GOOD MORNING

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• GOOD MORNING

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Endocrine System

• Regulates body systems
• Hormones secreted into the blood stream
• Each hormone has 1 or more target organs
  (receptor sites)
• Rhythmic pattern of release
• Problems arise from either production or receptor
  sites
• Most problems are chronic requiring
  self-management

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Hormones

• Responsible for regulating
• Reproduction
• Growth Development
• Energy production use
• Maintenance of internal environment

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Catecholamines

• Amino Acid derivatives
• Epinephrine
• Norepinephrine
• Thyroxin
• Easily replaced
• Many can be oral

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Proteins Peptides

• Chains of Amino Acids
• Difficult to isolate engineer
• None survive the GI system
• Proteins
• Larger molecules
• Insulin, Calcitonin, Growth Hormone, FSH
• Peptides
• Releasing Factors in Hypothalamus Posterior
  Pituitary (Neurohypophysis)
• Oxytocin, Vasopressin

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Steroids

• Formed from cholesterol
• Easily produced for replacement
• Most can be oral
• Include Adrenal and Sex Glands
• Aldosterone
• Cortisol
• Estrogen
• Testosterone

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Pharmacologic Uses

• Diagnostic
• ACTH to stimulate the Adrenals
• Thyroglobin to check thyroid response
• Replacement
• Insulin
• Estrogen
• Thyroid
• Pharmacologic Effects
• Steroids to decrease inflammation

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Feedback

• Secreted when the body identifies a need
• Changes in the blood level or other hormones may
  cause an increase or decrease in secretion
• Negative Feedback
• Hormone produces an effect, when it is strong
  enough, further hormone secretion is inhibited,
  decreasing physiologic effect.

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Feedback Loops
__
Hypothalamus
Negative Feedback Loop
Releasing Factor
__
Pituitary
Hormone A
Target Organ
Hormone B
Biologic Effect
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Physiologic Changes with Aging

• Reduction in hormone production
• Changes in hormone clearance
• Decreased cellular responsiveness
• Changes in
• Physical activity level
• Nutritional status
• Body composition

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Causes of Disease

• Over or Under Production
• Transport abnormalities
• Inability of target tissues to respond
• Problems with the feedback mechanism
• Primary
• Secondary

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Pituitary

• Anterior Pituitary
• Hypothalamic releasing factors stimulate the
  release or inhibit the release of hormones
• Posterior Pituitary
• Hormones produced in the hypothalamus are stored
  in the posterior lobe until stimulated by the
  hypothalamus via nerve impulses

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Hypothalamus
Neuro - Secretory Cells
Releasing Factor Producing Cells
Portal Vessel
Anterior
Posterior
Hormone Producing Cells
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Anterior Pituitary

• Growth Hormone (GH)
• Gonadotropic
• Lutenizing Hormone (LH)
• Follicle Stimulating Hormone (FSH)
• Adrenocorticotropic Hormone (ACTH)
• Thyroid Stimulating Hormone (TSH)
• Prolactin (PRL)
• Melanocyte-stimulating Hormone (MSH)

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Anterior PituitaryGrowth Hormone (Somatotropin)

• Growth Hormone increases bone growth and tissue
  cell size by changing metabolism, antagonizing
  the action of insulin, and increasing fat
  mobilization for energy use.
• Deficiency - Dwarfism delay in all body parts
  with no mental impairment.
• Excess - Gigantism in childhood, acromeglia in
  adults.

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Acromegaly

• Acromegaly is the Greek word for "extremities"
  and "enlargement
• Signs and symptoms vary, dependent upon how long
  the patient has had the disease, but may include
• Swelling of the hands and feet
• Facial features become coarse as bones grow
• Body hair becomes coarse as the skin thickens
  and/or darkens
• Increased perspiration accompanied with body odor
  
• Protruding jaw
• Voice deepening

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Anterior PituitaryGonadotropic Hormone

• Gonadotropin-releasing hormone (Gn-RH)
• Produced and released from the hypothalamus.
  Stimulates the secretion of follicle stimulating
  hormone (FSH) and lutenizing hormone (LH), from
  the anterior pituitary.

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Anterior PituitaryAdrenocorticotropic Hormone
(ACTH)

• Stimulates the adrenal cortex to synthesize and
  release cortisols in response to stress.

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Anterior PituitaryThyroid Stimulating Hormone
(TSH)

• Hypothalamus releases TRH
• Stimulates the anterior pituitary to produce TSH
• Regulates the amount of thyroid hormone produced
  and released into the bloodstream by the thyroid
  gland

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Posterior Pituitary

• Oxytocin
• Uterine contraction
• Milk let down
• ADH (Vasopressin)
• Renal conservation of water
• Vasoconstriction
• Increase GI motility
• Released in response to plasma osmolarity

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SIADH - Syndrome of Inappropriate ADH

• ADH release
• Water Reabsorption into circulation -Renal
  Tubules
• Extravascular Fluid
• Plasma Osmolality
• Glomerular Filtration Rate
• Serum Sodium Levels
  CEREBRAL EDEMA

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Diabetes Insipidus

• ADH Deficiency
• Water excretion and blood concentration
• ADH is a peptide and can not be taken orally
• Treatment
• Vasopressin (Pitressin) - short acting injection
• Lypressin and Desmopressin - nasal spray

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Adrenal Cortex

• Glucocorticoids (Cortisol)
• Release is under ACTH control
• Mineral-corticoids (Aldosterone)
• Renin-Angiotensin system and K levels
• Stimulated by NaCl depletion
• Androgens
• Growth of hair follicles
• Stress increases cortisol and aldosterone to
  maintain CV tone.
• Impairment of release leads to adrenal crisis

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Cushing Syndrome

• Excess of corticosteroids secreted by the adrenal
  cortex
• Iatrogenic - prolonged use
• Lab - 240 urine for cortisol
• Tx - Surgery, Radiation, Suppress synthesis using
  drug therapy
• Prolonged steroid use - TAPER doses
• Post-op care

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Addison's

• Adrenocorticol insufficiency
• Autoimmune
• Sxs - weight loss, anorexia, weakness, low BP,
  low sodium, high potassium, nausea vomiting,
  diarrhea
• Tx - Glucocorticoids
• Mineralcorticoids
• Adrenal Crisis

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Adrenal Medulla

• Pheochromocytoma
• Neoplasm increasing catecholamines
• Surgical removal
• Sxs - episodic HTN, increased metabolism,
  hyperglycemia
• Lab - urine metanephrines
• Monitor wide BP fluctuations

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The Thyroid Gland

• Normal thyroid levels are essential to regulate
  cellular metabolism, and for normal growth and
  development.
• Production of thyroid hormone is caused by
  release of TSH (stimulated by TRH)
• Thyroxin - T4
• Triiodothyronine - T3

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Thyroid

• Essential to regulate metabolism
• Caused by release of TSH
• Thyroxin - T4
• Triiodothyronine - T3
• Stimulated by increased Ca in blood
• Calcitonin - lowers blood levels by inhibiting
  bone re-absorption
• Low calcium levels suppress the release of
  calcitonin
• Elevated levels increase its secretion

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Prevalence of Thyroid Disorders

• In the United States, approximately 7.5 percent
  of the population (about 1 in every 13
  individuals) have been diagnosed with thyroid
  disorders, and nearly another 1 percent are
  estimated to have undiagnosed thyroid maladies.

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Hyperthyroid

• Graves Disease
• Multinodular Goiter
• Symptoms
• Increased metabolism
• Increase stimulation of sympathetic nervous
  system
• Exopthalmos
• Thyroid Storm Thyrotoxicosis----Severe and
  life threatening
• Treatment - Propylthiouracil, Inderol, Iodine,
  Radiation, Surgery

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Hypothyroid

• Infants - long gestation, failure to thrive
• Childhood - Autoimmune
• Adult - Atrophy or Decreased TSH
• Myxedema - interstitial edema, fatigue, lethargy,
  impaired memory leading to coma high mortality
  rate.
• Long term - Sxs related to increased protein
  turnover
• Cardiovascular, GI, and reproductive
• Replacement Therapy

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Parathyroid

• Maintains extracellular Ca levels
• Parathormone - Calcitonin antagonist
• Release stimulated by low blood levels of Ca or
  high levels of phosphates
• Increases Ca blood levels
• Reabsorption of Ca and Phos. from bones
• Increase GI absorption
• Increase reabsorption in kidneys

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Hyperparathyroid

• Primary - Parathyroid tumor or hyperplasia
• Secondary - Response to Low Ca levels
• ESRD - Response to phosphate excretion problems
• Nursing - increase fluids, low calcium diet,
  avoid immobility
• Mithramycin - antihypercalcemic agent
• Post-op removal - observe for tetany, fluid and
  electrolyte problems

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Hypoparathyroid

• Accidental removal or vascular damage during
  surgery
• Sxs - Tetany, Chvosteks sign
• Lab- low calcium, low PTH, and high Phos.
• Tx - Vitamin D, Calcium supplements, and
  Phosphate binders

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Pancreas

• Insulin
• Beta cells of Langerhans
• Stored in Beta Cells as Proinsulin
• Catalyst to cellular metabolism
• Promotes storage of CHO in liver, muscle cells,
  and fat deposits
• Glucagon
• Opposes the action of Insulin
• Alpha cells produce
• Acts to mobilize liver glycogen and convert to
  glucose

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Diabetes Mellitus

• Chronic hyperglycemia---main feature in all types
  of diabetes mellitus. Resulting from
• Insulin secretion
• Insulin action
• Or both
• Disease classified
• Age of onset
• Problem causing the lack of insulin
• Severity of the deficiency

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Cost of Diabetes in the United States, 2002

• Total (direct and indirect) 132 billion
• Direct medical costs 92 billion
• Indirect costs 40 billion (disability, work
  loss, premature mortality)

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Blood Glucose Values

• Normal Fasting blood glucose levels of lt110
  mg/dL
• Significant abnormal results Levelsgt126mg/dL
  obtained on at least two occasions are diagnostic
  of diabetes, even in older adults.

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Diabetes Causes

• Inability to use CHO
• Insulin action ineffective at tissue site or not
  enough Insulin available

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Diabetes Causes

• Glycogen fails to store in liver
• Conversion of glycogen to glucose NOT affected
• Increased metabolism of proteins and fats
• Leads to Ketone production

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Insulin

• Glucose transport across cell membrane
• Storage of glucose as glycogen
• Increased fat deposits
• Decreased protein breakdown
• Increased transport of amino acids into the cell
  for protein synthesis
• Absence Increased osmotic pressure
• 3 Polys

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Type I

• Beta cell destruction
• Rapid onset
• Must be given Insulin
• Ketoacidosis prone

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Type II

• Enough Insulin to prevent DKA
• May have increased or decreased Insulin
  production
• Decreased tissue response to Insulin
• Abnormal liver glucose regulation
• Oral Agent
• Increase Insulin production
• Improve cell receptor binding
• Regulate liver glucose production

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Impaired Glucose Tolerance

• Borderline Diabetes
• Blood Glucose levels above normal, but below
  levels to Dx Diabetes
• May progress to Diabetes
• Need close monitoring
• Diet and Exercise

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Gestational

• Intolerance of glucose during pregnancy
• Insulin resistance to increase glucose available
  to the baby
• Paced with placental hormones
• GTT returns to normal in 3-5 weeks after delivery
• Approximately 30 develop Diabetes within the
  next 5-10 years
• Glucose Tolerance Test

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Baby Effects

• Increase amounts of amniotic fluid
• Large fetus
• Hypoglycemic reactions after birth
• Respiratory Distress Syndrome

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Tests

• Blood Sugar
• Glycosylated Hemoglobin (HbA1c)
• The higher the number the poorer the control.
• GTT - Glucose Tolerance Test
• Capillary Blood Glucose (CBG)

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Treatment

• Diet
• ADA Exchange list
• Individually prescribed
• Exercise
• Type I - IDDM
• Increases Insulin sensitivity of cells
• Reduce Insulin dose or snack before exercise
• Type II - NIDDM
• Increases Insulin binding at receptors
• May initially elevate blood sugars

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Insulin Treatment

• Goal Match Normal Secretion Patterns of the Body
• Multiple types of Insulin
• Administration techniques
• Site Rotations
• Pumps
• New Technology

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Somogyi Effect

• Wide difference in CBGs
• Low in early AM
• High after breakfast
• Counter regulatory to hypoglycemia during the
  night
• Treatment - lower Insulin dose in the evening or
  increase food intake before bed

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Dawn Phenomenon

• High CBGs and possibly Ketones in the morning
• Dawn release of Growth Hormone or Cortisol
• Treatment - Change Insulin times and/or increase
  Insulin dose
• Look at clients entire management program

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Sulfonylureas

• Must be producing some Insulin
• Action
• Stimulate Beta cell release of Insulin
• Increase Insulin receptor sensitivity
• May decrease liver glucose production
• Do Not Take Extra if Overeats!
• Hypoglycemia may be prolonged

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Hypoglycemics

• Alpha-Glycosidase Inhibitors
• Delay digestion and absorption of CHO
• Biguanides
• Decrease glucose absorption, decrease glucose
  production in liver, and improves insulin
  sensitivity in tissues
• Meglitinides
• Stimulates Beta cells and improves insulin
  response to glucose
• Thiazolidinediones
• Lowers insulin resistance by re-sensitizing the
  body to its own insulin

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Hypoglycemia

• Too much Insulin or not enough food
• Symptoms due to rapid drop in Blood Sugar
• Adrenergic (Fight or Flight) Symptoms
• Glyconeurogenic (Brain) Symptoms
• Beta Blockers mask the symptoms
• Elderly often present with Brain symptoms FIRST

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DKA - Diabetic Ketoacidosis

• No Insulin leads to
• Use of glucose
• Breakdown of fats to fatty acids to Ketones
• Acidosis causes K to leave cells and water loss
• Severe dehydration with high serum K levels

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Jamie
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HHNK - Hyperglycemic Hyperosmolar NonKetosis

• Enough Insulin to Avoid DKA
• High Blood Glucose Levels lead to Osmotic
  Diuresis
• Hypovolemia
• Treatment Insulin and Rapid IV Fluid
  Replacement
• Prevent by Pushing Fluids When Serum Osmolarity
  Nears 320
• 2(NaK) BS BUN
  
• 18 2.8

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Chronic Complications

• 80 of Medical Spending
• Increasing as Population Ages
• Microvascular
• Macrovascular
• PATIENT EDUCATION

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Arthur
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Pattern Management Rule

• Target Glucose Goals
• Regular CBGs
• Record CBGs events
• Study a 3 day pattern
• Determine Insulin responsible for problems
• s Insulin by 1 or 2 Units
• One change at a time
• Treat low CBGs FIRST
• 3 days before another change

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Client 1
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Client 2
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Client 3
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Home Causes

• Oral Medication Errors
• Dose, Timing, Double Medication
• Bring ALL Meds from home
• Insulin Errors
• Technique Problems
• Observe technique ASAP
• Check dose and timing at home
• Diet Misinformation / Changes