1. Assessment and Management of Patients with Endocrine Disorders Dr Ibraheem Bashayreh

2. Location of the major endocrine glands.

3. Definition of Hormones • Chemical messengers of the body • Act on specific target cells • Regulated by negative feedback • Too much hormone, then hormone release reduced • Too little hormone, then hormone release increased

4. Glands of the Endocrine System • Hypothalamus • Posterior Pituitary • Anterior Pituitary • Thyroid • Parathyroids • Adrenals • Pancreatic islets • Ovaries and testes

5. Hypothalamus • Sits between the cerebrum and brainstem • Houses the pituitary gland and hypothalamus • Regulates: • Temperature • Fluid volume • Growth • Pain and pleasure response • Hunger and thirst

6. Hypothalamus Hormones • Releasing and inhibiting hormones • Corticotropin-releasing hormone • Thyrotropin-releasing hormone • Growth hormone-releasing hormone • Gonadotropin-releasing hormone • Somatostatin-=-inhibits GH and TSH

7. Pituitary Gland • Sits beneath the hypothalamus • Termed the “master gland” • Divided into: • Anterior Pituitary Gland • Posterior Pituitary Gland

8. Anterior Pituitary Gland • Promotes growth • Stimulates the secretion of six hormones • Controls pigmentation of the skin

9. Anterior Pituitary Gland Hormones • Growth Hormone-- • Adrenocorticotropic hormone • Thyroid stimulating hormone • Follicle stimulating hormone—ovary in female, sperm in males • Luteinizing hormone—corpus luteum in females, secretion of testosterone in males • Prolactin—prepares female breasts for lactation

10. Actions of the major hormones of the anterior pituitary.

11. Posterior Pituitary Gland • Stimulates the secretion of two hormones • Promotes water retention

12. Posterior Pituitary Hormones • Antidiuretic Hormone • Oxytocin—contraction of uterus, milk ejection from breasts

13. Adrenal Cortex • Mineralocorticoid—aldosterone. Affects sodium absorption, loss of potassium by kidney • Glucocorticoids—cortisol. Affects metabolism, regulates blood sugar levels, affects growth, anti-inflammatory action, decreases effects of stress • Adrenal androgens—dehydroepiandrosterone and androstenedione. Converted to testosterone in the periphery.

14. Adrenal Medulla • Epinephrine and norepinephrine serve as neurotransmitters for sympathetic system

15. Thyroid Gland • Butterfly shaped • Sits on either side of the trachea • Has two lobes connected with an isthmus • Functions in the presence of iodine • Stimulates the secretion of three hormones • Involved with metabolic rate management and serum calcium levels

16. Thyroid • Follicular cells—excretion of triiodothyronine (T3) and thyroxine (T4)—Increase BMR, increase bone and calcium turnover, increase response to catecholamines, need for fetal G&D • Thyroid C cells—calcitonin. Lowers blood calcium and phosphate levels • BMR: Basal Metabolic Rate

17. Parathyroid Glands • Embedded within the posterior lobes of the thyroid gland • Secretion of one hormone • Maintenance of serum calcium levels

18. Parathyroid • Parathyroid hormone—regulates serum calcium

19. Pancreas • Located behind the stomach between the spleen and duodenum • Has two major functions • Digestive enzymes • Releases two hormones: insulin and glucagon

20. Pancreatic Hormones Insulin Glucagon—stimulates glycogenolysis and glyconeogenesis Somatostatin—decreases intestinal absorption of glucose

21. Insulin • Produced by the Beta cells in the islets of Langerhans • Regulates blood glucose levels • Mechanisms • Eases the active transport of glucose into muscle and fat cells • Facilitates fat formation • Inhibits the breakdown and movement of stored fat • Helps with protein synthesis

22. Action of insulin and glucagon on blood glucose levels. (A) High blood glucose is lowered by insulin release.

23. (continued) Action of insulin and glucagon on blood glucose levels. (B) Low blood glucose is raised by glucagon release.

24. Glucagon • Produced by the alpha cells in the islets of Langerhans • Glucagon released when blood glucose falls below 70 mg/dL

25. Glucagon • Prevents blood glucose from decreasing below a certain level • Functions: • Makes new glucose • Converts glycogen into glucose in the liver and muscles • Prevents excess glucose breakdown • Decreases glucose oxidation and increases blood glucose

26. Kidney • 1, 25 dihydroxyvitamin D—stimulates calcium absorption from the intestine • Renin—activates the RAS • Erythropoietin—Increases red blood cell production • RAS: Renin-Angiotensin System

27. Adrenal Glands • Pyramid-shaped organs that sit on top of the kidneys • Each has two parts: • Outer Cortex • Inner Medulla

28. Adrenal Cortex • Secretion of two hormones • Glucocorticoids: cortisol • Mineralocortocoids: aldosterone • Involved with blood glucose level, anti-inflammatory response, blood volume, and electrolyte maintenance

29. Adrenal Medulla • Secretion of two hormones • Epinephrine • Norepinephrine • Involved with the stress response

30. Ovaries • Estrogen • Progesterone—inportant in menstrual cycle,*maintains pregnancy,

31. Testes • Androgens, testosterone—secondary sexual characteristics, sperm production

32. Thymus • Releases thymosin and thymopoietin • Affects maturation of T lymphocetes

33. Pineal • Melatonin • Affects sleep, fertility and aging

34. Prostaglandins • Work locally • Released by plasma cells • Affect fertility, blood clotting, body temperature

35. Past Medical History • Hormone replacement therapy • Surgeries, chemotherapy, radiation • Family history: diabetes mellitus, diabetes insipidus, goiter, obesity, Addison’s disease, infertility • Sexual history: changes, characteristics, menstruation, menopause

36. Physical Assessment • General appearance • Vital signs, height, weight • Integumentary • Skin color, temperature, texture, moisture • Bruising, lesions, wound healing • Hair and nail texture, hair growth

37. Physical Assessment • Face • Shape, symmetry • Eyes, visual acuity • Neck

38. Palpating the thyroid gland from behind the client. (Source: Lester V. Bergman/Corbis)

39. Physical Assessment • Extremities • Hand and feet size • Trunk • Muscle strength, deep tendon reflexes • Sensation to hot and cold, vibration • Thorax • Lung and heart sounds • Extremity edema

40. Older Adults and Endocrine Function • Relationship unclear • Aging causes fibrosis of thyroid gland • Reduces metabolic rate • Contributes to weight gain • Cortisol level unchanged in aging

41. 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, salt craving

42. Abnormal Findings (continued) • Ask the client: • Cardiovascular status: blood pressure, heart rate, palpitations, 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

43. Most Common Endocrine Disorders • Thyroid abnormalities • Diabetes mellitus

44. Diagnostic Tests • GH: fasting, well rested, not physically stressed • Water deprivation: fasting for 12 hours, no fluids/smoking after midnight • T3/T4: no specific preparation • Serum calcium/phosphate: fasting may or may not be required • Collection that needs to be iced or refrigerated

45. Diagnostic Tests • Cortisol/aldosterone level: two blood samples, client to be up for at least 2 hours before test is drawn • Urine 17-ketosteroids: 24-hour urine collection that needs to be iced or refrigerated

46. Diagnostic Tests • FBS: fast before the test • HbA1c: No fasting required • 2-hour OGTT: drink 75 g of glucose and do not eat anything until blood is drawn • Urine glucose/ketones: fresh urine specimen • Urine microalbumin: fresh urine specimen

47. Imaging Studies • MRI: metallic implants, lie motionless during test; remove all metal objects • CT scan: assess for allergies to iodine and seafood; lie immobile during the test • Thyroid scan: allergies to iodine and seafood; hold thyroid drugs containing iodine for weeks before the study

48. Imaging Studies • RAI: fast for 8 hours before; can eat 1 hour after radioiodine capsule/liquid taken; hold thyroid drugs with iodine for weeks before the study

49. THYROID DISORDERS Dr Ibraheem Bashayreh, RN, PhD

50. 1-The gland as seen from the front is more nearly the shape of a butterfly. 2-composed of 2 encapsulated lobes, one on either side of the trachea, connected by a thin isthmus. 3-The thyroid extending from the level of the fifth cervical vertebra down to the first thoracic. The gland varies from an H to a U shape,overlying the second to fourth tracheal rings. 4-The pyramidal lobe is a narrow projection of thyroid tissue extending upward from the isthmus and lying on the surface of the thyroid cartilage. Thyroid Anatomy