Endocrine (test 11)

Age related changes to the endocrine system

• Pituitary gland gets smaller

• hormones decrease (some)

• changes in sensitivity to insulin

• baseline glucose increases Medications used to treat hormone issues need lowered doses for older adults

Thyroid gland hormones

-thyroxine (T4)

• triiodothyronine (T3)

• Calcitonin (stops bone breakdown to lower calcium levels in body)

Where is the parathyroid located

On the back of the thyroid (in the neck)

Where is the pituitary located?

In the brain

Where are the adrenal glands located?

On the kidneys

Where is the thyroid gland located

In the neck

Parathyroid hormones

• Parathyroid hormone (PTH). Increases blood calcium by breaking down bones, increases calcium absorption in digestive tract, decreases calcium lost in urine. (by removing phosphorus)

*** release of this hormone is dependant on if calcium levels are high or low. Low calcium signals PTH to be released****

Adrenal cortex is the ___

doughnut

Adrenal medulla is the ____

jelly

Adrenal cortex hormones

• Mineralocorticoids (aldosterone) which increases sodium and water that the body holds on to

• Glucocorticoids (cortisol) which raises glucose and lowers inflammation

• androgens and estrogens which work with ovaries or testes

Adrenal medulla hormones

• Epinephrine/norepinephrine (fight or flight response, increases HR, BP, RR)

• triggered by sympathetic NS

Thyroid gland works by

• converting iodine into thyroid hormones (T4, T3) (T4 gets converted to T3)

• requires protein for this conversion

Describe a negative feedback loop and how it relates to hormones

If a hormone level is low, a signal will be sent to release more hormone until it is normal. The opposite is also true, if a hormone is high, a signal will be sent to stop releasing said hormone

Pituitary hormones

• Anterior Pituitary (AP) and posterior pituitary (PP)

• AP: growth hormone

• AP: thyroid stimulating hormone

• AP: follicle stimulating hormone (follicles in ovaries, spermatogenesis in men)

• AP: adrenocorticotropic hormone (ACTH) (cortisol secretion)

• AP: Luteinizing hormone (LH) (ovulation, progesterone, testosterone)

• AP: prolactin (milk production)

PP: ADH (increases kidney water and sodium absorption) PP: oxytocin (uterine contractions, milk ejection)

Nursing care for post pituitary surgery (or any surgery in neck, head, ect)

• ensure drainage is bloody/mucus, NOT clear and watery which could indicate cerebral spinal fluid leak

• do NOT increase ICP, no sneezing, coughing, leaning over

If a patient who is not pregnant or breastfeeding comes in with milk production, what lab do you expect to be high?

Prolactin

• could indicate tumor of pituitary

normal calcium

8-10

Normal phosphorus

2.8-4.5

Describe a radioactive iodine uptake test

• NOT during OB or lactation

• Small amount of radioactive iodine put into body to see if thyroid takes it in (assess thyroid function)

Why would a provider order an ECG for a patient with a hormone problem?

• if the hormone problem is leading to suspected dysrhythmias of the heart

S/S of pituitary adenoma (tumor)

• headache

• visual changes

Too much GH (growth hormone) can cause ___

Gigantism in kids (same characteristics as acromegaly) acromegaly in adults (large head, hands,feet)

Too much prolactin causes

• no periods

• abnormal lactation

• hair loss + impotence in males

Too little GH (growth hormone) can cause

Small stature, bone breakdown

Abnormal gonadotropins can cause

infertility/sterility

Diabetes Insipidus

• peeing all the time

• large amounts of diluted urine

• caused by too little ADH

Syndrome of inappropriate antidiuretic hormone

• Opposite of diabetes insipidus

• too much ADH

• not urinating enough or at all

Goiter

Enlargement of the thyroid gland

• can be caused by not enough iodine in diet (teach patient to increase salt!!)

• may also be caused by not enough protein in diet

• can also be caused by lack of TH (thyroid hormone), Ca, nodules

Labs for thyroid problems

• TRH

• TSH

• T3

• T4

• antibody titers

Nursing: administering iodine

• give through a straw (stains teeth otherwise)

• give well diluted

Hyperthyroidism

• too much T3 and T4 circulating blood

• LOW TSH because body is trying to slow thyroid production

• graves disease causes this often times

• everything speeds up, metabolism, heart rate, ect.

Symptoms of hyperthyroidism

• weight loss

• anxiety

• tremors

• tachycardia

• amenorrhea ( older adults may have CP, SOB, palpitations)

Treatment of hyperthyroidism

• Methimazole

• surgery/ablation (watch for thyroid storm/crisis after surgery, which is when manipluation of the thyroid causes increased levels of t4)

Graves disease

• Autoimmune disorder

• causes hyperthyroidism

• causes destruction and enlargement of thyroid so hormones spill out

Exophthalmos

bulging of eyeballs, common with graves disease

Thyroidectomy

Removal of thyroid, usually a last resort due to risk of

• hemorrhage

• loss of parathyroid

• thyroid storm/crisis Post op: high fowler's, neutral head

Thyroid storm/crisis

When manipulation of the thyroid causes release of T4

• common during surgery to remove thyroid

• S/S include sudden high fever, pulse increase, RR increase

Hypothyroidism

• LOW T3 and T4

• HIGH TSH (body trying to get thyroid to produce more)

• body processes slow down

• hashimotos is common cause

S/S of hypothyroidism

• Weight gain

• Constipation

• hair loss

• bradycardia

• low iodine

Treatment of hypothyroidism

• Levothyroxine (Synthroid)

• Armor (pig hormone!!)

levothyroxine for hypothyroidism tx patient teaching

• take on empty stomach

• take at same time each day

• may take 6-8 weeks to see improvement

• lifelong therapy, do not stop taking

Hypoparathyroidism

• too little parathyroid hormone

• usually caused by trauma or surgery to remove thyroid causing accidental damage

• cases low calcium, high phosphorus S/S: numbness, tingling, tatany, convulsions

Hyperparathyroidism

• too much parathyroid hormone High calcium, low phosphorus

• S/S lethargy, confusion, nausea, arrhythmias, bone fractures

Addison's disease

(Adrenal disorder)

• decrease in adrenal cortex function, less cortisol

• S/S: low BP, arrhythmias, low sodium, too much potassium, weakness, hypoglycemia

Adrenal crisis

Addison's disease with another stressor such as infection

• can be caused by stopping steroids too fast

• can cause death, shock

Cushing's disease

• too many hormones from adrenal cortex

• can be r/t long term steroid use S/S: buffalo hump, moon face, bruising, big body and skinny arms, abnormal hair

approximately _% of people have DM

10

Normal A1C

Below 5.6: normal 5.7-6.4: pre DM 6.4: DM

Type one DM

• Destruction of pancreas beta cells

• no insulin is produced

• requires insulin to survive

Type 2 DM

• Insulin resistance, bodies receptors do not respond to insulin

• may need insulin eventually

Latent autoimmune diabetes

• Mix of type 1 and type 2 DM (can be called 1.5)

• partial failure of beta cells, AND insulin resistance

• positive test for islet cell antibodies

Metabolic syndrome

• cluster of conditions that increase risk for CAD, stroke, DM

• cluster of conditions include: high B/P, high blood sugar, high high HDL, abd fat

Risk factors for diabetes

• Genes (people closer to you in family tree)

• race: (Type 1 more common in whites) (Type 2 more common in native americans, blacks)

• continued stress

• viral infection triggering type 1

• apple body shape

• obesity

S/S of Type 1 DM

• hyperglycemia (very high)

• polyuria, polydipsia (excessive thirst)

• weight loss

• blurry vision

• excessive hunger

S/S of Type 2 DM

• weight gain

• slow healing

• fatigue

DM management

• Diet

• exercise (lowers insulin resistance)

• if pre diabetic exercise and diet can stop you from getting full diabetes

• helps control type 2 DM and reduce insulin needs

Biguanides

Metformin

• Lowers A1C

• lowers liver release of glucose

• increases sensitivity to insulin DO NOT USE WITH CIRRHOSIS OR GFR less than 30

DPP-4

Gliptins

• controls hormones that control glucose and insulin

Alpha glucosidase inhibitors

• lowered absorption of CHO in gut

Meglitinides

Ends in glutides

• stimulates insulin production

Rapid acting insulin

Aspart (NovoLOg), Lispro (Humalog)

• acts in 15 min

• peaks in 1-3 h

• lasts 3-5 h

Short acting insulin

Regular insulin (humulin, novolin)

• onset in 30 min

• peaks in 2-4 h

• lasts 5-8 h

Intermediate insulin

(NPH, lente) Onset: 1h Peaks in 4-12 h Lasts 24 h

Long acting insulin

Glargine (lantus) Onset: 2-4 h Peaks in: n/a Lasts 24 hours

When drawing up insulin go___ to ____

clear to cloudy

Insulin best absorbed in

• Abdomen

• thighs, arms buttocks most slow

What can exercise do to glucose

Lower it

• lower insulin dose slightly if exercising

Diabetic ketoacidosis

• More common in type 1

• sugar gets too high for too long, body breaks down fat which produces ketones causing acidosis

• causes metabolic acidosis, electrolyte imbalance and dehydration

DKA s/s

• high RR

• fruity breath

• ketones in urine

• glucose in urine

• dry MM

• low B/P

• dehydration

Hyperglycemic hyperosmolar state

More common in type 2 DM, same as DKA but for type 2

• s/s same as DKA but with more neurologic symptoms

• more deadly than DKA

• NOT breaking down fat like with DKA so no ketones in urine

Dawn phenomenon

-Naturally higher glucose in the AM

Older adults more susceptible to ____

hypoglycemia

Poorly treated DM can cause

• blindness

• kidney failure

• amputation

Cortisol is higher in the ____

morning

• gets lower throughout the day

• when testing cortisol levels must test 2-3 times in 24 h

abnormal fasting glucose

-Over 126= bad

• over 100 = pre DM

• random over 200 = bad