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Endocrine 4

  1. Disorders of the Adrenal Gland
  2. Addison's disease
    1. Definition
      1. adrenal cortexsecretes too little adrenocorticotropic hormone(ACTH)
      2. decreases secretion of other adrenal products: mineralocorticoid, glucocorticoids, and sex hormones
      3. relatively rare
    2. Etiology - autoimmune adrenalitis
    3. Findings
      1. acute adrenal insufficiency (Addisonian crisis)
        1. severe headache or back pain
        2. severe generalized muscle weakness
        3. diarrhea or constipation
        4. confusion
        5. lethargy
        6. severe hypotension
        7. circulatory collapse
      2. adrenal insufficiency
        1. vague complaints or findings
        2. fatigue
        3. muscle weakness
        4. vague abdominal complaints: anorexia, nausea, vomiting
        5. personality changes
        6. skin pigmentation
    1. Diagnostics 
      1. history and physical exam
      2. ACTH stimulation test: low cortisol level
      3. low blood levels of sodium and glucose and high levels of potassium
      4. 24-hour urine collection: decreased levels of free cortisol
    2. Management 
      1. expected outcome: to return to hormonal balance
      2. Addisonian crisis
        1. emergency management of circulatory collapse
        2. intravenous hydrocortisone
      3. chronic insufficiency
        1. glucocorticoid replacement therapy: hydrocortisone (cortef)
        2. mineralocorticoid replacement therapy: fludrocortisone acetate (florinef acetate)
        3. diet high in protein, carbohydrates, and sodium
    3.
  3. Diagnostics 
    1. history and physical exam
    2. blood tests show
      1. increased levels of cortisol,
      2. increased sodium and glucose,
      3. decreased potassium
    3. 24-hour urine collection:
      1. elevated free cortisol
      2. elevated 17-ketosteroids
      3. elevated 17-hydroxycorticosterone
  4. Management
    1. expected outcome: to restore hormonal balance
    2. surgery for adrenal or pituitary tumor
    3. irradiation therapy
    4. pharmacologic
    5. adrenal enzyme inhibitors that block enzymes needed for cortisol synthesis
      1. aminogluthemide
      2. metyrapone
      3. mitotane
    6. potassium supplements
    7. high protein diet with sodium restriction
  5. Nursing interventions
    1. administer medications as ordered
    2. monitor diet therapy
    3. monitor for signs of hypokalemia, hypernatremia
    4. teach client 
      1. the need for lifelong treatment
      2. about medications and side effects
      3. the need for medical alert jewelry
    5. surgical treatment may cause adrenal or pituitary insufficiency
  6. Pheochromocytoma
  7. Definition
    Adrenal medulla secretes too much epinephrine and norepinephrine (called the catecholamines). Causes excessive stimulation of the sympathetic nervous system
  8. Etiology
    1. generally benign tumor of the adrenal medulla
    2. curable, but fatal if untreated
  9. Findings
    1. severe stress response
    2. panic metabolic state
    3. hypertensive crisis
    4. headache, usually severe
    5. orthostatic hypotension
    6. tachycardia
    7. pallor or flushing
    8. diaphoresis
    9. palpitations
    10. anxiety, high and sustained
    11. hyperglycemia
    12. dysrhythmias
  10. Diagnostics 
    1. increased BMR
    2. computerized tomogram (CT) scan
    3. 24-hour urine collection: increased urinary catecholamines
  11. Management
    1. expected outcomes: to remove the tumor and correct the imbalance
    2. surgical removal of the tumor: scheduled only after client has been normotensive for at least one week
    3. antihypertensive agents as needed preop
    4. alpha-adrenergic blocking agentand beta adrenergic blocking agent(beta blockers): phentolamine (regitine), nitroprusside (nitropress), propranolol (inderal)
    5. tyrosine inhibitors: alphamethylparatyrosine decreases circulating catecholamines
    6. antidysrhythmic agents as needed preop
  12. Nursing interventions
    1. monitor vital signs, especially blood pressure
    2. administer medications as ordered
    3. provide care of the client undergoing surgery
    4. if bilateral adrenalectomy performed, lifelong steroid therapy required
    5. teach client
      1. about medications and side effects
      2. need for lifelong followup
  13. Disorders of the Pancreas
  14. Diabetes mellitus
    1. Definition - a condition in which the pancreas produces too little insulin, or cells stop responding to insulin; results in hyperglycemia
      1. type 1 diabetes mellitus: genetic, auto-immune respones; severe insulin deficiency from beta cells stop production of insulin
      2. type 2 diabetes mellitus: obesity; cells stop responding to insulin
    1. Diagnostics
      1. history and physical exam
      2. fasting blood sugar: elevated serum glucose levels
      3. oral glucose tolerance test (GTT)
      4. after meal, serum glucose is elevated - post-prandial glucose
      5. glycosylated hemoglobin test (A1c test)
    2. Data collection
      1. hyperglycemia
      2. the 3 "polys" of diabetes mellitus: polydipsia, polyuria, polyphagia
      3. additional findings: fatigue, hunger, weight loss
      4. blurred vision
      5. slow wound healing
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