UNIT TWO

DISORDERS OF THE ENODCRINE

SYSTEM

1
 Review of Anatomy and physiology of the
Endocrine System
Endocrine glands – include
• The pituitary - Adrenals
• Thyroid - Pancreatic islets
• Parathyroid - Ovaries
 The glands secrete their products directly into the blood stream.
 The chemical substance they secret is called Hormone.
 Hormones help to regulate organ function in Conjunction with
the nervous system.
 Hypothalamus helps to provide the link b/n the endocrine &
nervous system.

2
Common anatomic features of endocrine gland

• They are composed of secretary cells arranged

in minute clusters.
• No ducts are present, but they have rich blood
supply.
• Hormone concentration in the blood stream is
regulated by feed back control mechanism

3
 Classification of Hormones
• Steroid Hormone /e.g., Hydrocortisone/
• Peptide or protein hormones / e.g., insulin/
• Amine Hormones /e. g., epinephrine /
Function of hormones
• Growth & differentiation
• Maintenance of homeostasis
• Reproduction

4
 PITUITARY GLAND
• Previously referred to as the master gland of
the endocrines. Because it secretes hormones,
that in turn control the secretion of hormones
by others endocrine glands.
• Located in the sella tunica an indention of the
sphenoid bone at the base of the brain.
• It is oval shaped, divided into two lobes
1.Anterior lobe (adeno-hypophysis)
2.Posterior lobe (neurohypophysis

5
 Function
1.The anterior pituitary gland Secretes tropic hormone
Hormones Target gland(tissue)
• Thyroid stimulating Hormone /TSH/  Thyroid gland
• Adrenocorticotropic Hormone /ACTH/ Adrenal cortex
• Follicle stimulating Hormone /FSH/  Ovaries &testes
• Luteninsing Hormone /LH/  Ovaries & testes
• Prolactine |LH|  Breast
• Growth Hormone |GH| All tissue

6
 Con…
• 2.Posterior Pituitary
• Antidiuretic Hormone /Vasoprisin/ Controls
the execration of water by the kidney.
• Oxytocine facilitates milk ejection during
lactation & increase the force of Uterine
Contraction.(All oxytocine are produced in the
hypothalmus )

7
 THYROID GLAND
• Located anteriorly in the neck directly below the
cricoids cartilage
• Weight about 18gm, has two lobes
• It is an extremely vascular gland.
• Blood supply can be from two pairs of arteries /
Branches of external carotid & Subclavian
• Innovations by adrenergic & cholinergic nervous
system
• Composed of follicular & Para follicular cells

8
 Con…
• Produce 3 different hormone :
- Thyroxin /T4
-Triadothyronin/T3/
-Calcitonin
Function
• Control the cellular metabolic activity
• Serve as general pacemaker by accelerating
metabolic process
• Because they influence cell replication they are
important in brain development.
• Reduce b\d ca level 9
 THE PARATHYROID GLAND
• Consists four small glands located to posterior
surface of the thyroid gland.
 Major Function- regulation of Ca & P
metabolism & its effect is manifested on 3
target organ (blood, muscle& nerve)
1.maintains normal limit of ca
2.nerve impulse transmission
3.muscle contraction

10
 ADRENAL GLAND
• They are 2 in number
• located in the retroperitoneal space at the
superior poles of each kidney.
• Consist of an – outer portion – cortex
- Inner portion – medulla

11
 Adrenal Cortex
• is essential for maintenance of life sustaining
physiological activity
• Constitute 90% of the adrenal gland
• Produce Corticosteroids \adrenocorticoids|is a
collective name for 3 hormons.These are:- -
=glucocorticoid /Cortisol or hydrocortison/
= Minerolo corticoid /aldosterone/
= Androgens

12
 Adrenal Medulla
• It is not essential to life.
• Functions as part of autonomic nervous
system
• Plays a role in the physiologic stress response
• Secrete Catecholamine /Epinephrine & nor –
epinephrine/ - released in response to
autonomic Ns & stress

13
 THE PANCREAS
• Located in the upper abdomen
• Has both exocrine & endocrine gland functions
Exocrine Pancreas
• Secretions are in the pancreatic duct
• Secretions are digestive enzymes high in
protein content & electrolyte rich fluids.
• The secretions are very alkaline
• The enzyme secretion include amylase, trypsin
lipase
14
 Endocrine Pancreas
• Islets of Langerhans are the cells involved in
the endocrine function
• Composed of 3 distinct types of cells:
-Alpha Cells Secret glucagon's
-Beta Cells Secret insulin
-Delta Cells Secret Somatostatin
• Glucagons & insulin have significant effect on
carbohydrates, protein & lipids metabolism

15
 Insulin
• lowers blood glucose level
• Promotes storage of fat in adipose tissue &
synthesis of protein
• Insulin - is anabolic hormone b\se it stimulate
the synthesis of glycogen, protein & lipid while
it inhibits  degradation of these substance
Glucagons
• raise the blood glucose level
• Secreted by Pancreases
16
Location of the major endocrine glands.

Prepared by sisay
 DISORDERS OF THE ISLETS OF
LANGRAHANS
Diabetes Mellitus
• Diabetes mellitus is a group of heterogeneous
disorder characterized by
elevated levels of glucose in the blood or
hyperglycemia
CHO, lipid& protein metabolism abnormality
resulting from relative or absolute absence of
insulin or its cellular metabolism effect.
18
 Con…
• In diabetes the body’s ability to respond to
insulin may decrease or the pancreas, may
stop producing insulin entirely. This lead to
hyperglycemia which may result in acute
complication such as
-Diabetic Keto-acidosis
-Hyperglycemia hyperosmolar non ketotic
(HHNK) syndrome

19
 Con…
• Long term hyperglycemia may contribute to
-Micro-vascular Complications
-Macro-vascular diseases
Classifications
• Two broad categories of DM are designated
-Type 1
-Type 2

20
 Con…
• Type 1 A – Dm results from autoimmune beta cell
destruction.
• Type 1 B-DM Characterized by insulin deficiency
and tendency to develop ketosis
• Type II DM
- Characterized by – Insulin resistance
- Impaired insulin secretion
-Increased glucose
production
21
 In the old classification
• Type I or Insulin Dépendant Diabetes Mellitus
• Type II or Non Insulin Dépendent Diabetes Mellitus
• Gestational diabetes mellitus (GDM)
Type I
• 5 to 10% of people with DM have type I insulin
dependant diabetes.
• In this form the beta cells of the pancreas that
normally produce insulin are destroyed by an
autoimmune process.
• It is characterized by sudden onset usually before the
age of 30yrs.
22
 Type II
• ~ 90 to 95% of people with diabetes
• Results from decreased amount of insulin
production
• Occurs most frequently in people who are
older than 30yrs of age and obese.

23
 Normal Physiology
• Insulin is secreted by Beta.cells of pancreases
• Insulin is an anabolic or storage hormone it has
the following effects.
 Stimulate storage of glucose in the liver and
muscle (in the form of glycogen)
 Enhance storage of dietary fat in adipose tissue.
 Accelerates transport of amino acids in to cells
* Insulin deficiency; diabetes the breakdown of
stored glucose, protein and fat is present.

24
 Pathophysiology of Diabetes
Type I Diabetes
• Inability to produce insulin because pancreas beta cell
has been destroyed.
• Fasting hyperglycemia
• Post prandial (after meal) hyperglycemia
• Glucose in the urine since the concentration is high in
the blood
• Excess glucose excreted in the urine
• Excessive loss of fluids and electrolytes
• osmotic diuresis – Polyuria
-Polydipsia
25
 Insulin deficiency
• impaired metabolism of protein and fats
• Weight loss
• Polyphagia – because of the decreased
storage of calories
• Further hyperglycemia from – Glycogenolysis
- Gluconeognesis
• Fat break down
• Production of ketone bodies leads to diabetic
Ketoacidosis (DKA)
26
 Type II – Diabetes
• There are two main problems
- Insulin resistance
- impaired insulin secretion
• Insulin resistance - decreased sensitivity of the tissue
to insulin
• To over came insulin resistance and to prevent the
build up of glucose in the b/d there must be an
increased in the amount insulin secretion
• If the Beta cells are unable to keep up of the
increased demand for insulin, the glucose level rises.
27
 TYPE II Diabetes Develops
• DKA does not occur in type II diabetes
• Occurs most commonly in people older than
30 years
• For most pt’s the problem detected
incidentally
• Long term Complications are common
• Wt loss is the primary Rx of type II DM and
also exercise and diet

28
 Etiology
Type I diabetes

• Combination of - Genetic
- Immunology
- Environmental factors
• People don’t inherent type I diabetes or
tendency.
• An abnormal response in which antibodies are
directed against normal tissue of the body
responding to tissue as if they are foreign
29
 Type II Diabetes

• Exact mechanisms that used to insulin

resistance and impaired secretion in type II
DM are unknown.
• But genetic factors play a role in addition to
age (>65 yrs), obesity, family history and
ethnic group.

30
 Diagnostic Evaluation

• The presence of abnormally high blood

glucose level on at least two occasions
Random plasma glucose >200mg/dl
Fasting plasma glucose > 140mg /dl
Oral glucose tolerance test >200 mg/dl

31
 Management goals
• To normalize insulin activity and blood glucose levels
• To prevent dev’t of the vascular and neuropathic
complications
• To normalize blood glucose level with out hypoglycemic
and with out seriously disrupting the pt usual activity
patterns.
• There are five components of Mx
-Diet
-Exercise
-Monitoring
-Medication
-Education 32
 Dietary Mx
• Constitutes the foundation of diabetes Mx has
the following goals
 provision of all the essential foods
Meeting energy needs
Provision of daily function in b/d glucose level
 Decrease of blood glucose lipid levels
• For obese pts wt loss is the key to Rx
• Important objective in dietary Mx of diabetes
is control of total calorie intake to attain or
maintain a reasonable body wt and control of 33
 Con…
• In a young pt with type I diabetes, priority
should be given to provide a diet with enough
calories to maintain normal growth & dev’t.
Exercise
• is extremely important in managements of DM
because its effects on lowering blood glucose
and reducing cardiovascular risk factors

34
 Monitoring of glucose
• self monitoring of blood glucose (SMBG)
allows for detection and prevention of
hypoglycemia and hyperglycemia and plays a
crucial role in normalizing blood glucose
levels, which reduce long term diabetic
complications

35
 Insulin Therapy
• Insulin lower blood glucose level after meals
by facilitating the uptake & utilization of
glucose by muscles, fat and liver cells.
• During periods of fasting insulin inhibits the
break down of stored glucose, protein & fat.
• In type I diabetes the body loses the ability to
produce insulin.Thus, exogenous insulin must
be administered.
• In type II diabetes insulin may be necessary on
a long term bases to controlled glucose levels
if diet and oral agents have failed. 36
 A. Insulin Preparation

• A number of insulin preparations are available

• They vary according to four major
characteristics
- Time course of action
- Concentration
- Species and source
- Manufactures

37
 Time Course
• Insulin may be grouped in to three main categories
based on onset, peak and duration of action
1. Short acting insulin
• Regular insulin (marked “R”)
• Onset of regular human insulin action is ½ to 1hr,
peak 2 to 3 hrs, duration 4 to 6hrs
• Clear in appearance & given 20 minutes before food
• Another name for regular insulin is crystalline zinc
insulin (CZI)

38
 2. Intermediate insulin

• NPH insulin (neutral protamine hagodorn)

• Lente insulin (“L”)
• Onset 3 to 4 hrs, peak 4 to 12 hrs, duration 16
to 20 hrs.
• White and milky in appearance
* It is important for the pt to have eaten some
food arrived the time of the onset and peak of
these insulin's

39
 3. Long Acting Insulin

• Ultra Lente Insulin (UL)

• Onset 6 to 8hrs, peak 12 to 16 hrs, duration
20 to 30hrs
Concentration
• U-40 and u- 80 were widely available before
• By now the most common concentration of
insulin used is u- 100
• Thus, a syringe that holds U-100 insulin is a
1-ml (cc) syringe. If a syringe holds 50 units of
u- 100 insulin, it is a 1/2 ml of u-100 syringe 40
 B. Insulin regimens
• vary from one to four injections per day.
• Usually these are a combination of a short
acting and longer acting insulin
• These are two general approaches to therapy

41
 1. Conventional Regimen
• Simplifying the insulin regimen as much as
possible with the aim of avoiding the acute
complications.
• This approach would be appropriate for
Terminally ill
The elderly with limited self care abilities
Pt completely unwilling or unable to engage in
self manage

42
 2. Intensive Regimen
• Uses a more complex insulin regimen to achieve as
much control over blood glucose level is safe.
• This regimen allows pts more flexibility to change
their eating and activity patterns.
• Pts who may not be appropriate candidate for
intensive regimen:-
Persons with autonomic neuropathy that can uses
then to have hypoglycemic an awareness.
 Pts who have recurrent severe hypoglycemia
Pts with permanent, irreversible complications of
diabetes.
43

 C. Administering the Injection
• Selection and rotation
• The four main areas for injection are the
abdomen, arms, thighs and the hip.
• Speed of absorption is high in the abdomen and
decreases progressively in the arm, thigh and
hip.
• Systematic rotation of injection site with in
anatomic areas is recommended to prevent
localized changes in fatty tissues (lipodystrophy)
44
 D. Problems with Insulin
1. local allergic reaction
• Redness, Swelling, tenderness at the site of
injection
• Usually occur during the beginning stages of
therapy and disappear with continued use of
insulin
2. Systemic Allergic Reaction
• First there is an immediate local skin reaction
that gradually spread into sever & generalized
• It is rare
45
 3. Insulin lipodystrophy
• refers to localized disturbance of fat metabolism
– Lipoatrophy:- loss of sc fat appears as a slight dimpling
– Lipohypertrophy:- dev't of fibro fatty masses at the
injection site
4. Insulin Resistance
• Occur most commonly in obesity.

46
 Oral Anti diabetic Agents
• Are effective for type II diabetic pts.
• They can not be used during pregnancy
• Oral agents include -Sulfonylurea
-Biguanamides
Sulfonylurea
• exert their primary action by directly stimulating
to pancreas to secret insulin
• Additionally improve insulin action at the cellular
level
• they may also directly decrease glucose
production by the liver
47
 Biguamides
• Facilitate insulin action on the peripheral
receptor sites. There fore it can be used only
in the presence of insulin( e.g. Metforming)

48
 Nursing Mgt
• Education - to develop life time of special self-
management behavior inorder to prevent diabetic
complication
 DM patient must be knowledgeable(simple
information/simple pathophysilogy/) about DM that
includes
• Nutrition
• Medication side effects
• Exercise
• Disease progression
• Blood glucose monitoring techniques
49
•
 Con…
• Basic def`n of DM (having high glucose level)
• Normal glucose range (80-120mg/dl
• Effect of insulin & exercise (decrease glucose)
• Effect of food & stress including Illness &
infections (increase glucose level).
• Basic Rx approaches.
• Recognition, Rx & prevention of hypoglycemia
& hyperglycemia

50
 Con…
• Where to buy & store insulin, syringes &
glucose monitoring devices.
• When & how to reach the physician.
• Information on preventive skills, such as foot
care & eye care and skin care. Esp. foot & eye
care is mandatory for reducing amputation &
blindness

51
 Complication of DM
A. Acute complication of DM
• Three major acute complications of glucose
imbalance
1. Hypoglycemia
2. DKA
3. Hyperglycemia Hyperosmolar Nonketotic
Syndrome
• All three conditions need emergency Rx and
can result in death if inappropriately treated
or not treated at all.
52
1. Hypoglycemia (Insulin Reaction)
• occurs when blood glucose level falls below
60 mg /dl
• Can be caused by too much insulin, oral
hypoglycemic agents, too little food, excessive
physical activity.
• occurs at any time of the day or night
• Hypoglycemia can be -Mild
-Moderate
-Severe
53
 Con…
• In severe hypoglycemia, CNS function is so
impaired that the pt needs the assistance of
another person for Rx. of hypoglycemia.
• Disoriented behaviors, seizures difficulty
arousing from sleep or loss of consciousness.
• Immediate Rx must be given
• Usual recommendation 10 to 15 gm of fast
acting sugar orally.

54
 Con…
• N.B Golden advice – diabetic pts must carry some
form of simple sugar with them all the times.
For Severe Hypoglycemia + unconscious pt
• Injection glucagon 1gm IM
• Simple sugar followed by a check
• Patient Education
• Pt should follow regular pattern of eating,
administering insulin and exercise.
• Routine blood glucose tests
• Pt should know potential symptoms of
hypoglycemia
55
 2. Diabetic Ketoacidosis(DKA)
• Caused by an absence or markedly inadequate
amount of insulin resulting in disorder of
metabolism of CHO, Protein & fats.
• The three main clinical features of DKA are
-Dehydration
-Electrolyte loss
-Acidosis

56
 CON…
• Cause of DKA
• Decreased or missed dose of insulin
• Illness or infection
• Initial manifestations of undiagnosed and
untreated diabetes.
• Pathophysiology of DKA
• Break down of fat / lipolysis /……….> Free fatty
acid & glycerol……….>Keton bodies & Metabolic
acidosis
57
 C/Manifestation
• Polyurea & polydysia
• Blurred vision, weakness & headache
• Orthostatic Hypotension
• Sign of dehydration eg. Increased HR
• Weak rapid pulse
• Nausea – vomiting
• Abdominal pain
• Kussmaul breathing with fruity odor “acetone”
• Mental Status Change - Lethargic
-Comatose 58
 Diagnostic criteria for DKA:

• hyperglycemia (>250 mg/dl)

• ketosis (ketonemia or ketonuria)
• acidosis (pH<7.3)
• supporting features are volume depletion and
Kussmaul’s breathing.

59
 Alcoholic Ketoacidosis
• by definition AKA occurs in chronic alcoholism
especially after drinking which occurs with
starvation.
• sever abdominal pain and tenderness
• Most presents with glucose level <150 mg/dl
and is rapidly reversed with IV glucose and
thiamin.

60
 Treatment of DKA
• Treatment: aimed at correction to the three main problems
-Dehydration
-Electrolyte loss
-Acidosis
Rehydration
• To maintain tissue perfusion
• Initially 0.9% N.S at high rate
• Monitor fluid volume status involving frequent
measurement of
 Vital sign
 Input & output
 Lung assessment
61
 Electrolyte Loss
• Major concern is potassium & replacement as soon as possible.
• Potassium: replacement is always necessary
-if value on arrival is high: delay replacement till reversal of
ketosis
-if values are low: give K early
-if values are very low: hold insulin for 60-90 min. till 40-50
mmol of K are given
Acidosis
• Results from fat break down
• Is reversed by insulin injection

62
Practically DKA mgt in hospital (eg in BLH)
• Secure iv line then resuscitate the pt by 0.9%
NS
1st bag over 30 minute
2nd bag over 1hr
3rd bag over 2hrs
4th bag over 4hrs………..
Give regular insulin 10 iu iv & 10 iu im stat
then 5 iu regular insulin after measuring RBS
every hr until urine ketone is negative 2 times.
Change NS to DW 5% when RBS is<250mg/dl 63
 Con…
Investigate urine ketone every 2hrs
Investigate serum potassium level every 2 or
4hrs
If potassium level is low, secure another iv line
& add 20-60meq potassium in the bag to run
maintainancely.

64
3. Hyperglycemia Hyperosmolar Nonketotic
Syndrome(HHNKS/HHS)
• It is an acute complication of type 2 DM
• Associated with insulin deficiency profound
dehydration and absence of ketosis
• Mgt –resuscitation & putting on sliding scale
• Mostly sliding scale means measure RBS every
six hrs and give
40% glucose if RBS<70mg/dl
Nil if RBS 70-140mg/dl
65
 Con…
4iu RI if RBS 141-180mg/dl
8iu RI if RBS 181-250mg/dl
12iu RI if RBS 251- 350mg/dl
16iu RI if RBS >350

66
 B. Chronic complication of diabetes
• Affect almost every organ system of the body.
• Categorized in to:
• Macro vascular complications
• Coronary artery disease
• Cerbrovascular disease
• Peripheral vascular disease
• Micro vascular Complications
• Characterized by capillary basement membrane
thickening
• Can be- Diabetic retinopathy
- Nephropathy
67
 Affect all types of nerves
• Peripheral
• Autonomic
• Spinal nerves
• Impaired function of CNS
• Inability to concentrate
• Headache, light headiness
• Confusion, memory lapses
• Numbness of the lips & tongues
• Slurred speech to coordination
• Emotional Change
• Irrational Behavior
• Double vision & drowsiness
68
 Foot and leg problems in diabetes (diabetic foot ulcer)

• 50-75% of lower extremity amputation are

performed on people with diabetes(50% of
theses amputation are preventable)
• Three diabetic complication contribute to the
increased risk of foot infections. they are
1. Neuropathy:-sensory neuropathy leads to lost
pain & pressure sensation, autonomic
neuropathy increased dryness & tissue of the
skin (secondary to decreased sweating)
69
 Con…
2. Peripheral vascular disease:- Poor circulate
the lower extremities, poor wound healing
and dev't of gangrene
3. Imunocompromise:- Hyperglycemia impairs
the ability of leukocytes to destroy bacteria.

70
 Foot care

1.Properly bathing, drying and lubricating feet

2.Apply lotion to entire foot except between toes
3.Inspect feet daily (using a mirror if necessary to see
bottom of foot), including inspection of cracks
between toes.
4. Behaviors that decrease the risk of foot ulcer
including
Wear shoes at all times
Wearing cotton socks
Avoiding constrictive shoes
Interior surfaces of shoes should be inspected for
71
 DISORDERS OF THE THYROID GLAND

Examination of the gland.

• By inspection & palpation
• Identification of specific anatomic land mark
• Position patient properly
• Palpate for – Size, Shape, Consistency,
Symmetry presence of tenderness
• Auscultation for audible Vibration

72
 Goiter
• It is swelling of the neck due to enlargement of
the thyroid gland.
• All grades of goiter are encountered from that are
barely visible to those producing disfigurment.
• Some are symmetrical and diffuse others are
nodular.
• Some are accompanied by hyperthyroidism in
which case they are described as toxic, others are
associated with euthyroid called non-toxic goiter

73
 A. Endemic (iodine deficient) goiter
• The most type of goiter encountered chiefly in
geographic regions which natural supply of
iodine deficient is the so called simple or
colloid goiter.
• simple goiter may also be caused by an intake
of large quantities of goitrogenic substances.
• Simple goiter represents a compensatory
hypertrophy of the thyroid glands, presumably
caused by stimulation by the pituitary glands.

74
 CON…
• Such goiters usually cause no symptoms except
for the swelling in the neck which may result is
tracheal compression when excessive.
Management
• Supplementary iodine such as saturated
solution of potassium iodide (SSKI)
• Surgery
Prevention:- Simple or endemic goiter can be
prevented by providing children in iodine poor
regions with iodine compounds (iodized salt)
75
 B. Nodular goiter
• Certain thyroid glands are nodular because of the
presence of one or several areas of hyperplasia
(over growth).
• These nodules slowly increase in size with some
descending in to the thorax w/r they cause local
pressure symptoms.
• The pt with many thyroid nodules may eventually
require surgery (associated with malignancy,
hyperthyroid state)

76
 Hypothyroidism
• It is a condition in which there is slow progression of
thyroid hypofunction
• More than 95% of patient with hypothyroidism have
primary or thyroidal hypothyroidism-which refers to
dysfunction of the thyroid glands itself.
• Central – Due to failure of the pituitary,
hypothalamus or both
• When thyroid deficiency is present at birth the
condition is known as cretinism (congenital
hypothyroidism) a syndrom of dwarfism, mental
retardation. In such instance the mother many also 77
 Causes
• The most common cause of hypothyroidism in
adults is autoimmune thyroiditis (Hoshimote
thyroditis) in which the immune system attacks
the thyroid glands.
• Hypothyroidism also commonly occurs in pts with
previous hyperthyroidism who have been treated
with radioiodine, surgery or antithyroid
medications.
• Iodine deficiency

78
 Clinical manifestation
• Early symptoms extreme fatigue, hair lose,
brittle nail, dry skin, hoarseness.
• Hypothyroidism affects women five times than
men and occur most after between 30-60yrs
of age.

79
 Sever hypothyroidism c/m
• Subnormal temperature & Pulse rate
• Weight gain without food intake
• The skin become thickened
• The hair thins & fall out .
• Pt complains being cold in warm environment
• Mental Process becomes dull
• Speech is slow, tongue enlarge, hand & feet
increase in size
• Elevated serum cholesterol level
arteriosclerosis, coronary heart disease.
80
 Myxedema coma c/m

• The most extreme severe stage of

hypothyroidism
• Pt will be hypothermic & unconscious.
• Increasing lethargy, progression to stupor &
then Comma.
• May be precipitated by infection, Systemic
disease or use of sedatives or opoid analgesic
• The pt respiratory drive is depressed &
mortality is very high
81
 Emergency Care

• Maintain a patent air way

• Replace fluid
• IV glucose
• Give levothyroxin Sodium IV
• Check temperature frequently
• Monitor blood pressure
• Cover the client with warm blanket

82
 Management

• Primary objective
• To restore a normal metabolic state by
replacing the missing hormone.
(Synthetic levathyroxine /levathyroid/)
• For treating hypothyroidism
• Suppress non –toxic goiter
• If replacement therapy is adequate, the
symptom of myxedema disappear, normal
metabolic activity is resumed.

83
 Nursing Management
• Activities Modification
• Ongoing monitoring (pts vital sign)
• Temperature regulation (extra clothing and
blankets)
• Emotional support
• patient education and home care
considerations

84
 TYROTOXICOSIS

• The state of thyroid hormone excess

Etiology: hyperthyroidism caused by: - Graves
disease
• Toxic multi – nodular goiter
• Toxic adenoma
Graves Disease
• Accounts for 60 to 80% of thyrotoxicosis,
caused by thyroid stimulating immuno
globulin that directed to the TSH

85
 Clinical manifestation
 Depends on Severity of thyrotoxicosis, duration
of the disease, individual Susceptibility to excess
thyroid hormone, and the age of the Pt.
• Unexplained weight loss
• Hyperactivity, nervousness, irritability
• Insomnia & impaired concentration
• Neurological manifestation-hyperreflexia, muscle
wasting, proximal myopathy
• Cardiovascular manifestation-Sinus tachycardia
palpitation
86
 Con..
• The skin is warm & moist, patient complains of
sweating & heat intolerance
• The fine hair texture & diffused alopecia
• Increased stool frequency with diarrhea
• Women experience oligomenorhea &
amenorrhea
• Impaired sexual function
• Lab evaluation – for TSH level-increased
• Thyroid hormone level -increased

87
 Management
• is aimed at reducing thyroid hormone
Synthesis by using anti thyroid drugs and
reducing the amount of thyroid tissue with
radioiodine treatment or subtotal
thyroidectomy
Drug
• Thiooamides - propylthyuracile 100-200mg
every 6 to 8hr
• Methimazole 10-20mg every 8 to 12hr

88
 Thyroid storm (thyrotoxic crisis)
• A form of severe hyperthyroidism usually of
abrupt onset & (characterized by high level,
extreme tachycardia & altered mental states)
• A life threatening condition & usually
precipitated by stress such injuries,
infections, non-thyroid surgery &
thyroidectomy. These factors will precipitate
thyroid storms in partially controlled and
completely untreated thyroid pt.
89
 Suggestive Sign & Symptoms
1. tachycardia over 130 beat / minute
2. Temperature above 37.70 C /1000F/
3. Exaggerated Symptoms of hyperthyroidism
4. Disturbance of major Symptom Such as
GI system /wt loss, diarrhea abdominal pain /
Neurology/ Psychosis, Coma/
Cardiovascular / edema, chest pain, dyspnea/
• Untreated thyroid storm is almost always fatal

90
 Management
• Immediate objective to reduce body
temperature : heart rate and prevent collapes.
• To reduce temperature
-Ice packs
-Cool env’t
-Hydrocortisone, Acetaminophen
• Improve tissue oxygenation
• Replace liver glycogen store
• To impede formation of thyroid hormone and
block synthesis of T4 and T3 propyithiouracil or
91
methimazole
 Con…
• Hydrocortisone to treat shock or adrenal
insufficiency
• Iodine to decrease out put of T4 from thyroid
gland
• propranolol in combination with digitalis to
reduce severe cardiac symptoms.

92
 Nursing intervention (hyperthyroidism)

• Improving nutritional status

• Enhancing coping measures Maintaining
normal body temperature
• Patient education and home care
consideration

93
 THYRODITIS
• Is an inflammation of the thyroid gland.
• It can be acute; sub acute and chronic in nature
• common characteristics to thyroditis includes
inflammation, fibrosis, lymphocyte,
Acute Thyroditis
• Caused by infection of the thyroid gland by bacteria,
fungi and parasite.
• Most common cause is S.aurous typically causes
anterior neck pain, swelling, fever dysphagia and
dysphonia.
• On exam warmth, erythematic tenderness of the
thyroid gland
94
 Treatment
• Antimicrobial agents and fluid replacement.
• Surgical incision if an abscess is present
Sub – Acute Thyroditis
• Inflammatory disorder of the thyroid gland that
predominantly affects women.
• Presents as painful swelling in the anterior neck
• Thyroid enlarges symmetrically and occasionally
painful
• Skin is often reddened and warm
• Swallowing may be difficult and uncomfortable
95
 Manifestations
• Irritability
• Nervousness
• Insomnia
• Wt. loss
Treatment
• Control the inflammation
• NSAIDs
• B-blocking agents to control symptoms of
hyperthyroidism
96
Chronic Thyroditis / Hashimoto’s thyroditis/
• Occurs most frequently in women
• Diagnosis is based on the histological
appearance of the inflamed gland.
• Chronic forms are not accompanied by pain
pressure symptoms or fever
• Thyroid activity is usually normal or low.
Rx Objective
• Thyroid hormone therapy – to decrease thyroid
activity and production of thyroglobulin

97
 Thyroidectomy
• Removal of thyroid gland, it can be partial or
complete, may be carried out as primary treatment
of
- thyroid carcinoma
-Hyperthyroidism
-Hyperparathyroidism
Pre-Operative Mx
1. Pharmacotherapy
• To reduce the risk of thyroid storm and
hemorrhage and return the thyroid hormone level
to normal. 98
 Con…
2. Nutritional Support
• Adequate intake of carbohydrate and protein for
compensation of high metabolic activity and
demand
• Supplemental Vitamins
• Avoid stimulants
3. Anxiety reduction
• Help pt gain confidence
• Protect Pt from tension of unknown

99
 Con…
4. Pt education – Demonstrating to the pt how to
support the neck after surgery to prevent stress on
the incision.
Post Operative Mx
• Move and turn the pt carefully to support there head
and avoid tension.
• Analgesics for pain, IV fluid as ordered
• Assess the surgical dressing periodically and observe
for bleeding
• Monitor the pulse and blood pressure
• Notice for any voice change it may indicate injury to
the recurrent laryngeal nerve. 100
 Complications

• Hemorrhage
• Hematoma formation
• Edema of glottis
• Injury to recurrent laryngeal nerve
• Removal of parathyroid gland

101
 PARATHYROID GLAND DISORDERS
A. HYPOPARATHYRODISM
• A problem manifested by decreased level of
parathyroid hormone in the blood.
• The most common cause is – inadequate
secretion of the parathyroid hormone after
interruption of the blood supply or surgical
removal of parathyroid gland during
thyroidectomy, parathyroidectomy or radical
neck dissection.

102
 Pathophysiology
• Deficiencies of parathyroid hormone result in
an elevation of blood phosphate and a
decrease in the concentration of blood
calcium.
↓
• Decreased intestinal absorption of dietary
calcium and decreased reabsorption of
calcium from bone the renal tubules

103
 Clinical Feature
• Irritability of the neuro muscular system
• Tetany – a general muscular hypertonia with tremor and
spasmodic or uncoordinated contractions with or without
to make voluntary contractions.
• In latent tetany – numbness, tingling and cramp in the
extremities with the pt complains of stiffness in the hands
and feet.
• Alert tetany – signs bronchospasm, laryngeal spasm, carp
pedal spasm.
• Anxiety, irritability, depression and delirium
• ECG changes and hypotension
• Serum calcium level 5-6 ml/dl or lower
104
 Management
Objective of therapy
 To raise the serum ca level to 9-10 mg/dl
 To eliminate the symptom of hypoparathyrodism
and hypocalcaemia.
• Calcium gluconate IV
• Sedatives – parathormone to treat acute
parathyrodism with tetany. For these pt. monitor
closely for changes in the serum calcium level
and allergic reaction.
105
 Con…
• Tracheostomy or mechanical ventilation along with
medication if the pt. develops respiratory distress.
• A diet high in calcium and low in phosphorus
• Oral table of calcium and salts in /calcium gluconate/
• Aluminum hydroxide or aluminum carbonate after
meal to bind phosphate and promote its excretion.
• Various measures that enhance ca absorption from
GIT
• Vit. D preparation

106
 Nursing Interventions
• Care of post operative pt. having
parathyroidectomy
• Ca gluconate at the bed side with necessary
equipment for IV administration.
• Continuous cardiac monitoring and careful
assessment b/c ca and digitalis increase systolic
contraction and they potentates each other.
• Teaching about medications and diet therapy and
symptoms of hyper calcemia and hypo calcemia
and report appropriately.
107
 B. Hyperparathyroidism
• It is over production of parathyroid hormone by the
parathyroid glands. It is characterized by bone
decalcification and the development of renal stones
containing calcium.
Clinical manifestation
• Apathy, fatigue, muscular weakness, nousea, vomiting
attributable to an increases concentrate of calcium in
the blood
• Diagnostic evaluation
• Persisted elevation of serum calcium levels and an
elevated level of paratharamone.
108
 Management

• Surgical removal of abnormal parathyroid

tissue
• Hydration (renal calculi)
• Mobility (bones give up less calcium)
• Nursing intervention
• The nursing Mx of patient undergoing
parathyroidectomy is the same as
thyroidectomy

109
 Disorder of the pituitary Glands
The anterior pituitary gland
 Anterior pituitary gland regulates
• Growth
• Metabolic activity and sexual development
Hypopituitarism
• Defn- - a state in w/c there’s a deficiency of
one of more of the anterior pituitary hormone
• Panhypopituitarism / Summand’s disease

110
 Con…
 is total absence of all pituitary secretions post
partum pituitary necrosis/ sheehan’s
syndromes/ is
• Failure of the anterior pituitary more likely occur
in women with severe blood loss hypovolemia &
hypotension at the time of delivery.
• The clinical entity that is seen most frequently is
a decrease synthesis & secretion of - LH
- FSH
111
 Con…
Deficiency of LH & FSH in male results in
- Testicular failure with decreased testosterone
production
- Deceased or absent spermatogenesis from the
seminiferious tubules.
In Females
• Absence of gonadotropins result in
- Ovarian failure….> loss of follicular Stimulation
- ovulation & formation of Corpus lutum
112
 Con…
• LH & FSH …..> deficiency result in
-Loss of failure to develop secondary sex
characteristics
• GH deficiency – May result from severe
malnutrition, rapid loss & depletion of body
fat.
Prevention
• Safety issue -reducing head trauma
- Use of helmets for motor
cycles. 113
 C/F

• Extreme weight Loss, emaciation.

• Atrophy of all endocrine glands & organs.
• Hair loss
• Impotence
• Amenorrhea
• Hypo metabolism & hypoglycemia
Mx
• Replacement of the missing hormones

114
 Hyperpituitarism /pituitary tumor/
• A pathologic state that occurs with pituitary
tumors or hyperplasia not associated with the
absence of regulatory feed back mechanisms.
• The disorders usually arise from – GH, ACTH.
• A common reason for hyperpituitorism is the
presence of a pituitary adenoma, a benign
epithelial tumor.

115
 Con…
• Alterations in neurogenic function may occur as
adenomas grow & compress surrounding structure: -
- Visual Defects
- Headache
-Increased intracranial Pressure
C/M
• Varies according to hormone problem /excess/
• GH – hyper secretion
- change in facial features /increased in lip, nose
size & prominent supra orbital ridge
- Enlarged head, hand & foot size 116
 Management
• For client with excess GH psychological
Support is important
• Drug therapy – Bromocriptine mesylate
/Paclod/ reduces GH level
• Radiation therapy
• Surgical Mx – Hypophysectemy
• N.B – pre & post operative care is important

117
 Disorders of the posterior pituitary Gland

• Directly related to deficiency or excess of the

hormone vasopressin, /ADH/.
Diabetes Insipidus
• A disorder of water metabolism caused by a
deficiency of ADH(Anti Diuretic Hormone)
• There is either a decrease in ADH secretion or
inability of the kidney to respond appropriately to
ADH Characterized by great thirst & large volume
of dilute urine
118
 Con…
• Can occur secondary to brain tumors, head
trauma, infections of the CNS, and surgical
ablation or radiation therapy
• C/M – large Volume of very dilute, water like
urine contain abnormal substance – glucose,
albumin.
- Intense thirst (4-40lt /day)
- Sever dehydration b/c high volume urine loss

119
 Mx
• Objective – To ensure adequate fluid
replacement
- Replace vasopressin
- Search & Correct Underlying Cause
• Drugs – Vasopressin Replacement
• - Chloropropamide /Diabinese/ & thiazide
diuretics
• Clofibrate – Fluid conservation anti diuretic
- They have effect on the synthesis of ADH
120
 Nursing Management
• Early detection of dehydration & maintenance
of adequate hydration.
• Measuring fluid intake & out put
• Checking urine specific gravity
• Recording daily weight
• Encourage oral fluid intake

121
 Adrenal Gland Disorders

Pheochromocytoma
• Is a benign tumor that originates from chromatin Cells of
the adrenal medulla
• In 80-90% of pts the tumor arises in medulla, the rest occurs
in the extra-adrenal chromatin tissue located in or near.
-The aorta
-Ovaries
-Spleens
• May occur at any age but is peak incidence in b/n ages 25 &
50 years.
• Pheochromocytoma is the cause of high blood pressure in
0.10% to 0.5% of pts with hypertension 122
 C/Features
• Nature & Severity of symptoms depend on relative
proportion of epinephrine & nor epinephrine
secretion
Fight or Flight
– Hypertension
– Tachycardia
– Palpitations
– Tremor
– Diaphoresis
– Anxiety

123
 Con…
-Hyperglycemia
-headache
-Vision Changes
-Risk for Stroke
-Risk for Organ Damage
-BPs exceeding 250/150 have occurred

124
 Dx

• Signs of sympathetic nervous system overactivity

& elevated blood pressure
• Urine & plasma level of catecholamine.
• Total plasma Catecholamine
• Urinary catecholamine metabolites
Management
• During an episode or attacked hypertension and
tachycardia – place the pt in bed rest with the
head of the bed elevated.

125
 Pharmacotherapy
• Adrenergic blocking agent – Phentolamine /
restine /
• Smooth muscle relaxants – Sodium nitroprusside
• To quickly lower the blood pressure:
• Long acting – alpha-blockers –Phenoxybenzamine
Dibenzyline to prepare the pt for surgery
• B-adrenergic blocking agent’s -propranolol /inderal/
• For pt with cardiac dysrhythmias or not responding
to blocking agents definitive treatment of
pheochromocytoma is surgical removal of with
adrenaloectomy 126
 Con…
• Corticosteroids replacement if bilateral
adrenalectomy is done
• IV – Methyl Prednisolone sodium
• Po – prednisone

127
 Adrenal Cortex Hormone
Imbalance
• Adrenal Cortex – necessary for life secretions
help the body to adopt to stress of all kinds
• Adrenal hormones – mineral Corticoid
- Glucocorticoid
- Androgens & estrogen

• Hyposecretion = Addison’s Disease

• Hypersecretion = Cushing’s Syndrome
128
 Adrenocortical Insufficiency/ Addison ’s
disease /
• Results when adrenal cortex function is inadequate to
meet the pt’s need for corticated hormones.
• Causes
• Autoimmune or idiopathic atrophy of the adrenal
glands =75%
• Surgical removal of adrenal glands
• Infection of the adrenal gland esp. by Tb
• Inadequate secretion of ACTH from the pituitary gland
• Sudden cessation of exogenous adreno cortical
hormone therapy 129
 Clinical Manifestation
• Muscle weakness, Anorexia, GI Symptoms,
fatigue ,emaciation, dark pigmentation of the skin /knees,
elbow, mucous membrane/
• Hypotension, low blood glucose.
• Low serum sodium & high serum potassium
• Addisons Crisis acute hypotension as a result of hypo-
corticism.( adrenal hypo function)
• Cyanosis, fever & signs of shock pallor apprehension, rapid
& weak pulse, rapid respiration, low B/P.
• Additionally headache, nausea, abdominal pain, diarrhea
• Sign of confusion & restlessness

130
 Dx – by lab test results

• Decrease in concentration of blood glucose &

sodium.
• Increased concentration of serum potassium
• Increased white blood count
• Low levels of adrenocortical hormones in the
blood or urine serum cortisol levels are
decreased

131
 Management
• Immediate treatment is directed to Combating shock-
restoring blood circulation
• Administering fluids
• Corticosteroids
• Monitoring V/S
• Proper positioning
• Hydrocortisone Iv
• Vasopressors amines – if hypotension persists
• Antibiotics – If the cause is infection
• Assess carefully to identify factors, stressors and illness

132
 Nursing Interventions
• Addisonian Crisis – an important part of nursing Mx
• Monitoring the Pt for S/S indicative of addisonian
crisis
• Manifestations of shock
• Physical and psychological stress must be avoided
Includes – Exposure to cold
- Over exertion, infection
- Emotional distress
• IV administration of fluid glucose and electrolytes
sodium
133
 Con…
• Replacement of missing corticosteroid and Vasopressors
• Monitor patient’s symptoms and vital sign, weight, fluid
electrolyte balance
• identify factors that may have led to the episode of crisis
• Restoring fluid balance
- Assess skin turgor & mucous mm
- Record daily weight changes
- Instruct the Pt to report thirst
- Frequent monitoring blood Pressure

134
 Cushing’s syndrome
• Results from excess adrenocortical activity
• Caused by – Several mechanisms
• Tumor of the pituitary gland that produces
ACTH
• Administration of corticosteroids or ACTH
excessively
• Ectopic production of ACTH by malignancies
• Ineffective feed back mechanism.
• Hyperplasia of adrenal cortex

135
 Clinical Manifestations

• Arrest of growth obesity and musculoskeletal

change
• Centered type obesity with a fatty buffalos hump
• The skin is thin, fragile & easily traumatized
• Ecchymosis (bruises) and striae develop
• Weakness and lassitude
• Sleep disturbance
• Muscle wasting and osteoporosis
• Kyphosis backache & Compression fracture
• Retention of Sodium and water
136
 Con…
• increased oiliness of the skin and acne
• Hyperglycemia or overt diabetes
• Wt gain, slow healing of minor cuts
• Appearance of masculine traits
• Excessive hair growth

• Increased in serum sodium and blood glucose

level

• Decreased serum potassium 137

Signs and Symptoms cont’d….

prepared By: A.T, 2011 138

 Management

• Treatment is directed at the pituitary gland

• Surgical removal of the tumor by transsphenoidal
hypophysectemy
• Radiation of pituitary gland.
Nursing Intervention
• Monitor and manage Potential Complication
• Fluid and electrolyte balance & corticosteroid
• Decrease risk for injury and infection
• Pre operative preparation & post operative care
• Encourage rest and activity
• Promoting skin care & improve body image
139
•