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ENDOCRINE SYSTEM
Pituitary gland
ANTERIOR PITUITARY POSTERIOR PITUITARY
- Growth hormone ✓ Dwarfism (varones) Enanism ✓ Acromegaly.
- Thyrotropin (TSH) ✓ Hyperthyroidism ✓ Hypothyroidism
- Adrenocorticotropic (ACTH) ✓ Addison ✓ Cushing
- FSH or follicle stimulant (menstruation)
- Luteinizing (LH)
- Oxytocin
- Vasopressin ADH ✓ SIADH ✓ Diabetes Insipidus (DI) Sheehan ‘s syndrome = Hypopituitarism = todo ↓
➢ Woman who loses a large amount of blood in child bird or
➢ A severe decrease BP after labor can deprive the amount of oxygen of the
pituitary gland.
Assessment:
▪ Inability to breast feeding
▪ Amenorrhea (no menstruation)
▪ Inability to regrow shave public hair
▪ Slow mental function (hypotiroidism)
▪ Weight gain
▪ Low BP
▪ Low B
▪ Cardiac dysrhythmias
Treatment
- Lifelong hormone replacement
DWARFISM (delicate features) ACROMEGALY ( Coarse features)
- Decreased GH
- Assessment Delicate features
- height below normal Body proportion are normal
- Bone and tooth development delayed
- Sexual maturity and organs delayed
- Fine skin Cause= tumor in the hypophysis - After 25 years old - Increased GH Assessment 1. Thickened lips 2. Increased head size 3. Lower jaw protrusion 4. Hyperglycemia
Treatment
- Somatotropin – (6H) GH replacement therapy until maturity (18 – 20 years old). 2. Gonadotropin chorionic
- Emotional support.
- Testosterone replacement
- Enlarged feet and hands
- Joint pain
- Deep voice
- Coordination poor
- Visual field changes
- Liver, heart, lungs enlargement Diagnostic = Increased GH Treatment = OJO Bromocriptine: is used to for neuroleptic malignant, hyperthermia malignant and Parkinson. Octreotide = Somatostatin) (stop grow) Surgical Intervention (remove tumor)
- Trans nasal Hypophysectomy Post – op - Intervention:
- HOB = 30 (head at the midline) bc expected ↑ ICP
- Mustache dressing and nasal package will be placed on the nose. (Halo sign)
- Teaching = Client must be breath through the mouth for 3-4 days after surgery.
- Avoid activities that ↑ ICP Complication 1 - Diabetes Insipidus (too much urine)> 150 ml (normal (30-50 in 1h) 2 - Cerebro-Spinal fluid (leakage) = Call Dr ♦ Halo sign in mustache dressing ♦ Positive to glucose liquid = Bedrest 30 3 - Meningitis = neck stiffness, headache and fever 4 - Expected ↓of sense of smell 4-6 weeks after 5 - Avoid activities that ↑ICP *no cepillarse los dientes 2 weeks after, solo enjuague y hilo dental. Nota: Acromegalia = crecen todos los órganos.
Thyroid Hypothyroidism (tiene frio) Hyperthyroidism (tiene calor) ✓ Myxedema. ✓ Hashimoto thyroiditis (typo of hypothyroidism)
- Decreased activity level Diagnostic T3, T4 ↓, TSH ↑ Assessment 1. Increased sensitive to cold
- Weight gain (basal metabolism ↓)
- Dry skin
- Decreased stimuli perception
- Respiratory difficulty
- Constipation
- Alopecia
- Bradycardia
- Decreased sweating
- Reproductive problems
- Low cardiac output (hypotension, fatigue)
- Peripheral edema
- Slow mental process (teaching: speech and writing)
- Hypercholesterolemia Intervention hypothyroidism 1. Medical Alert Bracelet 2. No OTC medication 3. Diet: high fiber, low carbohydrates. 4. Frequent rest periods between activities. 5. Teaching speech and writing. 6. Maintain temperature 75° F Medication Levothyroxine = Take in the morning before 7: am with an empty stomach + plenty fluid. Goal: normal functioning) Gravis disease (type of hyperthyroidism) =hyperthyroidism + exophthalmos Diagnostic: Increased T3, T4 ↑, TSH ↓ ✓ Uptake of iodine Radioactive iodine Less than 35 = OK More than 35 = hyperthyroidism Assessment 1. Hyperactivity
- Increased sensitive to heat
- Increased temperature
- Rest and sleep deprivation
- Increased stimuli perception
- Weight loss
- Diarrhea
- Diaphoresis
- Tachycardia
- Increased BP
- Cardiac dysthymia
- Fine soft hair
- Exophthalmos
- Photophobia
- Chest pain
- Mood swings. GOITER classification Grades ✓ O – No palpable, no visible (ultrasound) ✓ 1 - Mass no visible with neck in normal position, but can be palpable when Pt swallowing (se palpa por detras)
Side effects ✓ Hyperthyroidism. - Thyroid storm = complication of levothyroxine ✓ Fever ↑1° F temp. ✓ ↑ Tachycardia Complication of hypothyroidism ✓ Mixedema Coma Triggers factors. ✓ Acute illness ✓ Surgery ✓ Chemotherapy ✓ Stop thyroid replacement hormone (levothyroxine) ✓ Use of sedative and opioids Assessment ✓ LOC alteration, confusion, lethargy, coma. ✓ Respiratory failure (Respiratory Acidosis). ✓ Severe Hypotension ✓ Severe Hyponatremia ✓ Severe Hypothermia ✓ Severe Hypoglycemia. Intervention
1. Patency airway 2. IV fluids 3% NaCl (hypertonic)
- Levothyroxine IV 4. Glucose IV
- Steroids
- Monitor temperature every hour ✓ Cover with warm blanket
- Change position every 2 hours
- Aspiration precaution. Suction equipment at bed side. Note: resume ✓ 2 - Mass is visible as swelling when the neck is in the normal position, goiter is easily palpable and is usually asymmetric Intervention 1. ↓ Environmental stimulation. – restrict visitors. 2. Ensure that client has a fresh pitcher of ice water at bed side
- Change lines frequently, cold water shower Medications 1 - Methimazole (contraindicate 1st^ trimester pregnancy) 2 - Propylthiouracil PTU S/E for both:
- ↓WBC = Risk for infection – if fever or sore throat = call Dr. Note: Med that ↓WBC = Clozapine Clozaril, carbamazepine, and hyperthyroidism med. (contraindicated in immunocompromised)
- Liver toxicity
- Hypothyroidism, (Myxedema coma) If bradycardia call Dr. 3 - Lugol Solution (oral liquid)
- Use for shorth term (1-2weeks)
- 1 week before thyroid surgery or
- to treat thyroid storm S/E Teeth discoloration = use straw (same tetracycline) Metallic taste Skin rash
- Check behind the neck
- If respiratory distress call Dr 4. Thyroid storm Triggers
- Stress
- Thyroid Manipulation
- Acute Illness
- Surgery
- Thyroid Surgery
- Stop antithyroid meds. Assessment
- Fever or ↑1 F temperature
- Tachycardia (atrial Fib)
- Ansiety,
- tremors
- N/V
- Delirium,
- Agitation
- Zeusure. Treatement
- ICU admission
- Colling blanket
- Lugol solution
- Antypyretic
- Propranolol (no in Asthma)
- PTU or methymazole IV
Pheochromocytoma (suprarenal Gland tumor) ▪ Bening tumor of the adrenal gland. ▪ Do not palpate ▪ Hypertension crisis (no MAOIS)
Assessment
- Paroximal or sustained Hypertension (high BP)
- Trobbing Headache.
- Tachycardia and palpitation.
- Flushing
- Profuse diaphoresis- frequent bath with warm water
- Heat intolerant
- Weight loss
- Tremor
- Hyperglicemia
Diagnostic
- Vanil mandelic Acid. (VMA) = 24 hours urinary collection
- Avoid 72h before the test. o Coffee o Bananas o Vanilla o Chocolate
5/24h = positive for Tumor.
Treatment
- Check for BP to prevent complications. (Risk for stroke or MI)
- Medication = B-Blockers (LOL) to control BP
- During crisis use Phentolamine(vasodilator) (choice) sino hay este, dar: o Sodium nitroprusiate (es photosensitivity, use in ICU, blood pressure med potente, la luz lo inactiva, si se pone green or red tienes que botarlo, para ponerlo el Pt tiene que estar en cama y checarle la BP porque la baja mucho) o Hydralazine (use in pregnancy) o Niphedipine (choice for Autonomic dysreflexia)
- Decrease enviromental stimulation
- Restric visitor,
- Bed rest
- Do not palpate Abd sign bc increase BP
- Diet: Low Na, avoid stimulant a. High in calories, vitamins and minerals.
- Frequently bath with warm water
- Adrenalectomy Nota importante: Phentolamine(vasodilator): use for extravasation of vasoconstrictor Ex; epinephrine or dopamine, el antidote es phentolamine que se Administra subcutaneous. Note: Wilms Tumor: No biopsy, No palpate bc metastases. Conn’s Disease = Primary hyperaldosteronism
Agua y sodio para mi y potasio para el toilet
No with digoxin bc digoxin is toxica when K is low No with steroids bc decrease K No with licorice (herb) bc decrease K or Ginseng Lithium si se puede dar bc Na esta alto, y el es toxico cuando el Na es bajo. Assessment
- Increased Na
- Fluid retention
- Hypokalemia (U wave)
- Cardiac dysrhythmias
- Paresthesia = Tetany
- Visual change
- Glucose Intolerance
- ↑ Carbohydrates
- Wear a medical alert bracelet
- Lifelong steroid replacement
- Fludrocortisone (Choice) Oral.
Sino hay pueden dar entonces : Prednisone Complication
- Addisonian Crisis
Assessment
- Hypotension + Tachycardia
- Epigastric pain
- Severe headache
- Confusion
- Hyponatremia severe
- Hypoglycemia severe Treatment 1. IV fluids (Hypertonic solution 3%Nacl)
- Hydrocortisone (IV)
- Fludrocortisone PO (pastillas only) Note: Isotonic Solution: misma cantidad de agua que de Sodio
- Nacl 0.9%
- Ringer lactate
- 5% Dext in water
- 5% Dext in 0.225 Nacl Hypotonic = un # < 1 Ex: ¼ Nacl, 0.225Nacl = H2O Ex: near drowning in the Pacific Ocean. Hypertonic = un # > 1 = Na Ex: near drowning in fresh water.
- Assist with ambulation
- Elimination of environmental hazards to prevent
Osteoporosis. Medication
- Aminoglutethimide
- Hypophysectomy or Adrenalectomy Emotional support The most physical changes are reversible with treat. Post adrenalectomy care
- Lifelong Steroids
- High risk for infection
- Risk for respiratory acidosis)
(Acostarse sobre la herida 2-3 veces al dia para prevenir respiratory acidosis) Note: Cholecystectomy and nephrectomy or adrenalectomy cause respiratory acidosis, 2-3 times per day acuestate sobre la herida para prevenirlo.
Diabetes Mellitus
▪ Chronic disorder of impaired carbohydrate, protein and lipids metabolism
caused by deficiency of insulin or by increase peripheral resistance to insulin.
Type I Diabetes Type II Diabetes
- Absolute Insulin deficiency (B cell destruction)
- More frequently in childhood before 30 years
old.
- Insulin Dependent
- Relative lack of insulin or increase peripheral
resistance.
- 80% = Obesity (abdominal)
- Peak = 50 yrs.
Note: difference between diabetes mellitus and insipidus is polyphagia, that is for mellitus.
Metabolic syndrome
Acanthosis nigricans = Predisposition of 90% diabetes
- Bbd Obesity
- Waist circumference + 40 inch for men, + 35 inches for women
- Apple shape
- Hyperglycemia
- Fasting glucose 70-110 = normal
- 110 - 125 Metabolic syndrome
126 = Diabetes A1C = less than 5.6 = normal ➢ More than 6.5 = Diabetes ➢ 5.6-6.4 = Metabolic syndrome 7 for control value Less than 7 se porto bien More than 7 = Bad control
- Systolic BP between 130- 140
- Diastolic BP 85- 90 More than 140-90 = Hypertension.
- Hyperlipidemia ♦ Triglycerides > 150 ♦ HDL cholesterol >50 = ok ♦ Less than 40 in Men and 50 in Women = mal
Assessment for Diabetes Mellitus.
- Polyuria (increased urine)
- Polydipsia (increased thirst)
- Polyphagia (increased appetite)
- Decreased weight
- Hyperglycemia
- Healing retardation
- High risk for for vaginal Infection (Fungal)
- Blurred Vision Complication Short Term Long Term 1. Hypoglycemia 2. Diabetes Ketoacidosis (Type 1)
- Hyperosmolar non ketonic stage (Type II) (coma hyperosmolar) 1. Chronic Complication Diabetes Retinopathy = legal blindness 20/ Diabetes Nephropathy Initially proteinuria = chronic kidney diseases Lasting, = Renal insufficiency Diabetes Polyneuropathy = Diabetic foot Reproductive: Impotence Menstrual change Dry vaginal Hypoglycemia
- Blood glucose level falls below 70 mg/dl o Mild less than 70 o Moderate less than 40 o Severe less than 20
Assessment
- Hunger
- Palpitation/ tachycardia
- Kussmaul respiration
- Fruity breath Odor”
- Epigastric Pain
- Sign of hyperglycemia
❖ Polyuria, polydipsia, polyphagia and loss
weigh
- Dehydration
- Tachycardia
- Dry and warm skin
- Dehydration (more severe)
- LOC Alteration, confusion, coma Labs
- Serum glucose >300 – 600 (hyperglycemia)
- Plasma Osmolarity variable
- Urine Ketones- positive
- BUN increased > 20
- Hematocrit increased 35%
- K increased with acidosis
- PH Acid↓
- HCO3 ↓ = Metabolic Acidosis
- Serum glucose > 600
- Plasma Osmolality > 350 (severe
dehydration).
- Urine ketones – negative
- K = increase
- BUN Increased
- Hematocrit Increased
Do not administer Bicarbonate
Intervention (always cardia monitor)
1. IV fluids NaCl 0.9% or 0.45% NaCl (hypotonic) until blood glucose matches 250 to 300mg.
Add dextrose to IV fluid to prevent rebound Hypoglycemia
2. Administer insulin (R) IV (regular only) = IV bolus 5 – 10 units initially then continuous with
infusion in IV fluid.
3. Add K to the bag when K level = 3.5 to prevent rebound hypokalemia.
Diabetic Foot Care
1. Inspect your feet daily, especially between toes.
2. Wash your foot daily with lukewarm water and soap, then dry.
3. Apply moisturizing cream to your feet after bathing. Avoid between your toes.
4. Change into clean cotton socks daily.
5. Do not wear the same pair of shoes 2 days in a row, and wear leather or cloth,
no sandals, no open toes shoes.
6. Purchase your shoes later in the day.
7. Trim your nails straight across with a clipper. (Never curve, never soak your
feet.)
8. Use a mirror to see your feet If nobody can check them for you
9. Blister, corner, never treat at home.
10. Do not step into bathtub without checking the water temperature. Optimal
temp = 95F, Normal temp. = 110F.
11. Do. Not walk barefooted
12. Avoid smoking.
13. No hearing pads
Oral Hypoglycemic (only for type 2 diabetes)
Biguanides
Metformin
Sulfonylureas
No with Ginseng
Gli- at the beginning
Thiazolidinedione
Tazones = CHF
Meglitinide
Glinide at the
end
DPP- 4
Inhibitors
Gliptin at the
end
∝ Glucosidase
Inhibitors
Metformin
Mechanism action Intestinal glucose transport. Do not cause Hypoglycemia S/E Diarrhea/nausea
- ↓ weight
- More lethal Lactic Acidosis
- Check renal function before *Withhold metformin 24 hours before and 48 hours after any Dye exam.
Glyburide
Glipizide
Glibenclamide
Glimepiride
Mechanism action
- Lower fasting plasma, blood glucose by stimulate insulin production from β Cell.
- Cause hypoglycemics S/E
- No in Pts allergic to sulfa.
- No with ginseng
- No with alcohol To prevent disulfiram reaction.
- weight gain
Pioglitazone
Rosiglitazone
Mechanism action
- ↓ liver glucose production reducing fasting plasma and improve insulin receptors. S/E CHF Contraindicated Fluid overload SIADH Note: Tazon lleno Do not cause hypoglycemia but CHF symptoms
Netaglidine
Repaglinide
Mechanism Action
- Same to sulfonylurea)
- Cause Hypoglycemia
Saxagliptin
Sitagliptin
Linagliptin
Mechanism Action
- Same to sulfonylurea
- Delating gastric Empty. Cause Hypoglycemia S/E Pancreatitis Liver toxicity
Acarbose
Miglitol
Mechanism action
- Reduce the rate digestive of stretches.
- Delated absorption of carbohydrate from small intestine
- Do not cause Hypoglycemia
- Give with the first bite of each meal S/E GI Disturbances
- Abdominal discomfort
- Diarrhea
- vomiting
- indigestion Contraindicated
- In inflammatorily bowel disease (Chron Disease and colitis)
- No if bowel obstruction is suspect
Insulin
Injection Site
1. Abdomen
2. Posterior Arm
3. Anterior Thigh
4. Hips
U – 100 syringes = 100 U in 1ml
Administration
Do not massage
Do not aspirate
✓ Do not shake = Swirl
3. Wipe tops of insulin vial with alcohol.
4. Draw back amount of air into the syringe that equal total dose
5. Inject air equal to NPH dose into NPH vial.
6. Remove Syringe.
7. Inject air equal to regular dose into regular vial.
8. Invert regular insulin bottle and withdrawal regular insulin dose.
9. Carefully withdrawal NPH dose.
Nota: Exenatide (Byelta) = Used for Type II diabetes (Subcutaneous), because it is not
an insulin. Follow up = a Type I Patient wants to get it
Insulin complication
1. Lipodystrophy
2. Down Phenomenon
3. Somogyi Phenomenon
- Down Phenomenon - Somogyi Phenomenon
Hyperglycemia (Pre- Breakfast)
Early in the morning 5:00 am 7:00am
Check at 2:00 – 3:
If
- Normal Glycemia - Hypoglycemia
Or Hyperglycemia
Tto: Decrease Snack - Tto: Give snack at bet time
At bet time
- Increased insulin dose - ↓ Insulin dose NPH 4-10 pm
Insulin Pumps
1. Need check blood glucose apart.
2. Catheter Change every 2 – 3 days
3. Abdomen
4. Deliver a Continuous basal rate of insulin before each meal.
