endocrine

Acromegaly

-"Enlarged extremities" -When excessive GH occurs in adulthood -Bone and connective tissue continue to grow, but growth plates are closed. -Forehead, maxilla grow -Voice deepens -Hands and feet enlarge -Nerve entrapment - pain, carpal tunnel

Causes of Addison's

-Autoimmune *** -Seen with AIDS, TB, Type 1 diabetes -Adrenal mets from lung, breast, GI, melanoma -Bilateral adrenalectomy -Hemorrhagic infarction from trauma -Glucocorticoid use

Symptoms of Cushing's

-Central obesity -Muscle weakness an wasting (extremities) -Thin skin, abdominal striae, fragile capillaries -Steroid diabetes- altered glucose metabolism -E-lyte imbalance, dysrhythmias, edema, hypertension (K, NA, water retention) -Osteoporosis, compression fractures -Increased susceptibility to infection, but few symptoms due to immune supression -Hirsutism

Pituitary Gland

-Controls many glands, but primary disease is uncommon -Can indirectly cause many disease processes -Produces Somatotropin (growth hormone) -Produces several gland-stimulating hormones

Cortex

(peripheral) essential to life corticosteroids: Mineralocorticoids - aldosterone, controlled by renin. Glucocorticoids - cortisol & cortisone, released when stressed, affect carb metabolism. Androgens

Medulla

- (central) similar to substances produced in sympathetic nervous system epinephrine & norepinephrine

Treatment of Addisonian Crisis

-Correct F & E imbalance: Kayexalate enema - releases Na ions in place of K ions. Rapid hydration, vasopressors, volume expander (albumin, plasmonate). -Correct hypoglycemia- IV glucose -Replace steroids- hydrocortisone: Often IM, self-injected. Watch blood sugar. Watch for GI disturbances, ulcers. Cushing's symptoms.

Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

-Excessive ADH release from posterior pituitary, not in response to body needs: Too much antidiuretic means hold fluid -Due to trauma, CVA, lung or pancreas malignancy, some medications, stress -Small cell cancers produce ectopic ADH

Treatment for SIADH

-Hypertonic IV fluids- correct hyponatremia -Sodium restriction -Diuretics - increase plasma osmolality -Replace electrolyte loss -Demeclocycline to increase free water clearance (allow some water to be excreted and some to be absorbed) -Treat underlying cause (CVA, malignancy)

Assessment of SIADH

-Hyponatremia: Fatigue, H/A, anorexia, nausea, ↓ mental status, coma, seizure -Fluid volume excess: Weight gain, jugular vein distention, tachycardia, tachypnea, rales -Think: CONCENTRATED urine DILUTE serum

Treatment of DI

-IV fluids, oral fluids if tolerated -ADH replacement desmopressin - DDAVP - (nasal, bid) (a synthetic vasopressin - the hormone that reduces urine production) -Pressin tannate oil, IM - replaces ADH

Diabetes Insipidus (DI)

-Is not same as Diabetes Mellitus. Although symptoms appear similar (thirst, excess urination) -Hyposecretion of ADH, injury to pituitary, surgery to pituitary, infection - meningitis, encephalitis. Not enough antidiuretic leads to diuresis. -Often caused by CVA's, trauma, especially head injuries -Kidney tubules fail to reabsorb water -Are several kinds- neurogenic, gestational, nephrogenic, dipsogenic - don't need to know these levels

Addison's Education

-Lifelong hormone therapy -Recognize need for extra meds with stress -Teach signs and symptoms of Cushing's (excess hormone) -ID badge -Emergency 100mg IM hydrocortisone

Nursing Issues with Cushing's

-Monitor for fractures -Monitor blood sugars (steroids) -Low calorie, low carbohydrate, high protein diet -Daily weight -Monitor B/P -At risk for infection (steroids) -Skin integrity - no tape -Activity intolerance -Watch for mood swings, change in appearance, depression

Nursing Interventions for SIADH

-Monitor urine and serum labs -Watch for mental status changes -Daily weight, I&O -Restrict fluids to prevent further hemodilution (provide comfort measures for thirst - mouth care, ice chips, lozenges)

Nursing Interventions for DI

-Monitor vitals, neuro checks, CV status -Safe environment for cognitive impairment -Monitor lytes, signs of dehydration -I&O, ↓ urine specific gravity -Daily weight -↑ Plasma osmolality, increase sodium level (volume depletion) -Avoid caffeine - produce diuresis -Medic Alert Bracelet

Assessment for DI

-Polyuria up to 24 L per day -Polydipsia -Dehydration -Decreased skin turgor, dry mucous membranes -Inability to concentrate urine -Low urine specific gravity (1.006 or less) -Fatigue, muscle pain, H/A, tachycardia -Postural hypotension -Change in LOC, confusion -Think DILUTE urine, CONCENTRATED serum

Symptoms of Addison's

-Slow onset, insidious -Fatigue, irritability -Weight loss, N & V -Postural hypotension -Usually 90% loss of both adrenal cortices by diagnosis -Diagnosed by hormone levels, lytes, glucose- ↑K, NA, Blood glucose -Hyperpigmentation (Increased ACTH causes the striking feature of bronze-colored skin hyperpigmentation. It is seen primarily in sun-exposed areas of the body, at pressure points, over joints, and in the creases, especially palmar creases. The changes in the skin are most likely due to increased secretion of β-lipotropin (which contains melanocyte-stimulating hormone [MSH]). This tropic hormone is increased because of decreased negative feedback and subsequent low corticosteroid levels. Patients with secondary adrenocortical hypofunction usually do not have hyperpigmented skin because ACTH levels are low.)

Symptoms of Pheochromocytoma

-Sympathetic hyperactivity -increased blood glucose, glucosuria -*Hypertension often paroxysmal, H/A -increased metabolic rate- diaphoresis, agitation, tachycardia, palpitations -Emotional instability- crying, outbursts -Acute attacks- profuse sweating, dilated pupils, cold extremities

Pheochromocytoma

-Tumors of adrenal medulla (benign) -Produce epinephrine or norepinephrine (excess catecholamines). Stimulate sympathetic nervous system. -Diagnosed by epi and norepi in blood -Cause unknown -Rare, runs in families

Key features of SIADH

-Water retention -Hyponatremia- dilutional -Low serum osmolality (concentration). * Continual release of ADH → water retention from renal tubules; extracellular fluid volume increases; hyponatremia suppresses renin and aldosterone secretion causing ↓ in reabsorption of sodium

Addisonian Crisis

Acute Adrenal Insufficiency -Stress - pregnancy, surgery, infection, without appropriate hormone replacement -Sudden penetrating pain in back, abdomen or legs due to severe elyte imbalance -Changed mental function -Hypovolemia, hypotension, hypoglycemia -Loss of consciousness, shock

Addison's Disease

Adrenal insufficiency -Destruction or dysfunction of adrenal cortex -Chronic deficiency: Cortisol Aldosterone Androgens

Cushing's Syndrome

Hypercortisolism (Excess glucocorticoid) -Overactive adrenal cortex -Pituitary over stimulation -Excessive cortisol or ACTH -Women 30-50 yrs -Any age, drug induced: Long term steroids Organ transplant, asthma

The nurse administers corticosteroids to a patient with acute adrenal insufficiency. The nurse determines that treatment is effective if what is observed? a. The patient is alert and oriented. b. The patient's lung sounds are clear. c. The patient's urinary output decreases. d. The patient's potassium level is 5.7 mEq/L.

Answer: a Rationale: The patient in acute adrenal insufficiency will have the following clinical manifestations: hypotension, tachycardia, dehydration, hyponatremia, hyperkalemia, hypoglycemia, fever, weakness, and confusion. Collaborative care will include administration of corticosteroids. An outcome that would indicate patient improvement would be improved level of consciousness (i.e., alert and oriented).

An IV hydrocortisone infusion is started before a patient is taken to surgery for a bilateral adrenalectomy. Which explanation, if given by the nurse, is most appropriate? a. "The medication prevents sodium and water retention after surgery." b. "The drug prevent clots from forming in the legs during your recovery from surgery." c. "This medicine is given to help your body respond to stress after removal of the adrenal glands." d. "This drug stimulates your immune system and promotes wound healing."

Answer: c Rationale: Hydrocortisone is administered IV during and after a bilateral adrenalectomy to ensure adequate responses to the stress of the procedure.

clues for cushings vs. addisons

Cushings is over- secretion of glucocorticoids. (Think of UP) Addisons is under-production (need to ADD hormones to fix it)

Diagnosis Pheochromocytoma

Diagnosed by urinary fractionated metanephrines - catecholamine metabolites, such as VMA (vanillylmandelic acid) CT MRI for tumors

Diagnosis of Acromegaly

MRI CT to detect pituitary tumor

Treatment of Cushing's

Medications - treat symptoms, normalize hormone secretion. Adrenal blocking agents (supress the synthesis and secretion of cortisol from the adrenal gland (medical adrenalectomy)- mitotane (Lysodren), aminoglutethimide (Cytadren), ketoconazole (Nizoral). Hydrocortisone or prednisone may be needed to avoid adrenal insufficiency. ACTH reducing agents- Periactin Surgery - removal of adrenal tumor or whole gland - adrenalectomy. Life-long replacement drugs If result of a pituitary disease - removal of pituitary gland

Cushing Syndrome Nursing Diagnoses

Risk for infection related to lowered resistance to stress and suppression of immune system. • Imbalanced nutrition: more than body requirements related to increased appetite, high caloric content of foods, and inactivity. • Disturbed body image related to change in appearance from disease process. • Impaired skin integrity related to excess corticosteroids, immobility, and altered skin integrity (fragility).

Treatment Pheochromocytoma

Treatment = adrenalectomy (like in Cushings, but more severe) Nursing Interventions: -Avoid palpating abdomen - could cause sudden release of catecholamines and severe hypertension -Rest -Nutrition -Emotional support

Diagnosis DI

Water deprivation test - fluids withheld and urine concentration and output monitored. Positive for DI if unable to concentrate urine despite increased plasma osmolarity.

Cushing's Diagnosis

elevated plasma cortisol levels, elevated 24 hour urine for free cortisol

adrenal glands

medulla and cortex

Treatment of Acromegaly

surgery - transsphenoidal approach, radiation therapy, medication