Chapter 18: Alterations of Hormonal regulation

Physical features of acromegaly includes:

1) A protruding jaw 2) Increased bone density 3) Increased growth of soft tissues (nose and ears) 4) Large hands and feet

A diagnosis of diabetes mellitus is based on:

1) An elevated fasting plasma glucose concentration > or = 126 mg/dL or 2) An increased 2-hr plasma glucose during 75-g glucose tolerance testing > 200 mg/mL

Treatment of SIADH

1) Correction the underlying causal problems 2) Fluid restriction to 600-800 mL/day 3) Administration of Hypertonic Saline combined with furosemide (diuretic) therapy

Clinical manifestation of Acromegaly:

1) Enlarged tongues 2) Edema 3) Increase in size and function of sebaceous glands and sweat glands 4) Coarse skin and body hair

Symptoms of SIADH

1) GI symptoms occur early in the disease and include: - Nausea - Anorexia - Vomitting 2) Neuropsychiatric symptoms: - Headaches - Blurred vision - Lethargy - Apathy - Disorientation - Irritability - Seizures

2 forms of Type 1:

1) Immune-mediated: beta cell destruction that occurs as a result of an autoimmune attack on the pancreatic beta cell 2) Idiopathic: destruction without evidence of autoimmune markers.

Growth Hormone Disorders

1) Increase protein synthesis in most tissues of the body 2) Increase liver glycogenolysis (producing hyperglycemia) 3) Increase fat utilization in most tissues of the body due to increased fat mobilization 4) Stimulate increased muscle and skeletal growth

4 types of diabetes insipidus

1) Neurogenic: inability to produce and release ADH 2) Nephrogenic: kidneys inability to respond to ADH 3) Gestagenic is lack of ADH that develops during pregnancy 4) Primary polydipsia: ADH is suppressed by excessive fluid intake: a) Dipsogenic polydipsia: abnormality in thirst center b) Psychogenic polydipsia: compulsive water drinking due to psychiatric disorders

Chronic complication:

1) Neuropathies: sensory 2) Microvascular disease: Microangiopathy (thickening of capillary basement membrane due to hypoxia and ischemia); Retinopathy blind; Nephropathy (glomerulosclerosis) 3) Macrovascular disease: Brain (stroke), Heart (damage vessle), Extremities (gangrene and amputation)

3 "P"s in signs and symptoms for diabetes:

1) Polyuria 2) Polydipsia (excessive or abnormal thirst) 3) Polyphagia (excessive appetite or eating) Also: weight loss and fatique

Treatment of acromegaly

1) Surgical removal of the GH-secreting adenoma 2) Octreotide, a synthetic somatostatin analog, is very effective at suppresing production of GH and lower GH levels

Thyroid storm is charactered by:

1) Tachycardia 2) Hypertension 3) High temperature 4) Cardiac dysrhythmias and CHF

Hormonal alterations may be due to:

1) Too much hormone 2) Too little hormone 3) Faulure of target cell to response to hormone (clinically this situation is similar to "too little hormone")

Level of Na+ in SIADH

130-136 mEq/L mild symptoms 120-130 Moderate <115 is severe

Diabetic Ketoacidosis

300 - 750 mg/dL Develops when there is a deficiency of insulin (therefore, won't see in type 2) Hepatic glucose production increases and peripheral glucose usage decreases Fat is mobilized and ketogenesis is stimulated ADOLESCENCE

Hypoglycemia level:

45-60 mg/dL

HHNKS

600 - 4800 mg/dL Hyperosmolar hyperglycemic nonketonic syndrome - SImilar to Diabetic Ketoacidosis but less common since there is sufficient insulin present to prevent lipolysis and protein catabolism.

What are the signs and symptoms of syndrome of inappropriate antidiuretic hormone (SIADH)? Select all that apply.

A patient with SIADH has dyspnea, anorexia, dulled sensorium, impaired taste, and fatigue. Polyuria is a symptom of diabetes insipidus. Coarse skin is a symptom of acromegaly.

What are the signs and symptoms of diabetic ketoacidosis? Select all that apply.

A patient with diabetic ketoacidosis has fruity breath and Kussmaul respirations due to elevated blood glucose levels and reduced insulin production. Pallor, tremors, and sweating are signs and symptoms of hypoglycemia.

A severely hypertensive client presents with headache, tachycardia, and diaphoresis. Laboratory tests demonstrate excessive circulating catecholamine levels. The nurse suspects the client is experiencing which adrenal medulla disorder?

A pheochromocytoma is a catecholamine-secreting tumor that is usually located in the adrenal medulla and presents with headache, tachycardia, and diaphoresis that result from effects of the massive circulating catecholamine levels on the sympathetic nervous system. Hypersecretion of androgens causes virilization. Congenital adrenal hyperplasia results from the deficiency of an enzyme that is critical in cortisol biosynthesis, resulting in overproduction of either mineralocorticoids or androgens. Adrenocortical hypofunction can lead to Addison disease.

A nurse attends a seminar and learns about the effects of advanced glycation end products (AGEs) in clients with diabetes. Which information indicates the nurse has an accurate understanding of AGE effects on clients with diabetes?

AGEs cause tissue injury through a variety of mechanisms, including the production of free radicals, endothelial dysfunction, and thickening of basement membranes. AGEs do not cause increased formation of ketoacids. AGEs contribute to increased, not decreased, chronic complications of diabetes. AGEs cause increased, not decreased, platelet adhesion.

GH excess in adults

Acromegaly since epiphyseal plate closure at puberty

The nurse assesses for acute complications in a client with diabetes mellitus. Which conditions is the nurse monitoring for in this client? Select all that apply.

Acute complications of diabetes mellitus include hypoglycemia, Somogyi effect, DKA, and HHNKS. Chronic complications of long-term diabetes mellitus include diabetic retinopathy and coronary artery disease.

Alteration of mineralocorticoids (Aldosterone)

Aldosterone helps maintain blood pressure and water and salt balance in the body by helping the kidney retain Na+ & excrete K+ .

Graves disease

Autoimmune type II hypersensitivity reaction that targets the thyroid gland and causes overproduction of thyroid hormones (85% if all cases of hyperthyroidism is because of grave disease)

A nurse is administering an oral hypoglycemic drug to a client with diabetes that decreases glucose production by the liver. Which type of oral hypoglycemic drug did the nurse give?

Biguanide (metformin) decreases hepatic glucose production. Sulfonylureas stimulate insulin release from pancreatic beta cells. Thiazolidinediones increase insulin sensitivity, particularly in adipose tissue. α-Glucosidase inhibitor delays carbohydrate absorption in the gastrointestinal tract by inhibiting disaccharidases.

Goiter

Can be in both hyperthyroidism and hypothyroidism

GH deficiency in adults

Cause: traumatic head injuries or resection of pituitary tumors Sign and symptom: - Decreased lean body mass - Hypercholesterolemia - Decreased bone density

The nurse is planning an education session for clients with type 1 diabetes mellitus. Which disease characteristics should the nurse include in the teaching plan? Select all that apply. Clients are prone to diabetetic ketoacidosis. This type of diabetes results in insulin dependence. Most clients will be diagnosed before 30 years of age

Clients with type 1 diabetes mellitus are prone to diabetic ketoacidosis. Beta-cell destruction in type 1 diabetes leads to absolute insulin deficiency and insulin dependence. Individuals usually develop type 1 diabetes before 30 years of age. Type 2 diabetes is associated with dyslipidemia and hypertension. Maturity-onset diabetes of youth is associated with autosomal dominant gene mutations.

A client is diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNKS). Which clinical manifestations will the nurse expect? Select all that apply.

Clinical manifestations of HHNKS include severe dehydration, loss of electrolytes, including potassium, and neurologic changes, such as stupor. Ketonuria and Kussmaul respirations are clinical manifestations of diabetic ketoacidosis.

Which assessment findings indicate to the nurse that a client has type 2 diabetes mellitus? Select all that apply.

Clinical manifestations of type 2 diabetes mellitus include polydipsia, paresthesias, recurrent infections, and hypertension. Clients with type 2 diabetes will have polyuria, not anuria. Dysarthria is not a clinical manifestation of type 2 diabetes.

Which medication is used to treat a patient who has incomplete antidiuretic hormone deficiency (ADH)?

Clofibrate potentiates the action of endogenous antidiuretic hormone and alleviates the symptoms associated with insufficient antidiuretic hormone levels, so it is useful in treating patients with incomplete ADH. Cabergoline is a dopaminergic agonist used in patients who have a pituitary tumor called a prolactinoma. Thiazides such as hydrochlorothiazide are beneficial for patients with moderate nephrogenic diabetes insipidus. Levothyroxine is a hormone used to treat primary hypothyroidism.

Hyperaldosteroneism

Conn syndrome: - Hypervolemia - Hypertension - Hypokalemia (muscle aches, fatigue, mild weakness)

Alteration of glucorticoids (Cortisol)

Cortisol helps maintain BP and CV function, suppresses the immune system inflammatory response, stimulates gluconeogenesis, increases protein breakdown, and increases mobilization of FFA. ==> Anti-insulin

A nurse is preparing to teach the staff about diabetic ketoacidosis (DKA). Which information should the nurse include? Select all that apply.

DKA is much more common in type 1 diabetes because insulin is more deficient. Profound insulin deficiency results in accelerated gluconeogenesis and ketogenesis. DKA can develop when an increase in insulin counterregulatory hormones is present, including catecholamines, cortisol, glucagon, and growth hormone. Old age is not a risk factor.

Critical point in treatment of hyponatremia

Don't do too rapidly or it will develops central pontine myelinolysis (damage the myelin sheath)

A client has syndrome of inappropriate antidiuretic hormone (SIADH) secretion. Upon assessment, which findings would the nurse expect to observe? Select all that apply.

Dyspnea on exertion, muscle twitching, confusion, and thirst are all typical with SIADH. Peripheral edema is absent.

Which assessment finding will help the nurse determine if the client has primary or secondary adrenal insufficiency?

The clinical manifestations of secondary hypocortisolism (adrenal insufficiency) are similar to those of Addison (primary) disease, although hyperpigmentation usually does not occur. Hypotension occurs, not hypertension. Moon face and buffalo hump occur with Cushing disease.

Which clients will the nurse closely monitor for syndrome of inappropriate antidiuretic hormone (SIADH) secretion? Select all that apply.

Ectopic production of antidiuretic hormone has been noted in association with several types of tumors, such as small cell carcinoma of the duodenum, stomach, and pancreas and cancers of the bladder, prostate, and endometrium. Central nervous system disorders that may cause SIADH include encephalitis, meningitis, and intracranial hemorrhage. Liver disorders can lead to cirrhosis. An overactive adrenal cortex can lead to Cushing syndrome, hyperaldosteronism, or hypersecretion of adrenal androgens and estrogen. ADH is secreted by the posterior pituitary gland, not the anterior pituitary gland.

Which clients will the nurse closely monitor for syndrome of inappropriate antidiuretic hormone (SIADH) secretion? Select all that apply. A client with encephalitis A client with cancer of the bladder A client with small cell carcinoma of the stomach

Ectopic production of antidiuretic hormone has been noted in association with several types of tumors, such as small cell carcinoma of the duodenum, stomach, and pancreas and cancers of the bladder, prostate, and endometrium. Central nervous system disorders that may cause SIADH include encephalitis, meningitis, and intracranial hemorrhage. Liver disorders can lead to cirrhosis. An overactive adrenal cortex can lead to Cushing syndrome, hyperaldosteronism, or hypersecretion of adrenal androgens and estrogen. ADH is secreted by the posterior pituitary gland, not the anterior pituitary gland.

A client has an abnormality in endocrine functioning. Which factors may cause endocrine abnormalities? Select all that apply.

Elevated or depressed hormone levels result from (1) faulty feedback systems, (2) dysfunction of a gland or glands, (3) altered metabolism of hormones, or (4) production of hormones from nonendocrine tissues. An inadequate, not adequate, quantity of hormone precursors can cause an abnormality in endocrine functioning.

Which clinical manifestations will the nurse typically see in a client just diagnosed with hyperthyroidism? Select all that apply. Goiter, Wt loss

Enlarged thyroid gland (goiter) and weight loss are common signs of hyperthyroidism. Constipation occurs with hypothyroidism. Gait disturbances are not characteristic of hyperthyroidism. Hyperreflexia, not slow tendon reflexes, is common in hyperthyroidism.

Which pathophysiologic process should the nurse consider when caring for a client with the syndrome of inappropriate antidiuretic hormone (SIADH)?

Excessive antidiuretic hormone (ADH) secretion in SIADH stimulates increased water reabsorption in the collecting tubules, without sodium reabsorption. ADH does not cause renal retention or excretion of both sodium and water, nor retention of sodium alone.

Cushing disease

Excessive cortisol production due to pituitary hyperstimulation of the adrenal cortex (STEROID IS THE MOST COMMON CAUSE OF CUSHING DISEASE)

Myxedema

Facial swelling due to hypothyroidism Can cause myxedema coma (60% mortality)

A nurse is caring for a client with Graves disease. Which findings will the nurse typically observe upon assessment? Select all that apply. Diplopia, Pretibial, Exophthamalmos

Graves disease can produce exophthalmos, diplopia, pretibial myxedema, periorbital edema, and photophobia. Bradycardia and cold intolerance occur with hypothyroidism.

hyperparathyroidism

High serum Ca++ decreases neuromuscular excitability, leading to muscle and bone weakness. High serum Ca++ also can lead to cardiac arrhythmias and renal calculi. Treatment is to remove the abnormal gland

A nurse is assessing a client with suspected primary hyperparathyroidism. Which assessment findings would support this diagnosis? Select all that apply.

Hypercalcemia and hypophosphatemia are the hallmarks of primary hyperparathyroidism. Renal stones from the increased calcium may occur. Bone resorption may cause pathologic fractures, kyphosis, and compression fractures. Tetany occurs in hypoparathyroidism.

A client with type 2 diabetes has hyperosmolar hyperglycemic nonketotic syndrome. Which findings would the nurse observe upon assessment? Select all that apply.

Hyperosmolar hyperglycemic nonketotic syndrome is characterized by severe dehydration with poor skin turgor, severe hyperglycemia, no or slight ketosis, and a high mortality rate. Neurologic changes, such as stupor, are involved.

Which clinical manifestations will alert the nurse that the client with type 1 diabetes is experiencing hypoglycemia? Select all that apply.

Hypoglycemia can cause the following symptoms for those with type 1 diabetes: pallor, tremor, anxiety, tachycardia, diaphoresis, dizziness, fatigue, poor judgment, confusion, and coma. Ketoacidosis most often occurs with type 1 diabetes and is from hyperglycemia. Kussmaul respirations occur with ketoacidosis.

Untreated diabetes insipidus can produce :

Hypovolemia (decreases CO) hyperosmolality circulatory collapse loss of consciousness (decreased CO causes this) CNS damage.

Clinical manifestations of hypothyroidism

Low BMR Cold intolerance Lethargy Tiredness Constipation

A client develops secondary hyperparathyroidism. The nurse is caring for which client?

In end-stage chronic renal disease, persistent hypocalcemia causes secondary hyperparathyroidism by decreased renal activation of vitamin D. Secondary hyperparathyroidism is not caused by a pituitary tumor; hyperparathyroidism deals with the parathyroid gland. Genetic abnormalities can cause primary, not secondary, hyperparathyroidism. Primary hyperparathyroidism does not cause secondary hyperparathyroidism.

Cretinism

In infants and children due to lack of thyroid hormone (congenital hypothyroidism) - However, it can also develop later if there is a lack of iodine in the diet of the thyroid is diseased or surgically removed.

Congenital adrenal hyperplasia

In the newborn, congenital adrenal hyperplasia is a life-threatening condition because of inadequate circulating cortisol. Virilization in female Enlarged penis and hyperpigmented scrotum in male

GH Hypersecretion and Type 2 Diabetes mellitus

Inhibition of glucose uptake => Hyperglycemia => Hyperinsulinemia => Insulin resistance

Diagnosis of SIADH includes:

Serum hypoosmolality, Hyponatremia Urine hyperosmolality Urine Na+ excretion matches intake

Diabetes Insipidus

Large diuresis of very dilute urine due to deficiency of ADH (urine cannot be concentrated and free water is lost, causing hyperosmolality)

Thyroid storm

Life threatening. Excessive amounts of thyroid hormones being acutely released into the circulation

A client has a type of diabetes that is caused by autosomal dominant mutations, affecting beta cell function or insulin action. Which diagnosis will the nurse most likely observe written in the chart?

MODY includes six specific autosomal dominant mutations that affect critical enzymes involved in beta-cell function or insulin action. Type 1 diabetes is beta cell destruction leading to absolute insulin deficiency. Gestation diabetes is any degree of glucose intolerance with onset of first recognition during pregnancy. Drug-induced beta-cell dysfunction commonly is associated with glucocorticoids and thiazide diuretics.

A nurse is teaching the staff about the metabolic mechanisms that contribute to the chronic complications of diabetes mellitus. Which information should the nurse include in the teaching session? Select all that apply.

Metabolic pathways associated with persistent hyperglycemia and the chronic complications of diabetes mellitus include shunting of glucose into the polyol pathway, activation of protein kinase C, production of advanced glycation end products, increased activation of the hexosamine pathway, and overproduction of reactive oxygen species (oxidative stress). Hypothalamic malfunction and excess cortisol do not contribute to chronic complications.

Sex Steroid (Androgens)

Minor role in the development and maintenance of secondary sex characteristics - Exception is in children with congenital adrenal hyperplasia

Clinical manifestation of Cushing disease:

Moon face Cervical fat pad Central obesity Thin extremities Weight gain Thin skin Striae Hypertension Hyperglycemia Brusing

A client has a pituitary adenoma. Which information should the nurse remember when planning care for this client?

Most pituitary adenomas are microscopic. They arise from the anterior pituitary, are benign, and are usually slow growing in nature.

A client has myxedema coma. Which clinical manifestation will the nurse expect to find upon assessment?

Myxedema coma is a medical emergency with signs and symptoms including hypothermia without shivering, hypoventilation, hypotension, hypoglycemia, and lactic acidosis. Myxedema coma is severe hypothyroidism, not hyperthyroidism nor hypopituitarism.

Drugs and SIADH

No drugs to stop ADH release but there are drugs to make renal tubules resistant to ADH (Demaclocycline)

Vitiligo

Pigmentatiom disappears from a patch of skin

Growth hormone deficiency during childhood

Pituitary dwarfism

GH excess in childhood

Pituitary gigantism - Die early due to cardiovascular disease

Clinical manifestations of diabetes insipidus

Polyuria Nocturia Thirst Polydipsia Low urine specific gravity Low urine osmolality High-normal plasma osmolality

Which findings in a client with hypothyroidism will cause the nurse to notify the primary healthcare provider? Select all that apply. Hypotension, hypoventilation Diminished level of consciousness

The client is exhibiting findings of myxedema coma, which is a medical emergency. Diminished level of consciousness with hypothermia without shivering, hypoventilation, hypotension, hypoglycemia, and lactic acidosis are indicative of myxedema coma. Hyperthermia and hyperventilation do not occur.

Addison disease:

Primary adrenocortical insufficiency - Weight loss - Salt wasting - Volume depletion - Low blood pressure (due to volume depletion) - Hypoglycemia (due to decreased cortisol) - Hyperkalemia (due to decreased aldosterone) - Weakness - Fatigue HYPERPIGMENTATION (95% OF PATIENTS HAVE IT) VITILIGO (pigmentation disappears from a patch of skin)

Primary vs Secondary Hypothyroid disease

Primary: High TSH (more common) Secondary: Low TSH

Primary vs Secondary Adrenocortical insufficiency:

Primary: increased ACTH => ADDISON DISEASE Secondary: low ACTH (more common)

Cretinism can cause:

Retardation of physical and mental development 1) Growth is stunted 2) Skin is thick, flabby, and waxy in color 3) Nose is flattenned 4) Abdomen protrudes 5) Generally slowness of movement and speech

A nurse closely monitors a client with the syndrome of inappropriate antidiuretic hormone (SIADH) for which complications? Select all that apply. Convulsion Neurologic damage

Severe hyponatremia in SIADH can cause convulsions and irreversible neurologic damage. Acute kidney injury (ischemia or damage to the kidney), panhypopituitarism (in which all hormones are deficient from the pituitary), and myocardial infarction (in which lack of oxygen to the heart causes muscle damage) are not complications of SIADH.

SIADH

Syndrome of Inappropriate ADH secretion => ADH is continually released + Water retention + Hyponatremia

Octreotide

Synthetic somatostatin to lower GH levels

After reviewing the findings (see chart), the nurse immediately notified the primary healthcare provider for a client with hyperthyroidism. Which finding alerted the nurse that this notification was needed?

Thyrotoxic crisis (thyroid storm) is a rare but dangerous worsening of the thyrotoxic state in which death can occur within 48 hours without treatment. The systemic symptoms of thyrotoxic crisis include hyperthermia (high fever); tachycardia, especially atrial tachydysrhythmias; high-output heart failure; agitation or delirium; and nausea, vomiting, or diarrhea contributing to fluid volume depletion. Periorbital edema, ophthalmopathy, and pretibial myxedema are common manifestations of Graves disease and are not cause for alarm.

Type 1 Vs Type 2 Diabetes

Type 1: Absolute insulin deficiency (beta) cells in pancreas are destroyed. (glucagon must also present) Type 2: Insulin resistance with an insulin secretory deficit

The cause of acromegaly is

Usually a benign tumor of the pituitary gland (therefore, the only known risk factor for acromegaly is prior history of a pituitary tumor)

A client developed acute metabolic acidosis from insulin deficiency. Which pathophysiologic process should the nurse consider when planning care for this client?

With insulin deficiency, lipolysis is enhanced and there is an increase in the amount of nonesterified fatty acids delivered to the liver. The consequence is increased glyconeogenesis contributing to hyperglycemia and production of ketone bodies; however, lipolysis is enhanced, not decreased. Acidosis does not occur from protein catabolism but from incomplete fat catabolism. The term anaerobic means "without oxygen," but it is a lack of insulin that leads to the acidosis.

hypoparathyroidism

low serum Ca++ levels, which increases neuromuscular excitability, leading to tetany and seizures Treatment: Ca supplement

Secondary disorders

result from abnormal pituitary secretion of tropic signals.

Primary endocrine disorder

result from intrinsic defects within the hormone-secreting gland - Primary hyposecretion = low target gland hormone, high pituitary hormone - Primary hypersecretion = high target gland hormone, low pituitary hormone