3): 70 – 220 ng/dL (1.15 – 3.10 nmol/L) T3 Resin Uptake Test  indirect measure of unsaturated TBG; to determine the amount of thyroid hormone bound to TBG and the number of available binding sites  useful in evaluation of thyroid hormone levels in px who have received diagnostic/therapeutic doses of iodine  ↓ free binding sites = T3 reuptake > 35% = hyperthyroidism  ↑ free binding sites = T3 reuptake < 25% = hypothyroidism  CI: estrogen, androgen, salicylates, phenytoin, anticoagulants, corticosteroids Thyroid Antibodies  RIA techniques for antithyroid antibodies  90 % = chronic autoimmune thyroid disease; 100 % = Hashimoto’s; 80% = Grave’s disease Radioactive Iodine Uptake  measures rate of iodine uptake by the thyroid gland and counts the gamma rays released from the breakdown of iodine in the thyroid  CI: intake of iodine

 use of small-gauge needle to sample thyroid tissue  negative = benign; positive = malignant; indetermine = suspicious; inadequate = nondiagnostic  Thyroid Scan, Radioscan, Scintiscan  a scintillation detector or gamma camera which moves back and forth across the area  visual image is being made of the distribution of radioactivity in the area being scanned  determine size, location, shape and anatomic function  “hot” and “cold” areas  Serum Thyroglobulin  RIA to detect persistence or recurrence of thyroid carcinoma

 HYPOTHYROIDISM
 inadequate amount; underactive thyroid  Cretenism (children); Myxedema (adult)  TYPES:  PRIMARY/THYROIDAL  dysfunction of thyroid gland itself  SECONDARY/PITUITARY  entirely a pituitary disorder  TERTIARY/HYPOTHALMIC  disorder of the hypothalamus resulting in adequate secretion of TSH d/t ↓ stimulation of TRH  CENTRAL  failure of the pituitary gland, hypothalamus, or both  CRETENISM  thyroid deficiency present at birth  HYPOTHYROIDISM

 ETIOLOGIC FACTORS:
 fails to secrete several hormones  medications (Lithium, iodine

compounds, anti-thyroid meds) infiltrate diseases of the thyroid atrophy of thyroid with aging iodide insufficiency and excess thyroidectomy autoimmune response radiation therapy  RISK FACTORS:  50 years above (woman)  60 years above (man)  family history of thyroid problems  CLINICAL MANIFESTATION:  extreme fatigue  hair loss, brittle nails, dry skin, and numbness/tingling of fingers  husky voice and hoarseness  menstrual disturbances  severe hypothyroidism (subnormal temp and PR, wt gain, cachexia— debilitated states)  thickened skin, alopecia, expressionless/masklike facial features
     

tongue, hands and feet; constipation (↓ GI motility); possible deafness  advanced hypothyroidism: pleural effusion, pericardial effusion, and respiratory muscle weakness  MEDICAL MANAGEMENT:  GOAL: restore metabolic state by replacing missing hormone  Synthetic levothyroxine (Synthroid or Levothroid)  6 weeks  dosage is based on patient’s serum TSH concentration  prevention of cardiac dysfunction  long term hypothyroidism = ↑ cholesterol, atherosclerosis, and CAD  angina occurrence = oxygen needs of the myocardium exceeded its blood supply  prevention of med interactions  may ↑ blood glucose levels; adjust insulin levels  ↑ pharma effects of digitalis glycosides, anticoagulants, indomethacim  phenytoin and tricyclic antidepressants ↑ drug effects of thyroid  bone loss and osteoporosis may occur  hypnotic and sedative effects may cause respiratory depression  supportive therapy  measure ABG to determine CO2 retention  pulse oximetry to monitor O2 saturations  fluids are administered cautiously d/t danger of water intoxication  NURSING DIAGNOSIS:  ↓alveolar ventilation leading to bradycardia  activity intolerance r/t fatigue and depressed cognitive process  ↑ participation in activities and ↑ independence  risk for imbalanced body temp  maintenance of body temp  constipation r/t depressed GI function  return to normal bowel function  deficient knowledge about the therapeutic regimen for lifelong thyroid replacement therapy  knowledge and acceptance of the prescribed therapeutic regimen  ineffective breathing pattern r/t depressed ventilation  improved respi status and maintenance of normal breathing pattern

 cold intolerance  subdued emotional responses  slowed speech; enlarged

thought processes r/t depressed metabolism and altered CV and respi status  improved thought process  NURSING MANAGEMENT:  avoid heating techniques  ↓calorie diet  encourage activity to ↓ constipation; drink 6-8 glasses of water; ↑ fiberintake  maintain patient airway  administer oxygen  IVF  monitor I&O m  PATHOPHYSIOLOGY: inadequate thyroid hormones ↓ general slowing of all physical and mental processes ↓ general depression of most cellular enzyme systems ↓ ↓ metabolic activities of all cells ↓ ↓ ↓ ↓ ↓oxygen demand ↓ oxidation of less body heat ↓ nutrients ↓ hypoxia ↓ risk for ↓ ↓ energy hyponatremia ↓ ↓ ↓ ↓ hyperventilation bradycardia cold intolerance  MYXEDEMA COMA

 disturbed

 ACCUMULATION

OF

MUCOPOLYSACCHARIDES

IN

SUBCUTANEOUS AND OTHER INTERSTITIAL TISSUE

 MOST EXTREME, SEVERE STAGE OF  HIGH MORTALITY  CARBON DIOXIDE RETENTION,
THROIDISM

HYPOTHYROIDISM NARCOSIS ,

AND

 CARDIOVASCULAR COLLAPSE AND SCHOCK  INTENSIVE THERAPY IF PATIENT SURVIVE  ETIOLOGICAL FACTORS:  infection/other systemic disease  use of sedatives  CLINICAL MANIFESTATION:  initially:  depression, ↓ cognitive status, lethargy, somnolence  hypotension  bradycardia  unresponsive  hypoventilation  hypovolemia  convulsions  hypothermia  cerebral hypoxia  MEDICAL MANAGEMENT:  restore normal metabolic state by replacing missing hormone (TSH)— primary object

 oxygen therapy  T4 to T3 (Cytomel); Proloid (T4 to T3)

 ↑ dieresis because of edema  ↑ muscle tone  ↑ metabolic activity  slight fever  s/sx hypothyroidism in 3-12 weeks  ↓ TSH level  NURSING MANAGEMENT:  VS monitoring  administer hormone replacement  ↓ calorie, ↓ cholesterol, ↓ fat  manage constipation appropriately  provide warm environment  avoid sedatives and narcotics  report chest pain promptly  HASHIMOTO’S THYROIDITIS  COMMON WITH WOMEN (MULTIPLE PREGNANCY WITH BLEEDING )  ETIOLOGIC FACTOR:  idiopathic  CLINICAL MANIFESTATIONS:  firm enlargement of thyroid glands  no gross nodules  ↓ BMR  DIAGNOSTIC TEST:  T3, T4 normal to abnormal amounts  ↑ TSH  MEDICAL MANAGEMENT:  suppression of TSH  surgical resection of goiter if tracheal compression, cough/hoarseness  management of hypocalcemia

 controls nervousness  SURGICAL MANAGEMENT:  Thyroidectomy  can be all/part of the thyroid gland  patient who cannot tolerate antithyroid glands  PTU administered before surgery  Iodism – iodine toxicity  NURSING MANAGEMENT:  assess cardiac respiratory function  signs for thyroid storms  administer oxygen to avoid hypoxia  cool, comfortable temperature  improve nutritional status  reduce diarrhea  provide quiet atmosphere  record weight  enhance coping measures  reduce stress  improve self-esteem  provide eye protection

PARATHYROID GLANDS
 ANATOMY-PHYSIOLOGY
 mobilization of Ca from bone

 ↑ osteoclast activity; ↑ Ca level absorption of Ca from small intestine  Vitamin D  suppression of Ca loss in urine  ↓ rate of which Ca are loss in the urine  stimulate PO4 ions
 enhancing

 HYPERTHYROIDISM
 hypermetabolic condition characterized by excessive amounts of thyroid by abnormal stimulation of thyroid gland  HYPERTHYROIDISM:  ETIOLOGIC FACTORS:  medical conditions  age  gender (men are prone)  genetic factors  ethnic background  other factors  CLINICAL MANIFESTATIONS  enlarged thyroid  nervousness  heat intolerance  MEDICAL MANAGEMENT:  PTU and Methimazole  associated with Grave’s disease  SE: rash itching  Radioactive iodine therapy  destroys overactive thyroid cells  common treatment in elderly patients  hyperthyroidism will subside in 3-5 weeks  Potassium Iodide, Lugol’s solution  Beta-adrenergic blocking agents (Propanolol)

 HYPOPARATHYROIDISM
 inadequate parathyroid hormones  TYPES:

ACUTE

 iatrogenic  caused by accidental damage due to

removal of parathyroid aglands  CHRONIC  idiopathic  lethargy, thin, patchy hair  PSEUDOHYPOPARATHYROIDISM  Albright’s hereditary osteodystrophy  HYPOPARATHYROIDISM:  ETIOLOGIC FACTORS:  occurs more in women than men  CLINICAL MANIFESTATIONS:  Latent tetany  numbness  tingling  stiffness  cramp  Overt tetany (occurs after surgery)  bronchospasm  laryngeal spasm  hypocalcemia  anxiety  irritability  depression  delirium

 ECG changes  hypotension  carpopedal spasm  dysphagia  photophobia  cardiac dysrhythmias  seizures  DIAGNOSTIC TESTS:  Positive Trosseau’s sign: carpopedal spasm  use of BP cuff by applying 3050ammHg (applying hypoxia)  result: stiffening of wrists, and adduction of fingers  Positive Chvotek’s sign:  touching the earlobe  result: twitching of mouth and nose  Ca levels of 5-6mg/dl or lower  PHARMACOLOGICAL MANAGEMENT:  Oral Ca Carbonate tabs  Vitamin D  which can help absorb Ca and eliminate phosphorus  MEDICAL MANAGEMENT:  Parenteral Parathormone  for treatment for acute hypoparathyroidism  monitor for allergic reactions and changes in serum level  Sedative agents for neuromuscular irritability/seizures  Aluminum hydroxide gel and Aluminum carbonate  which should be taken after meals  Phenobarbital  for seizures  NURSING MANAGEMENT:  assess client at risk numbness/tingling  monitor lab values, VS, I&O  administer Ca gluconate slowly and cautiously  encourage fluid intake  provide health teaching  ↑ Ca diet (green leafy vegetables)  keep Ca gluconate and tracheostomy set  hand washing  provide stress-free environment  spinach is avoided (contains oxalate)  Vitamin D preparation  to ↑ Ca  care of post-op patient  trach set or mechanical ventilation  Ca gluconate

renal failure, phenytoin)  TERTIARTY

osteomalacia

(d/t

 HYPERPARATHYROIDISM:  CLINICAL MANIFESTATIONS:  apathy, muscle weakness, n/v, constipation, hypertension, cardiac dysrythmia, cardiac contraction  musculoskeletal sx  skeletal pain/tenderness  peptic ulcer and ↑ pancreatitis  renal damage  shortening of bone  irritability  renal system  polyuria  nephrocalcinosis  pain in weight bearing  shortening of body stature  fatigue, ↓ muscle tone, muscle weakness  abdominal pain ranging to the back  ASSESSMENT:  radioimmunoassay (RIA)  x-ray (bone changes)  ↑ concentrations of parathormone  ↑ serum Ca levels  spectrophotometry  ultrasound, MRI  biopsy (for cysts, adenoma, hyperplasia)  MEDICAL MANAGEMENT:  Parathyroidectomy  < 50 years old  serum Ca ↑ 1.0 mg/dl  urinary Ca level ↑ 400 mg/day  ↓ 30% in renal function  Mobility  bed rest is discouraged due to Ca excretion; when an individual moves, the Ca is stored in the bones rather than in the bloodstream  Hydration therapy  2000 ml/day  cranberry juice ↓ urinary pH  Diet and meds  avoid a diet with restricted/excess Ca  anorexia is common  Pharmacotherapy  Calcimimetic therapy  NURSING MANAGEMENT:  airway patency, dehydration, immobility, diet  ↑ fluid intake (3-4L/day)  acid-ash fruit juices (prune and cranberry juice)  protect from injury to prevent fracture  NS IV (↑ Na)  Ca excretion is promoted by Na excretion  mobility

 HYPERPARATHYROIDISM
 excessive parathyroid secretion  TYPES:  PRIMARY  one or more parathyroid glands affected  SECONDARY  destruction of the one that sends problem dietary from cause: rickets from vitamin D deficiency, chronic

 bed rest ↑ Ca
 diet/meds

 ↓ Ca diet  administer antacids those with peptic ulcer  thiazide diuretics must be avoided (as it promotes Ca reabsorption)

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