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Assessment and Management of Patients with Endocrine Disorders. Dr Ibraheem Bashayreh. Location of the major endocrine glands. Definition of Hormones. Chemical messengers of the body Act on specific target cells Regulated by negative feedback Too much hormone, then hormone release reduced

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definition of hormones
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
glands of the endocrine system
Glands of the Endocrine System
  • Hypothalamus
  • Posterior Pituitary
  • Anterior Pituitary
  • Thyroid
  • Parathyroids
  • Adrenals
  • Pancreatic islets
  • Ovaries and testes
hypothalamus
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
hypothalamus hormones
Hypothalamus Hormones
  • Releasing and inhibiting hormones
  • Corticotropin-releasing hormone
  • Thyrotropin-releasing hormone
  • Growth hormone-releasing hormone
  • Gonadotropin-releasing hormone
  • Somatostatin-=-inhibits GH and TSH
pituitary gland
Pituitary Gland
  • Sits beneath the hypothalamus
  • Termed the “master gland”
  • Divided into:
    • Anterior Pituitary Gland
    • Posterior Pituitary Gland
anterior pituitary gland
Anterior Pituitary Gland
  • Promotes growth
  • Stimulates the secretion of six hormones
  • Controls pigmentation of the skin
anterior pituitary gland hormones
Anterior Pituitary Gland Hormones
  • Growth Hormone--
  • Adrenocorticotropic hormone
  • Thyroid stimulating hormone
  • Follicle stimulating hormone—ovary in female, sperm in males
  • Luteinizing hormone—corpus luteum in females, secretion of testosterone in males
  • Prolactin—prepares female breasts for lactation
posterior pituitary gland
Posterior Pituitary Gland
  • Stimulates the secretion of two hormones
  • Promotes water retention
posterior pituitary hormones
Posterior Pituitary Hormones
  • Antidiuretic Hormone
  • Oxytocin—contraction of uterus, milk ejection from breasts
adrenal cortex
Adrenal Cortex
  • Mineralocorticoid—aldosterone. Affects sodium absorption, loss of potassium by kidney
  • Glucocorticoids—cortisol. Affects metabolism, regulates blood sugar levels, affects growth, anti-inflammatory action, decreases effects of stress
  • Adrenal androgens—dehydroepiandrosterone and androstenedione. Converted to testosterone in the periphery.
adrenal medulla
Adrenal Medulla
  • Epinephrine and norepinephrine

serve as neurotransmitters for sympathetic system

thyroid gland
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
thyroid
Thyroid
  • Follicular cells—excretion of triiodothyronine (T3) and thyroxine (T4)—Increase BMR, increase bone and calcium turnover, increase response to catecholamines, need for fetal G&D
  • Thyroid C cells—calcitonin. Lowers blood calcium and phosphate levels
  • BMR: Basal Metabolic Rate
parathyroid glands
Parathyroid Glands
  • Embedded within the posterior lobes of the thyroid gland
  • Secretion of one hormone
  • Maintenance of serum calcium levels
parathyroid
Parathyroid
  • Parathyroid hormone—regulates serum calcium
pancreas
Pancreas
  • Located behind the stomach between the spleen and duodenum
  • Has two major functions
    • Digestive enzymes
    • Releases two hormones: insulin and glucagon
pancreatic hormones
Pancreatic Hormones

Insulin

Glucagon—stimulates glycogenolysis and glyconeogenesis

Somatostatin—decreases intestinal absorption of glucose

insulin
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
slide22
Action of insulin and glucagon on blood glucose levels. (A) High blood glucose is lowered by insulin release.
slide23
(continued) Action of insulin and glucagon on blood glucose levels. (B) Low blood glucose is raised by glucagon release.
glucagon
Glucagon
  • Produced by the alpha cells in the islets of Langerhans
  • Glucagon released when blood glucose falls below 70 mg/dL
glucagon25
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
kidney
Kidney
  • 1, 25 dihydroxyvitamin D—stimulates calcium absorption from the intestine
  • Renin—activates the RAS
  • Erythropoietin—Increases red blood cell production
  • RAS: Renin-Angiotensin System
adrenal glands
Adrenal Glands
  • Pyramid-shaped organs that sit on top of the kidneys
  • Each has two parts:
    • Outer Cortex
    • Inner Medulla
adrenal cortex28
Adrenal Cortex
  • Secretion of two hormones
    • Glucocorticoids: cortisol
    • Mineralocortocoids: aldosterone
  • Involved with blood glucose level, anti-inflammatory response, blood volume, and electrolyte maintenance
adrenal medulla29
Adrenal Medulla
  • Secretion of two hormones
    • Epinephrine
    • Norepinephrine
  • Involved with the stress response
ovaries
Ovaries
  • Estrogen
  • Progesterone—inportant in menstrual cycle,*maintains pregnancy,
testes
Testes
  • Androgens, testosterone—secondary sexual characteristics, sperm production
thymus
Thymus
  • Releases thymosin and thymopoietin
  • Affects maturation of T lymphocetes
pineal
Pineal
  • Melatonin
  • Affects sleep, fertility and aging
prostaglandins
Prostaglandins
  • Work locally
  • Released by plasma cells
  • Affect fertility, blood clotting, body temperature
past medical history
Past Medical History
  • Hormone replacement therapy
  • Surgeries, chemotherapy, radiation
  • Family history: diabetes mellitus, diabetes insipidus, goiter, obesity, Addison’s disease, infertility
  • Sexual history: changes, characteristics, menstruation, menopause
physical assessment
Physical Assessment
  • General appearance
    • Vital signs, height, weight
  • Integumentary
    • Skin color, temperature, texture, moisture
    • Bruising, lesions, wound healing
    • Hair and nail texture, hair growth
physical assessment37
Physical Assessment
  • Face
    • Shape, symmetry
    • Eyes, visual acuity
    • Neck
physical assessment39
Physical Assessment
  • Extremities
    • Hand and feet size
    • Trunk
    • Muscle strength, deep tendon reflexes
    • Sensation to hot and cold, vibration
  • Thorax
    • Lung and heart sounds
    • Extremity edema
older adults and endocrine function
Older Adults and Endocrine Function
  • Relationship unclear
  • Aging causes fibrosis of thyroid gland
  • Reduces metabolic rate
  • Contributes to weight gain
  • Cortisol level unchanged in aging
abnormal findings
Abnormal Findings
  • Ask the client:
    • Energy level
    • Fatigue
    • Maintenance of ADL
    • Sensitivity to heat or cold
    • Weight level
    • Bowel habits
    • Level of appetite
    • Urination, thirst, salt craving
abnormal findings continued
Abnormal Findings (continued)
  • Ask the client:
    • Cardiovascular status: blood pressure, heart rate, palpitations, SOB
    • Vision: changes, tearing, eye edema
    • Neurologic: numbness/tingling lips or extremities, nervousness, hand tremors, mood changes, memory changes, sleep patterns
    • Integumentary: hair changes, skin changes, nails, bruising, wound healing
most common endocrine disorders
Most Common Endocrine Disorders
  • Thyroid abnormalities
  • Diabetes mellitus
diagnostic tests
Diagnostic Tests
  • GH: fasting, well rested, not physically stressed
  • Water deprivation: fasting for 12 hours, no fluids/smoking after midnight
  • T3/T4: no specific preparation
  • Serum calcium/phosphate: fasting may or may not be required
  • Collection that needs to be iced or refrigerated
diagnostic tests45
Diagnostic Tests
  • Cortisol/aldosterone level: two blood samples, client to be up for at least 2 hours before test is drawn
  • Urine 17-ketosteroids: 24-hour urine collection that needs to be iced or refrigerated
diagnostic tests46
Diagnostic Tests
  • FBS: fast before the test
  • HbA1c: No fasting required
  • 2-hour OGTT: drink 75 g of glucose and do not eat anything until blood is drawn
  • Urine glucose/ketones: fresh urine specimen
  • Urine microalbumin: fresh urine specimen
imaging studies
Imaging Studies
  • MRI: metallic implants, lie motionless during test; remove all metal objects
  • CT scan: assess for allergies to iodine and seafood; lie immobile during the test
  • Thyroid scan: allergies to iodine and seafood; hold thyroid drugs containing iodine for weeks before the study
imaging studies48
Imaging Studies
  • RAI: fast for 8 hours before; can eat 1 hour after radioiodine capsule/liquid taken; hold thyroid drugs with iodine for weeks before the study
thyroid disorders

THYROID DISORDERS

Dr Ibraheem Bashayreh, RN, PhD

thyroid anatomy
1-The gland as seen from the front is more nearly the shape of a butterfly.

2-composed of 2 encapsulated lobes, one on either side of the trachea, connected by a thin isthmus.

3-The thyroid extending from the level of the fifth cervical vertebra down to the first thoracic. The gland varies from an H to a U shape,overlying the second to fourth tracheal rings.

4-The pyramidal lobe is a narrow projection of thyroid tissue extending upward from the isthmus and lying on the surface of the thyroid cartilage.

Thyroid Anatomy
thyroid anatomy51
Thyroid Anatomy

5-The thyroid is enveloped by a thin, fibrous, nonstripping capsule that sends septa into the gland substance to produce an irregular, incomplete lobulation. No true lobulation exists.

6-The weight of the thyroid of the normal nongoitrous adult is: 10-20 g depending on body size and iodine supply.

7-The width and length of the isthmus average; 20 mm,

and its thickness is ;2-6 mm.

8-The lateral lobes from superior to inferior poles usually measure 4 cm. and their thickness is 20-39 mm.

relations of the lobes
Relations of the Lobes

1-Anterolaterally:

*The sternothyroid

*The superior belly of the omohyoid

*The sternohyoid

*The anterior border of the sternocleidomastoid

2-Medially:

*The larynx & the trachea.

*The pharynx & the oesophagus.

*Associated with these structures are the cricothyroid muscle & its nerve supply, the external laryngeal nerve.

*In the groove between the esophagus and the trachea is the recurrent laryngeal nerve.

relations of the lobes53
Relations of the Lobes

3-Posterolaterally:

The carotid sheath with: The common carotid artery, the internal jugular vein, and the vagus nerve.

Relations of the Isthmus

1-Anteriorly:

The sternothyroids

The sternohyoids

The anterior jugular veins

Fascia & skin.

2-Posteriorly:

The second, third, & fourth rings of the trachea.

venous drainage
Venous Drainage

1-The superior thyroid vein:

ascends along the superior thyroid

artery and becomes a tributary of the

internal jugular vein.

2- The middle thyroid vein:

follows a direct course laterally to the

internal jugular vein.

3- The inferior thyroid veins :

follow different paths on each side. The

right passes anterior to the innominate

artery to the right brachiocephalic vein or

anterior to the trachea to the left

brachiocephalic vein. On the left side,

drainage is to the left brachiocephalic vein.

Occasionally, both inferior veins form a

common trunk called the thyroid ima vein,

which empties into the left brachiocephalic

vein.

physiology
Physiology

The thyroid follicles secretes tri-iodothyronine(T3)and thyroxin(T4)synthesis involves combination of iodine with tyrosine group to form mono and di-iodotyrosine which are coupled to form T3 andT4.

The hormones are stored in follicles bound to thyrogobulin .

When hormones released in the blood they are bound to plasma proteins and small amount remain free in the plasma .

The metabolic effect of thyroid hormones are due to free (unbound)T3 and T4.

90%of secreted hormones is T4 but T3is the active hormone so, T4is converted to T3 peripherally.

physiological control of secretion
Physiological control of secretion

Synthesis and libration of T3 and T4 is controlled by thyroid stimulating hormone(TSH)secreted by anterior pituitary gland.

TSH release is in turn controlled by thyrotropin releasing hormone (TRH)from hypothalamus .

Circulating T3and T4 exert –ve feedback mechanism on hypothalamus and anterior pituitary gland .

So, in hyperthyroidism where hormone level in blood is high ,TSH production is suppressed and vice versa.

hypothyrodism
HYPOTHYRODISM

Hypothyroidism is the disease state in humans and animals caused by insufficient

production of thyroid hormone by the thyroid gland.

INCEDENCE

  • 30-60 yrs of age
  • Mostly women
  • Clinical Manifestations:

1. Goiter.

2. Fatigue.

3. Constipation.

4. Weight gain.

5. Memory and mental impairment and decreased

concentration.

6. Depression.

7. Menstrual irregularities and loss of libido.

8. Coarseness or loss of hair.

9. Dry skin and cold intolerance.

clinical manifestations
Clinical Manifestations:

10. Irregular or heavy menses.

11. Infertility.

12. Hoarseness.

13. Myalgias.

14. Hyperlipidemia.

15. Reflex delay.

16. Bradycardia, elevated diastolic BP.

17. Hypothermia.

18. Ataxia.

19. Decreased serum T4,T3 levels.

treatment
TREATMENT

LIFELONG THYROID HORMONE REPLACEMENT

levothyroxine sodium (Synthroid, T4, Eltroxin)

IMPORTANT: start at low does, to avoid hypertension, heart failure and MI

Teach about S&S of hyperthyroidism with replacement therapy

myxedema develops
MYXEDEMA DEVELOPS

Rare serious complication of untreated hypothyroidism

Decreased metabolism causes the heart muscle to become flabby

Leads to decreased cardiac output

Leads to decreased perfusion to brain and other vital organs

Leads to tissue and organ failure

LIFE THREATENING EMERGENCY WITH HIGH MORTALITY RATE

With low metabolism metabolites build up inside the cells which increases mucous and water leading to cellular edema

Edema changes client’s appearance

Nonpitting edema appears everywhere especially around the eyes, hands, feet, between shoulder blades

Tongue thickens, edema forms in larynx, voice husky

problems seen with myxedema coma
PROBLEMS SEEN WITH MYXEDEMA COMA

Coma

Respiratory failure

Hypotension

Hyponatremia

Hypothermia

hypoglycemia

treatment of myexedema coma
TREATMENT OF MYEXEDEMA COMA

Patent airway

Replace fluids with IV.

Give levothyroxine sodium IV

Give glucose IV

Give corticosteroids

Check temp, BP hourly

Monitor changes LOC hourly

Aspiration precautions, keep warm

hyperthyroidism
Hyperthyroidism

Hyperthyroidism is a condition caused by the effects of too much thyroid hormone on

tissues of the body. Although there are several different causes of hyperthyroidism, most

of the symptoms that patients experience are the same regardless of the cause.

Clinical Manifestations:

1.Heat intolerance.

2. Palpitations, elevated systolic BP.

3. Weight changes.

4. Menstrual irregularities and decreased libido.

5. Increased serum T4, T3.

6. Exophthalmos (bulging eyes)

7. Goiter.

8. Insomnia.

9. Muscle weakness.

10. Heat intolerance.

11. Diarrhea.

clinical presentation of specific condition
Clinical presentation of specific condition

THYROIDITIS:

Thyroiditis is an inflammation (not an infection) of the thyroid gland. Several types of thyroiditis exist .

1-Hashimoto's Thyroiditis. Hashimoto's Thyroiditis (also called autoimmune or chronic lymphocytic thyroiditis) is the most common type of thyroiditis.

Fatigue-Depression-Modest weight gain--Cold intolerance-Excessive sleepiness-Dry, coarse

hair-Constipation-Dry skin-Muscle cramps-Increased cholesterol levels-Decreased

concentration-Vague aches and pains-Swelling of the legs

2-De Quervain's Thyroiditis. (also called subacute or granulomatous thyroiditis). The thyroid gland generally swells rapidly and is very painful and tender.]

Patients will experience a hyperthyroid period as the cellular lining of colloid spaces fails,

allowing abundant colloid into the circulation, with neck pain and fever. Patients typically

then become hypothyroid as the pituitary reduces TSH production and the inappropriately

released colloid is depleted before resolving to euthyroid. The symptoms are those of

hyperthyroidism and hypothyroidism. In addition, patients may suffer from painful

dysphagia. There are multi-nucleated giant cells on histology.Thyroid antibodies can be

present in some cases.There is decreased uptake on isotope scan.

clinical presentation of specific condition67
Clinical presentation of specific condition

3-Silent Thyroiditis. Silent Thyroiditis is the third and least common type of thyroiditis..

Silent thyroiditis features a small goiter without tenderness and, like the other

types of resolving thyroiditis, tends to have a phase of hyperthyroidism followed

by a phase of hypothyroidism then a return to euthyroidism. The time span of each

phase is not concrete, but the hypo- phase usually lasts 2-3 months.

pressure effect
Pressure effect:

Dysphagia.

breathlesness & orthopnoea.

Hoarseness.

Facial congestion.

goitre
Goitre

Enlargement of thyroid gland.

Classification:

Simple (non-toxic) goitre.

Toxic goitre.

Neoplastic goitre.

Inflammatory goitre.

simple non toxic goitre
Simple (non-toxic) goitre

include:

simple hyperplastic goitre (colloid goiter)

Cause: -physiological in pregnancy, puberty

-iodine definiecy.

Appearance: Large, smooth firm, non-tendern goitre

Effect: euythyroid & pressure effect.

Multinodular goitre.

Cause: presence of areas of hyperplasia & areas of hypoplasia in gland.

Appearance: Large, irregular, nodular goiter

Effect: euythyroid & pressure effect.

toxic goitre
Toxic goitre

Grave’s disease

Cause: Autoimmune disease characterizeby presence of antibodies stimulate TSH receptors in gland.

Appearance: Diffuce, nodular, hyperemic gland.

Effect: hyperthyroidism.

Toxic Multinodular goiter (plummer’s disease)

Cause: Toxic effect of MNG

Appearance: Large, irregular, nodular goiter.

Effect: hyperthyroidism

neoplastic goitre
Neoplastic goitre

Include:

-benign: adenoma

-malignant: papillary, follicular, anaplastic, medullary and lymphoma

Cause: -complication of MNG.

-radiation

Appearance: Enlarged goiter associated with lymphadenopathy

Effect: -pressure effect.

-euthyroid.

-invasive effect

inflammatory goitre
Inflammatory goitre

Rediel’s thyroditis

Cause: Fibrosis of thyroid

Appearance: Enlarged stony hard thyroid

Effect: Pressure effect

De quervain’s thyroiditis

Cause: Viral infection

Appearance: Diffuse, firm, tender swelling

Effect: Mild hyperthyroidism

Hashimoto’s thyroiditis

Cause: Autoantibody against thyroid gland.

Appearance: Diffuse, enlarged, non-tender goitre

Effect: Hypothyroidism

investigation
Investigation:

Laboratory investigation:

-serum T3, T4.

-serum TSH.

-serum LATS: (Long Acting Thyroid Stimulator)

in grave’s disease

-thyroid antibodies:

in hashimoto’s disease.

-serum cholesterol

increase cholesterol level in hypothyroidism

laboratory assessment75
LABORATORY ASSESSMENT

IN HYPERTHYROIDISM:

T3

T4

TSH in Graves disease

Radioactive Thyroid Scan

Ultrasonography: used to determine goiter or nodules

EKG: note tachycardia

radiological investigation
Radiological Investigation:

-chest and neck x-ray:

Show descend of thyroid gland to thorax and mediastanal shifting in retrosternal goitre.

-iodine isotopes

By i.v injection of I131. Then, use gama rays to show hot and cold nodules.

-CT scan

Show thyroid size and if there is compression to trachea

slide77
Endoscopic investigation:

-bronchoscopy: show compression and infiltration of trachea by tumer

Biopsy:

-fine needle aspiration biopsy.

-true-cut biopsy.

drug therapy
DRUG THERAPY

Antithyroid drugs:

Thioamides: blocks thyroid hormone production; takes time

propylthiouracil (PTU)

methimazole (Tapazole)

carbimazole (Neo-Mercazole)

Need to control cardiac manifestations (tachycardia, palpitations, diaphoresis, anxiety) until hormone production reduced: use Beta-adrenergic blocking drugs: propranolol (Inderal, Detensol)

drug therapy79
DRUG THERAPY

Iodine preparations:

Lugol’s Solution

SSKI (saturated solution of potassium iodide)

Potassium iodide tablets, solution, and syrup

ACTION:

decreases blood flow through the thyroid gland

This reduces the production and release of thyroid hormone

Takes about 2 wks for improvement

Leads to hypothyroidism

drug therapy80
DRUG THERAPY

Lithium Carbonate

ACTION: inhibits thyroid hormone release

NOT USED OFTEN BECAUSE OF SIDE EFFECTS: depressions, diabetes insipidus, tremors, N&V

drug therapy81
DRUG THERAPY

RADIOACTIVE IODINE THERAPY:

Receives RAI in form of oral iodine

Takes 6-8 Weeks for symptomatic relief

Additional drug therapy used during this type of treatment

Not used on pregnant women

surgical management
SURGICAL MANAGEMENT

Why use surgery?

Used to remove large goiter causing tracheal or esophageal compression

Used for pts who do not have good response to antithyroid drugs

TWO TYPES OF SURGERIES:

Total thyroidectomy (must take lifelong thyroid hormone replacement)

Subtotal thyroidectomy

preoperative care
PREOPERATIVE CARE

Patient should become euthyroid before surgery to

prevent thyroid crisis.

Assessmment vocal cord condition

Low weight:

Hi protein, hi CHO diet for days/weeks before surgery

pre operative care
PRE-OPERATIVE CARE

Antithyroid drugs to suppress function of the thyroid

Iodine prep (Lugols or K iodide solution) to decrease size and vascularity of gland to minimize risk of hemorrhage, reduces risk of thyroid storm during surgery

Tachycardia, BP, dysrhythmias must be controlled preop

preoperative teaching
PREOPERATIVE TEACHING

Teach C&DB

Teach support neck when C&DB

Support neck when moving reduces strain on suture line

Expect hoarseness for few days (endotracheal tube)

C&DB: cough & deep breathing

post op thyroidectomy nursing care
POST-OP THYROIDECTOMY NURSING CARE

VS, I&O, IV

Semifowlers

Support head

Avoid tension on sutures

Pain meds, analgesic lozengers

Humidified oxygen, suction

First fluids: cold/ice, tolerated best, then soft diet

Limited talking , hoarseness common

Assess for voice changes: injury to the recurrent laryngeal nerve

postop thyroidectomy nursing care
POSTOP THYROIDECTOMY NURSING CARE

CHECK FOR HEMORRHAGE 1st 24 hrs:

Look behind neck and sides of neck

Check for c/o pressure or fullness at incision site

Check drain

REPORT TO MD

CHECK FOR RESPIRATORY DISTRESS

Laryngeal stridor (harsh hi pitched resp sounds)

Result of edema of glottis, hematoma,or tetany

Trach set/airway/ O2, suction

CALL MD for extreme hoarseness

complication of operation
Complication of operation:

Hemorrhage

Recurrent laryngeal nerve damage.

Superior laryngeal nerve damage

Hypoparathyrodism

Hypothyroidism

Septesis

Postoperative infection

Hypertrofic scaring (keloid)