Professional Documents
Culture Documents
Endocrine System
RAJ PARIHAAR
4/14/2009
Table of Contents
1. Overview of Anatomy & Physiology of Endocrine System ......................................................3
2. Pancreatic Disorder ...................................................................................................................9
Diabetes Mellitus (DM) .................................................................................................. 9
Diabetic Ketoacidosis (DKA) ........................................................................................ 22
Hyperglycemic Hyperosmolar Non-Ketotic Coma (HHNKC) ........................................ 24
3. Pituitary Disorder .................................................................................................................... 26
Diabetes Incipidus (DI) ............................................................................................... 26
Syndrome of Inappropriate Anti-diuretic Hormone Secretion (SIADH) ..................... 28
4. Thyroid Disorder...................................................................................................................... 30
Goiter ........................................................................................................................... 30
Hypothyroidism (Myxedema) ...................................................................................... 34
Hyperthyroidism .......................................................................................................... 38
5. peraThyroid Disorder .............................................................................................................. 41
hypoperathyroidism..................................................................................................... 41
Hyperparathyroidism ................................................................................................... 45
6. Adrenal Disorder ..................................................................................................................... 48
Pheochromocytoma ..................................................................................................... 48
Cushing Syndrome ....................................................................................................... 51
Addisons disease......................................................................................................... 54
Addisonian Crisis ......................................................................................................... 57
Corticosteroid Therapy ................................................................................................ 58
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ENDOCRINE SYSTEM
Is composed of an interrelated complex of glands (Pituitary G, Adrenal G, Thyroid G,
Parathyroid G, Islets of langerhans of the pancreas, Ovaries & Testes) that secretes a variety
of hormones directly into the bloodstream.
Its major function, together with the nervous system: is to regulate body function
HORMONES REGULATION
1. Hormones: chemical substance that acts s messenger to specific cells & organs (target
organs), stimulating & inhibiting various processes
Two Major Categories
a. Local: hormones with specific effect in the area of secretion (ex. Secretin,
cholecystokinin, panceozymin [CCK-PZ])
b. General: hormones transported in the blood to distant sites where they exert their
effects (ex. Cortisol)
2. Negative Feedback Mechanisms:
a. Decreased concentration of a circulating hormones triggers production of a stimulating
hormones from pituitary gland; this hormones in turn stimulates its target organ to
produce hormones
b. Increased concentration of a hormones inhibits production of the stimulating hormone,
resulting in decreased secretion of the target organ hormone
3. Positive Feedback Mechanisms:
c. Increased concentration of a circulating hormones triggers production of a stimulating
hormones from pituitary gland; this hormones in turn stimulates its target organ to
produce hormones
d. Decreased concentration of a hormones inhibits production of the stimulating hormone,
resulting in decreased secretion of the target organ hormone
4. Some hormones are controlled by changing blood levels of specific substances (ex. Calcium,
glucose)
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5. Certain hormones (ex. Cortisol or female reproductive hormones) follow rhythmic patterns
of secretion
6. Autonomic & CNS control (pituitary-hypothalamic axis): hypothalamus controls release of
the hormones of the anterior pituitary gland through releasing & inhibiting factors that
stimulate or inhibits hormone secretions
HORMONE FUNCTION
Endocrine G
Hormone
Functions
Pituitary G
Anterior lobe
TSH
ACTH
FSH, LH
GH, Somatotropin
Prolactin or LTH
Posterior lobe
ADH
Oxytocin
Intermediate lobe
MSH
Adrenal G
Mineralocorticoid
Adrenal Cortex
(ex. Aldosterone)
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Glucocorticoids
(ex. Cortisol,
corticosterone)
Sex Hormones
(androgens,
estrogens
progesterones)
Adrenal Medulla
Epinephrine,
Norepinephrine
Thyroid G
: T3, T4
: Thyrocalcitonin
Parathyroid G
: PTH
Insulin
Pancreas
(islets of Langerhans)
Beta Cells
Alpha Cells
Glucagon
Ovaries
: Estrogen,
Progesterone
Testes
: Testosterone
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Endocrine System
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ADRENAL GLANDS
Two small glands, one above each kidney; Located at top of each kidney
2 Sections of Adrenal Glands
1. Adrenal Cortex (outer portion): produces mineralocorticoids, glucocorticoids, sex
hormones
3 Zones/Layers
Zona Fasciculata: secretes glucocortocoids (cortisol): controls glucose metabolism:
Sugar
Zona Reticularis: secretes traces of glucocorticoids & androgenic hormones:
promotes secondary sex characteristics: Sex
Zona Glumerulosa: secretes mineralocorticoids (aldosterone): promotes sodium and
water reabsorption and excretion of potassium: Salt
2. Adrenal Medulla (inner portion): produces epinephrine, norepinephrine (secretes
catecholamines a power hormone): vasoconstrictor
2 Types of Catecholamines:
Epinephrine (vasoconstrictor)
Norepinephrine (vasoconstrictor)
o
THYROID GLAND
Located in anterior portion of the neck
Consist of 2 lobes connected by a narrow isthmus
Produces thyroxine (T4), triiodothyronine (T3), thyrocalcitonin
3 Hormones Secreted:
T3: 3 molecules of iodine (more potent)
T4: 4 molecule of iodine
T3 and T4 are metabolic hormone: increase brain activity; promotes cerebration
(thinking); increase V/S
Thyrocalcitonin: antagonizes the effects of parathormone to promote calcium
reabsorption.
PARATHYROID GLAND
4 small glands located in pairs behind the thyroid gland
Produce parathormone (PTH)
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Pancreatic Disorder
DIABETES MELLITUS (DM)
DEFINITION
Diabetes Mellitus represent a group of chronic metabolic disorders characterized by
hyperglycemia due to total or partial insulin deficiency or insensitivity of the cells to insulin
as a result of defect in insulin secretion, insulin action or both.
CLASSIFICATION
1. TYPE 1 - INSULIN-DEPENDENT DIABETES MELLITUS (IDDM) OR JUVENILE DIABETES (BRITTLE
DISEASE) - Insulin-producing pancreatic beta cells in the islets of langerhans are
destroyed by an autoimmune process resulting in little of no insulin production (Absolute
insulin deficiency). 10% general population has Type I DM
2. TYPE 2 (NON- INSULIN-DEPENDENT DIABETES MELLITUS (NIDDM) OR MATURITY ONSET
DIABETES -It May result to partial deficiency of insulin production &/or an insensitivity of
the cells to insulin. 90% of general population has Type II DM
3. GESTATIONAL DIABETES - Gestational diabetes is appearance of diabetes for the first time
during pregnancy and disappears postpartum.
ETIOLOGY
PREDISPOSING FACTORS
A. TYPE 1 DIABETES
1. Autoimmune disease such as Graves disease, hashimotos thyroiditis and addisions
disease
2. Due to viral infections mumps, rubella ect.
3. Drugs: diuretics (Lasix), Steroids, oral contraceptives
4. Related to carbon tetrachloride toxicity
B. TYPE 2 DIABETES
1. Genetic factors
2. Obesity: because obese persons lack insulin receptor binding sites
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PATHOPHYSIOLOGY
TYPE 1 DIABETES
DUE TO PREDISPOSING FECTORS
DEVOLOP IMMUNOLOGICAL RESPONSE
AUTOIMMUNITY AGAINST THE CELL
RESPONSE
DESTRUCTION OF CELL
RESPONSE
INSULIN DEFICIENCY
RESPONSE
CELLULAR STARVATION
CLINICAL TYPE 1 DM
HYPERGLYCEMIA
POLYPHAGIA
INCREASE
CATABOLISM
GLYCOGENESIS
GLYCOGENOLYSIS
POLYUREA
CELLULAR DEHYDRATION
WEIGHT LOSS
INCOMPLATE OXIDATION
IN LIVER
ATHEROSCLEROSIS
KETONES
POLYDYPSIA
DIABETIC COMA
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TYPE 2 DIABETES
CELLULAR STARVATION
CLINICAL TYPE 1 DM
POLYPHAGIA
INCREASE
CATABOLISM
GLYCOGENESIS
GLYCOGENOLYSIS
COMPLATE OXIDATION IN
LIVER
HYPERGLYCEMIA
INCREASE OSMOTIC DIURETICS
GLYCOSURIA
POLYUREA
CELLULAR DEHYDRATION
ATHEROSCLEROSIS
POLYDYPSIA
WEIGHT LOSS
HYPERTENSION; MI & CVA
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CLINICAL MANIFESTATION
1. Polyuria
7. Anorexia
2. Polydipsia
3. Polyphagia
9. Blurring of vision
4. Glucosuria
5. Weight loss
6. Fatigue
INVESTIGATION
1. Fasting Blood Sugar:
a. FBS of greater than or equal to 126 mg/dL at two occasions confirms DM
b. May be normal in Type II DM
2. Random blood glucose of greater than or equal to 200 mg/dL with classic symptoms
(polyuria, polydipsia, polyphagia, weight loss)
3. Oral Glucose Tolerance Test: elevated [insulin level <5 micro gm / ml]
4. Glycosolated Hemoglobin (hemoglobin A1c): elevated [>6%]
5. Uineanalysis
6. Islet cell antibody
7. WBC Count. And urine culture for infection.
MEDICAL MANAGEMENT
TREATMENT GOAL
The main principle aim of the management is to establish and maintains metabolic
control.
The main therapeutic aims are
Prevent complications
According to these therapeutic goals the DM management is divided into 5 components1. Nutritional management
2. Activity and exercise
3. Monitoring
4. Pharmacological therapy
5. Education
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NUTRITIONAL MANAGEMENT
Nutrition, diet and weight control are the foundation of diabetes management and it is
the first line treatment of the DM type-2.
The goal of meal planning is to control blood glucose and lipid levels
PRINCIPLE
1.
5060% carbohydrates
2030% fats
1020% proteins
ACTION
Carbohydrates should be varied to include
fruits, starches, and vegetables.
Protein selections that are lean will help
reduce fat and cholesterol intake.
Fats should be used low in total calories.
High in calories, fats contribute to weight
gain.
2.
measuring cups.
Know the equivalent amounts of commonly
used foods within a food group, eg, 1 slice
of bread = cup cooked pasta.
3.
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4.
5.
6.
7.
8.
noncaloric sweeteners in
moderation.
EXERCISE
Regularly scheduled, moderate exercise performed for at least 30 minutes most days of
the week to
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NOTE Clients should not begin exercising if glucose is above 250mg/dl and ketones are present
in the urine.
Clients are encouraged to exercise daily at the same time, using the same type of
activity if exercise is used to control blood sugar.
Clients should be encouraged to monitor blood sugar before, during, and after exercise
particularly if there is a potential for hypoglycemia (particularly so for clients using
insulin therapy and sulfonylurea treatment).
MONITORING
1. Self-monitoring of blood glucose
Two to three times per week if insulin is not required, including one test that is done
after meals (2 hours is suggested time).
Increase frequency of testing with changes in medications, activity, or diet and with
stress or illness.
HgbA1c contains glucose molecules, which attach to red blood cells; RBCs live in
body for 23 months; therefore, the HgbA1c reflects the average blood glucose level
over 23 months.
Normal ranges are usually 46% and indicate an almost normal blood glucose
control.
Levels over seven would indicate less than optimal control, putting the client at risk
for complications.
Every decline of one in HgbA1c produces up to a 40% risk reduction; for example
decrease in level from 8 to 7.
3. Urine Testing
Ketone bodies in the urine indicate that control of type 1 diabetes is deteriorating
and the risk of diabetic ketoacidosis (DKA) is high.
PHARMACOLOGICAL THERAPY
Insulin therapy for patients with type 1 diabetes to control initial hyperglycemia.
Oral antidiabetic agents for patients with type 2 diabetes who do not achieve glucose
control with diet and exercise only.
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INSULIN THERAPY
Insulin injected subcutaneously is the first line therapy in the treatment of type 1
diabetes. The different type of insulin are biased their time of onset and duration of
action, rapid, short, intermediate, long acting insulin and mixed insulin.
ONSET
PEAK
DURATION
INDICATION
Rapid-acting
Lispro(Humalog)
10-15
Aspart (Novolin)
min
0.5-1 hour
3-6 hours
To prevent nocturnal
hypoglycemia.
Short-acting
Humalog R
0.5-1
Novolin R
hour
2-3 hours
4-6 hours
(R Regular)
trauma;
management of poorly
controlled diabetes;
to supplement long-acting
insulin
Intermediate-acting
NPH (neutral
1-4
protamine
hours
6-12 hours
16-20 hours
Hagedorn)
Lente
Long-acting
Ultralente
6-8
12-16
hours
hours
20-30 hours
Very Long-acting
Glargine (Lantus)
1 hour
Continuous
24 hours
(no peak)
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Mixtures of insulin
The exception is glargine insulin, which should not be mixed with any other form of
insulin.
Preparations that contain a mixture of 70% NPH and 30% regular human insulin (ie,
Novolin 70/30, Humulin 70/30) are available, as is Humulin 50/50, but the fixed
ratios of intermediate-acting to rapid-acting insulin may restrict their use. In
addition, a 25/75 mixture of NPH and lispro insulin is available.
Hypoglycemia
Local allergic reactions at the injection site including local itching, erythematous and
indurate lesions, and discrete subcutaneous nodules.
Rarely, patients may develop systemic reactions, including generalised urticaria and
anaphylactic reactions.
Fat hypertrophy is attributed to the local lipogenic effects of the injected insulin.
MORNING HYPERGLYCEMIA
Insulin waning
Dawn phenomenon
Relatively normal blood glucose until about 3 AM, when the level begins to rise
result of normal nighttime release of hormones, which are counter regulatory to
insulin and cause an increase in blood sugar level
Somogyi effect
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NOTE in type 2 DM insulin therapy is given when the diet, exercise and oral antidiabetes
therapy is unresponsive.
ORAL HYPOGLYCEMIC AGENT
Oral antidiabetic agents used in addition to other treatment modalities in type 2 DM.
Sulfonylureas
Glucotrol
Diabeta
Amaryl
Biguanides
Glucophage
Metformin
Thiazolidinediones (glitonones)
Avandia
Actos
Insulin sensitizers
Meglitinides
Prandin
Starlix
Insulin secretagogues
EDUCATION
1.
2.
Diet
3.
Client should be able to plan a meal using exchange lists before discharge
Insulin
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Injection technique
Systematically rotate the site: to prevent lipodystrophy: (hypertrophy or atrophy
of tissue)
Insert needle at a 45 (skinny clients) or 90 (fat or obese clients) degree angle
depending on amount of adipose tissue
May store current vial of insulin at room temperature; refrigerate extra supplies
4.
Avoid alcohol intake while on medication: it can lead to severe hypoglycemia reaction
Instruct the client to take it with meals: to lessen GIT irritation & prevent
hypoglycemia
5.
May be satisfactory for Type II diabetics since they are more stable
Report result to physician if results are greater that 1%, especially if experiencing
symptoms of hyperglycemia
Urine testing for ketones should be done by Type I diabetic clients when there is
persistent glycosuria, increase blood glucose level or if the client is not feeling well
(acetest, ketostix)
6.
Use for Type I diabetic client: since it gives exact blood glucose level & also detects
hypoglycemia
Instruct client in finger stick technique: use of monitor device (if used), & recording
& utilization of test results
7.
General care
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Notify physician
Monitor urine or blood glucose level & urine ketones frequently
If N/V occurs: sip on clear liquid with simple sugar
8.
9.
Foot care
Wash foot with mild soap & water & pat dry
Never go barefoot
Inspect foot daily & notify physician: if cut, blister, or break in skin occurs
Exercise
Exercise is best performed after meals when the blood sugar is rising
10. Complication
Eat candy or drink orange juice with sugar added for insulin reaction (hypoglycemia)
COMPLICATIONS
Complications can be acute or chronic.
Atherosclerosis
Cerebrovescular disease
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Peripheral neuropathy
Peripheral neuropathy
Diabetic retinopathy,
Diabetic nephropathy
Miscellaneous complications
Skin infections
Necrobiosis Iipoidica
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PREDISPOSING FACTORS
1. Undiagnosed DM
2. Neglect to treatment
3. Infection
4. cardiovascular disorder
5. Hyperglycemia
CLINICAL MANIFESTATION
1. Polyuria
2. Polydipsia
3. Polyphagia
4. Glucosuria
5. ketonurea
tachypnea
6. Weight loss
7. Anorexia
16. Hypotension
8. N/V
17. Tachycardia
9. Abdominal pain
coma
INVESTIGATION
1. FBS: is increased
2. Serum glucose & ketones level: elevated
3. BUN (normal value: 10 20): elevated: due to dehydration
4. Creatinine (normal value: .8 1): elevated: due to dehydration
5. Hct (normal value: female 36 42, male 42 48): elevated: due to dehydration
6. Serum Na: decrease
7. Serum K: maybe normal or elevated at first
8. ABG: metabolic acidosis with compensatory respiratory alkalosis
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PREDISPOSING FACTORS
1. Undiagnosed diabetes
2. Infection or other stress
3. Certain medications (ex. dilantin, thiazide, diuretics)
4. Dialysis
5. Hyperalimentation
6. Major burns
7. Pancreatic disease
CLINICAL MANIFESTATION
1. Polyuria
2. Polydipsia
10. Dry
mucous
membrane;
soft
eyeballs
3. Polyphagia
4. Glucosuria
12. Hypotension
5. Weight loss
13. Tachycardia
6. Anorexia
7. N/V
15. Restlessness
8. Abdominal pain
INVESTIGATION
1. Blood glucose level: extremely elevated
2. BUN: elevated: due to dehydration
3. Creatinine: elevted: due to dehydration
4. Hct: elevated: due to dehydration
5. Urine: (+) for glucose
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Pituitary Disorder
DIABETES INCIPIDUS (DI)
Diabetes insipidus (DI) is a condition characterized by excretion of large amounts of
severely diluted urine and excessive thirst, caused by a deficiency of vasopressin, also
known as antidiuretic hormone (ADH) [central diabetes insipidus] and insensitivity of the
kidneys to ADH [nephrogenic diabetes insipidus].
Primary:
2.
Idiopathic.
Secondary:
head trauma,
Presence of tumor
intracranial or metastatic
3.
Inflammation
Nephrogenic DI:
hypokalemia,
some medications
CLINICAL MANIFESTATION
1. Severe polyuria with low specific gravity
2. Polydipsia (excessive thirst)
3. Fatigue
4. Muscle weakness
5. Irritability
6. Weight loss
7. Hypotension
8. Signs of dehydration
a. Adult: thirst; Children: tachycardia
b. Agitation
c. Poor Skin turgor
d. Dry mucous membrane
9. Tachycardia, eventually shock if fluids is not replaced
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INVESTIGATION
1. Urine Specific Gravity (NV: 1.015 1.030): less than 1.004
2. Serum Na: increase resulting to hypernatremia
3. H2O deprivation test: reveals inability to concentrate urine
For
patients
who
have
some
residual
hypothalamic
ADH
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Head injury
Cancers
Lung
cancer
cancer,
as
(especially
well
as
small
other
cell
lung
small-cell
Infections
Brain abscess
Pneumonia
Lung abscess
Drugs
Chlorpropamide
Clofibrate
Phenothiazine
SIADH
Cyclophosphamide
Carbamazepine
Selective serotonin reuptake inhibitors (SSRIs, a class of antidepressants)
Methylenedioxymethamphetamine (MDMA, commonly called Ecstasy)
CLINICAL MANIFESTATION
1.
2.
3.
Hypertension
Edema
Weight gain
Water intoxication: may lead to cerebral edema: lead to increase ICP; may lead to
seizure activity.
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INVESTIGATION
Laboratory findings in diagnosis of SIADH include1) Hyponatremia <130 mEq/L, and POsm <270 mOsm/kg.
2) Urine sodium concentration >20 mEqlL (inappropriate natriuresis)
3) Urine specific gravity is increase
4) Low blood urea nitrogen (BUN)
5) Low creatinine
6) Low uric acid
7) Low albumin
MEDICAL MANAGEMENT
1.
2.
3.
4.
Drugs
Care must be taken when correcting hyponatremia. A rapid rise in the sodium level may
cause central pontine myelinolysis.
NURSING INTERVENTION
1) Restrict fluid: to promote fluid loss & gradual increase in serum Na
2) Administer medications as ordered:
a. Loop diuretics (Lasix)
b. Osmotic diuretics (Mannitol)
3) Monitor strictly V/S, I&O & neuro check
4) Weigh patient daily and assess for pitting edema
5) Monitor serum electrolytes & blood chemistries carefully
6) Provide meticulous skin care
7) Prevent complications
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Thyroid Disorder
GOITER
Goiter also is enlargement in the thyroid gland due to iodine deficiency, which can lead
to a swelling of the neck or larynx.
CLASSIFICATION
They are classified in different ways:
1. Diffuse goiter - Diffuse goiter is a goiter that has spread through the entire thyroid.
2. Nodular goiter Nodular goiter is the goiter of the one node of the thyroid. If the
goiter is spread more then one node is called multinodular goiter.
1. Toxic goiter - Toxic goiter refers to goiter with hyperthyroidism. These most commonly
due to Graves' disease, but can be caused by inflammation or a multinodular goiter.
2. Nontoxic goiter - Nontoxic goiter is a diffuse or nodular enlargement of the thyroid
gland that does not result from an inflammatory or neoplastic process and is not
associated with abnormal thyroid function.
1.
Endemic: caused by nutritional iodine deficiency, most common in the goiter belt
area, areas where soil & H2O are deficient in iodine; occurs most frequently during
adolescence & pregnancy
2.
Sporadic: caused by
Increase intake of goitrogenic foods (contains agent that decrease the thyroxine
production: pro-goitrin an anti-thyroid agent that has no iodine).
Ex. cabbage, turnips, radish, strawberry, carrots, sweet potato, rutabagas, peaches,
peas, spinach, broccoli, all nuts
Goitrogenic drugs:
Anti-Thyroid Agent:
Propylthiouracil (PTU)
PASA (Aspirin)
Phenylbutazone
Cobalt
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ETIOLOGY
Worldwide, the most common cause for goiter is iodine deficiency.
In countries that use iodized salt, Hashimoto's thyroiditis becomes the most common
cause.
Hashimoto's thyroiditis or chronic lymphocytic thyroiditis is an autoimmune disease
where the body's own T-cells attack the cells of the thyroid. It was the first disease to be
recognized as an autoimmune disease
Other causes are:
Hypothyroid
Hyperthyroid
congenital hypothyroidism
Graves' disease
Ingestion of goitrogens
Side-effects
Thyroid cancer
of
pharmacological
therapy
PATHOPHYSIOLOGY
When
levels
of
thyroid
hormones
fall,
thyrotropin-releasing
hormone
(TRH)
produced
is
by
the
hypothalamus.
TRH
then
prompts
the
or
stimulating
thyroid
hormone
thyroid
glands
grow
in
size
by
CLINICAL MANIFESTATION
1. Enlarged thyroid gland
2. Dysphasia
3. Respiratory distress
4. Mild restlessness
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INVESTIGATION
1. Serum T4: reveals normal or below normal
2. Thyroid Scan: reveals enlarged thyroid gland.
3. Serum Thyroid Stimulating Hormone (TSH): is increased (confirmatory diagnostic
test)
4. RAIU (Radio Active Iodine Uptake): normal or increased
MEDICAL MANAGEMENT
1. Drug Therapy:
a. Hormone replacement with levothyroxine (Synthroid) (T4), liothyronine
(Cytomel) (T3)
b. Small dose of iodine (Lugols or potassium iodide solution): for goiter
resulting from iodine deficiency
2. Avoidance of goitrogenic food or drugs in sporadic goiter
3. Surgery:
a. Subtotal thyroidectomy: (if goiter is large) to relieve pressure symptoms & for
cosmetic reasons
NURSING INTERVENTION
1. Administer Replacement therapy as ordered:
a. Lugols Solution / SSKI (Saturated Solution of Potassium Iodine)
Color purple or violet and administered via straw to prevent staining of teeth.
b. Thyroid Hormones:
Levothyroxine (Synthroid)
Liothyronine (Cytomel)
Thyroid Extracts
Insomnia
Hypertension
Heat intolerance
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Seaweeds
Seafoods like oyster, crabs, clams and lobster but not shrimps because it
contains lesser amount of iodine.
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HYPOTHYROIDISM (MYXEDEMA)
Hypothyroidism is the disease state that caused by insufficient production of thyroid
hormone by the thyroid gland.
Cretinism is a form of hypothyroidism found in Children. That can lead to mental
retardation.
Myxedema is a form of hypothyroidism found in Adults. That can lead to non pitting
edema
sufficient
Myxedema
The
term
myxedema
refers
to
the
accumulation
of
Characterized
by
intensification
of
S/sx
of
hypothyroidism
&
neurologic
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CLINICAL MANIFESTATION
In adults, hypothyroidism is associated with the following clinical manifestation
Early symptoms
Fatigue
Depression
Goiter
Paleness
Decreased sweating
Bradycardia (low heart rate less than sixty beats per minute)
Constipation
Late symptoms
Slow speech and a hoarse, breaking voice deepening of the voice can also be
noticed
Decrease libido
Memory impairment
Psychosis
INVESTIGATION
1. Serum T3 and T4: is decreased
2. Serum Cholesterol: is increased
3. Serum Thyroid Stimulating Hormone (TSH): is increased
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MEDICAL MANAGEMENT
1. Drug Therapy:
Levothyroxine (Synthroid)
Thyroglobulin (Proloid)
Dessicated thyroid
Liothyronine (Cytomel)
IV thyroid hormones
Correction of hypothermina
NURSING INTERVENTION
1. Monitor strictly V/S & I&O, daily weights; observe for edema & signs of
cardiovascular complication & to determine presence of myxedema coma
2. Administer thyroid hormone replacement therapy as ordered & monitor effects:
a. Observe signs of thyrotoxicosis:
N/V
Diarrhea
Sweating
Tremors
Agitation
Dyspnea
7. Increase fluid & food high in fiber: to prevent constipation; administer stool
softener as ordered
8. Observe for signs of myxedema coma; provide appropriate nursing care
a. Administer medication as ordered
b. Maintain vital functions:
Correct hypothermia
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9. Myxedema coma:
Severe hypotension
Bradycardia
Bradypnea
Hypoventilation
Hyponatremia
Hypoglycemia
Hypothermia
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HYPERTHYROIDISM
Hyperthyroidism is the disease state that caused by overactive tissue within the thyroid
gland, resulting in overproduction and thus an excessive amount of thyroid hormone in
the blood causes an increase in metabolic process.
Hyperthyroidism is the second most prevalent endocrine disorder, after diabetes
mellitus.
Graves disease, the most common type of hyperthyroidism, results from an excessive
output of thyroid hormones caused by abnormal stimulation of the thyroid gland by
circulating immunoglobulins.
ETIOLOGY
The major causes in humans are
CLINICAL MANIFESTATION
Increase appetite (hyperphagia): but there is weight loss
Heat intolerance
Weight loss
Diarrhea: increase motility
Increased in all V/S: except wt & menses
Tachycardia
Increase systolic BP
Palpitation
Restlessness
Tremors
Insomnia
Hallucinations
Sweating
Hyperactive movement
Goiter
PS: Exopthalmus (protrusion of eyeballs)
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Amenorrhea
INVESTIGATION
Serum T3 and T4: is increased
RAIU (Radio Active Iodine Uptake): is increased
Thyroid Scan: reveals an enlarged thyroid gland
MEDICAL MANAGEMENT
1. Drug Therap:
a. Anti-thyroid
drugs:
Propylthiouracil
(PTU)
&
methimazole
(Tapazole):
blocke
NURSING INTERVENTION
1. Monitor strictly V/s & I&O, daily weight
2. Administer anti-thyroid medications as ordered:
a. Propylthiouracil (PTU)
b. Methimazole (Tapazole)
3. Provide for period of uninterrupted rest:
a. Assign a private room away from excessive activity
b. Administer medication to promote sleep as ordered
4. Provide comfortable and cold environment
5. Minimized stress in the environment
6. Encourage quiet, relaxing diversional activities
7. Provide dietary intake that is high in CHO, CHON, calories, vitamin & minerals with
supplemental feeding between meals & at bedtime; omit stimulant
8. Observe for & prevent complication
a. Exophthalmos: protects eyes with dark glasses & artificial tears as ordered
b. Thyroid Storm
9. Provide meticulous skin care
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Endocrine System
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peraThyroid Disorder
HYPOPERATHYROIDISM
Hypoparathyroidism is decreased function of the parathyroid glands, leading to
decreased levels of parathyroid hormone (PTH); characterized by hypocalcaemia,
hyperphosphatemia and neuromuscular hyper-excitability.
ETIOLOGY
IDIOPATHIC HYPOPARATHYROIDISM - it may result from autoimmune, genetic disorder, or
congenital absence of parathyroid gland (Di George Syndrome)
IATROGENIC OR ACQUIRED HYPOPARATHYROIDISM - Typically resulting from accidental
damage to or removal of parathyroid gland during thyroidectomy or any neck surgery. It
may also due to the ischemic infraction of parathyroid gland during surgery,
hemochromatosis, sarchoidotrauma, amyloidosis, tuberculosis, neoplasm, Trauma or
massive thyroid irritation.
REVERSIBLE HYPOPARATHYROIDISM it may result from hypomagnesaemia induced
impairment of hormone synthesis.
PATHOPHYSIOLOGY
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PATHOPHYSIOLOGY OF HYPOPARATHYROIDISM
CLINICAL MANIFESTATION
1. ACUTE HYPOCALCEMIA (TETANY)
Muscle spasm
Laryngospasm/bronchospasm
Dysphagia
Numbness
Fatigue
Weakness
Tremors
Muscle cramps
Cardiac arrhythmias
Personality changes
Cataract formation
Irritability
Photophobia
Memory impairment
Anorexia
Agitation
N/V
Hair loss
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INVESTIGATION
TROUSSEAUS SIGN (CARPOPEDAL SPASM):- positive when corpopedal spasm is induced by
occluding the blood flow to the arm for 3 min with a blood pressure cuff.
CHVOSTEK SIGN:- positive when a sharp tapping over the facial nerve just in front of the
parotid gland and anterior to the ear causes spasm or twitching of the mouth, nose and
eye.
LAB STUDIES
Serum Phosphate level: increased (Normal value: 2.5 4.5 mg/100 ml)
MEDICAL MANAGEMENT
ACUTE TETANY
1. Maintain patient airway.
2. 10% Calcium Gluconate slow IV drip as ordered
3. Administer anticonvulsant (phenytoin or phenorbital) to control seizures.
4. Alert: - Avoid the drug phenothiazine because of possible inducement of sever
dyskinesia.
5. Monitor serum calcium or phosphate level
6. Provide quite environment free from excessive stimuli
CHRONIC TETANY
1. Oral calcium preparation: Calcium Gluconate, Calcium Lactate, Calcium Carbonate
2. Large dose of vitamin D (Calciferol): to help absorption of calcium
3. If patient is not tolerating the pure form of the vitaminD, alternatives are
(Dihydrotachystrol if renal functions are adequate; If not ok then calcitriol.
4. Phosphate Binder: Aluminum Hydroxide Gel (Amphogel) or aluminum carbonate gel,
basic (basaljel): to decrease phosphate levels
NURSING MANAGEMENT
1. Administer medications as ordered
2. Institute seizure & safety precaution
3. Provide quite environment free from excessive stimuli
4. Avoid precipitating stimulus such as glaring lights and noise
5. Monitor signs of hoarseness or stridor; check for signs for Chvosteks & Trousseaus sign
6. Keep emergency equipment (tracheostomy set, injectable Calcium Gluconate) at
bedside: for presence of laryngospasm
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7. For Tetany or generalized muscle cramp: may use rebreathing bag or paper bag to
produce mild respiratory acidosis: to promote Increase ionized Ca levels
8. Monitor serum calcium & phosphate level
9. Provide high-calcium & low-phosphorus diet
10. Provide client teaching:
Medication regimen: oral calcium preparation & vit D to be taken with meal to
increase absorption
Prevent complications
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HYPERPARATHYROIDISM
Hyperparathyroidism is caused by overproduction of parathyroid glands that result in an
alter state of calcium; phosphate and bone metabolism. It is characterized by bone
decalcification and the development of renal calcium and other body stone.
ETIOLOGY
PRIMARY HYPERPARATHYROIDISM: caused by tumor & hyperplasia of parathyroid gland;
most commonly affects women especially in post-menopausal women
SECONDARY HYPERPARATHYROIDISM: cause by compensatory over secretion of PTH in
response to hypocalcaemia from:
Children: Ricketts
Adults: Osteomalacia
Malabsorption syndrome
PATHOPHYSIOLOGY
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CLINICAL MANIFESTATION
Patient may have no specific symptoms or may experiences sign and symptoms.
SKELETAL AND ARTICULAR SYSTEM RELATED: -Bone pain (especially at back); Bone
demineralization; Pathologic fracture
RENAL SYSTEM RELATED: - Kidney stones; renal colic; Polyuria; Polydipsia; Cool moist skin
GIT RELATED: -Anorexia; N/V; Gastric Ulcer; Constipation
CNS RELATED: - Irritability / Agitation; Personality changes; Depression; Memory
impairment; psychosis; stupor and coma.
CVS RELATED: - Cardiac arrhythmias; Hypertension
OTHER: - cataract; subcutaneous calcification; Muscle weakness; Fatigue
COMPLICATION
Formation of renal stones, calcification of kidney parenchyma, renal shutdown
Ulceration of upper GI tract leading to hemorrhage and perforation
Demineralization of bones, cysts, and fibrosis of marrow leads to fractures, especially of
vertebral bodies and ribs
Hypoparathyroidism after surgery
INVESTIGATION
Serum Calcium level: is increased (Normal value: 8.5 11 mg/100 ml)
Serum Phosphate level: is decreased (Normal value: 2.5 4.5 mg/100 ml)
Skeletal X-ray of long bones: reveals bone demineralization and ed in bone density
Serum PTH: high
MANAGEMENT
1.
2.
Dietary calcium is restricted, and all drugs that might cause hyperkalemia (thiazides,
vitamin D) are discontinued.
3.
Monitoring of daily serum calcium, blood urea nitrogen (BUN), potassium, and
magnesium levels
4.
NURSING MANAGEMENT
1.
2.
3.
Assist client with self-care: Provide careful handling, Moving, Ambulation - to prevent
pathologic fracture
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4.
5.
6.
Provide acid-ash juices (ex. Cranberry, orange juice): to acidify urine & prevent bacterial
growth
7.
8.
9.
Use
of
calcium
preparation
&
importance
of
high-calcium
diet
following
parathyroidectomy
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Adrenal Disorder
PHEOCHROMOCYTOMA
Pheochromocytoma is a tumor that is usually benign and originates from the chromaffin
cells of the adrenal medulla, so it is also known as chromaffin tumor.
It is characterized by paroxysmal or sustained hypertension due to overs creation of the
catecholamine epinephrine or nor-epinephrine. (Hyper function of the adrenal medulla)
ETIOLOGY
The cause of pheochromocytoma is unknown; about 5% of cases are hereditary
It May occur as component of multiple endocrine neoplasia, an autosomal-dominant
syndrome, thyroid cancer, hyperparathyroidism, and Cushing's syndrome with excess
ACTH.
It can occur at any age, but is most common between the ages of 40 and 60
It is uncommon in people older than age 65.
Most pheochromocytoma tumors are benign; 10% are malignant with metastasis.
CLINICAL MANIFESTATIONS
5 H Hypertension, Headaches, hyperhidrosis, hyper metabolism, and hyperglycemia
The nature and severity of signs and symptoms depends on the predominance of
norepinephrine or epinephrine secretion and on whether secretion is continuous or
intermittent.
Excess secretion of norepinephrine and epinephrine produces hypertension, hyper
metabolism, and hyperglycemia
The cardinal sign is Hypertension may be paroxysmal (intermittent) or persistent
(chronic); anti-hypertensive are not effective.
Headaches and vision disturbances are common.
The hyper metabolic and hyperglycemic effects produce excessive perspiration, tremor,
pallor or face flushing, nervousness, elevated blood glucose levels, polyuria, nausea,
vomiting, diarrhea, abdominal pain, and paresthesia.
Emotional changes, including psychotic behavior, may occur.
Symptoms may be triggered by allergic reactions, physical exertion, emotional upset, or
may occur without identifiable stimulus.
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INVESTIGATION
These signs can be associated with the five Hs: hypertension, headache, hyperhidrosis
(excessive sweating), hypermetabolism, and hyperglycemia.
Measurements of urine and plasma levels of catecholamines
Plasma catecholamines levels elevated (it is measured with the patient supine and
at rest for 30 minutes. To prevent elevation of catecholamine levels by the stress of
venipuncture, a butterfly needle, or cannula inserted 30 minutes before the blood
specimen is obtained.)
CT scan and MRI of the adrenal glands or of the entire abdomen are done to identify
tumor.
Clonidine suppression test drug does not suppress the Plasma catecholamines levels
MANAGEMENT
MEDICAL MANAGEMENT
Admitted in the intensive care unit for close monitoring of ECG changes
Administration of alpha-adrenergic blocking agents (e.g., phentolamine [Regitine]) or
smooth muscle relaxants (e.g., sodium nitroprusside [Nipride]) to lower the blood
pressure quickly.
Long-acting alpha-blocker (Phenoxybenzamine (Dibenzyline)) may be used when the
blood pressure is stable to prepare the patient for surgery.
Beta-adrenergic blocking agents, such as propranolol (Inderal), may be used in patients
with cardiac dysrhythmias or those not responsive to alpha-blockers.
Catecholamine synthesis inhibitors, such as alpha-methyl-p-tyrosine (metyrosine) are
occasionally used when adrenergic blocking agents do not reduce the effects of
catecholamines.
SURGICAL MANAGEMENT
The definitive treatment of pheochromocytoma is surgical removal of the tumor, usually
with adrenalectomy.
Bilateral adrenalectomy may be necessary if tumors are present in both adrenal glands.
NURSING MANAGEMENT
Ensure bed rest and elevate the head of bed 45 degrees during severe hypertension.
Carry out tasks and procedures in calm, unhurried manner when with the patient.
Instruct the patient about use of relaxation exercises.
Reduce environmental stressors by providing calm, quiet environment. Restrict visitors.
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POSTOPERATIVE CARE
Monitor vital signs, ECG, arterial BP, neurologic status, and urine output closely
postoperatively.
Assess for and report complications of hypertension, hypotension, and hyperglycemia.
Maintain adequate hydration with I.V. infusion to prevent hypotension. (Because
reduction of catecholamines immediately postoperatively causes vasodilation and
enlargement of vascular space, hypotension may occur.)
Monitor intake and output and laboratory results for BUN, creatinine, and glucose.
Corticosteroid replacement is required if bilateral adrenalectomy
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CUSHING SYNDROME
Cushing Syndrome is the condition resulting from excessive secretion of corticosteroids,
particularly glucocorticoid cortisol by the adrenal cortex. It is also as hypercrtisolism.
ETIOLOGY
PRIMARY CUSHINGS SYNDROME: - The most common cause of Cushings syndrome is
bilateral adrenal hyperplasia or adrenocortical tumors.
SECONDARY CUSHINGS SYNDROME (also called Cushings disease): caused by functioning
pituitary or non-pituitary neoplasm secreting.
Hyper-secretion of ACTH by the pituitary or from ectopic sources such as small cell
carcinoma of lungs, medullary carcinoma of thyroid, or tumor of thymus or pancreas
tumor
CLINICAL MANIFESTATION
Central obesity weight gain and altered
fat distribution with round (moon) face,
buffalo hump, and pendulous abdomen.
Hypertension
Physiological
weakness;
distribution
Muscle
Hypernatremia;
wasting;
Muscle
Fatigue;
hypocalcaemia;
constipation etc.
Decrease resistance to infection
Skin changes - Purple striae on trunk;
Acne; Thin skin; Easy bruising
Signs
of
masculinization
in
women:
INVESTIGATION
FBS: is increased
Plasma Cortisol: is increased
Serum Sodium: is increased
Serum Potassium: is decreased
Abnormal dexamethasone suppression test positive
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MANAGEMENT
Surgical excision of the adenoma
Metastatic and un-resectable adrenal carcinoma treated with mitotane, ketoconazole
metyrapone aminoglutethimide and adrenal enzyme inhibitor etc.
Ectopic tumors are resected by the surgery.
If the sources of ACTH cannot be resected or in case of uncontrolled adrenal hyperplasia
is treated with adrenalectomy.
NURSING MANAGEMENT
Maintain muscle tone
Assist in ambulation
Diet modification
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Endocrine System
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ADDISONS DISEASE
Addisons disease is caused by deficiency of the mineralocorticoids, glucocorticoids, &
sex hormones (androgens) due to the hypo-functioning of the adrenal cortex, which
leads to metabolic disturbance (hypoglycemia); Fluid and electrolyte imbalance (Na,
H2O, K) and Deficiency of neuromuscular function
ETIOLOGY
Relatively rare disease caused by:
CLINICAL MANIFESTATIONS
Fatigue, Muscle weakness
Anorexia, N/V, abdominal pain, weight loss
Symptoms of hypoglycemic reaction / Hypoglycemia
Tremors,
Tachycardia,
Irritability,
Restlessness,
Extreme fatigue,
Diaphoresis and
Depression
INVESTIGATION
FBS: is decreased (normal value: 80 100 mg/dl)
Plasma Cortisol: is decreased
Serum Sodium: is decrease (normal value: 135 145 meq/L)
Serum Potassium: is increased (normal value: 3.5 4.5 meq/L)
MANAGEMENT
Administer hormone replacement therapy as ordered:
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Glucocorticoids: stimulate diurnal rhythm of cortisol release, give 2/3 of dose in early
morning & 1/3 of dose in afternoon
Dexamethasone
Hydrocortisone
Prednisone
Mineralocorticoids
Fluid replacement therapy for restore and maintain the fluid and electrolyte balance.
Antibiotics may be given if any sign of infection.
NURSING MANAGEMENT
Administer hormone replacement therapy as ordered
Care when we are giving steroid therapy
Instruct client to take 2/3 dose in the morning and 1/3 dose in the afternoon to
mimic the normal diurnal rhythm
Hypertension
Edema
Hirsutism
Monitor V/S
Decrease stress in the environment
Prevent exposure to infection
Provide rest period: prevent fatigue
Weight daily
Provide small frequent feeding of diet: decrease in K, increase cal, CHO, CHON, Na: to
prevent hypoglycemia, & hyponatremia & provide proper nutrition
Monitor I&O: to determine presence of addisonian crisis (complication of addisons
disease)
Provide meticulous skin care
Provide client teaching regarding
Use of prescribe medication for lifelong replacement therapy: never omit medication
Need to avoid stress, trauma & infection: notify the physician if these occurs as
medication dosage may need to be adjusted
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Diet modification
Use of salt tablet (if prescribe) or ingestion of salty foods (potato chips): if
experiencing increase sweating
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ADDISONIAN CRISIS
Severe exacerbation of Addisons disease caused by acute adrenal insufficiency
Acute medical emergency due to extreme and sudden depletion of corticosteroid
production in body.
PREDISPOSING FACTORS
Strenuous activity
Stress
Trauma
Infection
Failure to take prescribe medicine
Iatrogenic:
CLINICAL MANIFESTATIONS
Generalized muscle weakness
Severe hypotension
Hypovolemic shock; vascular collapse
Hyponatremia: leading to progressive stupor and coma
INVESTIGATION
FBS: is decreased (normal value: 80 100 mg/dl)
Plasma Cortisol: is decreased
Serum Sodium: is decrease (normal value: 135 145 meq/L)
Serum Potassium: is increased (normal value: 3.5 4.5 meq/L)
NURSING INTERVENTION
Assist in mechanical ventilation
Administer IV fluids (5% dextrose in saline, plasma) as ordered: to treat vascular
collapse
Administer IV glucocorticoids: Hydrocortisone & vasopressors as ordered
Force fluids Administration
If crisis precipitate by infection: administer antibiotics as ordered
Maintain strict bed rest & eliminate all forms of stressful stimuli
Monitor V/S, I&O & daily weight
Protect client from infection
Provide client teaching same as Addisons disease
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CORTICOSTEROID THERAPY
Corticosteroids are a class of natural and synthetic analogues of the hormones secreted
by the adrenal gland.
Corticosteroids include:
The mineralocorticoids, which control water and salt balance through their effects on
the kidneys corticotrophins, which control the secretion of hormones by the pituitary
gland
Synthetic
corticosteroid
preparations
having
the
both
glucocorticoid
and
mineralocorticoid properties.
INDICATION
Commonly used in
Addisons disease,
Adrenal insufficiency,
Allergic reactions,
Arthritis,
Asthma,
Autoimmune disease.
Brain tumors,
Dermatitis,
Hepatitis,
Joint pain,
Uveitis,
CORTICOSTEROID MEDICATIONS
Corticosteroids are available in injections, oral medications, topical medications, nasal
medications, rectal foams, and ear and eye drops.
Corticosteroids suppress the bodys natural production of corticosteroids by inhibiting the
release of adrenorticotropic hormone.
Corticosteroid medications include:
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DOSE
In keeping with the natural secretion of cortisol, the best time of the day for the total
corticosteroid dose is in the early morning from 7 to 8 am or the dose is divided and
give 2/3 dose in the morning and 1/3 dose in the afternoon to produce the normal
diurnal rhythm.
Large-dose therapy give in the morning (at 8 am) when the gland is most active,
produces maximal suppression of the gland. A large morning dose is more
physiologic because it allows the body to escape effects of the steroids from evening
to next morning, when serum levels are normally low, hence minimizing cushingoid
effects.
Corticosteroids inhibit the bodys ability to produce natural corticosteroids; the dose
of Corticosteroid dosages are reduced gradually (tapered) over a period of weeks or
even months to allow normal adrenal function to return and to prevent steroidinduced adrenal insufficiency. Up to 1 year or more after use of corticosteroids, the
patient is still at risk for adrenal insufficiency in times of stress.
If
the
dose
is
reduced
too
quickly,
side
effects
of
fatigue,
body
aches,
Fluid retention,
Increased appetite,
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Indigestion,
Insomnia and
Menstrual irregularities,
Mood swings,
Nervousness
Stomach pain,
Weight gain,
Drug-induced paranoia,
Delirium,
Depression, and
Thin skin
Acne
Bone loss,
Glaucoma,
Susceptibility to infection.
Causing rash,
Itching,
Hives, and
Respiratory problems.
NOTE - Any adverse effects that develop after starting corticosteroids should be reported to
ones healthcare provider as soon as possible.
NURSING CARE
Instruct client to take 2/3 dose in the morning and 1/3 dose in the afternoon to mimic
the normal diurnal rhythm
Taper dose (withdraw gradually from drug)
Monitor side effects
Monitor V/S
Decrease stress in the environment
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