Assessment and Management of

Patients with Endocrine Disorders

Prepared by: Zyrine M. Salomon,R.N

01/26/16

Location of the major endocrine glands.

01/26/2016

Definition of Hormones
Chemical messengers of the body
Act on specific target cells
Regulated by negative feedback
Too much hormone, then hormone release reduced
Too little hormone, then hormone release increased

01/26/2016

Glands of the Endocrine

System
Hypothalamus
Posterior Pituitary
Anterior Pituitary
Thyroid
Parathyroids
Adrenals
Pancreatic islets
Ovaries and testes
4

01/26/2016

Hypothalamus
Sits between the cerebrum and brainstem
Houses the pituitary gland and hypothalamus
Regulates:
Temperature
Fluid volume
Growth
Pain and pleasure response
Hunger and thirst

01/26/2016

Hypothalamus Hormones
Releasing and inhibiting hormones
Corticotropin-releasing hormone
Thyrotropin-releasing hormone
Growth hormone-releasing hormone
Gonadotropin-releasing hormone
Somatostatin-=-inhibits GH and TSH

01/26/2016

Pituitary Gland
Sits beneath the hypothalamus
Termed the master gland
Divided into:
Anterior Pituitary Gland
Posterior Pituitary Gland

01/26/2016

Anterior Pituitary Gland

Promotes growth
Stimulates the secretion of six hormones
Controls pigmentation of the skin

01/26/2016

Anterior Pituitary Gland

Hormones

Growth Hormone--

Adrenocorticotropic hormone
Thyroid stimulating hormone
Follicle stimulating hormoneovary in female,

sperm in males
Luteinizing hormonecorpus luteum in females,
secretion of testosterone in males
Prolactinprepares female breasts for lactation

01/26/2016

Actions of the major hormones of the anterior pituitary.

10

01/26/2016

Posterior Pituitary Hormones

Antidiuretic Hormone
Oxytocincontraction of uterus, milk ejection

from breasts

11

01/26/2016

Adrenal Cortex
Mineralocorticoidaldosterone. Affects sodium

absorption, loss of potassium by kidney

Glucocorticoidscortisol. Affects metabolism,

regulates blood sugar levels, affects growth, antiinflammatory action, decreases effects of stress
Adrenal androgensdehydroepiandrosterone and

androstenedione. Converted to testosterone in the

periphery.
12

01/26/2016

Adrenal Medulla
Epinephrine and norepinephrine

serve as neurotransmitters for sympathetic system

13

01/26/2016

14

29/11/2010

Thyroid Gland
Butterfly shaped
Sits on either side of the trachea
Has two lobes connected with an isthmus
Functions in the presence of iodine
Stimulates the secretion of three hormones
Involved with metabolic rate management and

serum calcium levels

15

01/26/2016

Thyroid
Follicular cellsexcretion of triiodothyronine (T3)

and thyroxine (T4)Increase BMR, increase bone

and calcium turnover, increase response to
catecholamines, need for fetal G&D
Thyroid C cellscalcitonin. Lowers blood calcium
and phosphate levels

BMR: Basal Metabolic Rate

01/26/2016

16

Parathyroid Glands
Embedded within the posterior lobes of the thyroid

gland
Secretion of one hormone
Maintenance of serum calcium levels

17

01/26/2016

Parathyroid
Parathyroid hormoneregulates

serum calcium

18

29/11/2010

Pancreas
Located behind the stomach between the spleen

and duodenum
Has two major functions
Digestive enzymes
Releases two hormones: insulin and glucagon

19

01/26/2016

Pancreatic Hormones
Insulin - a hormone made by the pancreas that allows your body to
use sugar (glucose) from carbohydrates in the food that you eat for
energy or to store glucose for future use. Insulin helps keeps your
blood sugar level from getting too high (hyperglycemia) or too low
(hypoglycemia).

Glucagonstimulates glycogenolysis and

glyconeogenesis
Somatostatindecreases intestinal absorption of
glucose
20

01/26/2016

Insulin
Produced by the Beta cells in the islets of

Langerhans
Regulates blood glucose levels
Mechanisms
Eases the active transport of glucose into muscle and

fat cells
Facilitates fat formation
Inhibits the breakdown and movement of stored fat
Helps with protein synthesis

21

01/26/2016

Action of insulin and glucagon on blood glucose levels. (A) High blood glucose is lowered by
insulin release.

22

01/26/2016

(continued)

Action of insulin and glucagon on blood glucose levels. (B) Low blood
glucose is raised by glucagon release.

23

01/26/206

Glucagon
Produced by the alpha cells in the islets of Langerhans
Glucagon released when blood glucose falls below 70

mg/dL

24

01/26/2016

Glucagon
Prevents blood glucose from decreasing below a

certain level
Functions:
Makes new glucose
Converts glycogen into glucose in the liver and

muscles
Prevents excess glucose breakdown
Decreases glucose oxidation and increases blood
glucose

25

01/26/2016

Adrenal Glands
Pyramid-shaped organs that sit on top of the

kidneys
Each has two parts:
Outer Cortex
Inner Medulla

26

01/26/2016

Adrenal Cortex
Secretion of two hormones
Glucocorticoids: cortisol
Mineralocortocoids: aldosterone

Involved with blood glucose level, anti-

inflammatory response, blood volume, and

electrolyte maintenance

27

01/26/2016

Adrenal Medulla
Secretion of two hormones
Epinephrine
Norepinephrine

Involved with the stress response

28

01/26/2016

Ovaries
Estrogen
Progesteroneinportant in menstrual

cycle,*maintains pregnancy,

29

01/26/2016

Testes
Androgens, testosteronesecondary sexual

characteristics, sperm production

30

01/26/2016

Thymus
Releases thymosin and thymopoietin
Affects maturation of T lymphocetes

31

29/11/2010

Pineal
Melatonin
Affects sleep, fertility and aging

32

01/26/2016

Prostaglandins
Work locally
Released by plasma cells
Affect fertility, blood clotting, body temperature

33

01/26/2016

34

01/26/16

35

01/262016

36

01/26/2016

37

01/26/2016

38

01/26/2016

39

01/26/2016

40

01/26/2016

41

01/26/2016

42

01/26/2016

43

29/11/2010

MYXEDEMA COMA
occasionally called myxedema
crisis, is a rare life-threatening
clinical condition that represents
severe hypothyroidism with
physiological DE .compensation

44

01/26/2016

The

condition COMA
usually
occurs
in
MYXEDEMA
patients
with
long-standing,
undiagnosed hypothyroidism and is
usually
precipitated by infection,
cerebrovascular disease, heart failure,
trauma, or drug therapy. Patients with
myxedema
coma
are
generally
severely-ill
with
significant
hypothermia and depressed mental
status.

45

01/26/2016

MANAGEMENT:
Airway management

- Mechanical ventilation is commonly required during

the first 36-48 hours, but some patients require
prolonged respiratory support for as long as 2-3 weeks.

46

01/26/2016

47

01/26/2016

48

29/11/2010

49

01/26/2016

50

01/26/2016

51

01/26/2016

52

01/26/2016

53

01/26/2016

54

29/11/2010

ADRENAL CRISIS
also known as Addisonian crisis and

acute adrenal insufficiency, a medical

emergency and potentially life-threatening
situation requiring immediate emergency
treatment. It is a constellation of symptoms
that indicate severe adrenal insufficiency
caused by insufficient levels of the hormone
cortisol.

55

01/26/2016

Causes, incidence, and risk

factors:
Adrenal crisis occurs if the adrenal gland is

deteriorating (Addison's disease, primary adrenal

insufficiency), if there is pituitary gland injury
(secondary adrenal insufficiency), or if adrenal
insufficiency is not adequately treated.
Risk factors for adrenal crisis include physical stress
such as infection, dehydration, trauma, or surgery,
adrenal gland or pituitary gland injury, and ending
treatment with steroids such as prednisone or
hydrocortisone too early.
56

01/26/2016

MANIFESTATIONS:
Headache, Profound weakness, Fatigue
Slow, sluggish movement, Nausea and Vomiting
Low blood pressure, Dehydration
High fever, Shaking chills, Confusion or coma
Rapid heart rate, Joint pain, Abdominal pain
Unintentional weight loss
Rapid respiratory rate (see tachypnea)
Unusual and excessive sweating on face and/or palms
Skin rash or lesions may be present
Flank pain
Loss of appetite

57

01/26/2016

Signs and tests:

An ACTH (cortrosyn) stimulation test shows low

cortisol.
The baseline cortisol level is low.
Fasting blood sugar may be low.
Serum potassium is elevated ( usually primary adrenal
insufficiency).
Serum sodium is decreased (usually primary adrenal
insufficiency).

58

01/26/2016

Emergency
Management
for
Addisonian
Crisis

Maintain airway, breathing, and circulation in patients with

adrenal crisis.
Use coma protocol (ie, glucose, thiamine, naloxone).
Use aggressive volume replacement therapy (dextrose 5%
in normal saline solution [D5NS]).
Correct electrolyte abnormalities as follows:Hypoglycemia
(67%)
Hyponatremia (88%)
Hyperkalemia (64%, may be offset by concurrent
vomiting/diarrhea and potassium loss)
Hypercalcemia (6-33%)

59

01/26/2016

Emergency Management for Addisonian Crisis

Use dextrose 50% as needed for hypoglycemia.
Administer hydrocortisone 100 mg intravenously (IV)

every 6 hours. During adrenocorticotropic hormone

(ACTH) stimulation testing, dexamethasone (4 mg IV)
can be used instead of hydrocortisone to avoid
interference with testing of cortisol levels.
Administer fludrocortisone acetate (mineralocorticoid)
0.1 mg every day as needed. Mineralocorticoid
administration is usually not necessary for treatment of
secondary adrenocortical insufficiency.
60

01/26/2016

Emergency Management for Addisonian Crisis

Once the patient stabilizes, usually by the second day,

the corticosteroid dose may be reduced and then

tapered. Oral maintenance can usually be achieved by
the fourth or fifth day.
Always treat the underlying problem that precipitated
the crisis. Infectious etiologies commonly precipitate
adrenal crisis. Recognition and treatment of causative
factors are crucial aspects of managing adrenal
hypofunction.

61

01/26/2016

62

29/11/2010

MEDICAL & SURGICAL MANAGEMENT

MEDICATIONS:
Alpha blockers prevent noradrenaline from
stimulating the muscles in the walls of smaller arteries
and veins. Because these blood vessels remain open and
relaxed, blood flow improves and blood pressure lessens.
Examples of alpha blockers include phenoxybenzamine
(Dibenzyline), doxazosin (Cardura), prazosin
(Minipress) and terazosin (Hytrin). Side effects may
include irregular heartbeat, dizziness, fatigue, vision
problems, sexual dysfunction in men and swelling in
limbs.

63

01/26/2016

 Beta blockers, which inhibit the effect of adrenaline,

result in your heart beating more slowly and with less
force. Beta blockers also help keep blood vessels open
and relaxed by slowing the release of a particular
enzyme from kidneys. Examples of beta blockers include
atenolol (Tenormin), metoprolol (Lopressor, Toprol) and
propranolol (Inderal, Innopran). Side effects may include
fatigue, upset stomach, headache, dizziness,
constipation, diarrhea, irregular heartbeat, difficulty
breathing and swelling in the limbs.
Other medications that lower blood pressure may be
prescribed if blood pressure is not stabilized with alpha
blockers and beta blockers.

64

01/26/2016

Surgery
In most cases, the entire adrenal gland with a pheochromocytoma
is removed with laparoscopic, or minimally invasive, surgery.
Surgeon will make a few small openings through which he or she
inserts wand-like devices equipped with video cameras and small
tools.
The remaining healthy adrenal gland carries out the functions
normally performed by two, and blood pressure usually returns to
normal. In some unusual situations, such as when the other
adrenal gland has already been removed, a surgery may be
considered to extract only the tumor and spare some of the healthy
tissue.
If a tumor is cancerous (malignant), surgery may be effective only
if the tumor and any metastasized tissues are isolated. However,
even if all of the cancerous tissues are not removed, surgery may
limit hormone production and provide some control of blood
pressure.
01/26/2016
65

66

29/11/2010

HYPOGLYCEMIA

67

01/26/2016

68

01/26/2016

HYPERGLYCEMIA
a term referring to high blood glucose levels - the

condition that often leads to a diagnosis of diabetes.

High blood glucose levels are the defining feature of
diabetes, but once the disease is diagnosed,
hyperglycemia is a signal of poor control over the
condition.
Hyperglycemia is defined by certain high levels of blood
glucose:
Fasting levels greater than 7.0 mmol/L (126 mg/dL)
Two-hours postprandial (after a meal) levels greater than
11.0 mmol/L (200 mg/dL).
69

01/26/2016

Symptoms of hyperglycemia:
Thirst and hunger
Dry mouth
Frequent urination, particularly at night
Tiredness
Recurrent infections, such as thrush
Weight loss
Vision blurring.

70

01/26/2016

Causes of Hyperglycemia:
Eating more or exercising less than usual
Insufficient amount of insulin treatment (more

commonly in cases of type 1 diabetes)

Insulin resistance in type 2 diabetes
Psychological and emotional stress
The "dawn phenomenon" or "dawn effect" - an early
morning hormone surge.

71

29/11/2010

Fluid replacement. Administer fluids either orally

or through intravenously until patient is rehydrated.

The fluids replace those lost through excessive
urination, as well as help dilute the excess sugar in the
blood.
Electrolyte replacement. Electrolytes are minerals in
the blood that are necessary for the tissues to function
properly. Thetreatment
absence of insulin
lower the level of
Emergency
for can
severe
several electrolytes in the blood.

hyperglycemia

72

01/26/2016

Insulin therapy. Insulin reverses the

processes that cause ketones to build up in
the blood. Along with fluids and
electrolytes, you'll receive insulin therapy
usually through a vein.

73

01/26/2016

Thank You !!

74

01/26/2016

Never Stop Learning,

because life never
stops teaching
- Zyrine Salomon

75

01/26/2016

76

01/26/2016