Knowledge Check: Endocrine Disorders NURS 6501

Endocrine Disorders Guide

The endocrine system is composed of glands that produce hormones, which control and regulate important body functions. One of the endocrine glands is the Parathyroid, which secretes the Parathyroid hormone (PTH). The purpose of this guide is to educate nurses on the differences between hyperparathyroidism and hypoparathyroidism.

Causes and Diagnostic Tests

Hyperparathyroidism is a parathyroid condition caused by increased secretion of PTH. PTH acts on receptors in the intestines, kidneys, and bones. Elevated PTH levels act directly on the kidneys, resulting in increased reabsorption of calcium and excretion of phosphate in the kidneys. The outcome is hypercalcemia and hypophosphatemia. Elevated PTH levels in the bones cause increased bone resorption and calcium (Kochman, 2023). On the other hand, hypoparathyroidism occurs following a decreased parathyroid function (Pasieka et al., 2022). It results from Iatrogenic and Idiopathic causes and Hypomagnesaemia. Iatrogenic hypoparathyroidism occurs following the removal of the parathyroid tissue or surgical removal of the parathyroid glands. Idiopathic hypoparathyroidism is caused by autoimmune disorders.

The diagnostic tests for Hyperparathyroidism include measurement of serum calcium, phosphate, and PTH levels and urine cyclic adenosine monophosphate (cAMP) (Kochman, 2023). Diagnostic tests for hypoparathyroidism include blood tests, electroencephalography (EEG), and CT scans. Serum phosphate, calcium, magnesium, vitamin D, and cAMP levels are used to diagnose hypoparathyroidism.

Signs and Symptoms

The signs and symptoms of hyperparathyroidism include anorexia, nausea, vomiting, epigastric pain, weight loss, constipation, bone fractures, arthritis, and psychological distress (Kochman, 2023). Clinical manifestations of hypoparathyroidism are linked to the lack of PTH secretion or diminished efficiency of PTH on target tissue leading to hypocalcemia (Pasieka et al., 2022). Mild to moderate hypocalcemia causes mild tingling and numbness in the mouth, hands, and feet. Severe hypocalcemia causes spasms of hands and feet, muscle cramps, and seizures.

Nurse’s Role in Providing Multidimensional Care

Nurses have a primary role in the care of patients with hyperparathyroidism and hypoparathyroidism. The nurse’s role in caring for a patient with hyperparathyroidism includes monitoring the patient’s cardiac function and fluid intake and output every 2 to 4 hours during hydration therapy (Bandeira et al., 2022). Besides, the nurse has a role in preventing injury caused by pathologic bone fractures. The nurse should be aware that a patient with chronic hyperparathyroidism usually has marked bone density loss and is at high risk for pathologic fractures. Thus, the nurse should take appropriate interventions to prevent falls in the patient, like ensuring they are always escorted when ambulating. The nurse’s role when caring for a patient with hypoparathyroidism includes providing patient education on the medication (Clarke, 2022). Besides, patients are often anxious, and the nurse should teach them measures to alleviate anxiety. The nurse also has a role in providing dietary education like consuming high calcium and low phosphorus foods.

Response to the Interventions

A patient’s response to interventions for hyperparathyroidism can be evaluated by measuring serum calcium, phosphate, and PTH levels (Pavlidis & Pavlidis, 2023). The success of interventions for hypoparathyroidism can be evaluated through EEG. EEG changes get back to normal when hypocalcemia is corrected (Khan et al., 2022).

Conclusion

Hyperparathyroidism is caused by increased secretion of PTH, while hypoparathyroidism is caused by decreased parathyroid function. The signs of Hyperparathyroidism are linked to the effects of elevated PTH or the effects of hypercalcemia. Signs of hypoparathyroidism are due to hypocalcemia.

References

Bandeira, F., de Moura Nóbrega, J., de Oliveira, L. B., & Bilezikian, J. (2022). Medical management of primary hyperparathyroidism. Archives of endocrinology and metabolism, 66(5), 689–693. https://doi.org/10.20945/2359-3997000000558

Clarke, B. L. (2022). Hypoparathyroidism: update of guidelines from the 2022 International Task Force. Archives of endocrinology and metabolism, 66(5), 604–610. https://doi.org/10.20945/2359-3997000000549

Khan, A. A., Bilezikian, J. P., Brandi, M. L., Clarke, B. L., Gittoes, N. J., Pasieka, J. L., Rejnmark, L., Shoback, D. M., Potts, J. T., Guyatt, G. H., & Mannstadt, M. (2022). Evaluation and Management of Hypoparathyroidism Summary Statement and Guidelines from the Second International Workshop. Journal of bone and mineral research: the official journal of the American Society for Bone and Mineral Research, 37(12), 2568–2585. https://doi.org/10.1002/jbmr.4691

Kochman, M. (2023). Primary hyperparathyroidism: clinical manifestations, diagnosis and evaluation according to the Fifth International Workshop guidelines. Reumatologia, 61(4), 256–263. https://doi.org/10.5114/reum/170705

Pasieka, J. L., Wentworth, K., Yeo, C. T., Cremers, S., Dempster, D., Fukumoto, S., Goswami, R., Houillier, P., Levine, M. A., Pasternak, J. D., Perrier, N. D., Sitges-Serra, A., & Shoback, D. M. (2022). Etiology and Pathophysiology of Hypoparathyroidism: A Narrative Review. Journal of bone and mineral research: the official journal of the American Society for Bone and Mineral Research, 37(12), 2586–2601. https://doi.org/10.1002/jbmr.4714

Pavlidis, E. T., & Pavlidis, T. E. (2023). Update on the current management of persistent and recurrent primary hyperparathyroidism after parathyroidectomy. World journal of clinical cases, 11(10), 2213–2225. https://doi.org/10.12998/wjcc.v11.i10.2213

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Question 1

4 out of 4 points

Scenario 1: Syndrome of Antidiuretic Hormone (SIADH)

A 77-year-old female was brought to the clinic by her daughter who stated that her mother had become slightly confused over the past several days. She had been stumbling at home and had fallen twice but was able to walk with some difficulty. She had no other obvious problems and had

been eating and drinking. The daughter became concerned when she forgot he

Knowledge Check Endocrine Disorders NURS 6501

r daughter’s name, so she thought she better bring her to the clinic.

HPI: Type II diabetes mellitus (DM) with peripheral neuropathy x 30 years. Emphysema. Situational depression after death of spouse 6-months ago

SHFH: – non contributary except for 40 pack/year history tobacco use.

Meds: Metformin 1000 mg po BID, ASA 81 mg po qam, escitalopram (Lexapro) 5 mg po q am started 2 months ago

Labs-CBC WNL; Chem 7- Glucose-102 mg/dl, BUN 16 mg/dl, Creatinine 1.1 mg/dl, Na⁺116 mmol/L,

K⁺4.2 mmol/L, CO₂37 m mol/L, Cl^–97 mmol/L.

The APRN refers the patient to the ED and called endocrinology for a consult for diagnosis and management of syndrome of inappropriate antidiuretic hormone (SIADH).

Question:

1. Define SIADH and identify any patient characteristics that may have contributed to the development of SIADH

Selected Answer:	SIADH happens when increased ADH is produced in the body, causing water retention and electrolyte imbalance. Hypothalamus produces ADH, and the posterior pituitary secretes and stores ADH. ADH regulates water in the body through water retention, and it constricts blood vessels. It accomplishes this with kidneys. ADH causes renal tubules to retain water. An increased level of ADH causes extra water retention in the body, resulting in hyponatremia with hypo-osmolality and high urine osmolality. Causes of SIADH can be damage to the hypothalamus or posterior pituitary gland or ADH being produced somewhere else. The symptoms continue to become more severe if the SIADH goes untreated, including confusion, hallucinations, seizures, and even coma. Based on the patient history, this patient has emphysema and currently smokes 40 packs of tobacco a year. The current lab work shows that patient’s carbon dioxide level is elevated at 37. The normal range for serum carbon dioxide is 23-29. Also, their sodium level is abnormal at 116. The normal range of serum sodium ranges between 135-and 145. When the serum sodium level is too low, the syndrome of inappropriate antidiuretic hormone secretion (SIADH) diagnosis is possible
Correct Answer:	SIADH is a group of symptoms that occurs when antidiuretic hormone (ADH, arginine vasopressin) is secreted in the absence of osmotic or physiologic stimuli. These stimuli include: Increased serum osmolality, decreased plasma volume, and hypotension. A decrease in plasma osmolality normally inhibits ADH production and secretion. SIADH is characterized by fluid retention, dilutional hyponatremia, hypochloremia, concentrated urine, and lack of intravascular volume depletion. SIADH is characterized by normal to increased blood volume in normoproteinemia, nonedematous, and hyponatremic patients with normal renal and endocrine function.
Response Feedback:	[None Given]

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Question 2

4 out of 4 points

Scenario 2: Type 1 Diabetes

A 14-year-old girl is brought to the pediatrician’s office by his parents who are concerned about their daughter’s weight loss despite eating more, frequent urination, unquenchable thirst, and fatigue that is interfering with her school activities. She had been seemingly healthy until about 4 months ago when her parents started noticing these symptoms. She admits to sleeping more and gets tired very easily.

PMH: noncontributory.

Allergies-NKDA

FH:- maternal uncle with “some kind of sugar diabetes problem” but parents unclear on the exact disease process

SH: denies alcohol, tobacco or illicit drug use. Not sexually active.

Labs: random glucose 244 mg/dl.

DIAGNOSIS: Diabetes Mellitus type 1 and refers to an endocrinologist for further work up and management plan.

Question

1. Explain the pathophysiology of the three P’s for (polyuria, polydipsia, polyphagia)” with the given diagnosis of Type I DM.

Selected Answer:	Diabetes type 1 is also known as juvenile diabetes and is dependent on insulin injections. Type 1 diabetes happens when the pancreas does not produce enough or any of the insulin hormones in the body, which are necessary to help regulate the glucose in the body. Common signs and symptoms of type 1 DM can appear relatively suddenly. These symptoms include; increased thirst(polydipsia), frequent urination (polyuria), bed-wetting in children who previously did not wet the bed during the night, extreme hunger (polyphagia), and unintended weight loss, irritability and other mood changes, fatigue, weakness, and blurred vision. Pathophysiology of Polyuria Polyuria is one of the diabetes symptoms which means urine excretion is more than usual. High amounts of solutes within the renal tubules cause a passive osmotic diuresis and increased urine volume. In Diabetic patients, high urinary glucose levels exceed tubular reabsorption capacity, leading to increased glucose levels in the renal tubules; water follows passively, resulting in glucosuria and increased urine volume. Pathophysiology of Polydipsia Polydipsia can be the first sign that blood glucose levels are too high. A high blood glucose level in diabetic patients causes the kidney to produce more urine in order to remove excess glucose from the body. Furthermore, high blood glucose levels cause intracellular dehydration, and hypothalamus activation sends the thirst signal (Christ-Crain et al., 2019, pp. 2-3). Because more urine is being produced to reduce the amount of glucose circulating in the bloodstream, the brain instructs the body to increase the amount of fluid consumed. According to Seladi-Schulman (2020), persistent thirst can be caused by dehydration, osmotic diuresis (an increase in urination caused by excess glucose entering the kidney tubules that cannot be reabsorbed, resulting in increased water in the tubules), and mental health issues such as psychogenic polydipsia. Pathophysiology of Polyphagia Polyphagia is an excessive hunger feeling. This hunger usually dissipates once the person satisfies the craving by eating. In diabetics, the sense of hunger does not dissipate following consuming food. in diabetes, glucose can’t enter cells to be used for energy due to either low insulin levels or insulin resistance. The issue occurs when the conversion from glucose to energy is impaired, leading to continued hunger. With this being said, when the person consumes food, the glucose from that food then leads to increased blood glucose levels.
Correct Answer:	(polyuria) Hyperglycemia acts as an osmotic diuretic. The amount of glucose filtered by the glomeruli of the kidneys exceeds the amount that can be reabsorbed by the renal tubules. Glycosuria results accompanied by large amounts of water lost in the urine. (polydipsia) Because elevated blood glucose levels, water is osmotically attracted from body cells which results in intracellular dehydration and hypothalamic stimulation of thirst. (polyphagia) Depletion of cellular stores of carbohydrates, fats, and proteins results in cellular starvation and a corresponding increase in hunger.
Response Feedback:	[None Given]

Question 3

4 out of 4 points

Scenario 2: Type 1 Diabetes

PMH: noncontributory.

Allergies-NKDA

FH:- maternal uncle with “some kind of sugar diabetes problem” but parents unclear on the exact disease process

SH: denies alcohol, tobacco or illicit drug use. Not sexually active.

Labs: random glucose 244 mg/dl.

DIAGNOSIS: Diabetes Mellitus type 1 and refers to an endocrinologist for further work up and management plan.

Question

1. Explain the genetics relationship and how this and the environment can contribute to Type I DM.

Selected Answer:	Type 1 diabetes can occur due to genetics, environmental, and or lifestyle influences. Type 1 diabetes (T1D) is a chronic autoimmune disorder that leads to progressive pancreatic ß-cell destruction and culminates in absolute insulin deficiency and stable hyperglycemia. Environmental factors likely play a role in triggering islet autoimmunity. Factors such as gluten, breastfeeding and cow’s milk, vitamin D intake, the composition of your gut microbiota, infections acquired, antibiotics, and other medications taken may all play a role and affect the patient, leading to type 1 diabetes. Genetic factors include: Islet autoantibodies found in serum – Interferon (IFN)-stimulated genes – Excess IFIH1 (MDA5) levels may contribute to inflammation and autoimmunity. – PTPN22 contains risk polymorphisms that almost double the risk for T1D – High expression of CTLA-4 leads to inhibition of T cell activation – IL10 has an anti-inflammatory effect and has been identified as a risk factor for T1D – TNFAIP3 exerts anti-inflammatory function by inhibiting NF-κB activation and is associated with T1D. – Interleukin-21 and IL-2.
Correct Answer:	Islet cell autoantibodies (ICAs) were detected in serum from patients with autoimmune polyendocrine deficiency. They have subsequently been identified in 85 percent of patients with newly diagnosed type 1 diabetes and in prediabetic people. Autoantigens form on insulin producing beta cells and circulate in the blood and lymphatics. This leads to processing and presentation of autoantigen by antigen presenting cells
Response Feedback:	[None Given]

Question 4

4 out of 4 points

Scenario 3: Type II DM

A 55-year-old male presents with complaints of polyuria, polydipsia, polyphagia, and weight loss. He also noted that his feet on the bottom are feeling “strange” “like ants crawling on them” and noted his vision is blurry sometimes. He has increased an increased appetite, but still losing weight. He also complains of “swelling” and enlargement of his abdomen.

PMH: HTN – well controlled with medications. He has mixed hyperlipidemia, and central abdominal obesity. Physical exam unremarkable except for decreased filament test both feet. Random glucose in office 333 mg/dl.

Diagnosis: Type II DM and prescribes oral medication to control the glucose level and also referred the patient to a dietician for dietary teaching.

Question:

1. How would you describe the pathophysiology of Type II DM?

Selected Answer:	Type 2 diabetes is a chronic medical condition regarding how the body metabolizes glucose in the body. Two situations cause type 2 diabetes: the body develops insulin resistance, or the pancreas does not produce enough insulin. The cause of type 2 diabetes is unknown, although genetics and environmental factors, such as being overweight and inactive, seem to be contributing factors. Type 2 diabetes can be managed with diet and exercise in some cases. Once this therapy is unsuccessful, medications are added, changed, or increased. factors that put one at a higher risk for type ll DM include being overweight, high-fat content in the trunk, inactivity, family history, ethnicity/race, age, prediabetic, gestational diabetes, and polycystic ovarian syndrome.
Correct Answer:	There are very complex interactions that result in the development of Type II diabetes. The pathophysiology of type 2 diabetes mellitus is characterized by peripheral insulin resistance, impaired regulation of hepatic glucose production, and declining β-cell function, eventually leading toβ -cell failure. Type 2 diabetes mellitus consists of a constellation of dysfunctions characterized by hyperglycemia and resulting from the combination of resistance to insulin action, inadequate insulin secretion, and excessive or inappropriate glucagon secretion. It is often associated with obesity.
Response Feedback:	[None Given]

Question 5

4 out of 4 points

Scenario 4: Hypothyroidism

A patient walked into your clinic today with the following complaints: Weight gain (15 pounds), however has a decreased appetite with extreme fatigue, cold intolerance, dry skin, hair loss, and falls asleep watching television. The patient also tearfulness with depression, and with an unknown cause and has noted she is more forgetful. She does have blurry vision.

PMH: Non-contributory.

Vitals: Temp 96.4˚F, pulse 58 and regular, BP 106/92, 12 respirations. Dull facial expression with coarse facial features. Periorbital puffiness noted.

Diagnosis: hypothyroidism.

Question:

What causes hypothyroidism?

Selected Answer:	Hypothyroidism is a hypometabolic state that results from a deficiency in T4 and T3. The most common cause of hypothyroidism is an autoimmune disorder called Hashimoto disease, in which the thyroid is destroyed by antibodies or lymphocytes that attack the gland. Other causes are thyroiditis, congenital hypothyroidism, thyroidectomy, radiation to the thyroid, medications, iodine deficiency, and pituitary disease. Hypothyroidism is an underactive thyroid that does not produce enough hormones.
Correct Answer:	Patients with primary hypothyroidism have elevated TSH levels and decreased free hormone levels. Patients with elevated TSH levels (usually 4.5- 10.0 mIU/L) but normal free hormone levels or estimates are considered to have mild or subclinical hypothyroidism. The most common cause of hypothyroidism is autoimmune thyroiditis known as Hashimoto’s disease. Primary hypothyroidism is essentially the only disease that is characterized by sustained rises in TSH levels. As the TSH level increases early in the disease, conversion of T4 to T3 increases, maintaining T3 levels. In early hypothyroidism, TSH levels are elevated, T4 levels are normal to low, and T3 levels are normal.
Response Feedback:	[None Given]

Question 18

Needs Grading

A 27-year-old man comes to the Veteran’s Administration Hospital at the insistence of his fiancée who accompanies him to the appointment. She tells the APRN that her fiancée has not “been the same” since he returned from his second tour in Iraq. He was an infantryman with a local Marine Reserve unit and served 2 tours and was honorably discharged. Since his return, he has had difficulty sleeping, and says he “sleeps with one eye open” and fears sleep. Deep sleep brings vivid nightmares. He grudgingly admits to having experienced several traumatic events during his second tour of duty. He is unwilling to discuss them and will not reveal specific details. He is short tempered and irritable and is afraid to be around people as he doesn’t want to snap at people and alienate them. He startles easily at loud noises, especially the sounds of cars backfiring. He admits to thinking there are threats everywhere and spends an excessive amount of time searching for them but never finding any. He has intrusive memories almost every day and says he really isn’t interested in doing much of anything. He is very worried that these symptoms are irreparably hurting his relationship with his fiancée who he loves very much. The APRN diagnoses him with post-traumatic stress disorder (PTSD).

Question 2 of 2:

Briefly discuss the role glucocorticoids may have on the development of PTSD.

Selected Answer:	People with PTSD have normal-low circulating cortisol levels despite a high Corticotropin-Releasing Factor (CRF) and ongoing stress. Cortisol reduces CRF production. With low cortisol levels, the levels of CRF levels increase and this stimulates the release of norepinephrine by the anterior cingulate. Norepinephrine also plays a major role in increasing blood pressure and a rapid heartbeat seen in individuals with flashbacks.
Correct Answer:	People with PTSD tend to have normal to low circulating levels of cortisol despite their ongoing stress and elevated levels of Corticotropin Releasing Factor (CRF). Cortisol leads to decreased production of CRF. If cortisol is low, then CRF continues to be high and stimulates norepinephrine release by the anterior cingulate. This norepinephrine contributes to the rapid heartbeat, and blood pressure elevations seen in people experiencing flashbacks.
Response Feedback:	[None Given]

Question 19

Needs Grading

A 17-year-old male high school junior comes to the clinic to establish care. He recently moved from a relatively urban area to a very rural area and has just started his junior year in a new school. The mother states that she has noticed that her son has been frequently washing his hands and avoids contact with any dirty or soiled object. He uses paper towels or napkins over the knob on a door when opening it. According to the mother, this behavior has just appeared since moving. The patient, upon close questioning, admits that he is “grossed out” by some of the boys in the boys’ room since they use the toilet and do not wash their hand afterwards. He is worried about all the germs the boys are carrying around. Past medical history is noncontributory. Social history -lives with parents and 2 siblings in a house in a new town. Is an honors student. Based on these behaviors, The APRN thinks the patient has obsessive-compulsive disorder (OCD).

Question 1 of 2:

What is primary pathophysiology of OCD?

Selected Answer:	Among people with OCD, primary studies have indicated that its pathogenesis is associated with increased metabolic activity and flow of blood in the limbic structures, orbitofrontal cortex, thalamus, and caudate with a high right-sided dominance. There is also a pathophysiological brain circuit that comprises the orbitofrontal cortex, anterior thalamus, dorsal anterior cingulate cortex, and in the subregions of the basal ganglia of the putamen and caudate.
Correct Answer:	Neuroimaging studies have shown increases in blood flow and metabolic activity in the orbitofrontal cortex, limbic structures, caudate, and thalamus, with a trend toward right-sided predominance. There is a pathophysiological brain circuit that consists of the anterior thalamus, orbitofrontal cortex, dorsal anterior cingulate cortex, and predominately in the basal ganglia subregions of the caudate and putamen is involved in OCD.
Response Feedback:	[None Given]

Question 20

Needs Grading

Question 2 of 2:

Describe the role the dorsal anterior cingulate cortex (dACC) has in reinforcement of obsessive behaviors.

Selected Answer:

Neuroimaging studies indicate that individuals with OD have dACC hyperactivity. This is attributed to the fact that dACC is thought to be a primary center for receiving negative emotions, reinforces information, and integrates it to direct motivated behavior.

Correct Answer:

Neuroimaging studies have demonstrated hyperactivity of the dACC in people with OCD as compared to controls. The dACC is thought to be a key center that receives negative emotion and reinforcing information and integrates that information to direct motivated behavior.

Response Feedback:

[None Given]