In this discussion, I will go over the endocrine system with the basics of the system's functioning and some specifics about Cushing's and Addison's. Before you dive into this content, be sure you are free from distractions and can give it your full attention. Be sure that you have read the textbook pages that are associated with this content.
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Here are the learning objectives for this discussion. Make sure that you understand what the purpose of this is and that you'll be able to meet these objectives upon the completion. The endocrine system is made up of endocrine glands. And these glands are specialized collections of tissues that secrete specific hormones.
And these hormones are chemical substances that the gland will secrete in response to some stimulation within the body. And they are intended to produce a response. the target of the hormone. There is a difference between exocrine and endocrine glands. Exocrine glands have ducts that carry secretions to epithelial surfaces.
And for example, the pancreas performs some exocrine functions. It creates digestive enzymes. And those enzymes get released directly into the GI system to help with digestion.
Another example is our salivary glands. They produce digestive enzymes and they get released into the mouth. On the other hand, endocrine glands will secrete their hormones in the system.
So they'll either be directly into the bloodstream or into the lymphatic system. For instance, we have the pancreas again, which also serves with some endocrine function. And in its endocrine function, it secretes insulin and glucagon, which help regulate blood sugar. And they're needed systemically. Whereas the exocrine function.
of the pancreas is more local to the specific needs of the digestive system, whereas insulin and glucagon go system-wide. Another example is our thyroid gland. Thyroid gland, the hormones T3, T4, and calcitonin that are secreted by the thyroid gland are needed by all the body tissues, so they get secreted into the bloodstream so that they're in general circulation for the whole body. You can see on this image that we have from top to bottom, hypothalamus, the pineal, pituitary, the thyroid, the parathyroids, thymus, adrenals, and the islets of Langerhuis and the pancreas, as well as the testes and the ovaries.
All of these. are endocrine glands. However, we are not going to spend time on every one of these endocrine glands.
We are going to talk a lot about the pituitary and its influence on the whole system, thyroid gland, parathyroids, the adrenal glands, and the pancreas. Remember that homeostasis and the body's efforts to maintain balance. That is a big impact of what the endocrine system does is it helps with compensation and adaptation when the system is out of balance. It is based on a negative feedback system and what that means is that there'll be some stimulation from say the pituitary gland.
it sends a message to the thyroid gland, tells the thyroid gland to make more of its hormones. And then when the pituitary can sense that the level of thyroid hormone has reached the appropriate level, it slows down its stimulation of the thyroid gland. It's that negative response, negative feedback.
Think of it kind of like setting the thermostat in your house or your apartment. You go up to the thermostat, you tell it that you want the house to be 75 degrees. And when the temperature drops below 75, then your thermostat is alerted to that change in temperature, and your heat comes on to bring the temperature back to 75 degrees. Or, um... you set your air conditioner to 72 degrees and over the course of the day the house warms up and now it's 74 degrees in your house and the air conditioner turns on but it doesn't run forever it only runs until it reaches that set temperature that's what a negative system looks like a negative feedback system so That's what's happening in the bloodstream with these different hormones.
The pituitary sends out a signal, the thyroid responds and changes its production plus or minus, depending upon the signal. And then after that, then the pituitary shuts down the signal once it's reached the level that the body needs. Another aspect that we need to think about in dealing with understanding the endocrine system is it's a complex system.
One part of the system impacts other parts of the system. And so we have the influence of, say, the pituitary. Let's just keep going with the pituitary and the thyroid. So the pituitary sends out thyroid-stimulating hormone called TSH.
That's coming from the pituitary gland in the brain. It sends that message through the thyroid-stimulating hormone. to the thyroid gland.
The thyroid gland, if it's functioning appropriately, will respond by changing its level of thyroid hormone to match what the pituitary is asking for. But let's say that there's a problem with the pituitary and the pituitary is sending out too much stimulating hormone and causing the thyroid to overact. okay when the pituitary is the problem that's called secondary endocrine problem so it's like hyperthyroid but it's secondary cause because it's not the gland itself that's the problem it's the pituitary now if the pituitary is sending out an adequate signal but the thyroid is malfunctioning and it is overstimulating, over producing its hormones, now we have a primary hyperthyroidism because the problem is in the gland itself.
Now tertiary would occur if the problem is coming from the hypothalamus. This is rather rare that the hypothalamus is really causing the problem, but if the hypothalamus is giving the wrong signals to the pituitary, which then is in turn giving the wrong signals to the other gland, then the problem is tertiary. And then we have a final fourth cause called eratogenic.
This is because another medical intervention, like say a medication is being given, that's what's causing the overactive or underactive gland. For example, if a patient is taking corticosteroids for, say, an autoimmune issue, if they're taking an excess, then they can develop Cushing's syndrome, which affects the adrenal glands. So the corticosteroid is what's actually causing the adrenal glands to overproduce and causing Cushing's syndrome.
It's not... any of the body glands that are making the problem. It's a medication. That's a retigenic.
Another cause could be, let's say a patient has some cancer in their throat, and they're receiving targeted radiation therapy to their throat. Well, that could damage the thyroid gland or the parathyroid glands, causing them to either be hypoactive or hyperactive. That's not a problem in the gland.
It's not a problem in the pituitary or the hypothalamus. It's because of the other conditions that are being targeted towards the body. Here we have a chart that just explains which glands secrete which hormones. And I'm not going to go over all of these with you.
You guys should be familiar with what all of these stand for and what they do within the body. So whatever the pituitary is sending out, what's its target? Where is it going and how is that impacting the overall system of the body?
On that note, I would encourage you to pause and think about this for a minute. Review the list of hormones that Just for instance, that the anterior pituitary gland secretes and what bodily functions those hormones are supposed to impact. Now, after you've thought about that, I want you to consider that you have a patient that has a pituitary tumor that's going to require the surgical removal of the anterior pituitary.
Now, what systems or organs would be impacted by that procedure? how is that going to be affecting the other parts of the body? Now we're going to discuss the Cushing syndrome, which is a condition where there's too much adrenal hormones.
When the pituitary and adrenal have dysfunction, we end up with overproduction of ACTH, which then tells the adrenal glands to make excess of. their hormones. So if the pituitary gland is the problem, it's overstimulating the adrenal glands. The adrenal glands will react by overproducing these hormones. Okay, and the hormones of the adrenal glands are glucocorticoids, which impact sugar and blood sugar regulation in the body, mineral corticoids, which impact salt and water electrolytes, in the body and androgens or the sex hormones which help us have our secondary sex characteristics, our sexual drive, breast changes, changes in hair distribution, those kind of things.
Now, think about a patient that has too much of all of these going on. Think about a patient that has too high of a blood sugar and an imbalance of sodium in their body and changes in their androgens that causes maybe a male patient to look more female-like body type and a female to look more like a male body type based on these hormones. And think about one patient having all of these issues and how much they can have an impact on their health.
Most frequently, Cushing syndrome is caused by exogenous corticosteroid use, be that from medication given for another condition or taken for specific health reasons or overtaking medications. that help build muscle and do strength training that sometimes athletes do. And then the second most frequent cause is pituitary gland influence.
But regardless of whether it's coming from the pituitary or coming from exogenous corticosteroids being consumed for whatever reason, We're going to have the same signs and symptoms, but the treatment will be tailored to the cause. If the pituitary is secreting too much ACTH, then it may need to be surgically removed. If the adrenal glands have a tumor and they're secreting too much of their hormones, then that tumor may need to be removed.
If it's from endogenous... corticosteroids being given, then those doses might need to be adjusted. Our clinical manifestations, let's kind of go top to bottom. Ophthalmically, this patient is predisposed to cataracts and glaucoma. Cardiovascular system is impacted by hypertension and heart failure.
The endocrine system has alterations in calcium metabolism, adrenal suppression. This is where that buffalo hump develops. It's related to the endocrine metabolic functions. Hyperglycemia, so excess blood glucose, hypokalemia, low potassium. This patient may suffer from impotence or if it's a female menstrual irregularities and they're predisposed to metabolic alkalosis.
They get that moon face which is kind of just in general a puffy round face. They have a negative nitrogen balance, sodium retention, and truncal obesity. So they have thin extremities and a large um Immune function is decreased, inflammatory responses are impaired, wound healing is impaired, they have an increased susceptibility to infection. They can develop aseptic necrosis of the femur, that's a pretty frequent problem, which can cause them to need hip replacement surgery. Osteoporosis is also associated with this condition.
Spontaneous fractures, vertebral compression fractures. Their GI system, they are at an increased risk of developing peptic ulcers. They have an increase in gastric secretion, so there's a high amount of acid in the system. They have an increased risk of pancreatitis they have muscle weakness and myopathy their skin can develop acne or ecchymosis or petechiae and striae often on the abdomen they get these purple striae and they have thinning of the skin and as far as their psychiatric considerations. There are mood alterations and possibly personality changes or even psychosis that can come with this condition.
Of course, our nursing assessment is going to include a good head-to-toe and you can see in this description that I've given you. and the pictures here that I'm showing you, that it would be a good idea to look at this patient from top to bottom, head to toe, and look at all of the possible ways that this disease process is impacting them physically. But specifically, I would want to look at their musculoskeletal system, if they have weakness and osteoporosis and and thin bones and thin skin. I'm concerned that this patient is a great fall risk and that if they fell, they could have some significant injury. That ties in also with the skin.
If the skin is thin and fragile, then there's a higher risk of them to have an injury or have like a break in the skin that would give them an opportunity for an infection. And I'm concerned about their mental capacities and their mental status. Are they stable?
Are they depressed? Are they experiencing some of those psychosis or personality changes? Sometimes these patients can be rather irritable and it's not them, it's the overproduction of the hormones that's causing that. Medical management, we're going to be looking at doing some diagnostic testing. A lot of this you can see in the physical manifestations and start to recognize the signs and symptoms, but we want to do some testing.
They'll do some testing with dexamethasone to see if it changes the levels of the cortisol in the body. They'll sometimes do a 24-hour urine collection for this patient, where the process for that would include that the patient has all of the urine for 24 hours collected, and then it's tested to see about the levels. The urine has to be kept in a specialized container and that container has to be kept cold so the yarn is not even at room temperature for the whole 24 hours.
So in the hospital that means getting a tub and keeping ice in it and getting the container, keeping the container on the ice, changing out the contents of that tub as frequently as needed so if the ice melts, we gotta change that out and put fresh ice in it. And we do that for 24 hours. And the process for the collection would include that we have to collect every drop of urine during that 24 hours.
So we ask the patient to go ahead and urinate and that first urine we dump but that marks the time for the beginning of the 24 hours. So at that point we ask them to save every bit of urine. If they're using a urinal then we just measure that recorded in their chart.
put it into dump that into that container on ice every time they urinate and if they're using the commode then we can put a specie hat in the commode we can do the same thing at the bedside commode but we want to save all the urine add it to the container keep it on ice so the clock starts with that urine that we dump okay because we want a full 24 hours to the minute if we possibly can get it then every time they urinate we save it we get to the end of the 24 hours and we're back to this next day at that same time we ask them to urinate one more time we take whatever they were able to empty out of their bladders and add it to the container and that completes the 24 hours that is the process for doing a 24-hour urine which nurses at United Regional and other hospitals have to do pretty frequently. So what are we going to do for this patient besides do all this testing? We can do irradiation of the pituitary if that's what is causing the problem. We can do adrenal enzyme inhibitors, which tamp down the effects.
of the adrenal hormones. They can have cortisol therapy. Sometimes they'll have the actual adrenal glands removed, maybe one, maybe both, depending upon what's causing it.
And if only one can be removed, then we could see how well the patient can manage with the other one. And then sometimes they'll do surgical removal of the pituitary gland if it is the problem and it has, say, a tumor on it. That is a surgical procedure called a transphenoidal, means going through the sinuses, transphenoidal hypophysectomy.
Our nursing care considerations for this, we are aware that this patient has a lot of increased risks, risk for injury, risks for infection, risks. for activity intolerance, impaired skin integrity, disturbed body image, which is a big deal. All of these aspects of their care we would need to monitor for. If the patient is having surgical removal of the pituitary or surgical removal of the adrenal glands, then we have pre-op care and post-op care to deal with.
This patient will have blood sugars that have to be monitored and addressed with insulin therapy to help keep them in the right place. They're probably going to be on some kind of PPI or H2 blocker because of the excess acid to help prevent them from developing peptic ulcers. As far as education of the patient and the families, they're going to need to continue on whatever medication regimen and they'll need a lot of education around meds, dietary modifications that need to be made to help them deal with this situation. If they can't come off the meds that's causing it or they can't have the surgical relief that they need. to correct this.
Then we're going to be dealing with lifelong administration of certain meds and certain dietary modifications that's going to need to go on. They need to be told to monitor their blood sugar, their blood pressure, their weight. They ought to be taught to wear a medical alert bracelet so that if something happens to them, The nurse will know that this patient has Cushing's and has certain risks so that they can take precautions for that at the time that they're giving care. And they need to inform their other providers including their dentist if they have this condition. It will help them to be better managed in all those care areas.
As far as the holistic and the psychosocial, we need to be considering our listening. and are educating and are caring about these patients. These physical changes are pretty disturbing. I can imagine that the woman in this picture would be pretty disturbed about the changes to her body and she needs to have an outlet for that.
She needs to be able to talk about it if she wants to. She needs to tell us her thoughts and feelings, her concerns. Sometimes these conditions are reversible when the corrections are made to the problem.
So that can be something that we can help the patient understand and give them back some hope. Often these, also the psychological changes, like the personality changes and the increased irritability and stuff, are often also reversed with treatment. So hopefully this patient will have some relief from all of those things, the physical, the emotional, and the psychological impacts of the overproduction of these hormones. Here's another opportunity for you to pause and think. I would like you to look over all of that we just discussed and all that you've seen about Cushing's syndrome and think about at least three safety considerations you would have for this patient as the nurse.
What are your concerns regarding this patient in the realm of safety? And then think about psychosocial considerations for this patient and name at least three nursing care considerations for a patient with Cushing's in the realm of psychosocial or holistic care needs. Now we'll look at the flip side of that, which is Addison's disease, a condition in which the patient has not enough of the adrenal hormones.
Okay, this slide is a repeat from one previously, but now we're highlighting what would happen to a patient who has an insufficient amount of glucocorticoids, mineral corticoids, and androgens because of Addison's disease. Addison's is when there is insufficient amounts of the adrenal hormones and this can be caused from autoimmune so it's like a body attacking itself thinking that that tissue is a foreign invader and trying to destroy it. or it can be idiopathic atrophy of the adrenal glands.
They just atrophy and can't produce as much of the hormones. Or perhaps there's an infection that attacks the adrenal glands and now the glands can't do their function. And then occasionally it happens that a patient has both, one or both, adrenal glands surgically removed. And now they're facing Addison's disease with the loss of those glands. Think about what cortisol does to the body, which is one of the main losses that we get from Addison's disease.
Now, without cortisol, our bodies don't respond to stress. Cortisol is what kicks in our stress response. helps us deal with stresses, and even initiates the fight or flight response that is very protective within our bodies. This patient's also going to have hypoglycemia, so they're going to have a less glucose response from cortisol.
So there's less cortisol, therefore the body makes less glucose, and now we can have hypoglycemia. And we have hypovolemia. because of an imbalance with sodium and water being lost. The clinical manifestations you're going to see in this patient is fatigue, which is the most common symptom and gets steadily worse over time. Patches of dark skin, which are hyperpigmentated, they kind of look bronze.
They'll show up most prominently around scars or in the creases of our skin, like say the inner part of your... elbow or your wrist where there's creases that happen, abdominal pain with nausea, vomiting, and diarrhea. So that's our GI disturbances, loss of appetite, unintentional weight loss. So this patient is losing weight, having GI issues. They have muscle pain, muscle spasms, sometimes joint pain.
Dehydration comes because with this loss of fluids, loss of sodium and loss of fluids. Low blood pressure which can lead to lightheadedness or dizziness when they stand. So those orthostatic changes or postural hypertension changes.
They can have changes in mood and behavior like irritability or depression or maybe a poor ability to focus and concentrate. They might be craving. salty foods, which is the body's way of saying I'm low on sodium, I need some more, and they'll have some low blood sugar issues.
As far as our nursing assessment goes, as always, it's good to do a head-to-toe plus the patient-specific focused assessments. So in this case, If I knew a patient had Addison's disease, I really want to focus on the cardiac system. I'm worried about the hypotension, hypovolemia, which comes from the loss of the fluid and the salt, hyperkalemia, which is the other part of the electrolytes that become imbalanced and can cause arrhythmias for this patient.
I'm concerned about their musculoskeletal system, their muscle weakness, and their fatigue. Their GI system, they have loss of appetite and all those other GI symptoms that we mentioned. Their endocrine system, this patient is going to be hypoglycemic, so I need to be monitoring for those signs and symptoms of hypoglycemia. So recall those that go with hypoglycemia and what that looks like this patient is going to have some activity intolerance for sure their immune system is going to have a decreased ability to fight infection their skin is going to show that dark pigmentation and especially those areas where the skin folds like the knuckles and the knees the elbows Psychologically, mentally, they're going to have perhaps depression. Emotional liability where they just kind of fluctuate between emotions.
They may have apathy. Sometimes that's just exhaustion and sometimes there's confusion. Low serum sodium and high serum potassium can lead to arrhythmias.
or even some with the loss of sodium in water can be chronic dehydration that this patient has. Our medical management, our diagnostic testing is going to consist mostly of blood work. We're going to be looking at levels of sodium, potassium, cortisol, and ACTH in the blood.
If it's a pituitary problem that's causing this, then ACTH will be low because the pituitary is failing to send out the signals to stimulate the adrenal glands. If the adrenal glands are the cause, then ACTH will probably be high trying to tell the adrenal glands to do more work, but they can't respond. So likely sodium will be low, potassium will be high, and cortisol will be low. There is a test called the ACTH stimulation test. where ACTH is given to determine if the adrenal glands can respond to the stimulation.
And another way that they check is insulin-induced hypoglycemia test. So the patient is given fast-acting insulin to see if the cortisol will respond to rise up because of the hypoglycemia. Obviously, this test would need to be done under medical supervision because you wouldn't want to initiate hypoglycemia and the patient not be able to respond and bring it back up.
And if they can't, then they need someone there to give them like the oral carbs to help them, fast acting carbs. A CT scan may be done to look at the adrenal glands to see if there's damage, deterioration. or even if they look infected.
In most cases treatment will include life long replacement of cortisol and aldosterone. Our nursing care will be focused on preventing circulatory shock because of this hypovolemia that's often the case. So we're going to be monitoring labs for sodium, monitoring the patients for signs and symptoms of hypovolemia, signs and symptoms of dehydration, checking a daily weight, doing orthostatic blood pressure readings. And if you don't recall what that means, it means you check the patient's blood pressure while they're lying down. And then you have them sit up and you check their blood pressure while they're sitting up.
And then finally you have them stand. and you check their blood pressure while they're standing. A decrease in the systolic of 20 milligrams of mercury or more may indicate depletion of volume especially if they have other symptoms like lightheaded or dizziness or they feel like they're going to faint. Be careful when you do this test. Any patient that this test is needed on is if they're positive.
for this and they have those changes, they are a fall risk. So you want to be standing nearby while you're doing this to make sure that you can steady them or help them sit back down immediately if they get dizzy, lightheaded, or faint. Another nursing consideration is we need to help them with any infections or manage stressors.
This patient, because they can't get a cortisol response to stress means they have a decreased significantly decreased ability to handle stressful situations so that means we want to decrease their stress as much as possible now a patient may be in the hospital because they're having an addisonian crisis but also they could be in the hospital because they got pneumonia They are having a knee surgery, but those stresses still are stresses that their bodies are not prepared to handle. So we need to help manage those and try to protect the patient from undue stress, if at all possible, perhaps by letting them rest undisturbed for as long as possible, keeping their room quiet, those kind of things. We'll likely be giving them corticosteroids and mineralocorticoids as ordered. Another stressor that we sometimes don't even think about is keeping the room too cold.
can stress their body and their ability to manage being overexerted, having an infection, or just having an emotional stress. Those are things that we need to be mindful of and try to help mitigate for our patients. Some of the common complications of Addison's would be dehydration, electrolyte imbalances, Weakness and fatigue, stress, emotional state can be dysregulated there. Nutrition may be imbalanced because they have all these GI symptoms and anorexia, and they will have some level of activity intolerance. Life-threatening complications.
I mentioned a minute ago, Addisonian crisis. An Addisonian crisis is a medical emergency. If they have an injury, if they have a severe illness, if some type of disease, time of intense stress comes upon them.
Symptoms can come on quickly and cause life-threatening events which is an Addisonian crisis or acute adrenal failure. If it's not treated it can lead to shock and death. Symptoms include extreme weakness, sudden severe pain in the low back, in the stomach, or in the legs, feeling restless, confused, or afraid, or having other mental changes, severe vomiting and diarrhea, maybe even contributing to some dehydration, low blood pressure, a rapid weak pulse, rapid respiration rate, pallor, and even loss of consciousness. This patient will require immediate treatment with IV fluids.
glucose and electrolytes, especially sodium, okay, and replacement of missing steroid hormones and probably vasopressors to help bring that blood pressure up. If it's been precipitated by an infection, then we need antibiotics on board as soon as possible. We also want to try to identify whatever stressors might have contributed to this and try to mitigate those. This can be something that we need to do preemptively as well. So if a patient comes in for a knee replacement, they have Addison's, their provider should be kind of prophylactically, preventatively giving them some of these interventions during this most stressful time and we'll need to be helping by monitoring the effects of that and see if it's adequate.
This is another patient that really should wear a medical alert bracelet and they need to let other providers that care for them know what's going on so that they can wisely get these other procedures done like even dental work. Other life-threatening complications include renal shutdown, which can happen from the severe chronic dehydration, and the hypovolemia, which can also bring on hypovolemic shock. And those electrolyte imbalances can cause arrhythmias and mental status changes and other problems.
can impact the whole patient. Life-threatening if not cared for. So educating comes down to medication regimen is lifelong in most cases and they may need to have an adjusted dose. You need to keep close communication with their providers. If they start developing an illness, they may need to have a higher dose of their meds.
If they know that something is increasing the stress in their life, okay, we need to teach them about the importance of health promotion, disease prevention, because if we can prevent them from developing other medical conditions, then that's less stress on the body that their body can't handle. We need to have their screenings done so that they can be preventative. in their care.
Teach them about avoiding stresses whenever possible. If they need help with taking care of their activities of daily living, then they should be seeking help and we should be educating them on some of those resources. Their diet may need to be modified.
This was a patient that really should increase the sodium in their diet as opposed to most that are advised to decrease sodium. the medical alert brace that I mentioned already, they should rest. when they feel fatigue and weakness because trying to press on just exacerbates the problem and they need to keep in close contact with their providers and let them know when they're struggling because they may need some additional help or additional medications.
As far as our psychosocial and holistic care, this patient will need Someone, you know, they may need somebody to listen or to help them understand some of these physical changes that are going on. They need our therapeutic communication to just hear their concerns. This is lifelong disease management.
They may require assistance with their ADLs and have a hard time giving up their independence to do for themselves. And some people would rather skip the difficult tasks than ask somebody to help them. So in our conversations, maybe we have an opportunity to uncover that. Maybe we have an opportunity to offer some support to help a patient see the benefit of getting help and maybe overcome their reluctance to give up. that independence for the benefits of better health and a better life.
All right, here's our pause and think for this section, and these are the same questions that we just did on the Cushing Syndrome, but now they apply to Addison's. So think about safety considerations for a patient with Addison's and the things a nurse could do to help a patient. with those safety concerns.
And then the psychosocial and holistic care considerations. Apply that thought process to the Addison's disease and think of ways that the nurse can be helping the patient in these aspects of their care. This is the end of the content.
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