NURSING MANAGEMENT OF PATIENT WITH

ENDOCRINE DISORDERS

Prepared By:Mr. Prakash makasare; M.Sc. NursingMrs. Nutan Makasare; M.Sc. NursingCollege of Nursing ; G.M.C. Nagpur

The nervous system and the interconnected network of glands known as the endocrine system control body systems.

En docrine disorders are the consequences of hypo function and hyper function of each endocrine gland.

INTRODUCTION

Glands of the Endocrine System

The chemical substances secreted by the endocrine glands are called hormones.

The endocrine glands are composed of secretory cells arranged in minute clusters known as acini.

Glands are ductless with a rich blood supply, so the hormones they produce enter the bloodstream rapidly.

Hormone concentration in the bloodstream is maintained at a relatively constant level.

When the hormone concentration increases, further production of that hormone is inhibited & vice versa.

Negative feedback.

Function and Regulation of Hormones

1.Steroid hormones (e.g., hydrocortisone), 2. Peptide or protein hormones (e.g., insulin), 3.Amine hormones (e.g., epinephrine), 4. Fatty acid derivatives (e.g., retinoids).

Classification of Hormones

Widespread effects on the body and a wide variety of signs and symptoms

Changes in energy level and fatigue Tolerance of heat and cold as well as recent changes in

weight: Changes in sexual function and secondary sex

characteristics Changes in mood, memory, and ability to concentrate

and altered sleep patterns

Health History and Clinical Manifestations

Changes in skin texture with both hypo function and hyper-function

Eye changes, such as exophthalmos, Changes in physical appearance (e.g., appearance of facial hair

in women, "moon face," "buffalo hump," thinning of the skin, obesity of the trunk and thinness of the extremities, increased size of the feet and hands, edema)

Vital signs Elevated B.P. may occur with hyper function of the adrenal cortex or tumor of the adrenal medulla and Decreased blood pressure may occur with hypo function of the adrenal cortex.

Physical Assessment

Anatomic and Physiologic Overview The pituitary gland, or hypophysis, about 1.27 cm in

diameter located on the inferior aspect of the brain. Commonly referred to as the master gland. Control the se cretion of hormones by other endocrine

glands. The pituitary itself is controlled by the hypothalamus. The pituitary gland is divided into the anterior and

posterior lobes.

THE Pituitary Gland

The major hormones

Follicle-stimulating hormone (FSH), Luteinizing hormone (LH), Prolactin, ACTH, TSH, Growth hormone (somatotropin). Other hormones include melanocyte-stimulating

hormone and beta-lipotropin.

Anterior Pituitary

The important hormones

Vasopressin, also called antidiuretic hormone or ADH, Oxytocin. (Oxytocin secretion is stimulated during

pregnancy and at childbirth. )

Posterior Pituitary

disease of the pituitary gland itself or disease of the hypothalamus,

complication of radiation therapy to the head and neck area,

total destruction of the pi tuitary gland by trauma, tumor, or vascular lesion.

The result is extreme weight loss, emaciation, atrophy of all endocrine glands and organs, hair loss, impotence, amenorrhea, hypo metabolism.

Hypofunction of the pituitary gland (hypopituitarism)

Cushing's syndrome.( ACTH or growth hormone) Acromegaly Gigantism. Dwarfism. Panhypopituitarism. Hypopituitarism may result from destruction of the

anterior lobe of the pituitary gland. Postpartum pituitary necrosis (Sheehan's syndrome)

Oversecretion (hypersecretion)

The most common disorder related to posterior lobe dysfunction is Diabetes insipidus.

Posterior Pituitary

Pituitary Tumors Pituitary tumors are usually benign types of pituitary

tumors represent an overgrowth of (1) eosinophilic cells,(2) basophilic cells, or(3) chromophobic cells (i.e., cells with no affinity for

either eosinophilic or basophilic stains).

Specific Disorders of the Pituitary Gland

Definition

Gigantism, an overgrowth of the long bones, develops in children before the age when the epiphyses of the bones close. Clients suffering gigantism may grow to 9 feet tall.

Acromegaly is a disease of adults and develops after closure of the epiphyses 'of the long bones.i.e. increase in bone thick ness and hypertrophy of the soft tissues.

GIGANTISM AND ACROMEGALY

Etiology Gigantism and Acromegaly result from GH-secreting adenomas of the anterior pituitary gland.

Acidophilic,GH-producing tumors an excessive secretion of GH.

rapid growth in all body tissues. Gigantism Acromegaly

before after closure of the epiphysis

Pathophysiology

Clients with gigantism: develop hyperglycemia. About 10 per cent of the clients develop full-blown diabetes mellitus.

As the tumor grow, destruction of the entire pituitary gland, leading to hypopituitarism.

Pressure on the optic nerve, may lead to blindness.

Prognosis: depends on the age at which the client develops an over secretion of GH and seeks health intervention.

Clinical Manifestations

Gigantism

characteristic appearance.

Acromegaly

The coarsening of the facial features, The prognathism (protrusion of the jaw),

broad hands with spade like fingers

In addition, clients with acromegaly develop local manifestations such as,

diplopia, headache blindness, and lethargy, due to compression of brain tissue by the tumor.

In advanced cases, clients can suffer from associated hormonal disturbances such as,

diabetes mellitus, goiter, Cushing's disease, changes in libido and menstrual disorders.

Irradiation of the pituitary gland to destroy the tumor. This is usually performed through a radiation implant via the transsphenoidal approach.

Medical Management

Sromocriptine (Parlodel) can reduce the levels of growth hormone and decrease tumor size. This agent can be used if the levels of growth hormone remain high after surgery or until the effects of radiation occur.

Pharmacologic Management

The treatment of choice for both gigantism and acromegaly is a surgical hypophysectomy.

Partial or complete removal of the pituitary gland.

Following surgery, the need for cortisone replacement may be permanent.

Surgical Management

Nursing Diagnosis: Knowledge Deficit R/T surgery and possible outcomes. High risk for injury R/T post operative complications. Knowledge Deficit R/T self administration of pituitary replacement hormones.

Nursing Management

Hypopituitarism

Hypopituitarism is a deficiency of one or more of the hormones produced by the anterior lobe of the pituitary.

When both the anterior and posterior lobes fail to secrete hormones, the condition is called panhypopituitarism. (Simmond’s disease)

Definition

Incidence Hypopituitarism and panhypopituitarism (Simmond’s disease) are rare disorders.

Etiology/Pathophysiology The five most important causes of

hypopituitarism

Hypophysectomy Nonsecreting Pituitary Tumors:

Nonfunctioning chromophobe adenoma and craniopharyngioma.

Decreased Growth Hormone Postpartum Pituitary Necrosis Functional Disorders: anorexia nervosa, severe

anemia, and GIT disorders.

Short stature, stunted growth results from either: - congenital lack of GH or - the develop ment of space-occupying intracranial tumors, meningitis, or

brain injury during early childhood. Secondary adrenocortical insufficiency due to diminished

synthesis of ACTH

Hypothyroidism,(diminished TSH)

Sexual and reproductive disorders r/t deficiencies of the gonadotropins (LH and FSH) can produce sterility, diminished sexual drive, and decreased secondary sex characteristics,infertility and amenorrhea, diminished spermato genesis, and testicular atrophy.

Clinical Manifestations

ACTH: secondary adrenal insufficiency.Cortisol levels: are low in both primary and secondary hypothyroidism.Thyroid hormone, TSH levels: hypothyroidism. FSH and LH: Sexual and reproductive disorders

Diagnostic Assessment

Treatment for hypopituitarism involves:

(1) removal, if possible of the causative factor (e.g., tumors) and

(2) permanent replacement of the hormones secreted by the target organs.

Medical Management

Injections of HGH successfully treat GH deficiency

Medications prescribed to replace hormones include

(1) corticosteroids for correction of secondary

adrenocortical insufficiency, (2) thyroid hormone for treatment of myxedema, and (3) sex hormones to correct hypogonadism.

Pharmacologic Management

Nursing Management

Posterior lobe (neurohypophyseal) disorder:

The major disorder of the posterior lobe is ADH deficiency (diabetes insipidus) Excessive ADH causes the syndrome of

inappropriate ADH secretion (SIADH).

DIBETES INSIPIDUS

Definition

Diabetes insipidus is a deficiency of ADH resulting in a physiologic imbalance of water.

Incidence

Diabetes insipidus is a rare disorder.

DIBETES INSIPIDUS

Primary diabetes insipidus: Abnormalities in the hypothalamus and pituitary gland from familial or idiopathic causes.

Secondary diabetes insipidus: Destruction of the gland by tumors in the hypothalamic-pituitary region, trauma, infectious processes, vascular accidents, or metastatic tumors from the breast or lung.

Medications such as phenytoin (Dilantin), alcohol, and lithium carbonate, can interfere with the synthesis or release of ADH in some clients.

Nephrogenic diabetes insipidus: Owing to an inherited defect, the kidney tubules cannot respond to ADH.

Etiology

Risk factors include head injuries, infections, and other factors that lead to destruction of

the gland. Certain medications also may lead to the

development of diabetes insipidus.

Risk Factors

The major functions of ADH are to promote water reabsorption by the kidney and control the osmotic pressure of the extracellular fluid.

ADH production decreases excessively kidney tubules fail to reabsorb waterlarge amounts of dilute urine excreted

diabetes insipidus.

Pathophysiology

Its two major manifestations are Polyuria (urine is dilute, with a specific

gravity of 1:001 to 1.005 (normal specific gravity is 1.00 1 - 1.030).

Polydipsia (The client can drink and excrete 5 to 10 liters of fluid per day.)

 

Clinical Manifestations

A water deprivation test. Instruct the client not to drink water, to concentrate the urine. Test results are positive for diabetes insipidus if the urine remains dilute.

DIAGNOSTIC ASSESSMENT

Pharmacologic Management Ad ministration of the benzothiadiazine diuretics, either

alone or in combination with sylfonylurea clorpropamide. Injection of ADH or vasopressin (aqueous Pitressin) can

control the symptoms of diabetes insipidus. The synthetic polypeptide desmopressin acetate (DDA VP)

can be insufflated through the nose in the morning and at bedtime.

After administering vasopressin, clients need to be assessed for signs and symptoms of water intoxication, which can lead to fluid overload, cerebral edema, and seizures .

Medical Management

Surgical Management: Surgical resection of the tumor

Maintaining adequate hydration, Electrolyte balance, and Preventing complications. Assess the effectiveness of the medication. The client also must learn self-administration

of either the injections or the nasal spray. If the client undergoes hypophysectomy,

nursing care for the same.

Nursing Interventions

SYNDROME OF INAPPROPRIATE ANTIDIURETIC HORMONE (SIADH)

Definition

SIADH is a disorder associated with excessive amounts of ADH, resulting in a water imbalance.

Incidence

SIADH is one of the most common causes of hypona tremia, although the exact incidence of SIADH itself is not known.

Etiology There are a wide variety of causes of SIADH, including the stress of surgery and many disorders and medications. Risk Factors Treatment of diabetes insipidus with vasopressin can

lead to SIADH if excessive amounts are administered.

A variety of malignancies are risk factors for SIADH.

SIADH is the opposite of diabetes insipidus. Instead of large fluid losses, clients with SIADH may have water

intoxication due to fluid retention. Under normal circumstances, ADH regulates serum osmolality. When serum osmolality falls, a feedback mechanism causes

inhibition of ADH. This, in turn, promotes increased water excretion by the

kidneys to raise serum osmolality to normal. When this feedback mechanism fails and ADH levels are

sustained, fluid retention results. Ultimately, serum sodium falls, resulting in hyponatremia and

water intoxication.

Pathophysiology

CNS dysfunction, characterized by alterations in level of consciousness, seizures, and coma, can become evident when serum sodium falls to 120 mEq/L or less.

Hyponatremia can result in diminished gastrointestinal function, and this problem is further complicated by the need for fluid restriction.

Clinical Manifestations

DIAGNOSTIC ASSESSMENT Diagnosis rests on the presence of

hyponatremia with a normal or expanded plasma volume.

fluid restriction, very careful replacement of sodium

chloride, administration of diuretics and

demeclocycline, and correction of the cause, if possible.

Medical Management

Assessment:

Fluid status and electrolytes should be closely monitored. cardiovascular status also should be assessed regularly

so any alterations are immediately noted. The client's weight should be recorded, and any gain of

more than 2 pounds should be reported to the physician. The client's neurologic status should be monitored so any

alterations related to the hyponatre mia are immediately diagnosed and treatment can be started.

Nursing Management

Injury, High Risk for R/T to the danger of cerebral edema, water intoxication, and CNS dysfunction.

Fluid Volume Excess R/T excessive secretion of ADH secondary to SIADH.

Nursing Diagnosis :