endocrine

• Opacity (clouding) of lens in eye

  Related to abnormal metabolism of glucose
• Ischemia in circulation to peripheral nerves

  Impaired sensation, numbness, tingling, weakness, muscle wasting
• Autonomic nerve degeneration


  Urinary incontinence, impotence, diarrhea
• Hypothalamus


  • Hypothalamus-releasing hormones → Stimulate the anterior pituitary gland to release a specific hormone
  • Hypothalamus-inhibiting hormones → Decrease release of a hormone from the anterior pituitary gland
• Pituitary gland-Anterior Lobe


  • Growth hormone- protein synthesis
  • Deficit: dwarfism
  • Excess: giantism
  • Adrenocorticotropic hormone (ACTH) Adrenal cortex → Cortisol, aldosterone, androgens
  • Thyroid stimulating hormone (TSH) Thyroid gland → thyroid hormones
• Adrenal Glands


  • Sweet Cortisol- increase glucose level, decrease immune response
  • Salty Aldosterone- increases sodium & water reabsorption, increases potassium excretion
• Diabetes


  • Deficit insulin secretion
  • Production of insulin antagonists (glucagon)
  • Increased resistance to insulin

  
• Role of the liver and pancreas in diabetes

  1. Pancreas releases glucagon from Alpha cells in response to decreased glucose levels

  2. Liver does glycogenolysis to make glucose from glycogen

  3. Liver does gluconeogenesis to make glucose from other sources, lipolysis fuels this process

  
• Liver stores glucose as glycogen


  Decreases blood glucose

  
• Liver changes glycogen to glucose (glycogenolysis)

  Increases blood glucose

  
• Type 1 Diabetes


  • Results from autoimmune destruction of Beta cells with genetic tendency
  • Do not secrete insulin
  • Acute onset in children & adolescents, can develop at any age
  • More severe form of diabetes
  • Can lead to strokes (CVA), peripheral vascular disease, amputation, myocardial infarction, kidney failure, blindness - DM damages blood vessels

  
• Type 2 Diabetes


  • Results from decreased production of insulin and/or insulin resistance
  • Oral hyperglycemic medications may be used, are not dependent on insulin
  • Onset is slow & insidious
  • Associated with obesity
  • Component of metabolic syndrome (central adiposity)

  
• Pathophysiology of Diabetes - Initial stage

  1. Insulin deficit

  2. Excess glucose enters urine (glucosuria)

  3. Osmotic diuresis

  4. Dehydration and decreased nutrients

  
• General manifestations of all types of diabetes

  • Polyphagia
  • Polydipsia
  • Polyuria
  • Fatigue
  • Blurred vision
  • Itchy skin
  • Dry mouth

  
• Diabetes: Diagnostic Tests


  • Fasting state blood glucose level
  • Glucose tolerance test
  • Glycosylated hemoglobin test (HbA1c)
  • Urine tests and ABG analysis to check for ketoacidosis

  
• Hypoglycemia


  Critically low insulin levels, causes include dosage error, skipping meal after taking insulin, strenuous exercise, vomiting

  
• Hypoglycemic shock: Signs and Symptoms

  • Disorientation/decreased consciousness
  • Slurred speech
  • Staggering gait/lack coordination
  • Hypotension
  • Tachycardia
  • Pale, moist skin
  • Activation of SNS - Anxiety + tremors
• Hypoglycemic shock: Treatment


  1. Give glucose immediately to prevent brain damage

  2. Juice or candy if conscious or use another route if unconscious
• Progressive Effects - Severe/prolonged insulin deficit

  1. Lack of glucose in cells

  2. Catabolism of fats and proteins - excessive amounts of fatty acids and ketones

  3. Excess number of ketones in blood

  4. Liver and cells can't process fatty acids or ketones fast enough

  5. Ketoacids bind with bicarbonate in blood, decreasing serum bicarbonate levels

  6. Decreased pH of body fluids

  7. Ketoacids are excreted in the urine (ketonuria)

  8. As dehydration develops, the glomerular filtration rate (GFR) decreases, and the kidneys can't excrete the ketoacids

  9. Decompensated metabolic acidosis occurs - Diabetic Ketoacidosis (DKA) or Diabetic Coma

  
• Diabetic ketoacidosis (DKA)


  • Liver does lipolysis to produce ketones
  • Kussmaul = rapid, deep respiration to compensate for acidosis
  • Osmotic diuresis leads to dehydration, loss of electrolytes
  • Initially see hyperkalemia, then hypokalemia

  
• Hyperglycemic Hyperosmolar Nonketotic syndrome (HHNK)

  • Occurs in type 2 diabetes
  • Insidious in onset and diagnosis may be missed
  • Often occurs in older clients with an infection or who had excess carbohydrate intake and end up using more insulin

  
• HHNK Manifestations


  • Hyperglycemia yet have enough insulin to prevent ketoacidosis
  • Severe dehydration
  • Increased hematocrit
  • Loss of skin turgor
  • Increased heart rate and respirations
  • Neurologic deficits
  • Muscle weakness
  • Difficulties with speech
  • Decreased reflexes

  
• Treatment for DKA and HHNK

  1. Insulin

  2. Fluids

  3. Potassium

  
• Chronic Complications of Diabetes

  • Increased incidence of atherosclerosis
  • Tissue necrosis and loss of function
  • Neuropathy and loss of sensation
  • Retinopathy - leading cause of blindness
  • Chronic renal failure - degeneration in glomeruli of kidney
  • High incidence of heart attacks, strokes, peripheral vascular disease
  • Ulcers on feet and legs
  • Cataracts
  • Peripheral neuropathy - ischemia in circulation to peripheral nerves, impaired sensation, numbness, tingling, weakness, muscle wasting, autonomic nerve degeneration leading to urinary incontinence, impotence, diarrhea

  
• Hypothalamus


  Releases hormones that stimulate the anterior pituitary gland, and inhibiting hormones that decrease release of hormones from the anterior pituitary gland
• Pituitary gland - Anterior Lobe


  • Growth hormone - protein synthesis
  • Adrenocorticotropic hormone (ACTH) - stimulates adrenal cortex
  • Thyroid stimulating hormone (TSH) - stimulates thyroid gland

  
• Adrenal Glands


  • Cortisol - increases glucose level, decreases immune response
  • Aldosterone - increases sodium & water reabsorption, increases potassium excretion
  • Testosterone - development of male sex organs & female body hair
  • Epinephrine - "adrenaline" - fight or flight/stress response
  • Norepinephrine - general vasoconstriction

  
• Cushing's syndrome


  Excessive level of glucocorticoids (steroids - cortisol/hydrocortisone)
• Signs/symptoms associated with Cushing's syndrome

  • Round face (moon face), with ruddy color
  • Truncal obesity, with fat pad between scapulae (buffalo hump), but thin limbs
  • Hirsutism- increased hair growth
  • Retention of sodium and water (aldosterone) - hypertension, edema
  • Atrophy of lymph tissue - suppression of the inflammatory & immune responses & decreased protein synthesis - delayed healing & increased infection
  • Osteoporosis
  • Insulin resistance - hyperglycemia/diabetes mellitus
• Addison Disease


  • Decreased glucocorticoids
  • Decreased blood glucose levels
  • Inadequate stress response
  • Decreased mineralocorticoids - low serum sodium levels from aldosterone, hypotension, high potassium
  • Decreased androgens - decreased body hair

  
• Addison crisis


  1. Caused by sudden withdrawal of steroids, undiagnosed Addison disease, or major stress such as hemorrhage, infection, or infarction

  2. Sudden severe hypotension and low glucose

  3. Treatment - Need IV Cortisol (solu-cortef)
• Monitor glucose levels


  Risk for infection

  
• Iatrogenic Cushing


  Decreased stress response due to too much glucocorticoids
• Iatrogenic Cushing is most common
• Patient will need medication dose increases with stressful events and gradual decreases after stressful event
• Treatment for iatrogenic Cushing

  1. Treat adenoma/carcinoma

  2. Decrease glucocorticoids
• Addison Disease


  Need to add more glucocorticoids
• Symptoms of decreased glucocorticoids

  • Decreased blood glucose levels
  • Inadequate stress response
  • Fatigue
  • Frequent infections
  • Decreased mineralocorticoids
  • Low serum sodium levels from aldosterone
  • Hypotension
  • High potassium
  • Decreased androgens à Decreased body hair

  
• Addison crisis


  Sudden withdrawal of steroids, undiagnosed Addison disease, or major stress such as hemorrhage, infection, or infarction
• Addison crisis treatment


  Need IV Cortisol (solu-cortef)