medical surgical nursing

2. Objective
At the end of this chapter you will be able to;-
 Describe Over View of anatomy and physiology of Endocrine System
 Describe Over View of Assessment of Endocrine System.
 Mention Diagnostic Studies of Endocrine System.
 Describe;-
Causes of disorder
Clinical manifestations
Medical management
Surgical management
Nursing management
5/5/2023
By Mohammed A
2

3. INTRODUCTION
⚫Endocrine system consist of ductless glands that function
individually or conjointly to integrate and control innumerable
metabolic activities in the body.
⚫These glands automatically regulate various body processes by
releasing chemical messengers called hormones.
⚫Overactivity or underactivity of any one of them affects the
whole system.
5/5/2023
By Mohammed A
3

4. Cont.…
Compared to other organs of the body, the organs of the endocrine
system are small and unimpressive, however, functionally the
endocrine organs are very impressive, and when their role in
maintaining body homeostasis is considered, they are true giants.
The endocrine system is closely linked with the nervous system
and the immune system to control body systems.
5/5/2023
By Mohammed A
4

5. GLANDS OF ENDOCRINE SYSTEM
5/5/2023
By Mohammed A
5

6. HYPOTHALAMUS
• Regulates:
– Temperature
– Fluid volume
– Growth
– Pain and pleasure response
– Hunger and thirst
5/5/2023
By Mohammed A
6

7. HYPOTHALAMUS HORMONES
Releasing and inhibiting hormones
• Corticotropin-releasing hormone
• Thyrotropin-releasing hormone
• Growth hormone (GH)-releasing hormone
• Gonadotropin-releasing hormone
• Somatostatin= inhibits GH and TSH
5/5/2023
By Mohammed A
7

8. PITUITARY GLAND
• Located beneath the hypothalamus
• Also known as the “master gland”
• Divided into:
– Anterior Pituitary Gland
– Posterior Pituitary Gland
5/5/2023
By Mohammed A
8

9. 5/5/2023
9
By Mohammed A

10. ANTERRIOR PITUITARY
Thyroid stimulating hormone (TSH)
• Stimulates thyroid growth and secretion of the thyroid hormone
Andrenocorthropic hormone (ACTH)
• Stimulates adrenal cortex growth and secretion of glucocorticoids
Growth hormone (GH)
• stimulate growth
Prolactin / Lactogen
• Stimulate breast development during pregnancy and milk secretion
after delivery
5/5/2023
By Mohammed A
10

11. ANTERRIOR PITUITARY
Follicle stimulating hormone (FSH)
• Stimulates ovarian follicles to mature and produce
estrogens; in the male stimulates sperm production
Luteinizing hormone (LH)
• Acts with FSH to stimulate estrogen production;
causes ovulation; stimulates progesterone
production by corpus luteum; in male stimulate
testes to produce testosterone
Melanocytes stimulating hormone
• Synthesis and spread of melanin in the skin 5/5/2023
By Mohammed A
11

12. POSTERIOR PITUITARY
ADH antidiuretic hormone
• Stimulate water retention by kidneys to
decrease urine secretion
Oxytocin
• Stimulate uterine contraction, causes
breast to release milk into ducts
5/5/2023
By Mohammed A
12

13. ADRENAL GLANDS
13
• Pyramid-shaped organs that located on top of the kidneys
• Each has two parts:
– Outer Cortex
– Inner Medulla
• The adrenal cortex produces three major groups of steroid
hormones, which are collectively called corticosteroids–
mineralocorticoids, glucocorticoids, and sex hormones. 5/5/2023
By Mohammed A

14. ADRENAL CORTEX
14 Mineralocorticoid
• regulating the water and electrolyte balance in the body.
• regulating the mineral (or salt) content of the blood, particularly the concentrations of
sodium and potassium ions
Glucocorticoids—cortisol & hydrocortisone
• The middle cortical layer mainly produces glucocorticoids, which include cortisone and
cortisol; glucocorticoids promote normal cell metabolism and help the body to resist long-
term stressors, primarily by increasing blood glucose levels, thus it is said to be a
hyperglycemic hormone; it also reduce pain and inflammation by inhibiting some pain-
causing molecules called prostaglandins.
Adrenal androgens (sex hormone)
• Both male and female sex hormones are produced by the adrenal cortex
throughout life in relatively small amounts; although the bulk of sex
hormones produced by the innermost cortex layer are androgens (male sex
hormones), some estrogens (female sex hormones), are also formed.
5/5/2023
By Mohammed A

15. ADRENAL MEDULLA
15
Catecholamines. When the medulla is stimulated by sympathetic nervous system
neurons, its cells release two similar hormones, epinephrine, also called
adrenaline, and norepinephrine (noradrenaline), into the bloodstream;
collectively, these hormones are referred to as catecholamines.
•Function. Basically, the Catecholamines increase heart rate, blood pressure, and
blood glucose levels; the catecholamines of the adrenal medulla prepare the
body to cope with a brief or short-term stressful situation and cause the so-
called alarm stage of the stress response.
5/5/2023
By Mohammed A

16. THYROID
16
•Butterfly shaped
•Located on either side of the trachea
•Has two lobes connected with an isthmus
5/5/2023
By Mohammed A

17. Composition.
• Internally, the thyroid gland is composed of hollow structures called follicles, which
store a adhesive colloidal material.
Types of thyroid hormones.
• Thyroid hormone often referred to as the body’s major metabolic hormone, is actually
two active, iodine containing hormones, thyroxine or T4, and triiodothyronine or T3.
Thyroxine.
• Thyroxine is the major hormone secreted by the thyroid follicles.
Triiodothyronine.
• Most triiodothyronine is formed by conversion of the thyroxine to
triiodothyronine. 5/5/2023
By Mohammed A
17

18. Function.
• Thyroid hormone controls the rate at which glucose is
“burned” oxidized, and converted to body heat and
chemical energy; it is also important for normal tissue
growth and development.
Calcitonin.
• Calcitonin decreases blood calcium levels by causing
calcium to be deposited in the bones;
• calcitonin is made by the so-called parafollicular cells
found in the connective tissues between the follicles.5/5/2023
By Mohammed A
18

19. THYROID GLAND
19
5/5/2023
By Mohammed A

20. PARATHYROID GLANDS
20
The parathyroid glands are mostly tiny masses of glandular tissue.
• Location. The parathyroid glands are located on the posterior
surface of the thyroid gland.
• Parathormone. The parathyroids secrete parathyroid hormone
or parathormone, which is the most important regulator of
calcium ion homeostasis of the blood; PTH is a hypercalcemic
hormone (that is, it acts to increase blood levels of calcium),
whereas calcitonin is a hypocalcemia hormone.; PTH also
the kidneys and intestines to absorb more calcium. 5/5/2023
By Mohammed A

21. Pancreas
The pancreas, located close to the stomach in the abdominal cavity, is a
mixed gland.
Two important hormones produced by the Islets of Langerhans cells are
insulin and glucagon.
5/5/2023
By Mohammed A
21

22. Cont.…
 Insulin. Insulin acts on just about all the body cells and increases their
ability to transport glucose across their plasma membranes; because insulin
sweeps glucose out of the blood, its effect is said to be hypoglycemic.
 Glucagon. Glucagon acts as an antagonist of insulin; that is, it helps to
regulate blood glucose levels but in a way opposite that of insulin; its action
is basically hyperglycemic and its primary target organ is the liver, which it
stimulates to break down stored glycogen into glucose and release the
glucose into the blood.
5/5/2023
By Mohammed A
22

23. OVARIES
23
•Location. The female gonads are located in the pelvic
cavity.
•Steroid hormones. Besides producing female sex cells,
ovaries produce two groups of steroid hormones, estrogen,
and progesterone.
5/5/2023
By Mohammed A

24. Cont.…
Cont.… ovaries
• Estrogen. Alone, the estrogens are responsible for
development of sex characteristics in women at
puberty; acting with progesterone, estrogens
promote breast development and cyclic changes in
the uterine lining (menstrual cycle).
• Progesterone. Progesterone acts with estrogen to
bring about the menstrual cycle; during pregnancy, it
quiets the muscles of the uterus so that an implanted
embryo will not be aborted and helps prepare breast
tissue for lactation. 5/5/2023
By Mohammed A
24

25. TESTES
25
The testes of the male are paired oval organs in a sac.
• Location. The testes are suspended in a sac, the scrotum, outside the pelvic
cavity.
• Male sex hormones. In addition to male sex cells, or sperm, the testes also
produce male sex hormones, or androgens, of which testosterone is the most
important.
• Testosterone. At puberty, testosterone promotes the growth and maturation of the
reproductive system organs to prepare the young man for reproduction; it also
causes the male’s secondary sex characteristics to appear and stimulates male sex
drive; Testosterone is also necessary for the continuous production of sperm.
5/5/2023
By Mohammed A

26. THYMUS
26
The thymus gland is large in infants and children
and decreases in size throughout adulthood.
• Location. The thymus gland is located in the upper thorax,
posterior to the sternum.
• Thymosin. The thymus produces a hormone called thymosin and
others that appear to be essential for normal development of a
special group of white blood cells (T-lymphocytes, or T cells) and
the immune response 5/5/2023
By Mohammed A

27. PINEAL
27
The pineal gland, also called the pineal body, is a
small cone-shaped gland.
• Location. The pineal gland hangs from the roof of the third
ventricle of the brain.
• Melatonin. Melatonin is the only hormone that appears to be
secreted in substantial amounts by the pineal gland; the levels of
melatonin rise and fall during the course of the day and night;
peak levels occur at night and make us drowsy as melatonin is
believed to be the “sleep trigger” that plays an important role in
establishing the body’s day-night cycle.
5/5/2023
By Mohammed A

28. Assessment
Clinical Manifestation of Endocrine Disorder
• Widespread effects on the body and wide variety of signs
and symptoms
• Changes in energy level & fatigue
• Tolerance of heat and cold as well as recent changes in
weight
• Changes in sexual function and secondary sex
characteristic
• Changes in mood, memory, and ability to concentrate and
altered sleep patterns
5/5/2023
By Mohammed A
28

29. PHYSISCAL ASESSMENT
General appearance
• Vital signs, height, weight
Integumentary
• Skin color, temperature, texture, moisture
• Bruising, lesions, wound healing
• Hair and nail texture, hair growth
Physical appearance
• Buffalo bump, thinning of skin, increased size of the feet and
hands
5/5/2023
By Mohammed A
29

30. PHYSICAL ASSESSMENT
30
Face
• Shape, symmetry
• Eyes, visual acuity
• Eye changes – exophthalmos
• Neck
5/5/2023
By Mohammed A

31. Palpating the thyroid gland from behind the client. (Source: Lester V. Bergman/Corbis)
31
5/5/2023
By Mohammed A

32. PHYSICAL ASSESSMENT
32
Extremities
• Hand and feet size
• Trunk
• Muscle strength
• Sensation to hot and cold
• Extremity edema
Thorax
• Lung and heart sounds
5/5/2023
By Mohammed A

33. 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
38
5/5/2023
By Mohammed A
33

34. ABNORMAL FINDINGS (CONT)
Ask the client:
• Cardiovascular status: blood pressure, heart rate, 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
39
5/5/2023
By Mohammed A
34

35. LABAROTORY STUDIES
Test of thyroid
• To differentiate primary and secondary hypothyroidism
Serum thyroid stimulating hormone
• To measure serum thyroid stimulating hormone
Serum thyroxine and triiodothyronine
• To measure concentration of thyroxine T4 in the blood
Test of parathyroid function
• To measure the concentration of calcium, phosphorus, alkaline,
phosphatase, parathyroid hormone and osteocalcin in the blood. 5/5/2023
By Mohammed A
35

36. LABAROTORY STUDIES
Test of adrenal function
• To measure concentration of adrenocortical hormones and adrenal medullary
hormones through urine and blood specimen
Aldosterone level
• Aids in the diagnosis of hyperaldosteronism
Urine catecholamines
• To assess function of the adrenal medulla
Test of thyroid structure & function
• To assess the size, shape, position and fucntion of the thryroid through
ulstrasound, MRI, CT scan, & radionuclide imaging
5/5/2023
By Mohammed A
36

37. Diabetes mellitus
is a group of metabolic disorders characterized by elevated
levels of blood glucose (hyperglycemia).
 Results from defects in insulin secretion, lack of response to
insulin, or both.
is a contributing factor to development of cardiovascular
disease, hypertension, kidney disease, and stroke.
5/5/2023
By Mohammed A
37

38. DM Classification
1. Type 1 DM
2. Type 2 DM
3. Gestational DM
5/5/2023
By Mohammed A
38

39. Cont.…
TYPE I DIABETES MELLITUS
Accounts about 5-10% of diabetes mellitus
Happened due to autoimmune destruction of the beta cells.
It is believed to be initiated by genetic or environmental factors
such as viruses or toxins.
usually occurs at a young age, and there are no successful
interventions to prevent the disease.
5/5/2023
By Mohammed A
39

40. Cont.…
TYPE II DIABETES MELLITUS
 About 90% to 95% of patients with diabetes have type 2 diabetes.
Is a progressive condition due to increasing inability of cells to respond to
insulin (insulin resistance)
Decreased production of insulin by the beta cells.
It often occurs later in a client’s life due to obesity, inactivity, and heredity,
age ≥ 40 years.
The exact mechanism that lead to insulin resistance and impaired insulin
secretion in type ii diabetes mellitus is unknown.
5/5/2023
By Mohammed A
40

41. Gestational Diabetes Mellitus
 Hyperglycemia diagnosed in some women during pregnancy.
 placental hormones, causes insulin resistance.
 During pregnancy, GDM requires treatment to normalize maternal
blood glucose levels to avoid complications in the infant.
5/5/2023
By Mohammed A
41

42. Cont.…
 After pregnancy, 5% to 10% of women with gestational diabetes
are found to have T2D.
 Women who have had gestational diabetes have a 20% to 50%
chance of developing T2D in the next 5-10 years.
 Screening for diabetes during pregnancy is now being
recommended between the 24th & 28th weeks of gestation.
5/5/2023
By Mohammed A
42

43. Cont.…
GDM occurs more frequently among :
• age 25 years or younger and obese;
• family Hx of diabetes in first-degree relatives; or
• Member of an ethnic/racial group with a high prevalence
of diabetes (e.g., Hispanic American, Native American,
Asian American, African American).
5/5/2023
By Mohammed A
43

44. RISK FACTORS OF DM
Risk factors that cannot
be changed:
• Family history of diabetes
• High-risk ethnic population
• History of heart disease
• History of GDM or delivery of
babies over 4kg (9 lbs)
• Age ≥ 45 years
Risk factors that can
be changed:
• Overweight (i.e., BMI >25
kg/m2)
• High blood pressure (≥140/90
mm Hg)
• Physical inactivity
• cholesterol level≤ 35 mg/dL
44 5/5/2023
By Mohammed A

45. SIGNS AND SYMPTOM
Hall marks
symptom of DM
Polyuria
Polydipsia
polyphagia
5/5/2023
By Mohammed A
45

46. SIGNS AND SYMPTOM
Type I:
• Increased appetite (polyphagia) because cells are starved for energy
• Increased thirst (polydipsia) from the body attempting to rid itself of glucose
• Increased urination (polyuria) from the body attempting to rid itself of glucose
• Weight loss since glucose is unable to enter cells
• Frequent infections as bacteria feeds on the excess glucose
• Delayed healing because elevated glucose levels in the blood hinders healing
process
5/5/2023
By Mohammed A
46

47. Cont.…
Type II:
Slow onset because some insulin is being produced
Increased thirst (polydipsia) from the body attempting to rid itself of glucose
Increased urination (polyuria) from the body attempting to rid itself of
glucose
infection as bacteria feeds on the excess glucose
Delayed healing because elevated glucose levels in the blood hinder the
healing process
5/5/2023
By Mohammed A
47

48. Laboratory Tests
1. Blood Tests
FBG test: two tests > 126 mg/dL
RBGT: > 200 mg/dL at 2hrs.
Glycosylated haemoglobin (HbA1c) test 4%-6%
5/5/2023
By Mohammed A
48

49. Cont.….
2. Urine Test:
 Ketone
 Renal function
 Glucose
5/5/2023
By Mohammed A
49

50. FBS(mg/dL) Indication
70 to 99 Normal
100 to 125 Pre-diabetic (impaired fasting
glucose)
126 and above Diabetes
* Confirmed by repeating the test on a different day
5/5/2023
By Mohammed A
50

51. (RBS) mg/dl Indication
139 and below Normal
140 to 199 Pre-diabetic (impaired glucose tolerance)
200 and above Diabetes*
5/5/2023
By Mohammed A
51

52. Hemoglobin A1c is:
 glycosylated haemoglobin.
 a good indicator of blood glucose control.
 is the blood test with a memory.
 gives a % that indicates control over the preceding 2-3 months.
 Performed 2 times a year.
 A hemoglobin of 6% indicates good control and level >6%
indicates diabetes mellitus.
5/5/2023
By Mohammed A
52

53. Diabetes Management
The main goal of diabetes treatment is
to normalize
• Insulin activity and
• Blood glucose levels
To reduce the development of vascular
and neuropathic complications.
5/5/2023
By Mohammed A
53

54. Cont.…
There are five components of diabetes management which are
equally important
5/5/2023
By Mohammed A
54

55. 1. Nutritional therapy
5/5/2023
By Mohammed A
55

56. Cont.…
Nutrition is the foundation of diabetes management
Meal planning should consider the patient’s food preferences
Calorie prescription is based on energy needs, age, and size;
50% to 60% of calories should be derived from
carbohydrates,
20% to 30% from fat, and
the remaining 10% to 20% from protein.
5/5/2023
By Mohammed A
56

57. 2.EXERCISE
Exercise is very important in managing diabetes Mellitus because
it lowers BGL by;
Increasing the up take of glucose by body mussels and
Improving insulin utilization
5/5/2023
By Mohammed A
57

58. Cont.…
 Positive benefits
Reduces cardiovascular risks, BP, body fat, weight
Lowers blood glucose
Increases insulin sensitivity in T2D
may decrease in the demand of exogenous insulin or the dose of Oral
hypoglycemic agents
 Time
150 min per week ( 3 days)
5/5/2023
By Mohammed A
58

59. Cont.…
 Problems
 Either hypo/ hyperglycemia
 Guidelines to avoid these problems
 Monitor blood glucose before, during & after exercise
 Delay exercise if:
 Blood Glucose > 250 mg/dl and
 Ketone bodies are present
 If blood Glucose < 100 mg/ dl, ingest carbohydrate before exercise
5/5/2023
By Mohammed A
59

60. Cont.…
General Precautions for Exercise in Diabetics
• Use proper footwear and, if appropriate, other protective
equipment.
• Avoid exercise in extreme heat or cold.
• Inspect feet daily after exercise.
• Avoid exercise during periods of poor metabolic control.
• For many patients, walking is a safe and beneficial form of
exercise.
5/5/2023
By Mohammed A
60

61. 3. Monitoring Glucose levels and ketones
 Blood glucose monitoring is a cornerstone of diabetes management, and
self-monitoring of blood glucose (SMBG) levels has dramatically altered
diabetes care.
 Frequent SMBG enables people with diabetes:
to adjust the treatment regimen
for detection and prevention of hypoglycemia and hyperglycemia
To normalizing blood glucose levels
To reduce the risk of long-term diabetic complications.
5/5/2023
By Mohammed A
61

62. 4. Pharmacologic Therapy
 Includes treatment with insulin or oral anti- diabetic agents
 Decisions in drug treatment should be based primarily on the
type of diabetes and the goals for glycemic control.
 The choice of therapy is simple all patients need Insulin.
5/5/2023
By Mohammed A
62

63. INSULIN
• Insulin allows glucose to move into cells to make energy
• Pancreas secretes 40-50 units of insulin daily :
– Secreted at low levels during fasting ( basal insulin secretion
– Increased levels after eating (prandial)
– An early burst of insulin occurs within 10 minutes of eating
– Then proceeds with increasing release as long as hyperglycemia is
present
5/5/2023
By Mohammed A
63

64. Calculation of Insulin Dose
How much insulin ?
- A good starting dose is 0.6 U/kg/day
Example: For a 50 kg patient
- The total dose = 0.6X50 = 30 U/day
5/5/2023
By Mohammed A
64

65. Calculation of Insulin Dose
Monitoring
Most Type 1 patients require
0.5-1.0 U/kg/d
The initial regimen should be modified based on:
- Symptoms
- SMBG
- HbA1C
5/5/2023
By Mohammed A
65

66. Insulin Syringe
Syringes must be matched with the insulin concentration
(e.g., U-100). Currently, three sizes of U-100 insulin syringes
are available:
• 1-mL (cc) syringes that hold 100 units
• 0.5-mL syringes that hold 50 units
• 0.3-mL syringes that hold 30 units
5/5/2023
By Mohammed A
66

67. Administration sites
A. Abdomen;
B. Lateral and Anterior Aspects of Upper Arm and Thigh;
C. Scapular Area on Back; and
D. Upper Ventrodorsal Gluteal Area.
5/5/2023
By Mohammed A
67

68. Rotation
Rotation within site must occur to prevent lipoatrophy
Inject at appropriate angle (45-90) depending on depth of
subcutaneous tissue
5/5/2023
By Mohammed A
68

69. Adverse effects
Hypoglycemia
- Treatment:
- Patients should be aware of symptoms of hypoglycemia
- Oral administration of 10-15 gm glucose
- IV dextrose in patients with lost consciousness
- 1 gm glucagon IM if IV access is not available
Skin rash at injection site
- Treatment: Use more purified insulin preparation
Lipodystrophies (increase in fat mass) at injection site
- Treatment: rotate the site of injection
5/5/2023
By Mohammed A
69

70. Future Developments
Beta cell transplantation
Non-injectable formulations of insulin
Inhaled insulin
5/5/2023
By Mohammed A
70

71. Oral Hypoglycaemic Agents
 T2DM generally results from either a decrease in:
Insulin resistance (activity) OR insulin secretion
 The use of oral medications with diet & exercise can manage the problem
 But oral hypoglycaemics are NOT insulin & therefore cannot replace
insulin
 Hypoglycaemics help the body to utilise or make insulin
Beta cells must make enough insulin to work, otherwise combination
with insulin is necessary.
5/5/2023
By Mohammed A
71

72. Classes of Oral Hypoglycaemic Agents
Target insulin secretion
• Sulphonylureas (glibenclamide)
• Meglitinides (repaglinide)
Target insulin resistance
• Biguanides (metformin)
• (Thiazolidinediones) (rosiglitazone)
Target glucose absorption from intestine
• Alpha glucosidase inhibitors (ascarbase)
5/5/2023
By Mohammed A
72

73. Insulin Therapy in Type 2 Diabetes
Reasons for use of insulin
• People uncontrolled with maximal doses of OHA therapy
(who are insulin resistant)
• Pregnancy (oral therapy contraindicated)
• Patients with organ failure for whom oral therapy is
contraindicated
• Acute illness/surgery in T2D
5/5/2023
By Mohammed A
73

74. 5.Patient Education
Patient Education should focus on
• Storage and dose preparation of insulin
• Insulin injection
• Blood glucose monitoring
• Interpretation of results
• Frequency of testing
• Blood glucose therapy goals
5/5/2023
By Mohammed A
74

75. Cont.…
With drawing insulin
Proper skin and footcare
Proper Eye Exam
Proper diet and fluids
5/5/2023
By Mohammed A
75

76. Teach pt. on correct administration of
insulin and other hypoglycemic agents.
 Insulin in current use may be stored at room temp., All others in ref. Or
cool area
 Avoid injecting cold insulin because lead to tissue reaction
 Roll insulin vial to mix, do not shake, remove air bubbles from syringe
 Press (do not rub) the site after injection (rubbing may
Alter the rate of absorption of insulin)
 Rotate sites
 Failure to rotate sites may lead to lipodystrophy
5/5/2023
By Mohammed A
76

77. DIABETES COMPLICATIONS
Acute
Complications
• Diabetic Ketoacidosis (DKA)
• Hyperglycemic Hyperosmolar
Nonketotic Syndrome (HHNS)
• Hypoglycemia
5/5/2023
By Mohammed A
77

78. Hypoglycemia
 Is abnormally low blood glucose level occurs when the blood
glucose falls to < 50 to 60 mg/dL.
 Blood glucose values 45mg/dl are too low for normal
neurological (brain) function.
 Even people without diabetes may develop symptoms of
hypoglycemia when the blood glucose level is <65 mg/dl.
5/5/2023
By Mohammed A
78

79. Causes
• Too much insulin/tablets
• Delayed or missed meal
• Not enough carbohydrate in a meal
• More exercise than usual
• Illness
5/5/2023
By Mohammed A
79

80. Signs and Symptoms
 Trembling/Vibrating
 Rapid heart rate
 Pounding heart (palpitations)
 Sweating
 Pallor
 Hunger and/or nausea
5/5/2023
By Mohammed A
80

81. Cont.…
Difficulty in concentrating
Irritability
Blurred or double vision
Difficulty hearing
Slurred speech
Poor judgment and
confusion
Dizziness and unsteady
gait
Tiredness
Nightmares
Loss of consciousness
Seizures
Death
5/5/2023
By Mohammed A
81

82. Management of hypoglycemia
Immediate treatment.
If the pt is having severe symptoms, give either:
 IV glucose (e.g. 10% glucose drip or 1ml/ kg of 25% dextrose)
OR
 IV, IM or SC glucagon (1 mg for adults).
After an injection of glucagon, the blood glucose would be expected
to rise within 10 -15 mins.
5/5/2023
By Mohammed A
82

83. Cont.…
If neither glucagon nor IV glucose is available, the usual
recommendation is 15 g of a fast-acting concentrated source of
CHO such as the following, given orally:
3 or 4 commercially prepared glucose tabs
4 to 6 oz of fruit juice
6 to 10 Life Savers or other hard candies
2 to 3 teaspoons of sugar or honey
5/5/2023
By Mohammed A
83

84. Cont.…
 If no improvement within 5 – 10 minutes, repeat the high oral food/drink
 Once improvement has occurred (feeling better, BGL rising if testing is
available) then follow with a low GI snack.
E.G. Glass of milk
Yoghurt
Sandwich
Piece of fruit
5/5/2023
By Mohammed A
84

85. 2. Diabetic Ketoacidosis(DKA)
 is an acute metabolic crisis in pts with DM.
 is caused by an absence or markedly inadequate amount of
insulin.
This deficit in insulin results in disorders in the metabolism of
CHO, protein, and fat.
5/5/2023
By Mohammed A
85

86. Cont.…
The three
clinical
of DKA are:
Hyperglycemia
Dehydration and
electrolyte loss
Acidosis
5/5/2023
By Mohammed A
86

87. Signs and symptoms
Pathophysiologic effect Clinical features
Elevated blood glucose Elevated blood glucose and urine glucose
Dehydration Sunken eyes, dry mouth, decreased skin turgor,
decreased perfusion
Altered electrolytes Irritability, change in level of consciousness
Metabolic acidosis (ketosis) Acidotic breathing, nausea, vomiting, abdominal
pain, altered LOC
87
5/5/2023
By Mohammed A

88. Lab Findings
RBS: Hyperglycemia
Urine and serum ketones
5/5/2023
By Mohammed A
88

89. Treatment of DKA
Managing DKA involves the following steps:
1: Correction of shock
2: Correction of dehydration
3: Correction of deficits in electrolytes
4: Correction of hyperglycemia
5: Correction of acidosis
6: Treatment of infection
7: Treatment of complications (cerebral oedema)
5/5/2023
By Mohammed A
89

90. Cont.…
1.Replace fluids:
• 2–3L of 0.9% NS in 1–3 hrs.; the reduce to 250–500 mL/h; change to 5%
glucose when plasma glucose reaches 250 mg/dl in DKA and 300mg/dl in
HHS. HHS requires more fluid. Assess hydration status, BP and urine
output frequently.
2.Administer short-acting insulin:
• Regular Insulin 10units IV and 10 units IM, stat,
• then 0.1 units/kg per hour by continuous IV infusion OR 5 units, I.V
boluses every hour.
• If serum glucose does not fall by 50 to 70 mg/dL from the initial value in
the 2-3 hours,
• the insulin infusion rate should be doubled every hour until a steady decline
in serum glucose is achieved 5/5/2023
By Mohammed A
90

91. Cont.…
Potassium
• All patients with DKA have potassium depletion irrespective of the serum
K+ level.-
• If the initial serum K+ is 5.3 mmol/L, do not supplement K+ until the level
reaches < 5.3.
• If K+ determination is not possible delay initiation of K+ replacement until
there is a reasonable urine out put(>50 ml/hr.)
• The serum potassium should be maintained between 4.0 and 5.0 meq/l
• Add 40–60 meq/l of IV fluid when serum K+ < 3.7 meq/L
• Add 20-40meq/l of IV fluid when serum K+ < 3.8-5.2 meq/l
5/5/2023
By Mohammed A
91

92. Precipitant identification ;-
• treatment-noncompliance, infection, trauma,
• Initiate appropriate workup for precipitating event (cultures,
CXR, ECG)
Follow up of response;-
• Blood glucose every 1–2hrs,
• Urine ketones every 4hr,
• electrolytes (especially K+) every 6 h for first 24 h.
Continuation of treatment;-
• the above treatment should continue until the patient is stable,
ketone free.
5/5/2023
By Mohammed A
92

93. Transition;-
• Insulin infusion may be decreased to 0.05–0.1 units/kg
per hour or 2-3 units,IV, hourly. Overlap in insulin
infusion and SC insulin injection for about 3-5hrs.
SC long acting Insulin;-
• start SC NPH as soon as the patient eats. Monitor
blood glucose every 4-6 hour and give correctional
doses of regular insulin when needed.
• DO NOT USE SLIDING SCALE
5/5/2023
By Mohammed A
93

94. Complications of DKA
Shock
• If not improving with fluids r/o MI
Vascular thrombosis
• Severe dehydration
• Cerebral vessels
• Occurs hours to days after DKA
Pulmonary Edema
• Result of aggressive fluid resuscitation
Cerebral Edema
• First 24 hours
• Mental status changes
• Tx: Mannitol
• May require intubation with hyperventilation
5/5/2023
By Mohammed A
94

95. Prevention of DKA
Never omit insulin
Prevent dehydration and
hypoglycemia
Monitor blood sugars
frequently
Monitor for ketosis
Treat underlying triggers
Maintain contact with medical
team
5/5/2023
By Mohammed A
95

96. Hyperosmolar Nonketotic Syndrome
Extreme hyperglycemia & dehydration
Unable to excrete glucose as quickly as it enters the
extracellular space.
Extreme hyperglycemia
High mortality (12-46%)
At risk
Older patients with intercurrent illness
Impaired ability to ingest fluids
5/5/2023
By Mohammed A
96

97. HHNS Presentation
Glucose > 600 mg/dl
Sodium
Normal, elevated
Potassium
Normal or elevated
Bicarbonate >15 mEq/L
Osmolality > 320 mOsm/L
5/5/2023
By Mohammed A
97

98. Clinical Errors
Fluid shift and shock
• Giving insulin without sufficient fluids
• Using hypertonic glucose solutions
Hyperkalemia
• Premature potassium administration before insulin has begun to act
Hypokalemia
• Failure to administer potassium once levels falling
Recurrent ketoacidosis
• Premature discontinuation of insulin and fluids when ketones still present
Hypoglycemia
• Insufficient glucose administration
5/5/2023
By Mohammed A
98

99. Long-Term Complications of DM
Macrovascular complications
• Cardiovascular disease (heart attack)
• Cerebrovascular disease (strokes)
Microvascular complications
• Retinopathy (vision) problems
• Diabetic neuropathy
• Diabetic nephropathy
• Male erectile dysfunction
5/5/2023
By Mohammed A
99

100. Disorders Of The Thyroid Gland
5/5/2023
By Mohammed A
100

101. Goiter
A lack of iodine in the patient’s diet causes the thyroid gland to
become enlarged.
The thyroid gland can also become enlarged.
by ingesting large amounts of goitrogenic drugs or
goitrogenic foods that decrease production of thyroxine,
such as strawberries, cabbage, peanuts, peas, peaches,
and spinach.
5/5/2023
By Mohammed A
101

102. Cause
• Iodine deficiency
• Graves diseases
• Thyroid cancer
• Pregnancy
• inflammation
5/5/2023
By Mohammed A
102

103. SIGNS AND SYMPTOMS
• Difficulty in swallowing (dysphagia) due to a large
thyroid pressing on the esophagus
• Enlarged thyroid gland
• Respiratory distress causing pressure on the trachea
• A tight feeling in the throat
• Coughing
5/5/2023
By Mohammed A
103

104. TREATMENT
• If increased TSH, administer hormone replacement with
levothyroxine (T4), desiccated thyroid, or liothyronine (T3).
• If the thyroid gland is overactive, then administer small
doses of Lugo's solution or potassium iodide solution.
• If the simple goiter cannot be reduced through medication,
then a thyroidectomy is performed during which all or part of
the thyroid is removed. 5/5/2023
By Mohammed A
104

105. Nursing Intervention
• Avoid goitrogenic foods
• Use iodized salt to prevent and treat endemic goiter
• Explain to patient:
• The need for life-long thyroid replacement after
thyroidectomy.
• The need for intermittent lab work to monitor the
thyroid.
• Visits to the primary care practitioner to monitor size of
thyroid gland.
5/5/2023
By Mohammed A
105

106. Hyperthyroidism
There is an overproduction of T3 and T4 by the thyroid
gland that can be caused by an autoimmune disease where
the body’s immune system attacks the thyroid gland.
 Other causes can be a benign tumor (adenomas) resulting
in an enlarged thyroid gland (goiter) or an overproduction of
TSH by the pituitary gland, caused by a pituitary tumor.
5/5/2023
By Mohammed A
106

107. Causes of hyperthyroidism
• Graves’ disease;-is the most common cause. Autoimmune
antibodies result in hypersecretion of thyroid hormones.
• Toxic nodular goiter, a less common form of
hyperthyroidism, is caused by overproduction of thyroid
hormone due to the presence of thyroid nodules.
• Exogenous hyperthyroidism;-is caused by excessive
dosages of thyroid hormone.
5/5/2023
By Mohammed A
107

108. SIGNS AND SYMPTOMS
• Enlarged thyroid gland (goiter) caused by tumor
• Protrusion of the eyeballs (exophthalmos) due to lymphocytic infiltration
which pushes out the eyeball
• Sweating (diaphoresis); excess thyroid hormone raises the metabolic rate
• Increased appetite due to increased metabolism
• Nervousness due to high levels of thyroid hormone
• Weight loss due to increased metabolism
• Menstrual changes due to elevated levels of thyroid hormone
5/5/2023
By Mohammed A
108

109. Laboratory Tests
• Serum TSH test – Decreased in the presence of Graves’
disease.
• Thyrotropin-releasing hormone (TRH) stimulation test
5/5/2023
By Mohammed A
109

110. 5/5/2023
By Mohammed A
110
TREATMENT
• For mild cases and for young patients,
• Administer antithyroid medication such as
methimazole to block synthesis of T3 and T4.
• For Graves’ disease and for patients 50 years of age
or older,
• Administer Lugo's solution, or potassium iodide.
• For severe cases where the size of the thyroid gland
interferes with swallowing or breathing, the thyroid
gland is surgically reduced in size or removed.

111. 5/5/2023
By Mohammed A
111
Nursing Intervention
• Monitor vital signs.
• Provide cool environment.
• Provide a diet high in carbohydrates, protein, calories, vitamins, and
minerals.
• Monitor for laryngeal edema following surgery (hoarseness or inability to
clearly speak).
• Keep oxygen, suction, and a tracheotomy set near bed in case the neck swells
and breathing is impaired.
• Semi-Fowler’s position to decrease tension on the neck following surgery.
• Monitor for muscle spasms and tremors (tetany) caused by manipulation of
the parathyroid glands during surgery.
• Check drainage and hemorrhage from incision line; red flags are frank
hemorrhage and purulent, foul smelling drainage.
• Monitor for signs of hypocalcemia (tingling of hands and fingers).
• The treatment is IV calcium, administered quickly.

112. Check for Trousseau’s sign
(inflate blood pressure cuff on the arm and muscles contract).
Check for Chvostek’s sign
(tapping of the facial nerve causes twitching of the facial muscles).
 Both this sign are positive when the parathyroid glands have been
manipulated during thyroid surgery, in which case they secrete too much
phosphorus and not enough calcium.
 Since muscles,
i.e.the heart, need calcium for work, a low calcium level may
cause muscle spasms which are easily detected by Chvostek’s sign
and Trousseau’s sign.
5/5/2023
By Mohammed A
112

113. 5/5/2023
By Mohammed A
113

114. Complication
• Hemorrhage at the incision site due to a released surgical tie, excessive coughing,
or movement.
• Thyroid Storm/Crisis ;-Thyroid storm/crisis results from a sudden gush of large
amounts of thyroid hormones into the bloodstream, causing an even greater
increase in body metabolism.
• Airway Obstruction;-Hemorrhage, tracheal collapse, tracheal mucus accumulation,
laryngeal edema, and vocal cord paralysis can cause respiratory obstruction, with
sudden stridor and restlessness.
• Hypocalcemia and Tetany;-Damage to parathyroid gland causes hypocalcemia and
tetany
5/5/2023
By Mohammed A
114

115. Hypothyroidism
is a condition in which there is an inadequate amount of
circulating thyroid hormones triiodothyronine (T3 ) and
thyroxine (T4 ), causing a decrease in metabolic rate that affects
all body systems.
5/5/2023
By Mohammed A
115

116. 5/5/2023
By Mohammed A
116 Classifications of hypothyroidism by etiology
Primary;-
• Primary hypothyroidism stems from dysfunction of the thyroid gland.
Secondary;-
• Secondary hypothyroidism is caused by failure of the anterior
pituitary gland to stimulate the thyroid gland
Tertiary ;-
• Tertiary hypothyroidism is caused by failure of the hypothalamus to
produce thyroid-releasing factor.

117. Risk Factors
• Gender( female more than Male affected)
• Age( 30 to 60 years of age are more affected)
• Use of medications (lithium amiodarone)
• Inadequate intake of iodine
5/5/2023
By Mohammed A
117

118. SIGNS AND SYMPTOMS
• Fatigue due to slow metabolism
• Hypothermia due to slow metabolism
• Brittle nails due to low levels of thyroid hormone, which helps growth
and development
• Thick dry hair from lack of thyroid hormone
• Dry skin from lack of thyroid hormone
• Menstruation changes due to diminished levels of thyroid hormone
• Slow cognitive function due to slow metabolism
• Weight gain,low levels of thyroid hormone causes fatigue,
sluggishness
5/5/2023
By Mohammed A
118

119. Diagnostic Procedures
• Skull x-ray, computed tomography scan, and magnetic
resonance imaging. These procedures can locate pituitary
or hypothalamic lesions that may be the underlying cause
of hypothyroidism.
• ECG . Sinus bradycardia, flat or inverted T waves, and
ST deviations
5/5/2023
By Mohammed A
119

120. TREATMENT
• Replacement hormone; levothyroxine is the treatment of
choice.
• Serum measurements of T3 and T4 will need to be performed
after 6 to 8 weeks to determine if the patient is taking the
correct dose.
• The patient needs to be aware that this is a lifetime
replacement.
5/5/2023
By Mohammed A
120

121. Nursing intervention
• Monitor vital signs.
• Provide a warm environment.
• Low-calorie diet.
• Increase fluids and fiber to prevent constipation.
• Take thyroid replacement hormone each morning to avoid insomnia.
• Monitor for signs of thyrotoxicosis (an increase in T3): nausea,
vomiting, diarrhea, sweating, tachycardia.
• Explain to the patient:
• Side effects of thyroid hormone replacement.
• Review the signs of hyperthyroidism and hypothyroidism.
5/5/2023
By Mohammed A
121

122. Complications
Myxedema;-
• Is a life-threatening condition that occurs when
hypothyroidism is untreated or when a stressor (such as
infection, heart failure, stroke, or surgery) affects an individual
who has hypothyroidism.
• Clients who have been taking levothyroxine and suddenly
stop the medication are also at risk.
5/5/2023
By Mohammed A
122

123. Clinical Manifestations
• Significantly depressed respirations (hypoxia,
hypercapnia)
• Decreased cardiac output
• Worsening cerebral hypoxia
• Lethargy, stupor, coma
• Hypothermia
• Bradycardia, hypotension
• Hyponatremia
5/5/2023
By Mohammed A
123

124. Nursing Actions
• Maintain airway patency with ventilatory support if
necessary.
• Provide continuous ECG monitoring.
• Warm the client with blankets.
• Monitor the client’s body temperature until stable
5/5/2023
By Mohammed A
124

125. 5/5/2023
By Mohammed A
125
Nursing Action cont.…
• Replace thyroid hormone
• by administering large doses of levothyroxine IV bolus.
• Monitor vital signs
• because rapid correction of hypothyroidism can cause adverse cardiac
effects.
• Monitor intake and output, and daily weights.
• With treatment, urine output should increase, and body weight should
decrease; failure to do so should be reported to the provider.
• Treat hypoglycemia with glucose.
• Administer corticosteroids.
• Check for possible sources of infection (blood, sputum, urine) that may have
precipitated the coma. Treat any underlying illness.

126. Disorders of the parathyroid glands
5/5/2023
By Mohammed A
126

127. Hypoparathyroidism
is diminished functioning of the parathyroid glands leading to
low levels of PTH, which causes hypocalcemia.
The primary cause of hypoparathyroidism is destruction of the
glands by an autoimmune cause.
Occasionally the gland(s) may be accidentally removed during
thyroidectomy
5/5/2023
By Mohammed A
127

128. SIGNS AND SYMPTOMS
• Tetany (muscle irritability) due to abnormal levels of calcium
• Tingling of periorbital area, hands, and feet from abnormal
calcium levels
• Lethargy due to low levels of parathyroid hormone
• Cataract development
• Convulsions due to acute low calcium levels
5/5/2023
By Mohammed A
128

129. INTERPRETING TEST RESULTS
• Decreased serum calcium due to low levels of PTH.
• Increased serum phosphate due to low levels of PTH.
• Decreased serum PTH due to diminished secretion from the
parathyroid glands.
• Decreased urinary calcium from diminished PTH.
• Positive Chvostek’s sign due to decreased calcium levels.
• Positive Trousseau’s sign due to decreased calcium levels.
5/5/2023
By Mohammed A
129

130. TREATMENT
• Administer calcium gluconate by slow IV drip for acute hypocalcemia
• Oral calcium—calcium gluconate, lactate, carbonate (Os-Cal).
• Large doses of vitamin D (calciferol) to help absorption of calcium.
• Aluminum hydroxide gel (Amphogel) or aluminum carbonate gel; basic
(Basaljel) to decrease phosphate levels.
• Keep tracheostomy set and injectable calcium gluconate at bedside for
impaired respiration from swelling as well as for emergency administration
of calcium.
5/5/2023
By Mohammed A
130

131. Nursing Intervention
• Monitor patients condition
• If the parathyroids were damaged during thyroid
surgery:
• Administer calcium to maintain the serum levels in a
low normal range.
• Testing should be done every 3 months. 5/5/2023
By Mohammed A
131

132. Hyperparathyroidism
Overactivity of the parathyroid glands caused by a tumor
produces too much PTH, resulting in hypercalcemia and
hypophosphatemia.
Parathyroid tumors are usually benign.
5/5/2023
By Mohammed A
132

133. SIGNS AND SYMPTOMS
• Asymptomatic
• Increased serum calcium level
• Bone pain or fracture as a result of excreting
calcium from bone
• Kidney stones
• Frequent urination as a result of increased
calcium in the urine (hypercalciuria)
5/5/2023
By Mohammed A
133

134. INTERPRETING TEST RESULTS
• Increased serum calcium.
• Increased serum PTH.
• Decreased serum phosphate.
• Increased urine calcium.
• Presence of parathyroid tumor shows on ultrasound.
• Fine needle biopsy of the parathyroid tumor.
5/5/2023
By Mohammed A
134

135. TREATMENT
• Surgical removal of the parathyroid tumor.
• Administer bisphosphonates to lower serum
calcium by increasing calcium absorption in
the bone.
• IV normal saline to dilute serum calcium.
• Diuretic such as furosemide to excrete
excess calcium in the urine.
5/5/2023
By Mohammed A
135

136. Nursing Intervention
• Monitor intake and output.
• Monitor for fluid overload.
• Monitor electrolyte balance.
• Strain urine for kidney stones.
• Place the patient on a low-calcium and high-phosphorus
diet.
• Explain to patient:
• Avoid over-the-counter calcium supplements.
• Maintain daily activities.
5/5/2023
By Mohammed A
136

137. Disorders of the pituitary gland
5/5/2023
By Mohammed A
137

138. Causes of Disorder of PituitaryGland
Mainly of 2 reasons:
• Hyperpituitarism/hyperactive
• Hypopituitarism/hypoactive
5/5/2023
By Mohammed A
138

139. Hypopituitarism
Results when the pituitary gland is unable to secrete a normal
amount of pituitary hormones.
Primary causes are tumors, inadequate blood supply to the
pituitary gland, infection, radiation therapy, or surgical removal
of a portion of the pituitary gland.
 Secondary causes affect the hypothalamus, which regulates the
pituitary gland.
5/5/2023
By Mohammed A
139

140. Signs and Symptoms
• Fatigue caused by a decreased production of ACTH
• Lethargy and diminished cognition caused by a decreased production
of TSH
• Sensitivity to cold due to low TSH, which stimulates thyroid hormone
• Decreased appetite due to TSH deficiency
• Infertility due to luteinizing hormone (LH) and follicle-stimulating
hormone (FSH) production
• Short stature due to diminished secretion of growth hormone
• Infertility, amenorrhea caused by decreased production of FSH and LH
5/5/2023
By Mohammed A
140

141. The clinical features depends upon type of hormone
deficiency.
Type of
hormone
Symptoms
LowACTH Decrease production of cortisol by the
adrenal glands which causes symptoms
related to adrenal insufficiency.
Low growth
hormone
Failure of growth in children causing
short height (dwarfism) and undue
tiredness and weakness in adults.
5/5/2023
By Mohammed A
141

142. Type of
hormone
Symptoms
Low LH &
FSH
In Men: decrease in libido, impotence &
impaired fertility due to a decreased ability
to produce testosterone.
In Female: irregular or absent menstrual
periods leading to infertility.
Low thyroid
hormone
Undue tiredness, weight gain,
constipation, dry skin and feeling
colder than usual.
5/5/2023
By Mohammed A
142

143. Types of hormone Symptoms
Lack ofADH From the posterior part of
the pituitary gland results in
the passing of uncontrolled
large amounts of urine and
causes severe thirst.
Prolactin deficiency Low levels can lead to a
woman inability to produce
breast milk after childbirth.
5/5/2023
By Mohammed A
143

144. Interpreting Test Results
• Decreased ACTH usually due to a lesion of the pituitary.
• TSH deficiency due to a mass, trauma, surgery, or idiopathic.
• Decreased prolactin due to a mass, causing diminished or lack of
prolactin from the anterior pituitary.
• Presence of a pituitary tumor shown on MRI.
5/5/2023
By Mohammed A
144

145. TREATMENT
• Administer replacement hormones (estrogen,
testosterone, corticosteroids, growth hormone, and
thyroid hormone).
• Surgical removal of the pituitary tumor if it exists.
5/5/2023
By Mohammed A
145

146. Nursing Intervention
• Monitor weight daily because antidiuretic hormone (ADH) and
adrenocorticotropic hormone (ACTH), from the pituitary, regulate
fluid retention and excretion in the body.
• Monitor intake and output to ensure the balance is equal due to
hormone regulation.
• Explain to the patient:
• The need to take medication for the rest of the patient’s life.
• The need for frequent laboratory tests.
5/5/2023
By Mohammed A
146

147. HYPERPITUTARISM
• is the primary hypersecretion of pituitary
hormones.
• It typically results from a pituitary adenoma.
• There are usually three hormones that are over
secreted due to pituitary adenoma are
prolactin, adrenocorticotropic hormone (ACTH)
(ACTH) and growth hormone (GH).
5/5/2023
By Mohammed A
147

148. Cont.…
 Some of the common disorders as a result of
hypersecretion of piutitary glands are as follows:
 Excess prolactin: Prolactinoma.
 Excess ACTH: Cushing’s disease.
 Excess GH: Gigantism and Acromegaly.
5/5/2023
By Mohammed A
148

149. ETIOLOGY
 Pituitary tumor
 Inherited condition known as multiple
endocrine neoplasia.
5/5/2023
By Mohammed A
149

150. Hyperprolactinemia
is an overproduction of the prolactin hormone that promotes
lactation.
Excessive secretion is usually caused by a pituitary tumor
(prolactinoma) but may also be due to hypothyroidism, chronic
kidney disease, and medications that affect the pituitary gland.
5/5/2023
By Mohammed A
150

151. SIGNS AND SYMPTOMS
The primary symptom is decreased fertility.
 In females, symptoms may include decreased or absent
menstruation, headache and mood changes from hormone
imbalance.
Males may experience erectile dysfunction, diminished libido,
gynecomastia, headache and mood changes from too much
hormone.
5/5/2023
By Mohammed A
151

152. INTERPRETING TEST RESULTS
Increased serum TSH as hypothyroidism can be a contributing
factor to hyperprolactinemia.
Increased creatinine as renal failure can be a contributing
factor.
Serum human chorionic gonadotropin test for pregnancy (
HCG) as pregnancy can cause hyperprolactinemia.
Serum AST, ALT, and bilirubin will be increased as cirrhosis
has been known to cause hyperprolactinemia.
Serum testosterone, FSH, LH and prolactin may be decreased
in hypogonadism.
 Pituitary tumor present in MRI.
5/5/2023
By Mohammed A
152

153. TREATMENT
Administer dopamine agonists:
• bromocriptine
• cabergoline to shrink pituitary tumor and return prolactin to normal
levels
Discontinue medications that may be causing the pituitary glands to overproduce prolactin:
• estrogens
• methyldopa
• tricyclic inhibitors
• verapamil
Radiation therapy to reduce the pituitary tumor.
Surgical removal of the pituitary tumor.
5/5/2023
By Mohammed A
153

154. Nursing intervention
Monitor vital sign
Monitor patient condition
Monitor serum hormone levels to assure that medication is
improving the patient’s condition.
5/5/2023
By Mohammed A
154

155. Posterior Pituitary Disorder
5/5/2023
By Mohammed A
155

156. DIABETES INSIPIDUS
 It is a disorder of the posterior lobe of the pituitary
gland characterized by a deficiency of antidiuretic
hormone (ADH), or vasopressin.
 Great thirst (polydipsia) and large volumes of dilute
urine characterize the disorder.
5/5/2023
By Mohammed A
156

157. CAUSES
• Head trauma
• Brain tumor
• Surgical removal
• irradiation of the pituitary gland
• Infections of the central nervous system
• Failure of the renal tubules to respond to ADH
5/5/2023
By Mohammed A
157

158. CLINICAL FEATURES
• Excessive thirst
• May be intense or uncontrollable
• Involves craving for water
• Excessive urine volume
5/5/2023
By Mohammed A
158

159. DIAGNOSIS
• Urine analysis
• Monitoring urine output
• MRI
5/5/2023
By Mohammed A
159

160. Assessment
• The fluid deprivation test is carried out by withholding fluids for
8 to 12 hours or until 3% to 5% of the body weight is lost.
• The patient continues to excrete large volumes of urine
experiences weight loss.
• The patient’s condition needs to be monitored frequently during
the test, and the test is terminated if tachycardia, excessive
weight loss, or hypotension develops.
5/5/2023
By Mohammed A
160

161. Treatment objective
• To replace ADH (which is usually a long-term
therapeutic program).
• To ensure adequate fluid replacement.
• To identify and correct the underlying intracranial
pathology.
5/5/2023
By Mohammed A
161

162. Contd…
1. Fluid replacement
2. Central diabetes insipidus may be controlled with vasopressin
(desmopressin, DDAVP). It can be taken as either an injection, a nasal
spray, or tablets.
3. Chlorpropamide (Diabinese) and thiazide diuretics are also used in mild
forms of the disease because they potentiate the action of vasopressin
5/5/2023
By Mohammed A
162

163. Nursing care
• The nurse is responsible to educate the patient, family,
and other caregivers about follow-up care, prevention
of complications, and emergency measures.
• Specific verbal and written instructions should include
the dose, actions, side effects, and administration of all
medications and the signs and symptoms of
hyponatremia
5/5/2023
By Mohammed A
163

164. COMPLICATIONS
 Dehydration: Electrolyte imbalance
• Dry skin and mucus • Fatigue
• Fever & Rapid heart rate • Headache
• Sunken eyes
• Unintentional weight loss
• Irritability
• Muscles pain
5/5/2023
By Mohammed A
164

165. Syndrome of inappropriate antidiuretic
hormone (SIADH)
is caused by too much ADH being secreted by the posterior
pituitary gland.
ADH is responsible for controlling the amount of water
reabsorbed by the kidney; it prevents the loss of too much fluid.
 When too much water is detected, ADH production or secretion
is stopped.
5/5/2023
By Mohammed A
165

166. Cont.…
SIADH may be caused by damage to the hypothalamus or
pituitary, inflammation of the brain, some medications such as
selective serotonin receptor inhibitors (SSRIs), carbamazepine,
cyclophosphamides, and chlorpropamide.
Certain cancers, especially lung, may produce ADH.
5/5/2023
By Mohammed A
166

167. SIGNS AND SYMPTOMS
• Headaches
• Nausea and vomiting
• Confusion
• Personality changes due to hyponatremia
5/5/2023
By Mohammed A
167

168. Interpreting Test Results
• Hyponatremia (low serum sodium) due to the dilution
Treatment
• Administer saline IV to replace sodium.
• Treat underlying cause.
5/5/2023
By Mohammed A
168

169. Nursing Intervention
• Monitor electrolytes to determine sodium levels.
• Restrict fluid because excess fluid dilutes sodium
levels.
• Weigh the patient daily using the same scale, at same
time of day with similar clothing.
• Monitor intake and output.
5/5/2023
By Mohammed A
169

170. D I S O R D E R O F A D R E N A L
G L A N D
5/5/2023
By Mohammed A
170

171. ADDISON’S DISEASE
• Also called chronic adrenal insufficiency,
hypocortisolism,hypoadrenalism)
• is a rare, chronic endocrine system disorder in which the
adrenal glands do not produce sufficient steroid hormones.
5/5/2023
By Mohammed A
171

172. Cont.…
• Age- can affect people of any age, most common between the
ages of 30 and 50.
• Sex- more common in women than men.
5/5/2023
By Mohammed A
172

173. Etiology
• Anatomic destruction of gland (chronic or acute)
• Autoimmune or idiopathic atrophy
• Surgical removal of both adrenal glands
• Infections (tuberculosis, fungal, viral—especially in AIDS)
• Inadequate secretion of ACTH from pituitary gland.
5/5/2023
By Mohammed A
173

174. Types ofAddison’
s disease
Primary
• Associated with primary inability of the
adrenal to secrete sufficient quantities of
hormone
Secondary
• Associated with a secondary failure due to
inadequate ACTH formation or release
5/5/2023
By Mohammed A
174

175. Clinical
Manifestations
17
5
5/5/2023
By Mohammed A

176. Hyperpigmentation
By Mohammed A 17
6
5/5/2023

177. Diagnostic Measures
Specific LAB test
• Serum cortisol
• Plasma ACTH
– If the ACTH level is high, the person probably has primary
adrenal insufficiency.
– If the ACTH level is low, the person probably has secondary
or tertiary adrenal insufficiency.
• Serum glucose
• Serum electrolytes level
• Complete blood count
• CT, MRI;To rule out pituitary and adrenal mass
5/5/2023
By Mohammed A
177

178. Management
Correct fluid and electrolyte imbalances:
• Directed primarily toward repletion of circulating glucocorticoids and replacement of
the sodium and water deficits.
Correct Hypoglycemia:
• An IV infusion of 5% glucose in normal saline solution(DNS) or 25% dextrose bolus.
Replace Steroids:
• a bolus iv infusion of 100 mg hydrocortisone.
• Maintenance100-mg bolus of hydrocortisone IV every 6 h.
• Lifelong replacement of corticosteroids and mineralocorticoids
• Mineralocorticoid supplementation - 0.05–0.1 mg fludrocortisone per day PO.
5/5/2023
By Mohammed A
178

179. NURSING MANAGEMENT
• Physical and psychological stressors must be avoided like exposure to cold,
overexertion, infection, and emotional distress.
• Intravenous administration of fluid, glucose, and electrolytes, especially
sodium; replacement of missing steroid hormones; and vasopressors.
• Assesses the patient’s skin turgor, mucous membranes, weight.
• Encourages the patient to consume foods and fluids and select foods high in
sodium
• Administer hormone replacement as prescribed and to modify the dosage
during illness and other stressful occasions.
5/5/2023
By Mohammed A
179

180. CUSHING’S SYNDROME
is a cluster of clinical abnormalities caused by excessive
levels of adrenocortical hormones (particularly cortisol).
• affects 13 of every 1 million people.
• is more common in women than in men and occurs
primarily between ages 25 and 40
5/5/2023
By Mohammed A
180

181. Etiology
• Excess. In approximately 70% of patients, Cushing’s
syndrome results from excessive production of corticotropin
and consequent hyperplasia of the adrenal cortex.
• Pituitary hypersecretion and pituitary tumors.
5/5/2023
By Mohammed A
181

182. Clinical manifestation
A typical patient is
characterized by
⚫A Buffalo hump
⚫A moon face
Weight gain/central obesity
Diabetes
Hypertension
Skin changes(abdominal
striae)
Muscle weakness
Menstrual irregularity
Hypokalemia
5/5/2023
By Mohammed A
182

183. 5/5/2023
By Mohammed A
183

184. 5/5/2023
By Mohammed A
184

185. Diagnosis
• Imaging studies. Ultrasound, CT scan, or angiography
localizes adrenal tumors and may identify pituitary tumors.
• Serum Electrolyte levels
• Increased blood glucose
5/5/2023
By Mohammed A
185

186. Cont.…
Measurement of a 24-h urine free cortisol can also be used
as a screening test.
A level >140 nmol/d (50 μg/d) is suggestive of Cushing's
syndrome.
5/5/2023
By Mohammed A
186

187. Management
Pituitary irradiation;-Patients with pituitary-dependent
Cushing's syndrome with adrenal hyperplasia may require
pituitary irradiation.
Adrenal enzyme inhibitors;-Metyrapone, aminoglutethimide,
mitote ne, and ketoconazole may be used to reduce
hypoadrenalism.
5/5/2023
By Mohammed A
187

188. Cont.…
Cortisol therapy;-Cortisol therapy is essential during and
after surgery.
Diabetes mellitus and peptic ulcer common in the patient with
Cushing’s syndrome. Therefore, insulin therapy and
medication to treat peptic ulcer may be initiated if needed.
5/5/2023
By Mohammed A
188

189. Nursing Interventions
• Decreasing Risk for injury
• Decreasing risk for infection
• Preparing patient for surgery
• Encouraging rest and activity
• Promoting Skin integrity
• Improving Body image
• Improving thought process
5/5/2023
By Mohammed A
189

190. The end thank you very much
every body for your valuable
attention.
5/5/2023
By Mohammed A
190