Comprehensive Textbook Chapter — Glands, Hormones, Disorders & Nursing Management
Secrete hormones directly into blood. Act on target organs. Local: CCK-PZ. General: TSH, ACTH, etc.
Secrete enzymes, sweat, sebum via ducts. Direct effect at production site. E.g., salivary amylase, gastric juice.
Link between nervous and endocrine systems via pituitary. Produces releasing hormones: GnRH, GHRH, TRH, CRH. Also produces ADH and oxytocin (stored in posterior pituitary).
Located in sella turcica. Two lobes:
Anterior (Adenohypophysis): GH, TSH, ACTH, FSH, LH, prolactin, MSH.
Posterior (Neurohypophysis): Stores ADH (vasopressin) — water reabsorption in distal tubules/collecting ducts; Oxytocin — milk release, uterine stimulation.
Produces T₃, T₄ (regulate metabolic rate, growth/development), and calcitonin (↓ serum Ca, ↑ serum phosphate).
Produce PTH — regulates calcium and phosphate (↑ Ca, ↓ P).
Cortex (3S hormones):
Medulla: Epinephrine/norepinephrine — emergency hormones: ↑ HR, BP, bronchodilation, glycogen → glucose.
Islets of Langerhans: Alpha cells (glucagon — ↑ blood glucose via gluconeogenesis/glycogenolysis), Beta cells (insulin — converts glucose to glycogen).
Pineal body: Serotonin & melatonin — sleep/wake cycle. Thymus: Thymosin — T-cell development. Ovaries: Estrogen, progesterone. Testes: Testosterone.
| Test | Normal Value |
|---|---|
| T₄ (thyroxine) | 5–13 mcg/dL |
| Free T₄ (active form) | 0.8–1.8 ng/dL |
| T₃ (triiodothyronine) | 0.8–1.1 mcg/dL |
| TSH | 0.40–4.5 mIU/L |
| RAIU (24h) | 5%–30% |
| Test | Normal / Threshold Values |
|---|---|
| FBS | 70–99 mg/dL |
| PPBS | < 140 mg/dL |
| HbA₁c — normal | < 5.7% |
| HbA₁c — prediabetes | 5.7–6.4% |
| HbA₁c — diabetes | ≥ 6.5% |
| HbA₁c — goal for DM | < 7% |
| GTT (3h) — fasting | ≥ 95 mg/dL abnormal |
| GTT — 1 hour | ≥ 180 mg/dL abnormal |
| GTT — 2 hour | ≥ 155 mg/dL abnormal |
| GTT — 3 hour | ≥ 140 mg/dL abnormal |
Fluid deprivation test: Deprive fluid 4–18 hours. If nephrogenic DI — urine output ↓ and osmolality ↑. If central DI — both remain unchanged.
Cortisone, Hydrocortisone (Solu-Cortef), Prednisone (Deltasone), Methylprednisolone (Solu-Medrol), Dexamethasone (Decadron).
Adrenal insufficiency (Addison's), anti-inflammatory (↑ICP, COPD, arthritis), autoimmune disorders (MG, SLE), allergic conditions.
CV: HTN, CHF. GI: Peptic ulcer. Integumentary: Bruising, acne, hirsutism, fragile skin, striae, buffalo hump, moon face. MSK: Muscle weakness, osteoporosis. Endocrine: Hyperglycemia, menstrual dysfunction. Neuro: Mood changes, insomnia, seizures. Ophthalmic: Cataracts, glaucoma. Other: Hypokalemia, hypernatremia, weight gain, poor wound healing, ↑ infection risk.
Pathophysiology: Hypofunction of posterior pituitary → ADH deficiency.
Causes: Tumor, trauma, inflammation, hypophysectomy.
S/S: Polydipsia, polyuria, fatigue, muscle weakness, irritability, weight loss, tachycardia, shock.
Diagnosis: Urine specific gravity < 1.004, urine output > 800–900 mL/2 hours.
Management: Fluid replacement. Hormone replacement: vasopressin (Pitressin), vasopressin tannate IM (shake well, warm to body temp), desmopressin acetate (DDAVP), lypressin nasal spray (Diapid). Instruct: medic-alert bracelet.
Pathophysiology: Excess ADH release → water retention → dilutional hyponatremia.
Causes: Trauma, stroke, stress, small cell lung cancer, meds (phenothiazines, carbamazepine).
S/S: HTN, tachycardia, weight gain, A/N/V, dilutional hyponatremia, water intoxication, altered LOC, seizures.
Management: Fluid restriction, diuretics, 3% NaCl as ordered, demeclocycline, conivaptan (Vaprisol). Chemotherapy if tumor-related.
Pathophysiology: Deficiency of 3S hormones → adrenocortical insufficiency. Often idiopathic (autoimmune).
S/S: Hypotension, weak pulse, hypoglycemia, muscle weakness, A/N/V, weight loss, skin pigmentation, vitiligo, anemia.
Diagnosis: Hyponatremia, hyperkalemia, hypoglycemia, low cortisol, ↓ Hct.
Medical Management: Hormone replacement: glucocorticoids (cortisone, hydrocortisone), mineralocorticoids (fludrocortisone / Florinef), sex hormones.
Nursing: High-Na, high-carb, high-protein diet. Small frequent feedings. Salt tablets if excessive sweating. Never omit medications. Avoid stress/trauma/infection. Report signs of Addisonian crisis.
Addisonian Crisis: Causes: stress, infection, noncompliance, adrenalectomy, rapid steroid withdrawal. Findings: severe weakness, severe hypotension, hypovolemia, shock. Management: IV fluids, IV glucocorticoids, vasopressors, treat cause.
Pathophysiology: Excess corticosteroids (especially cortisol). Primary: adrenal tumor. Secondary (Cushing's disease): pituitary/non-pituitary ACTH-secreting tumor. Iatrogenic: prolonged steroid use.
S/S: Same as corticosteroid side effects: buffalo hump, moon face, pendulous abdomen, hyperglycemia, HTN, osteoporosis, bruising, striae, poor wound healing, ↑ infection risk.
Diagnosis: DST, ↑ cortisol, slight hypernatremia, hypokalemia, hyperglycemia.
Management: Hypophysectomy (pituitary), adrenalectomy (adrenal), gradual steroid taper (iatrogenic). Nursing: prevent falls, ROM exercises, maintain skin integrity.
Excess mineralocorticoids from adrenal tumor. More common in women. S/S: HTN, cardiac arrhythmias (hypokalemia), polyuria, polydipsia, headache. Management: K⁺-sparing diuretics, Na restriction, strict I&O, BP monitoring. Prepare for adrenalectomy.
Functioning tumor of adrenal medulla → excess epinephrine/norepinephrine.
S/S: Paroxysmal hypertensive crisis (PHC), severe headache, apprehension, palpitations, profuse sweating, N/V, pupil dilation, flushing, heat intolerance, cold extremities, tremors.
Complications: CHF, stroke, cardiomegaly, hypertensive retinopathy/nephropathy, shock/death.
Diagnosis: Catecholamine level / VMA.
Management: Phentolamine (Regitine), phenoxybenzamine (Dibenzyline), nitroprusside (Nipride). Nursing: frequent BP monitoring, promote rest, ↓ stressful stimuli, avoid stimulants. Prepare for adrenalectomy.
Unilateral or bilateral (laparoscopic or open). Indications: adrenal tumors (Cushing's, Conn's, pheochromocytoma), metastatic breast/prostate cancer.
Pre-op: Correct hyperglycemia/HTN. Give glucocorticoids morning of surgery.
Post-op: Monitor hemorrhage/shock, urinary output, dressing for bleeding. Coughing/deep breathing. Surgical asepsis for dressing changes. Bilateral = lifelong hormone replacement. Unilateral = 6–12 months replacement.
Pathophysiology: Slowing of metabolic processes due to thyroid hypofunction. Myxedema in adults; cretinism in children.
Causes: Primary (Hashimoto's thyroiditis — autoimmune), Secondary (↓ pituitary TSH), Iatrogenic (surgery, over-treatment of hyperthyroidism).
S/S: Fatigue, lethargy, slow mental processes, anorexia, weight gain, constipation, cold intolerance, dry scaly skin, brittle nails, hair loss, bradycardia, macroglossia, menstrual irregularity. ↑ sensitivity to sedatives/narcotics/anesthetics.
Myxedema coma (emergency): Bradycardia, hypotension, hypothermia, lethargy, hypoventilation, syncope. Causes: missed medication, infection, cold, sedatives/narcotics. Management: IV thyroid hormone, correct hypothermia, maintain vital functions.
Management: Hormone replacement — levothyroxine (Synthroid). Nursing: low-calorie, high-roughage diet, plenty fluids, warm environment, careful with sedatives/narcotics.
Pathophysiology: Excess T₃/T₄ with ↑ metabolic activity. Autoimmune. More common in women 30–50.
S/S: Irritability, agitation, restlessness, tremor, sweating, insomnia, ↑ appetite, hyperphagia, weight loss, diarrhea, heat intolerance, exophthalmos, goiter, warm smooth skin, tachycardia, ↑ systolic BP, palpitations, lid lag (Graefe's sign).
Medical Management: Antithyroid drugs: PTU, methimazole (Tapazole) — agranulocytosis risk. Beta blockers (propranolol). Radioactive iodine therapy (RAI) — precautions for 1 week: limit contact with pregnant women/children, separate toilet (flush 2–3×), disposable utensils, separate bed. Thyroidectomy if drugs not effective.
Thyroid Storm (emergency): Causes: stress, infection, unprepared surgery. Findings: extreme temp (106°F), tachycardia, CHF, restlessness, respiratory distress, delirium, coma. Management: maintain airway/O₂, antithyroid drugs, corticosteroids, sedatives.
Nursing: Uninterrupted rest, private room, cool environment, 6 large meals high in nutrients, protective eye care (artificial tears, dark glasses, eye patch).
Pre-op: Stabilize cardiac/nutritional status. Antithyroid drugs + iodine (Lugol's) to ↓ gland size/vascularity, preventing hemorrhage and thyroid storm.
Post-op: Monitor for hemorrhage, respiratory distress (edema/hemorrhage/tetany → laryngospasm). Keep tracheostomy set + calcium gluconate available. Encourage voice rest. Extreme hoarseness = laryngeal nerve damage. Monitor for thyroid storm. IV fluids until tolerating PO.
Pathophysiology: PTH deficiency → ↓ Ca, ↑ P. Often due to accidental removal/damage during thyroidectomy.
S/S — Acute tetany: Tingling fingers/lips, painful muscle spasm, dysphagia, laryngospasm, convulsions, cardiac arrhythmias. + Chvostek's sign (tap facial nerve → twitching). + Trousseau's sign (BP cuff → carpopedal spasm).
Chronic: Fatigue, cramps, personality changes, memory impairment, dry skin, hair loss, cataracts.
Management — Acute: IV calcium gluconate, rebreathing mask, seizure precautions. Chronic: Oral calcium + vitamin D, phosphate binders (aluminum hydroxide, calcium acetate, sevelamer). High-Ca, low-P diet.
Over-secretion of PTH → ↑ Ca, ↓ P. Causes: parathyroid tumor, compensatory (chronic hypocalcemia).
S/S: Bone pain, pathologic fractures, renal stones, polyuria, polydipsia, A/N/V, constipation, muscle weakness, irritability, arrhythmias, HTN.
Management: Drugs to reduce bone resorption (gallium nitrate, mithramycin, etidronate, calcitonin). IV fluids + Lasix to excrete Ca. Nursing: assist ADL, careful handling, force fluids, acid-ash diet, strain urine for stones. ↓Ca, ↑P diet.
Impaired metabolism of carbohydrate, fat, and protein caused by insulin deficiency → hyperglycemia.
| Feature | Type 1 (IDDM) | Type 2 (NIDDM) |
|---|---|---|
| Pathophysiology | Little or no insulin production | Partial deficiency + insulin resistance |
| Management | Insulin required | OHAs ± insulin |
| Typical onset | Children & non-obese adults | Obese adults > 40 |
| S/S | 3 Ps, A/N/V, weight loss | Often obesity, hyperglycemia, slow wound healing |
| Type | Appearance | Onset | Peak | Duration | Key Nursing Points |
|---|---|---|---|---|---|
| Rapid Acting Lispro (Humalog) Aspart (Novolog) Glulisine (Apidra) | Clear | 15 min 5–10 min | ½–1½ hr 1–3 hr | 4–5 hr 3–5 hr | Eat within 15 min of meal to prevent hypoglycemia |
| Short Acting Regular (Humulin R, Novolin R) | Clear | ½–1 hr | 2–4 hr | 4–6 hr | Give 20–30 min before meal. Only type given IV. |
| Intermediate NPH (Humulin N, Novolin N) Lente (Humulin L) | Cloudy | 1–2 hr | 6–12 hr | 24 hr | Can be given after meals |
| Long Acting Detemir (Levemir) | Cloudy | 6–8 hr | 12–16 hr | 18–24 hr | Useful to control fasting blood sugar |
| Very Long Acting Glargine (Lantus) | Clear | 1 hr | No peak (flat) | 24 hr | Same time daily. Maintains steady level. Do NOT mix with other insulins. |
| Premixed 70/30 (70% NPH + 30% Regular) | Cloudy | ½ hr | 2–12 hr | 18–24 hr | Sustained action |
| Class | Drugs | Mechanism | Key Nursing Points |
|---|---|---|---|
| Sulfonylureas (1st gen) | Acetohexamide, Chlorpropamide, Tolazamide, Tolbutamide | ↑ insulin release from beta cells | Risk of hypoglycemia, weight gain, photosensitivity, Steven-Johnson syndrome |
| Sulfonylureas (2nd gen) | Glimepiride (Amaryl), Glipizide (Glucotrol), Glyburide (Micronase) | ||
| Biguanides | Metformin (Glucophage) | ↓ gluconeogenesis & intestinal glucose absorption | Not given if renal impairment. Hold 24–48h before surgery/contrast. Avoid alcohol. Monitor LFTs. |
| Alpha-glucosidase inhibitors | Acarbose (Precose), Miglitol (Glyset) | Prevent carbohydrate digestion | Take with first bite of meal. S/E: flatulence, diarrhea. |
| Thiazolidinediones | Rosiglitazone (Avandia), Pioglitazone (Actos) | ↓ insulin resistance | Regular LFTs. May cause fluid retention. |
| Meglitinides | Repaglinide (Prandin), Nateglinide (Starlix) | ↑ insulin production | Take before meals. Short-acting. |
| DPP-4 Inhibitors | Sitagliptin (Januvia), Saxagliptin, Vildagliptin | ↑ incretin → ↓ glucagon, ↑ insulin | Well tolerated. Monitor renal function. |
| Injectable | Exenatide (Byetta) | Incretin mimetic — ↑ insulin, ↓ glucagon, slows gastric emptying | Given SC. Risk of pancreatitis. |
| Parameter | Hypoglycemia (Insulin Reaction) | DKA (Diabetic Ketoacidosis) | HHNS (HHNK) |
|---|---|---|---|
| Onset | Rapid | Slow (hours to days) | Slow (hours to days) |
| Causes | Insulin overdose, inadequate food, excessive exercise, OHAs, vomiting | Undiagnosed DM, missed treatment, stress, infection | Infection, stress, meds (Dilantin, thiazides), TPN, pancreatitis |
| Skin | Cold, clammy | Warm, dry, flushed | Warm, dry |
| Breath | Normal | Acetone/fruity | Normal |
| Respirations | Normal | Kussmaul (deep, rapid) | Normal |
| Blood sugar | < 70 mg/dL | 350–800 mg/dL | 600–1200 mg/dL |
| Other labs | — | ↑ Ketones, ↑ BUN/Cr, pH < 7.35, ↑ anion gap | No ketosis, no acidosis |
| S/S | Dizziness, slurred speech, jitteriness, confusion, LOC changes, headache | 3 Ps, N/V, dehydration (dry mucous membranes, soft eyeballs, hypotension, tachycardia), altered LOC | Similar to DKA except no Kussmaul/acetone breath. Blurred vision, lethargy, coma |
| Management | Conscious: oral carbs (OJ, hard candy, glucose tabs). Unconscious: 50% dextrose IV or 1 mg glucagon IM/IV/SC. Recheck in 15 min. | Airway. IVF: NS → ½ NS (add dextrose when BS 250–300). K⁺ replacement. Insulin drip/push. Correct acidosis. Hourly urine output. | Same as DKA except no acidosis/ketosis correction needed |
| Condition | Key Features | Management |
|---|---|---|
| Congenital Hypothyroidism (Cretinism) | Short stature, macroglossia, hypothermia, short thick neck, delayed dentition, hypotonia. Untreated → physical & mental retardation by 3 months. | Neonatal screening. Oral thyroxine + vitamin D replacement. |
| Hypopituitarism (Dwarfism) | ↓ GH → falls below normal by 1 year. Normal proportions, delayed puberty, normal IQ. | GH replacement, sex hormones at puberty. Treat according to chronological age, not physical appearance. |
| Hyperpituitarism (Gigantism) | ↑ GH → height beyond max percentile, enlarged bones of head/hands/feet, coarse features. | GH suppressants (bromocriptine), hypophysectomy, radiation. |