Wednesday, November 22, 2006

More endocrine.....review...never ending endo

ADRENALS there are two of these, and each has two parts…the adrenal medulla and the adrenal cortex. The hormone secretion is regulated by the pituitary ACTH. The adrenal medulla is at the center of the gland and it secretes catecholamines. These regulate metabolic pathways to promote the catabolism of stored fuels to meet calorie needs. They increase the blood sugar and increase the metabolic rate. Epinephrine--of course…again is responsible for the fight/flight response. In times of emergency it decreases blood flow to the extremities, GI (not needed) and increase blood supply to the brain and heart. The cortex is the outer portion of the gland. It secretes Steroids and sex hormones (covered last year). Steroids are needed to regulate the body’s response to physical and psychological stress….Glucocorticoids--important to glucose metabolism. Increased secretion leads to increase blood glucose. These are often given to reduce inflammatory response such as allergic reaction, anaphylaxis. Side effects= increase blood glucose, osteoporosis, ulcer, poor wound healing. Mineralcorticoids (Aldosterone) Primary hormone for long term Na+ balance. Act on the kidneys and GI to increase the sodium absorption in exchange for excretion of K+ or Hydrogen ions. Occurs in the presence of angiotensin 2.
(Minimally) Adrenal Sex hormones= Androgens- like male sex hormones. Estrogen--secretes small amounts of this.
DYSFUNCTION OF ADRENAL GLANDS (4)
In the Medulla--PHEOCHROMOCYTOMA--catecholamines are increased. The severity depends on how much epinephrine and norepinephrine are secreted. Causes hypertension (I mean really high) Tumor usually on the adrenal medulla. Clinical s/s= tremor, headache flushing, anxiety, hyperglycemia (remember what epinephrine does) Liver and muscle glycogen turning into glucose. Diagnostics= check urine and plasma levels of catecholamines. The most direct and conclusive test for over activity of the adrenal medulla is t he 24 hour urine for VMA (vanillylmandelic acid) Test.--levels of VMA in the urine will be increased. Diet for this test is no coffee, tea, bananas, chocolate, vanilla, (Oh No!!!) and aspirin prior to the test. ADRENALECTOMY--removal of the tumor. Manipulating the tumor may cause a release of stored epi/norepi….which may increase the heart rate and blood pressure. If both adrenals are removed, Corticosteroids replacement is needed. Hypotension or hypoglycemia may occur because of the sudden withdrawal of catecholamines. Check plasma and urine levels (of catecholamines)! To see if the surgery has been successful.
On to the Cortex…..ADDISONs DISEASE not enough adrenocortical hormones. Caused by TB destroying the gland. Or maybe autoimmune atrophy. Clinical s&s= muscle weakness, fatigue, wasting, anorexia, GI--nausea, vomit, diarrhea leading to dehydration, weight loss. Increased melanocyte hormone causes bronze darkening of mucus membranes, skin, knuckles, knees. Hypotension from hyponatremia--low Na+ craving salt. K+ may be elevated leading to cardiac arrhythmias. *******Hypoglycemia--tired and weak*********
Addisons Crisis
---severe hypotension and shock, cyanosis, fever, headache, GI symptoms. On slight overexertions, cold temp, infections or decrease in salt. Leading to shock, circulatory collapse and death. To prevent all this would be Corticosteroids replacement. Labs= low blood sugar, low sodium, high K+, high white blood cells, low levels of adrenocortical hormones, low cortisol levels. Management= fight the shock. Restore blood circulation, fluids, Corticosteroids replacement, treat infections, Provide IV therapy with Na+. Glucose, lytes. Rest. TEACHING= patient should be taught to prevent hyponatremia to increase sodium intake, to prevent illness, stress. Lifelong hormone replacement, to increase CHO and protein.
CUSHINGS SYNDROME has increased production of ACTH. The problem is from to much Corticosteroids being secreted by the adrenal cortex. Caused by adrenocortical tumor or pituitary tumor secreting ACTH which then causes increased secretion of glucocorticoids. If the cause is a pituitary hormone…..treatment of choice is removal of the pit gland. Signs/symptoms= cortisol levels are increased, hypernatremia leading to fluid retention, hypocalcemia, hyperglycemia. Nursing Care= protect from infection, skin care, decrease stress, check edema, accuchecks and insulin as ordered, diet--low calorie, low Na+, high K+, high Ca+, high vit D. daily weights, I&O.
PITUITARY GLAND (covered)
HYPOPITUITARISM disease of pit gland or hypothalamus…tumor, trauma or radiation. Treatment= replace the hormones! Corticosteroids, thyroid hormone, sex hormones, gonadotropins. Diagnose= x ray, CT scan. (to see tumor)
HYPOPHYSECTOMY--partial or complete. 2 approaches. To gain access to the pituitary gland the common approach transsphenoidal. The surgeon makes an incision beneath the upper lip to get inside the nasal cavity. The surgical site is the sella turcica. . Post operative nursing care=Increase head of bed to ease pressure on the sella turcica, and to promote normal drainage. Assess for clear drainage from the nose, constant swallowing, check for glucose in drainage--if positive= CSF Leak. Leak usually resolves in 72hr. May need spinal tap to decrease pressure. Anticipate antibiotics to prevent meningitis. Reduce Cerebral Edema- expect meds to reduce edema- mannitol (draws free water) Decadron may be given IV q6 hours for 24-72 hours….then tapered off. Relieve pain and reduce seizures= Acetaminophen for temp greater than 99.6 F (37.5C) and for pain. Codeine or morphine may be ordered for pain. Monitor the ICP. I&O . Urine specific gravity after each voiding. Check nasal packing frequently for blood and CSF. Oral Care every four hours…they are dry from mouth breathing. Teaching=No bending, no straining, for 2 months post op, no tooth brushing until sutures are out and heal--10days. If whole gland removed patient will have permanent diabetes insipid is.
ABSENCE OF PITUITARY GLAND
Menstruation ceases, Infertility occurs. Need Replacement hormone therapy. Testosterone for me, estrogen for women and HPG may restore fertility in women.
DIABETES INSIPIDIS hypofunction of the posterior pituitary. Leads to deficiency of ADH or Vasopressin. Cause= brain tumor, head trauma, inflammation, removal of the pit gland. S/s= thirst for cold water. Can drink up to 20 Liters a day. Dehydration, polydipsia, low specific gravity of urine ( 1.001-1.005) Large volumes of dilute urine. Diagnosis of DI is the fluid deprivation test. =withhold fluids for 8-12 hours or until 3-5% of body weight is lost. During test= frequent weights, plamsa and osmality of urine, specific gravity of urine. Stop Test if patient becomes tachycardia, weight loss greater than 5 %, If hypotension. Treatment= fluid and lyte replacement. I&O, weights. Administer hormone replacement as ordered= vasopressin (Pitressin) and vasopressin tannate IM, Lypressin nasal spray.
So there it is...I am studying instead of drawing. I have alot more to do.

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