Care of the Client with Problems Related to the Endocrine System

Week 10 Hyperactvity - Gigantism

Disorders of Pituitary  Over-secretion of Growth hormones

1. Gigantism
o Sustained hypersecretion of growth
Gland hormone in children
o General overgrowth of long bones,
skeleton and tissue
o Marked increase in height and weight

Gigantism is a rare condition that causes abnormal

growth in children. This change is most notable in
terms of height, but girth is affected as well. It occurs
when your child's pituitary gland makes too much
growth hormone, which is also known as
somatotropin. Early diagnosis is important.
Gigantism is most often caused by a benign tumor on
the pituitary gland called a pituitary adenoma.
However, it can also be caused by the following
disorders: Neurofibromatosis. McCune-Albright
syndrome (MAS)
What organs are affected by gigantism?
Gigantism is a serious condition that is nearly always
caused by an adenoma, a tumor of the pituitary gland.
Gigantism occurs in patients who had excessive
growth hormone in childhood. The pituitary tumor
cells secrete too much growth hormone (GH), leading
to many changes in the body.

What are pituitary disorders?

Pituitary disorders are conditions caused by too
much or too little of one or more of the hormones
produced by the pituitary gland. A pituitary tumor
compressing surrounding tissues can also
cause symptoms of a pituitary disorder.

Acidophilic cells- Anatomical terminology. In the

anterior pituitary, the term "acidophil" is used to
describe two different types of cells which stain well
with acidic dyes. somatotrophs, which secrete growth
hormone (a peptide hormone) lactotrophs, which
secrete prolactin (a peptide hormone).
 Care of the Client with Problems Related to the Endocrine System

 Treatments for gigantism aim to stop or slow your

child’s production of growth hormones.

 Microscopes or small cameras may be used to help

the surgeon see the tumor in the gland. In most
cases, your child should be able to return home
from the hospital the day after the surgery.

 very large hands and feet

 thick toes and fingers
 a prominent jaw and forehead Medication
 coarse facial features
 Doctor may recommend medication if surgery
is not an option.
 This treatment is meant to either shrink the
tumor or stop the production of excess growth
hormone.
 Octreotide or Lanreotide to prevent the growth
The symptoms your child has may depend on the size hormone’s release.
of the pituitary gland tumor. As the tumor grows, it  Given as an injection about once a month.
may press on nerves in the brain. Many people
experience headaches, vision problems, or nausea from In some cases, surgery may not be an option. For
example, if there’s a high risk of injury to a critical
tumors in this area. Other symptoms of gigantism may
blood vessel or nerve.
include:

 excessive sweating Bromocriptine and cabergoline are drugs that can be

 severe or recurrent headaches used to lower growth hormone levels. These are
typically given in pill form. They may be used with
 weakness
octreotide. Octreotide is a synthetic hormone that,
 insomnia and other sleep disorders
when injected, can also lower the levels of growth
 delayed puberty in both boys and girls hormones and IGF-1.
 irregular menstrual periods in girls
 deafness In situations where these drugs are not helpful, daily
shots of pegvisomant might be used as well.
Pegvisomant is a drug that blocks the effects of growth
Children with gigantism may also have flat
hormones. This lowers the levels of IGF-1 in your
noses and large heads, lips, or tongues. child’s body.

Treatment
Surgery
 Removing the tumor is the preferred treatment
for gigantism if it’s the underlying cause.

 The surgeon will reach the tumor by making

an incision in the child’s nose.

 Hypophysectomy

How is gigantism treated? How is gigantism diagnosed?

 Care of the Client with Problems Related to the Endocrine System

If your child’s doctor suspects gigantism, they may Acromegaly is a disorder that results from excess
recommend a blood test to measure levels of growth growth hormone (GH) after the growth plates have
hormones and insulin-like growth factor 1 (IGF-1), closed.
which is a hormone produced by the liver. The doctor
The initial symptom is typically enlargement of the
also may recommend an oral glucose tolerance test.
hands and feet. There may also be an enlargement of
During an oral glucose tolerance test, your child will the forehead, jaw, and nose.
drink a special beverage containing glucose, a type of
Causes: Too much growth hormone
sugar. Blood samples will be taken before and after
your child drinks the beverage. Symptoms: Enlargement of the hands, feet,
Medication: Somatostatin analogue, GH recept…
Complications: Type 2 diabetes, sleep apnea, ...
In a normal body, growth hormone levels will drop
after eating or drinking glucose. If your child’s levels
remain the same, it means their body is producing too What is the difference between
much growth hormone.
acromegaly and gigantism?
If the blood tests indicate gigantism, your child will
need an MRI scan of the pituitary gland. Overproduction of growth hormone causes excessive
growth. In children, the condition is called gigantism.
In adults, it is called acromegaly. Excessive growth
hormone is almost always caused by a noncancerous
(benign) pituitary tumor.
When you have too much growth hormone, your bones
increase in size. In childhood, this leads to increased
height and is called gigantism. But in adulthood, a
change in height doesn't occur. Instead, the increase in
bone size is limited to the bones of your hands, feet
and face, and is called acromegaly.

2. Acromegaly
 sustained hypersecretion of growth hormone in
adults after epiphyseal closure
 Bone grows wider and thicker
 Extremities are enlarged
 Soft tissues on hands or feet enlarged and
coarse
 Prognathism
 Lengthened lower jaw
 Bridge of nose broader
 Care of the Client with Problems Related to the Endocrine System

When the pituitary gland releases GH into your

bloodstream, it triggers your liver to produce a
hormone called insulin-like growth factor-1 (IGF-1) —
sometimes also called insulin-like growth factor-I, or
IGF-I. IGF-1 is what causes your bones and other
tissues to grow. Too much GH leads to too much IGF-
1, which can cause acromegaly signs, symptoms and
complications.
In adults, a tumor is the most common cause of too
much GH production:
Pituitary tumors. Most acromegaly cases are caused by
a noncancerous (benign) tumor (adenoma) of the
pituitary gland. The tumor produces excessive amounts
of growth hormone, causing many of the signs and
symptoms of acromegaly. Some of the symptoms of
acromegaly, such as headaches and impaired vision,
Illustration showing a person with are due to the tumor pressing on nearby brain tissues.
ACROMEGALY
Nonpituitary tumors. In a few people with acromegaly,
Because acromegaly is uncommon and the physical tumors in other parts of the body, such as the lungs or
changes occur slowly over many years, the condition pancreas, cause the disorder. Sometimes, these tumors
sometimes takes a long time to recognize. Untreated, secrete GH. In other cases, the tumors produce a
high levels of growth hormone can affect other parts of hormone called growth hormone-releasing hormone
the body, in addition to your bones. This can lead to (GH-RH), which signals the pituitary gland to make
serious — sometimes even life-threatening — health more GH.
problems. But treatment can reduce your risk of
complications and significantly improve your
symptoms, including the enlargement of your features.

Causes
Acromegaly occurs when the pituitary gland produces
too much growth hormone (GH) over a long period of
time.

What is the most common cause of

acromegaly?
In adults, a tumor is the most common cause of too Where is the Supraorbital?
much GH production:
The supraorbital foramen, is a bony elongated opening
Pituitary tumors. Most acromegaly cases are caused located above the orbit (eye socket) and under the
by a noncancerous (benign) tumor (adenoma) of the forehead. The supraorbital foramen lies directly under
pituitary gland. The tumor produces excessive amounts the eyebrow.
of growth hormone, causing many of the signs and
symptoms of acromegaly.
The pituitary gland is a small gland at the base of your
brain, behind the bridge of your nose. It
produces GH and a number of other
hormones. GH plays an important role in managing
your physical growth.
 Care of the Client with Problems Related to the Endocrine System

bone, an enlarged nose, thickened lips, and wider

spacing between your teeth.
Because acromegaly tends to progress slowly, early
signs may not be obvious for years. Sometimes, people
notice the physical changes only by comparing old
photos with newer ones.
Overall, acromegaly signs and symptoms tend to vary
from one person to another, and may include any of
the following:

 A deepened, husky voice due to enlarged vocal

cords and sinuses
 Severe snoring due to obstruction of the upper
airway
 Vision problems
 Headaches, which may be persistent or severe
 Menstrual cycle irregularities in women
 Erectile dysfunction in men
 Loss of interest in sex
Can you reverse acromegaly?
Unfortunately, however, the disease is rarely caught
early enough to prevent permanent damage or even
premature death. Bone changes of acromegaly are
permanent. Many of the soft-tissue changes, such as
swelling, enlarged tongue, thickened skin, acne, and
A common sign of acromegaly is enlarged hands and carpal tunnel syndrome are reversible with treatment.
feet. For example, you may notice that you aren't able
to put on rings that used to fit, and that your shoe size When to see a doctor
has progressively increased. If you have signs and symptoms associated with
acromegaly, contact your doctor for an exam.
SYMPTOMS
Acromegaly usually develops slowly. Even your
1. Enlarged hands and feet family members may not notice the gradual physical
2. Enlarged facial features, including the facial changes that occur with this disorder at first. But early
diagnosis is important so that you can start getting
bones, lips, nose and tongue
proper care. Acromegaly can lead to serious health
3. Coarse, oily, thickened skin problems if it's not treated.
4. Excessive sweating and body odor
5. Small outgrowths of skin tissue (skin tags)
6. Fatigue and joint or muscle weakness
7. Pain and limited joint mobility

Symptoms READ THIS FIRST

Acromegaly may also cause gradual changes in your

face's shape, such as a protruding lower jaw and brow
 Care of the Client with Problems Related to the Endocrine System

Most patients with Cushing's disease have small

tumors (pituitary microadenomas). However, it can be
difficult to diagnosis Cushing's disease, and the
diagnosis is often delayed.

Cushing syndrome occurs when your body is exposed

to high levels of the hormone cortisol for a long time.
Cushing syndrome, sometimes called hypercortisolism,
may be caused by the use of oral corticosteroid
medication. The condition can also occur when your
body makes too much cortisol on its own.

Cushing's Disease vs. Cushing's

Syndrome
Cushing's disease is not the same as Cushing's
syndrome. Cushing's syndrome refers to the general
state characterized by excessive levels of cortisol in the
blood. Elevated cortisol levels can occur for reasons
other than a pituitary tumor, including:
Tumors of the adrenal glands producing cortisol
Cushing's syndrome is much more common than
Cushing's disease. The most common cause of
elevated cortisol levels is taking medications that have
cortisol, including: hydrocortisone, prednisone pills,
skin ointments, asthma inhalers and joint steroid
injections.
Cushing's disease is a serious condition of an excess of
the steroid hormone cortisol in the blood level caused
by a pituitary tumor secreting adrenocorticotropic
hormone (ACTH). ACTH is a hormone produced by
the normal pituitary gland. ACTH stimulates the
adrenal glands (located on top of the kidneys) to
produce cortisol, commonly referred to as the stress
hormone.
Care of the Client with Problems Related to the Endocrine System

Your doctor will conduct a thorough physical exam

and ask you about your symptoms and medical history.
In general, the first step in making the diagnosis is
establishing a state of excessive blood cortisol (i.e.
Cushing's syndrome). Assuming cortisol intake is
excluded, this typically is done by hormone testing.
After this diagnosis is established, an MRI is obtained
to determine if a pituitary tumor is visible.
24-hour urine free cortisol (UFC) measurement
Cortisol saliva testing
Blood ACTH
If low, may suggest the presence of an adrenal tumor
producing cortisol

Other Treatment Options

If the tumor cannot be removed surgically and does not
respond to medication or radiation, your doctor may
recommend removing the adrenal glands (bilateral
adrenalectomy), or BLA. If you undergo BLA:
You will need replacement of cortisol with
hydrocortisone or prednisone after the surgery.
You must wear a medical alert bracelet or necklace.
 Care of the Client with Problems Related to the Endocrine System

Rapid tumor growth can occur (Nelson's syndrome),  Retardation of growth on 1st year, chubby
since BLA does not affect the pituitary tumor growth.  Lack muscular development, delayed puberty

Nursing management

 Injection of growth hormone

Dwarfism is short stature that results from a genetic or
medical condition. Dwarfism is generally defined as an
adult height of 4 feet 10 inches (147 centimeters) or
less. The average adult height among people with
dwarfism is 4 feet (122 cm).
Growth hormone deficiency (GHD), also known
as dwarfism or pituitary dwarfism, is a condition
caused by insufficient amounts of growth hormone in
the body. Children with GHD have abnormally short
stature with normal body proportions. GHD can be
present at birth (congenital) or develop later
(acquired).

Hypoactivity
 deficiency of pituitary hormones At what age is dwarfism
 Panhypopituitarism
diagnosed?
o When both anterior and posterior
lobes fail to secrete hormones Disproportionate dwarfism is usually apparent at birth
Causes: or early in infancy. Proportionate dwarfism may not
be diagnosed until later in childhood or the teenage
 Hypophysectomy years if your child isn't growing at an expected rate.
 Nonsecreting pituitary tumors
Some people prefer the term "short stature" or "little
 Pituitary dwarfism
people" rather than "dwarf" or "dwarfism." So it's
 Postpartum pituitary necrosis
important to be sensitive to the preference of someone
 Functional disorders who has this disorder. Short stature disorders do not
o Starvation, anorexia nervosa, severe include familial short stature — short height that's
anemia considered a normal variation with normal bone
development.
Dwarfism
Secondary to congenital lack of growth hormone or
space occupying tumors
 Care of the Client with Problems Related to the Endocrine System

The main symptom of pituitary dwarfism is below-

average growth, although body proportions will be
normal. Other characteristics might include an
immature appearance, a chubby body build, a
prominent forehead, and an underdeveloped bridge of
the nose.
Can dwarfism be cured?
Currently, there is no cure for dwarfism. “These results
describe a new approach for restoring bone growth and
suggest that sFGFR3 could be a potential therapy for
children with achondroplasia and related disorders,”
researchers concluded in their study, published in the
Causes top journal Science.

Most dwarfism-related conditions are genetic

disorders, but the causes of some disorders are
unknown. Most occurrences of dwarfism result from a
random genetic mutation in either the father's sperm or
the mother's egg rather than from either parent's
complete genetic makeup.
Panhypopituitarism is a condition of inadequate or
absent production of the anterior pituitary hormones. It
is frequently the result of other problems that affect the
pituitary gland and either reduce or destroy its function
or interfere with hypothalamic secretion of the varying
pituitary-releasing hormones. The antithesis (direct opposite) of acromegaly; a
condition in which the bones of the face and limbs are
small and delicate; possibly due to a deficiency of
somatotropin. [acro- + G.

Types of dwarfism: LARON,

PSYCHOGENIC, DYSTROPHIA
ADIPOSOGENITALIS
Stunted growth is a reduced growth rate in human
development. ... The definition of stunting according to
the World Health Organization (WHO) is for the
"height for age" value to be less than two standard
deviations of the WHO Child Growth Standards
median.
What are symptoms of pituitary dwarfism?
 Care of the Client with Problems Related to the Endocrine System

Simmonds disease is a chronic deficiency of function

of the pituitary gland, a form of hypopituitarism, that
leads to atrophy of many of the viscera, including the
heart, liver, spleen, kidneys, thyroid, adrenals, and
gonads. The disease results in emaciation and death if
left untreated.

Simmonds disease is a chronic deficiency of function

of the pituitary gland, a form of hypopituitarism, that
leads to atrophy of many of the viscera, including the
heart, liver, spleen, kidneys, thyroid, adrenals, and
gonads. The disease results in emaciation and death if
left untreated.
 Care of the Client with Problems Related to the Endocrine System

Diabetes Insipidus
 Passage of excessive amounts of highly diluted
urine
o Diagnostic Assessment
 (+) water deprivation test

o Nursing Management
 Surgery (removal of tumor)-
transphenoidal hypophysectomy
 Desmopressin (DDAVP)
intranasal
 Pitressine tannate- vasopressin
tannate in oil
 Salt and protein restricted diet
Care of the Client with Problems Related to the Endocrine System

WEEK 11

Disorders of the
Thyroid gland
 Iodine regulates body metabolism (oxygen
consumption and heat production)
 Regulate growth and development
o TSH- from anterior pituitary stimulates thyroid
gland to release thyroxine, triiodothyromine,
thyrocalcitonin
o Euthyroid- normal thyroid function and
secretion

Diagnostic Assessment:
1. Thyroid function
a. Serum TSH
b. Serum free T4 (0.9 to 1.7 ng/dL)
c. Serum free T3 (70 to 220 ng/dL)
d. Triiodothyronin (T3) resin uptake test
(25% to 35%)
e. Radioactive iodine (131I) uptake and
excretion test
f. Thyrotropin-releasing hormone
g. Serum cholesterol- increased in patients with
myxedema or hypothyrodism
 Care of the Client with Problems Related to the Endocrine System

84  Hormone therapy for life (synthroid, cytomel)

Disorders of the Thyroid Gland

Goiter- enlargement of the Thyroid Gland Cretinism
Etiology
a. lack of iodine  Usually silent baby
 Severe hypothyroid condition of infancy due to
(simple goiter), pregnancy, lactation, iodine
deficiency of thyroid hormone synthesis during
deficient areas
fetal life or soon after birth
b. Intake of too much goitrogenic foods
Nutritional goitrogens that inhibit thyroxine Nursing assessment:
production
 Physical and mental retardation
Such as cabbage, soybeans, peanuts, spinach,
 Stunted stature
peaches, radish, strawberries
 Wide open mouth and lolling tongue
c. Inflammation - thyroiditis
 Small eyes and half closed with swollen lids
d. Thyroid cancer
 Stolid expressionless face
 Squat figure
 Muddy dry skin
Nursing Management
a. Prevention
 Iodized salt, avoid goitrogenic foods Disorders of the Thyroid Gland
b. Lugol’s solution or Potassium Iodide Saturated  Hyperthyroidism; Grave’s Disease
Solution (KISS) o Excessive production of T3 or T4 or
 Dose comes in drops; mixed with cold both
water and given with a straw o Toxic diffuse goiter or exophthalmic
goiter
c. Thryroid hormone replacement
 Watch for thyrotoxicosis
o Tachycardia, increase appetite,  Incidence: females
diarrhea, sweating, tremor, Hyperthyroidism increase rate in body metabolism
palpitations, shortness of breath 8x more frequently than men
Onset 2nd to 4th decade of life

Hypothyroidism
 Myxedema- deficiency in thyroid synthesis in
Nursing Assessment
adult d. Agitated, nervous, irritable
Asymptomatic to full blown e. Goiter (excessive thyroid hormone in blood)
f. Heat intolerance
Nursing Assessment:
g. Increased appetite
 Fatigue and apathetic
h. Amenorrhea
 Obesity: puffy and edematous with course
i. Exophthalmus
features
o Abnormal protrusion of eyes
 Dry and sparse hair, dry flaky skin
 Severe intolerance to cold decreased metabolic Nursing Management
rate
 Fecal impaction, hypersensitive to narcotics, a. Antithyroid therapy
barbiturates, and anesthetics To suppress thyroid secretions
Prophylthiouracil PTU; methimazole tapazole
MANAGEMENT: b. Iodine- lugol’s solution or KISS
 Care of the Client with Problems Related to the Endocrine System

To decrease the vascularity and size of the Management on Hypocalcemia

thyroid
c. Radioactive Iodine Therapy  Increase Ca – 100% sol of calcium carbonate
to middle aged and elderly clients or gluconate or calcium lactate
 Calcium supplement and Vit D

d. Surgery
When patient is euthyroid

e. Post-operative
Week 12
Semifowler’s position when conscious Thyroid storm
tracheostomy set at bedside
Overactivity of thryroid characterized by increased
Ambulate 2nd post-operative day temperature, severe tachycardia, delirium, dehydration
and irritability, hypotension

Thyroidectomy Nursing management:

Limit client talking and assess level of consciousness  Cool darkened quiet room
 Antipyretic oral or parenteral antithyroid drug
followed by K iodine; corticosteroids,
Complications propanolol- to relieve heart arrythmias
 Hemorrhage
Check dressings by sliding hand on the Hyperparathyroidism
patient’s nape
 Increased serum levels of calcium

 Respiratory obstruction  Management:

o Parathyroidectomy
Laryngeal edema- observe for sudden
o Hydration therapy/cranberry juice
difficulty in breathing o No thiazide diuretics
Keep tracheostomy set at bedside o Treatment of GI disorders

 WOF: Hypercalcemic crisis

Nursing Management: o Diuretics, hydration, dialysis,
complications calcitonin

 Accidental injury to the laryngeal nerve

Watch for decreasing voice Causes bone decalcification and formation of renal stones

Primary and secondary hyperparathyroidism

 Hypocalcemia or tetany
Accidental removal of parathyroid gland
(+) Chvostek’s sign Hypoparathyroidism
Spasms of the facial muscles when
 Decreased serum levels of calcium
tapped
(+) Troussaeu’s sign  Management:
 IV calcium gluconate
Carpopedal spasms upon constriction
 Parenteral parathormone
of the extremities
 Care of the Client with Problems Related to the Endocrine System

 Noise-free environment
 Aluminum hydroxide gel

End!