Care of the Client with Problems Related to the Endocrine System

Week 10 Hyperactvity - Gigantism

Disorders of • Over-secretion of Growth hormones

1. Gigantism
o Sustained hypersecretion of growth hormone
in children
Pituitary Gland 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

• very large hands and feet Medication

• thick toes and fingers
• a prominent jaw and forehead • Doctor may recommend medication if surgery is
• coarse facial features 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
hormone’s release.
• Given as an injection about once a month.
The symptoms your child has may depend on the size of In some cases, surgery may not be an option. For
the pituitary gland tumor. As the tumor grows, it may
example, if there’s a high risk of injury to a critical blood
press on nerves in the brain. Many people experience vessel or nerve.
headaches, vision problems, or nausea from tumors in this
area. Other symptoms of gigantism may include: Bromocriptine and cabergoline are drugs that can be used
to lower growth hormone levels. These are typically
• excessive sweating given in pill form. They may be used with octreotide.
• severe or recurrent headaches Octreotide is a synthetic hormone that, when injected, can
• weakness also lower the levels of growth hormones and IGF-1.
• insomnia and other sleep disorders In situations where these drugs are not helpful, daily
• delayed puberty in both boys and girls shots of pegvisomant might be used as well. Pegvisomant
• irregular menstrual periods in girls is a drug that blocks the effects of growth hormones.
• deafness This lowers the levels of IGF-1 in your child’s body.

Children with gigantism may also have flat

noses and large heads, lips, or tongues.

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.
How is gigantism diagnosed?
• Hypophysectomy
If your child’s doctor suspects gigantism, they may
recommend a blood test to measure levels of growth
How is gigantism treated? hormones and insulin-like growth factor 1 (IGF-1), which is
✓ Treatments for gigantism aim to stop or slow your a hormone produced by the liver. The doctor also may
recommend an oral glucose tolerance test.
child’s production of growth hormones.
During an oral glucose tolerance test, your child will drink
✓ Microscopes or small cameras may be used to help a special beverage containing glucose, a type of sugar.
the surgeon see the tumor in the gland. In most Blood samples will be taken before and after your child
cases, your child should be able to return home from drinks the beverage.
the hospital the day after the surgery.
 Care of the Client with Problems Related to the Endocrine System

In a normal body, growth hormone levels will drop after What is the difference between
eating or drinking glucose. If your child’s levels remain
the same, it means their body is producing too much acromegaly and gigantism?
growth hormone. Overproduction of growth hormone causes excessive
If the blood tests indicate gigantism, your child will need growth. In children, the condition is called gigantism.
an MRI scan of the pituitary gland. 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

Acromegaly is a disorder that results from excess

growth hormone (GH) after the growth plates have
closed.
The initial symptom is typically enlargement of the hands Illustration showing a person with ACROMEGALY
and feet. There may also be an enlargement of the
forehead, jaw, and nose. Because acromegaly is uncommon and the physical
changes occur slowly over many years, the condition
Causes: Too much growth hormone sometimes takes a long time to recognize. Untreated, high
levels of growth hormone can affect other parts of the
Symptoms: Enlargement of the hands, feet, body, in addition to your bones. This can lead to serious
— sometimes even life-threatening — health problems.
Medication: Somatostatin analogue, GH recept… But treatment can reduce your risk of complications and
Complications: Type 2 diabetes, sleep apnea, ... significantly improve your symptoms, including the
enlargement of your features.
 Care of the Client with Problems Related to the Endocrine System

Causes Where is the Supraorbital?

Acromegaly occurs when the pituitary gland produces too The supraorbital foramen, is a bony elongated opening
much growth hormone (GH) over a long period of time. located above the orbit (eye socket) and under the
forehead. The supraorbital foramen lies directly under
What is the most common cause of acromegaly? the eyebrow.
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.
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.
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, are due to the tumor
pressing on nearby brain tissues.
A common sign of acromegaly is enlarged hands and feet.
Nonpituitary tumors. In a few people with acromegaly, For example, you may notice that you aren't able to put
tumors in other parts of the body, such as the lungs or on rings that used to fit, and that your shoe size has
pancreas, cause the disorder. Sometimes, these tumors progressively increased.
secrete GH. In other cases, the tumors produce a
hormone called growth hormone-releasing hormone (GH- SYMPTOMS
RH), which signals the pituitary gland to make more GH.
1. Enlarged hands and feet
2. Enlarged facial features, including the facial
bones, lips, nose and tongue
3. Coarse, oily, thickened skin
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
 Care of the Client with Problems Related to the Endocrine System

Symptoms READ THIS FIRST

Acromegaly may also cause gradual changes in your

face's shape, such as a protruding lower jaw and brow
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: Cushing syndrome occurs when your body is exposed to
high levels of the hormone cortisol for a long time.
• A deepened, husky voice due to enlarged vocal Cushing syndrome, sometimes called hypercortisolism, may
cords and sinuses be caused by the use of oral corticosteroid medication.
• Severe snoring due to obstruction of the upper The condition can also occur when your body makes too
airway much cortisol on its own.
• 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 Cushing's Disease vs. Cushing's Syndrome
early enough to prevent permanent damage or even
premature death. Bone changes of acromegaly are Cushing's disease is not the same as Cushing's syndrome.
permanent. Many of the soft-tissue changes, such as Cushing's syndrome refers to the general state
swelling, enlarged tongue, thickened skin, acne, and carpal characterized by excessive levels of cortisol in the
tunnel syndrome are reversible with treatment. blood. Elevated cortisol levels can occur for reasons
other than a pituitary tumor, including:
When to see a doctor
Tumors of the adrenal glands producing cortisol
If you have signs and symptoms associated with
Cushing's syndrome is much more common than Cushing's
acromegaly, contact your doctor for an exam.
disease. The most common cause of elevated cortisol
Acromegaly usually develops slowly. Even your family levels is taking medications that have cortisol, including:
members may not notice the gradual physical changes hydrocortisone, prednisone pills, skin ointments, asthma
that occur with this disorder at first. But early diagnosis inhalers and joint steroid injections.
is important so that you can start getting proper care.
Acromegaly can lead to serious health problems if it's not Cushing's disease is a serious condition of an excess of
treated. 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.
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.
Care of the Client with Problems Related to the Endocrine System
 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. Hypoactivity
Cushing's syndrome). Assuming cortisol intake is excluded,
this typically is done by hormone testing. After this • deficiency of pituitary hormones
diagnosis is established, an MRI is obtained to determine if • Panhypopituitarism
a pituitary tumor is visible.
o When both anterior and posterior lobes
24-hour urine free cortisol (UFC) measurement fail to secrete hormones
Cortisol saliva testing Causes:
Blood ACTH
If low, may suggest the presence of an adrenal tumor
• Hypophysectomy
producing cortisol
• Nonsecreting pituitary tumors
• Pituitary dwarfism
Other Treatment Options
• Postpartum pituitary necrosis
If the tumor cannot be removed surgically and does not • Functional disorders
respond to medication or radiation, your doctor may o Starvation, anorexia nervosa, severe
recommend removing the adrenal glands (bilateral anemia
adrenalectomy), or BLA. If you undergo BLA:
Dwarfism
You will need replacement of cortisol with
hydrocortisone or prednisone after the surgery. Secondary to congenital lack of growth hormone or
space occupying tumors
You must wear a medical alert bracelet or necklace.
Rapid tumor growth can occur (Nelson's syndrome), since • Retardation of growth on 1st year, chubby
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).
 Care of the Client with Problems Related to the Endocrine System

At what age is dwarfism diagnosed? Types of dwarfism: LARON, PSYCHOGENIC,

Disproportionate dwarfism is usually apparent at birth or DYSTROPHIA ADIPOSOGENITALIS
early in infancy. Proportionate dwarfism may not
be diagnosed until later in childhood or the teenage years Stunted growth is a reduced growth rate in human
if your child isn't growing at an expected rate. development. ... The definition of stunting according to the
World Health Organization (WHO) is for the "height for
Some people prefer the term "short stature" or "little age" value to be less than two standard deviations of the
people" rather than "dwarf" or "dwarfism." So it's WHO Child Growth Standards median.
important to be sensitive to the preference of someone
who has this disorder. Short stature disorders do not What are symptoms of pituitary dwarfism?
include familial short stature — short height that's The main symptom of pituitary dwarfism is below-average
considered a normal variation with normal bone growth, although body proportions will be normal. Other
development. 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 top
journal Science.

Causes
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 The antithesis (direct opposite) of acromegaly; a
frequently the result of other problems that affect the condition in which the bones of the face and limbs are
pituitary gland and either reduce or destroy its function small and delicate; possibly due to a deficiency of
or interfere with hypothalamic secretion of the varying somatotropin. [acro- + G.
pituitary-releasing hormones.
 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

84
 Care of the Client with Problems Related to the Endocrine System

Disorders of the Thyroid Gland Cretinism

Goiter- enlargement of the Thyroid Gland ▪ Usually silent baby
▪ Severe hypothyroid condition of infancy due to
Etiology deficiency of thyroid hormone synthesis during fetal
a. lack of iodine life or soon after birth
(simple goiter), pregnancy, lactation, iodine
deficient areas Nursing assessment:
b. Intake of too much goitrogenic foods
▪ Physical and mental retardation
Nutritional goitrogens that inhibit thyroxine
production ▪ Stunted stature
Such as cabbage, soybeans, peanuts, spinach, ▪ Wide open mouth and lolling tongue
peaches, radish, strawberries ▪ Small eyes and half closed with swollen lids
c. Inflammation - thyroiditis ▪ Stolid expressionless face
d. Thyroid cancer ▪ Squat figure
▪ Muddy dry skin

Nursing Management
a. Prevention Disorders of the Thyroid Gland
▪ Iodized salt, avoid goitrogenic foods
▪ Hyperthyroidism; Grave’s Disease
b. Lugol’s solution or Potassium Iodide Saturated o Excessive production of T3 or T4 or
Solution (KISS) both
▪ Dose comes in drops; mixed with cold water o Toxic diffuse goiter or exophthalmic
and given with a straw goiter

c. Thryroid hormone replacement ▪ Incidence: females

▪ Watch for thyrotoxicosis
o Tachycardia, increase appetite, Hyperthyroidism increase rate in body metabolism
diarrhea, sweating, tremor, 8x more frequently than men
palpitations, shortness of breath Onset 2nd to 4th decade of life

Hypothyroidism Nursing Assessment

➢ Myxedema- deficiency in thyroid synthesis in 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
i. Exophthalmus
➢ Obesity: puffy and edematous with course
o Abnormal protrusion of eyes
features
➢ Dry and sparse hair, dry flaky skin Nursing Management
➢ Severe intolerance to cold decreased metabolic
rate a. Antithyroid therapy
➢ Fecal impaction, hypersensitive to narcotics, To suppress thyroid secretions
barbiturates, and anesthetics Prophylthiouracil PTU; methimazole tapazole
b. Iodine- lugol’s solution or KISS
MANAGEMENT: To decrease the vascularity and size of the
➢ Hormone therapy for life (synthroid, cytomel) thyroid
c. Radioactive Iodine Therapy
to middle aged and elderly clients
 Care of the Client with Problems Related to the Endocrine System

d. Surgery Week 12
When patient is euthyroid
Thyroid storm
e. Post-operative Overactivity of thryroid characterized by increased
temperature, severe tachycardia, delirium, dehydration
Semifowler’s position when conscious
and irritability, hypotension
tracheostomy set at bedside
Nursing management:
Ambulate 2nd post-operative day
➢ Cool darkened quiet room
➢ Antipyretic oral or parenteral antithyroid drug
Thyroidectomy
followed by K iodine; corticosteroids,
Limit client talking and assess level of consciousness
propanolol- to relieve heart arrythmias

Complications Hyperparathyroidism
➢ Hemorrhage
➢ Increased serum levels of calcium
Check dressings by sliding hand on the patient’s
nape ➢ Management:
o Parathyroidectomy
o Hydration therapy/cranberry juice
➢ Respiratory obstruction o No thiazide diuretics
Laryngeal edema- observe for sudden o Treatment of GI disorders
difficulty in breathing
➢ WOF: Hypercalcemic crisis
Keep tracheostomy set at bedside o Diuretics, hydration, dialysis, calcitonin

Nursing Management: complications Causes bone decalcification and formation of renal stones

➢ Accidental injury to the laryngeal nerve Primary and secondary hyperparathyroidism

Watch for decreasing voice

➢ Hypocalcemia or tetany
Hypoparathyroidism
Accidental removal of parathyroid gland
➢ Decreased serum levels of calcium
(+) Chvostek’s sign
Spasms of the facial muscles when ➢ Management:
tapped ▪ IV calcium gluconate
(+) Troussaeu’s sign ▪ Parenteral parathormone
Carpopedal spasms upon constriction of ▪ Noise-free environment
the extremities ▪ Aluminum hydroxide gel
Management on Hypocalcemia
➢ Increase Ca – 100% sol of calcium carbonate or
gluconate or calcium lactate
➢ Calcium supplement and Vit D End!