ENDOCRINE SYSTEM

Exocrine glands:
• Discharge secretions through a duct onto an epithelial surface
• Have lubricating or digestive function

Endocrine glands:
• Discharge secretions directly into the bloodstream, called hormones.

Hormones
• Chemical substances secreted by endocrine glands directly into the blood stream to act on specific
target cell.
• Regulate growth and development, F & E, reproduction, adaptation to stress and metabolism.
• Types are:
a. Protein peptides (insulin, ADH, GH, ACTH).
b. Amine & amino acid derivatives (epinephrine & norepinephrine).
c. Steroids (cortisol, estrogen, testosterone)
• May or may be controlled directly or indirectly by feedback mechanisms
a. Negative feedback mechanism
b. Positive feedback mechanism

Some nonendocrine organs secrete special endocrine cells that also secrete hormone:
a. Kidneys: renin and REF
b. GI Tract: gastrin

Glands Related to Endocrine System

PITUITARY GLAND
• A small pea-shaped gland connected to the hypothalamus
• 2 lobes – anterior and posterior

Anterior
• Secretes 6 hormones
a. GH promotes tissue growth
• Helps metabolize fats
• Promotes protein synthesis by facilitating amino acid entry into the cells.
• Enhances fat metabolism of energy
b. Prolactin – stimulates milk secretion by the breasts (prepared by estrogen & progesterone)
• Thyrotropin-releasing hormone (TRH) stimulates its secretion
c. TSH – stimulates thyroid gland to synthesize and secrete thyroid hormones
• Thyroxine (T4) and Triiodothyronine (T3) – control general metabolic processes.
• TRH stimulates its secretion
d. ACTH – stimulates the adrenal cortex to manufacture and secrete adrenocorticol hormones.
• Controlled by ACTH-releasing factor from the hypothalamus
• Controls carbohydrates metabolism.
e. FSH and LH – gonadotropic hormones
• Growth and development of the gonads
• Development of secondary sex characteristics.
• LHRH – regulates the 2; from the hypothalamus
Posterior
a. Oxytocin
• Contraction of pregnant uterus
• Stimulates milk ejection
b. Antidiuretic hormone (ADH, vasopressin)
• Promotes water retention

THYROID GLAND
• 2 lateral lobes fixed to the anterior surface of the upper trachea

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• Pituitary TSH  T3 & T4 (negative feedback)
• Metabolic effects of T3 and T4
a. Controls rate of metabolic process
b. Normal growth and development
c. Maturation of nervous system

PARATHYROID GLANDS
• 4 small structures embedded in the surface of the thyroid gland
• Secrete parathyroid hormone – principal regulator of calcium metabolism
• Together with Vitamin D – raise blood calcium level
• Thyrocalcitonin – lowers blood calcium level

ADRENAL GLANDS
• Located on top of the kidneys
• Consists of an outer cortex and an inner medulla

Adrenal cortex
• Secretes 3 hormones:
a. Glucocorticoids – cortisol (major), corticosterone and cortisone, which acts by:
• Raising the blood glucose through gluconeogenesis
• Promoting protein breakdown into amino acids  converted into liver as glucose
b. Mineralocorticoids
• Promotes sodium absorption and potassium excretion at the renal tubules.
• The major is aldosterone
c. Sex hormones
• Small amounts of progesterone, estrogen and testosterone.
• Small amounts of androgen appears  sex drive for women

Adrenal Medulla
• Produces catecholamines (norepinephrine and epinephrine)
• Emotional stress activates sympathetic nervous system  release by A. Medulla
• Liberated catecholamines  “Fight or Flight”
a. Tachycardia, increased CO
b. Vasoconstriction
c. Hyperglycemia, glucogenesis, gluconeogenesis, glycolysis
d. Increased alertness

ISLETS OF LANGERHANS
• Islets are about 1 million cell clusters throughout the pancreas.
• Classified with cells:
a. Alpha
• 20% of islet cells
• Produces glucagon – raises blood glucose level by promoting the conversion of liver
glycogen into glucose
b. Beta
• 70% of islet cells
• Secretes insulin which lowers blood glucose level

Other functions of Insulin

1. Influences carbohydrate, protein and fat metabolism
2. Actions to liver cells, muscle tissues and adipose tissue.
• Promotes entry of glucose into the cells
• Enhances the use of glucose as a source of energy
• Promotes storage of glucose to muscles and liver cells.
• Promotes the entry of amino acids into cells
• Stimulates protein synthesis

c. Delta

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 • 10% of islet cells
• Secretes somatostatin – suppresses insulin and glucagons release

DIAGNOSTIC TESTS

1. T3 T4 levels
• - hyperhyroidism
• ↓ - hypothyroidism

2. PBI (Protein – Bound Iodine)

• Preparation: No Foods, drugs, test dyes with iodine 7–10 days before the test

3. RAIU (Radioactive I Uptake)

• Tracer dose of I131, p.o.
• 2°, 6°, 24° → exposure to scintillation camera
• X Foods, drugs, test dyes with I 7 – 10 to days before the test
• Temporarily discontinue contraceptive pills
Uptake – hyperthyroidism
↓ Uptake – hypothyroidism
4. Thyroid Scan
• Radioisotope / IV
• Exposure to scintillation camera

5. FNB (Fine Needle Biopsy)

6. BMR (Basal Metabolic Rate)
• Measures 02 consumption at the lowest cellular activity
• Preparation
1. NPO 10 – 12°
2. Night Sleep 8 - 10°
3. Don’t get up from the bed the following morning until the test is done
4. A device with a noseclip and a mouthpiece is used; the client performs deep breathing
exercises
5. Normal : ± 20% (euthyroid)

7. Reflex Testing (Kinemometry): Tendon of Achilles Reflex

HYPERTHYROIDISM

• Grave’s Disorder / Parry’s Disorder / Basedow’s Disorder / Exophthalmic Goiter / TOXIC Diffuse
Goiter
• Higher in females, below 40 yrs.
• Severe emotional stress
• Autoimmune Disorder

3 Basic Concepts:
a. Increased metabolic rate
b. Increased body heat production
c. Hypocalcemia

Assessment:

1. Thyroidal disturbances
• Restlessness, nervousness, irritability, • Diaphoresis
agitation • Diarrhea
• Fine tremors • Heat intolerance
• Tachycardia • Amenorrhea
• Hypertension • Fine silky hair
• appetite to eat • Pliable nails
• Weight loss

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2. Ophalmopathy
• Exophthalmos

Von Graefe’s sign (LID LAG)

• Long and deep palpebral fissure when one looks down

Jeffrey’s sign
• Forehead remains smooth when one looks up

Dalyrimple’s sign (Thyroid stare)

• Bright – eyed stare
• Infrequent blinking

3. Dermopathy
• Warm, flushed sweaty skin
• Thickened hyperpigmented skin at the pretibial area

Management:

1. Rest.
• Non – stimulating cool environment
2. Diet
• High caloric
• Low fiber
3. Promote safety
4. Protect the eyes
• Artificial tears at regular intervals
• Wear dark sunglasses when going out under the sun.
5. Replace fluid – electrolyte losses
6. Pharmacotherapy
a. Beta – blockers : Inderal (to control tachycardia, HPN)
b. Iodides : Lugol’s solution
c. SSKI
• To inhibit release of thyroid
• Mix with fruit juice with ice or glass of water
• Provide drinking straw
• Side effects: Allergic reaction, Increased salivation, Coryza

d. Thioamides:
• PTU (Propylthiouracil) & Tapazole (Methimazole)
a. To inhibit synthesis of thyroid hormones
• Side effects:
a. Agranulocytosis / Neutropenia
b. Fever, Sore throat, Skin rashes
e. Ca – channel blockers
f. Dexamethasone
– Inhibit the action of thyroid hormones
–
7. Radiation therapy (I131) – Isolation for few days
8. Surgery
• Subtotal Thyroidectomy

Preoperative Care

1. Promote euthyroid state

• Control of thyroid disturbance
• Stable VS
2. Administer Iodides as ordered
• To reduce the size & vascularity of thyroid gland, thereby prevent postop hemorrhage ,thyroid
crisis
3. ECG

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 • Heart failure / cardiac damage results from HPN / tachycardia

Postoperative Care

1. Position : Semi – Fowler’s with head, neck & shoulder erect.

2. Prevent Hemorrhage
• Ice collar over the neck
3. Keep tracheostomy set available for the first 48° postop.

Parathyroid damage  Hypocalcemia  Laryngospasm  Airway Obstruction

4. Ask the patient to speak q hr.

• To assess for recurrent laryngeal nerve damage
5. Keep Ca gluconate readily available
• Tetany occurs if hypoCa is present
6. Monitor Body Temperature
• Hyperthermia is an initial sign of thyroid crisis
7. Monitor BP
• To assess for Trousseau’s sign (hypocalcemia)
8. Steam inhalation to soothe irritated airways.
9. Advise to support neck with interlaced fingers when getting up from bed
10. Observe for s/sx of potential complications
a. Hemorrhage
b. Airway obstruction
c. Tetany
d. Recurrent laryngeal nerve damage
e. Thyroid crisis / storm / thyrotoxicosis
f. myxedema
11. Client Teaching
a. ROM exercises of the neck 3 – 4 x / day after discharge.
b. Regular follow – up care

HYPOTHYROIDISM
o Myxedema (Adult)
o Cretinism (Children)
o Causes
• Autoimmune • Radiation therapy
• Surgery • Antithyroid drugs

3 Basic Concepts:
1. Decreased metabolic rate
2. Decreased body heat production
3. Hypercalcemia

Assessment:
• Slowed physical, mental reactions • Cold intolerance
• Dull look • Constipation
• Anorexia • Coarse, dry, sparse hair
• Obesity • Brittle nails
• Bradycardia • Irregular menstruation
• Hyperlipidemia

Management:
1. Monitor VS. Be alert for s & sx of CV disorders
2. Diet
• ↓ caloric
• fiber
3. Provide warm environment during cold climate.
4. Pharmacotherapy
• Proloid (Thyroglobulin)
• Synthroid (Levothyroxine)

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 • Dessicated Thyroid Extract
• Cytomel (Liothyronine)

 BP , PR before administration
 Start with low dose , gradually increase

DIABETES MELLITUS

Diagnostic Tests

1. FBS
• 80 – 120 mg / dl
• DM: 140 mg / dl for 2 readings
2. 2° PPBS
• Initial blood specimen is withdrawn
• 100 g. of carbohydrate in diet
• 2° after meal blood specimen is withdrawn – blood sugar returns to normal level
3. OGTT / GTT (Oral Glucose Tolerance Test)
• Take high CHO diet (200- 300 g) for 3 days
• Avoid alcohol, coffee, and smoking for 36 hours
• NPO for10- 16 hours
• Initial urine & blood specimen are collected
• 150 – 300 g. of CHO / p.o./IV
• Done when results of FBS / 2°PPBS are borderline (high normal)

4. Glycosylated Hgb
• Most accurate
• Reflects s. CHO levels for the past 3 – 4 mos.

excess glucose in the blood  attach to hemoglobin  hgb (component of rbc)

• Cause – Unknown
• Predisposing Factors
1. Stress 4. Viral infection
2. Heredity 5. Autoimmune Disorder
3. Obesity 6. Women: Multigravida with Large babies
Types:

IDDM
 Juvenile – onset
 Brittle DM
 Unstable DM
 < 30 yrs.
 Absolute Insulin deficiency
 Thin
 Prone to DKA
 Management:
1. Diet
2. Activity/ Exercise
3. Insulin

NIDDM
 Maturity – onset Stable DM
 Ketosis – resistant DM
 > 40 yrs.
 With insulin sec., demands
 Obesed
 Prone to HHNC
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 Management:
1. Diet
2. Activity/ Exercise
3. OHA
4. Insulin – stress, surgery, infections, pregnancy

Pathophysiology

Insulin Deficiency
↓
Hyperglycemia
↓

A. blood osmolarity
• ICF dehydration
B. Glycosuria
• Glucose level exceeds renal threshold
C. Polyuria
• Glucose exerts high osmotic pressure within the renal tubules
• Osmotic diuresis occurs
• Hypovolemia
• ECF dehydration
D. Polydipsia
• Results from ECF/ICF dehydration
E. blood viscosity
• Sluggish circulation
• Proliferation of microorganisms

↓
Infections
 Periodontal
 UTI
 Vasculitis
 Cellulitis
 Vaginitis
 Furuncles
 Carbuncles
 Retarded Wound
 Healing

F. Polyphagia - the cells are starve

lipolysis
↓
Hyperlipidemia
↓
Atherosclerosis
 Macroangiopathy
 Brain : CVA
 Heart : MI
 Peripheral arteries: PVD’s
 Microangiopathy
 Kidneys : RF
 Eyes : Retinopathy / cataract
 Neuropathy
 Peripheral neuropathy
 Numbness / tingling
 Paralysis
 Gastroparesis
 Neurogenic bladder

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  ↓ libido, impotence

↓
Ketonemia

Acetone, Aceto – acetic acid, Beta – hydroxy – butyric acid

 ↓ blood ph - KETOACIDOSIS
 Ketonuria

 CHON breakdown
↓
(-) Nitrogen balance
A. BUN, s. creatinine
B. Tissue wasting
C. Weight loss
D. Debilitation

Management

Diet
o High caloric diet
o 20% CHON, 30% HCHO, 50% CHO
o Low fiber diet
o Complex carbohydrates

Activity
o Increases CHO uptake by the cells
o Decreases Insulin requirements
o Allows additional sources of CHO: Snacks
o Maintains IBW, S. CHO & S. Lipids
o Done 1 – 2° p.c.
o Regular pattern

Medications
1. OHA
o Stimulates I of L to secrete insulin
o Indicated only in Type II DM
Diabenese Glucotrol
Orinase Daonil
Tolinase Diamicron
Micronase Glucophage
Dymelor Glucobay
o Observe for s/sx of G.I. Upset
o Hypoglycemia
2. Insulin
a. Rapid – Acting : Clear insulin
Examples: Regular, Humulin – R, Semilente, Crystalline zinc, Actrapid
Onset : 30 mins. - 1°
Peak : 2 – 4°
Duration : 6 – 8°
b. Intermediate – Acting: cloudy
Examples: NPH, Humulin – N, Lente, Monotard
Onset : 1 - 2°
Peak : 6 - 8°
Duration : 18 - 24°
c. Long Acting : Cloudy
Examples: PZI, Ultralente
Onset : 3 - 4°
Peak : 16 - 20°
Duration : 30 – 36°

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Nursing Responsibilities in Insulin Therapy
1. Route : Subcutaneous
o slow absorption
o less painful
o IV – DKA
o SC - 90°L thin: 3/8”
obesed: ½”, 5/8”
o Don’t massage site of injection

2. Administer insulin at room temperature

o Cold Insulin → LIPODYSTROPHY
3. Rotate the site of injection
o Prevent lipodystrophy
Store vial of insulin in current use @ room temperature
o Other vials should be refrigerated.
4. Gently roll vial in between the palms to redistribute insulin particles.
o Never Shake; bubbles make it difficult to aspirate exact amount.
5. Observe for side – effects:
a. Localized:
o Induration or Redness
o Swelling
o Lesion at the site
o Lipodystrophy
b. Generalized
o Edema
Sudden resolution of hyperglycemia  retention of water
o Hypoglycemia
o Somogyi phenomenon

Prolonged
doses of INSULIN Tx
↓
↓ s. CHO levels
↓
Stress responses are triggered
Counterregulatory hormones are secreted
(EPI, NE, Glucocorticoid)
↓
REBOUND HYPERGLYCEMIA

Foot Care:
1. Inspect the feet daily.
2. Wash feet with warm water and mild soap.
3. Pat dry the feet – X rub
4. Wear comfortable properly – fitted pair of shoes (leather/ canvass)
5. Break – in new pair of shoes for 1 – 2° only until it becomes comfortable.
6. Use white cotton socks (males)
7. X go barefooted
8. Trim the toenails straight across. Do not cut at lateral edges, ingrowns may develop.
9. Apply lotion on the feet ( X interdigital spaces)
10. Exercise / massage the feet.
11. X wear knee – high / stay – up stockings
12. For any s & sx of injury; consult a PODIATRIST.

CUSHING’S DISEASE AND CUSHING’S SYNDROME

Diagnostic Tests:
o Dexamethasone Suppression Test

Description:

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 o hypersecretion of adrenal hormones due to excess secretion of ACTH
o hypercorticism resulting from Cushing’s disease or due to administration of steroid hormones.

Etiology:
o Tumor (adrenal gland neoplasm)

Pathophysiology:
Cause
↓
Elevated steroids
↓
Exaggeration of hormonal effects

o Steroids antagonize insulin  increased serum glucose levels and possible diabetic state.
o Adipose tissue accumulates in the abdomen and behind he shoulders (buffalo hump); the arms
and legs become thinner.
o Accelerated protein catabolism  muscle wasting  weakness and difficult movement.
o Other manifestations can include:
o Mood changes (from euphoria to depression)
o Amenorrhea
o Immunosuppresion
o Changes in skin pigmentations (as ACTH stimulates melanocytes)

Nursing Interventions:
1. Monitor vital signs.
2. Monitor serum laboratory values.
3. Administer antihypertensive drugs, as prescribed, to control hypertension.
4. Provide adequate nutrition.

ADRENAL HYPOFUNCTION

Description:

Insufficient hormone secretion due to adrenal gland abnormality due to adrenal cortex destruction
↓
glucocorticoid and mineralocorticoid production impairment

May be:
o Primary (Addison’s disease)
o Secondary.

Pathophysiology:
1. Adrenal cortex dysfunction  deficient mineralocorticoid and glucocorticoid secretion.
2. Aldosterone and cortisol, are deficient.
3. Low level aldosterone  reduced sodium absorption
4. Water is excreted along with sodium  hypovolemia and hypotension .
5. Hyperkalemia because of hyponatremia.

Nursing Interventions:
1. Replacement therapy of mineralocorticoid and glucocorticoid, as ordered.
2. Low-potassium, high-sodium diet.
3. Monitor for sleep disturbances.
4. Assess for signs of dehydration.
5. Assess vital signs
6. Prepare the patient for surgery, if a tumor is the causative factor.
Adrenalectomy / Hypophysectomy

HYPERPITUITARISM

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Description:
o Chronic, progressive disease
o Excessive growth hormone (GH) secretion and tissue over-growth.
o Appears as:
o Gigantism
o Acromegaly

Etiology:
o An anterior pituitary adenoma

Pathophysiology:
o Overgrowth of tissues (neurologic and secretory problems)
o Local expansion of a pituitary adenoma (when present) causes both neurologic and secretory
effects.
o Optic and trigeminal nerve involvement causes visual disturbances.

Nursing Intervention:
1. Counseling to deal with feelings about change body image.
2. Assist with ROM to maximize joint movement.
3. Monitor for visual disturbances.
4. Prepare the patient for surgery, if indicated.

HYPOPITUITARISM

Description:
o Deficient secretion of the anterior pituitary hormones
o Marked by:
o Dwarfism
o metabolic dysfunction
o sexual immaturity
o growth retardation.

Etiology:
o Tumors
o Congenital defects
o Pituitary ischemia
o Partial or total hypophysectomy
o Radiation therapy
o Chemical agents
o Head injury.

Pathophysiology:
o The gland must be at least 75% dysfunctional before manifestations become apparent.
o S/Sx
o Headache (tumor)
o Weight loss
o Hair loss
o Impotence
o Amenorrhea

ADH – RELATED PROBLEMS

SIADH
o Characterized by excessive retention of water.
o Edema
o Weight gain
o Hypertension
o Hyponatremia

Diabetes Insipidus
o Inability of the renal tubules to retain water.
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o Polyuria (20 L/day)
o Dehydration
o Constipation
o Dilute, water-like urine (↓specific gravity)

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