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Common tumors of ear nose and throat (ENT)

Peri-Operative Care (Summary)

Preparation for surgery should begin as soon as the doctor makes a diagnosis and decides that an operation is necessary. From that moment on, the patient and relatives are faced with the decision of accepting this treatment and its consequences or not.

Pre-Operative Care

Admission

Explanation of the surgery: The patient is informed about the nature of the surgery, its purpose, and potential outcomes.
Informed Consent: The patient provides written consent for both admission and the surgical procedure.
Baseline Assessment: Vital signs (temperature, pulse, blood pressure, respiration), lab tests, and imaging studies are performed to establish a baseline for comparison post-surgery.
Counseling and Reassurance: Patients receive emotional support and guidance to address anxieties and concerns.
Addressing Patient Questions: Concerns are discussed, and questions are answered to reduce fear and anxiety.
Spiritual Care: Patients can access spiritual support if desired, with access to religious leaders provided.
Physical Examination: Weight, height, and nutritional status are assessed to ensure overall health.
Site Preparation: The surgical area is marked and prepared, including shaving if necessary.
Removal of Obstacles: Jewelry, dentures, and prosthetics are removed to prevent complications.
IV Line Insertion: An IV line is placed to administer fluids and medications.
Rehydration: IV fluids are given to ensure adequate hydration.
Premedication: Prescribed medications are given to prepare the patient for surgery.
Procedural Preparation: Procedures like nasogastric tube (NGT) placement, catheterization, and bowel irrigation are performed if needed.
Rest and Sleep: Patients are encouraged to rest and sleep to ensure optimal recovery.
Post-Operative Education: Patients are informed about anticipated activities and restrictions after surgery.
NPO (Nil Per Os): Food and drink are withheld according to the doctor’s orders to prepare for surgery.
Post-Operative Bed Preparation: The post-operative bed is prepared with necessary equipment like oxygen and suction apparatus.

Post-Operative Care

Reception from Theater: The patient is received from the operating room with instructions from the surgical team.
Vital Signs Monitoring: Temperature, pulse, blood pressure, respiration, and oxygen saturation are monitored regularly.
Bleeding and Shock Monitoring: Closely observing for signs of bleeding and shock.
Post-Operative Bed Admission: The patient is transferred to a warm, comfortable bed.
IV Fluid and Medication Administration: Fluids and medications are administered via IV.
Fluid Balance Chart: Fluid intake and output are meticulously recorded and monitored.
Post-Operative Medications: Prescribed medications are administered as ordered.
Bowel and Bladder Care: Support for bowel function and urinary elimination is provided.
Rest and Sleep: Patients are encouraged to rest and sleep to promote healing.
Drainage Management: Drains are properly managed and monitored to remove excess fluid.
Pain Management: Pain medication is administered to provide comfort.
Positioning: Patients are repositioned regularly to prevent pressure sores and promote comfort.
Nutrition: Diet is adjusted based on patient tolerance and recovery stage.
Wound Care: Surgical incisions are inspected and cleaned regularly.
Bed Hygiene: The bed is kept clean and dry.
Body and Skin Hygiene: Patients are assisted with hygiene to prevent infections.
Physiotherapy: Breathing exercises and other physical therapy techniques are initiated to improve lung function and mobility.
Psychological Care: Emotional support is provided to address anxiety, fear, and other psychological needs.

Advice on Discharge or Health Education

Explanation of Surgery, Cause, and Prevention: The patient is given a clear understanding of the surgery, the underlying condition, and measures to prevent its recurrence.
Treatment Completion: The importance of finishing the prescribed treatment plan is emphasized.
Hygiene Maintenance: Patients are advised on maintaining good hygiene practices to prevent infections.
Balanced Diet: The benefits of a balanced diet for overall health and recovery are explained.
Rest and Sleep: Adequate rest and sleep are encouraged for optimal healing.
Follow-up Appointment: The importance of attending scheduled follow-up appointments is stressed.
Light Exercise and Activity Restriction: Patients are advised to engage in light exercise but avoid strenuous activities and heavy lifting.

Potential Complications

Hemorrhage: Bleeding, either internal or external, may occur after surgery.
Shock: A life-threatening condition characterized by a sudden drop in blood pressure and oxygen levels.
Pain: Pain is a common post-operative experience, but it should be manageable with medication.
Vomiting: Nausea and vomiting can occur due to anesthesia or changes in diet.
Inability to Walk: Temporary difficulty in walking can result from anesthesia, pain, or muscle weakness.
Paralytic Illness: A rare but serious complication that can affect breathing muscles.
Constipation: Post-operative constipation is common, and measures to promote bowel function are often necessary.
Hiccups: Hiccups can be persistent after surgery and can be uncomfortable.
Burst Abdomen: A rare but serious complication where the surgical wound opens up.
Incisional Hernia: A bulge or protrusion through the surgical incision.
Infections: Infections can develop in the surgical wound or other parts of the body.
Retention of Urine: Difficulty in urinating can occur due to anesthesia or other factors.
Hypostatic Pneumonia: Pneumonia caused by fluid buildup in the lungs due to immobility.

EAR

Outer Ear: The outer ear consists of the pinna (visible part of the ear) and the external auditory canal. The pinna helps collect sound waves and directs them into the ear canal.
Middle Ear: The middle ear is an air-filled space behind the eardrum (tympanic membrane) that contains the three ossicles (tiny bones): the malleus (hammer), the incus (anvil), and the stapes (stirrup). These bones transmit sound vibrations from the eardrum to the inner ear.
Inner Ear: The inner ear comprises the cochlea, vestibule, and semicircular canals. The cochlea is responsible for converting sound vibrations into electrical signals, which are then transmitted to the brain for interpretation. The vestibule and semicircular canals are involved in balance and spatial orientation.

Tumors of the Ear

Tumors are abnormal growths that can occur in any part of the body, including the ear.

They can be benign (non-cancerous) or malignant (cancerous).

Types of Ear Tumors:

1. Benign (Non-Cancerous) Tumors:

Ceruminous Gland Adenomas: These slow-growing tumors arise from the ceruminous glands in the ear canal, responsible for producing earwax. These glands produce cerumen, better known as earwax.

Symptoms:

Hearing Loss: As the adenoma grows, it can block the ear canal, leading to conductive hearing loss.
Feeling of Fullness in the Ear: The tumor can cause a feeling of pressure or fullness in the ear.
Discharge: Some adenomas may produce a clear, watery discharge.
Pain: In rare cases, the adenoma may become painful if it becomes inflamed or infected.

Causes: Unknown, but may be linked to genetic predisposition.

Acoustic Neuroma (Vestibular Schwannoma): This is a benign tumor that arises from the Schwann cells that surround the vestibulocochlear nerve (also called the eighth cranial nerve). This nerve is responsible for hearing and balance. It develops within the inner ear, in the area where the vestibulocochlear nerve exits the brainstem.

Symptoms:

Gradual Hearing Loss: Often the first symptom, typically affecting one ear.
Tinnitus: A persistent ringing, buzzing, or other sound in the ear.
Dizziness and Balance Problems: Can cause vertigo (spinning sensation) or difficulty with coordination and balance.
Facial Numbness or Weakness: In some cases, as the tumor grows, it can compress the facial nerve, causing facial weakness or numbness.

Causes: The exact cause is unknown, but it is not related to exposure to loud noises or any other environmental factors. It may be linked to genetic predisposition in some cases.

Cholesteatoma: This is a non-cancerous, but destructive, growth that develops in the middle ear space, behind the eardrum. It is formed from skin cells that migrate into the middle ear, usually due to chronic ear infections or trauma. The middle ear space, often behind the eardrum.

Symptoms:

Hearing Loss: Often the first symptom, can be conductive (problems with sound transmission) or sensorineural (damage to the inner ear).
Ear Pain: Can be constant or intermittent, sometimes severe.
Ear Discharge: Often foul-smelling, and may contain pus or blood.
Recurrent Ear Infections: Cholesteatomas can contribute to chronic ear infections.
Facial Nerve Paralysis: In rare cases, a large cholesteatoma can compress the facial nerve, causing facial weakness or paralysis.

Causes:

Chronic Otitis Media (Ear Infections): Repeated ear infections can lead to a buildup of pressure in the middle ear, allowing skin cells to migrate behind the eardrum.
Trauma: Injury to the eardrum, such as a blow to the head, can create a pocket where skin cells can grow.

Keloids: Overgrowth of scar tissue following an injury or ear piercing. Keloids are firm, rubbery, and often have a shiny, smooth surface. They can range in color from pink or red to dark brown or black.

Symptoms: Raised, firm, and often itchy scars.
Causes: Overproduction of collagen in response to injury.

2. Malignant (Cancerous) Tumors:

Squamous Cell Carcinoma: This is the most common type of skin cancer that can affect the external ear.

Symptoms: A red, scaly patch, a non-healing sore, a lump, or a change in skin texture.
Causes: Prolonged exposure to sunlight, chronic ear infections, and certain genetic conditions.

Chondrosarcoma: A rare, malignant tumor of cartilage that can occur in the ear.

Symptoms: A painless mass, pain, hearing loss, facial nerve paralysis, and bone destruction.
Causes: Unknown, but may be related to radiation exposure or genetic predisposition.

Signs and Symptoms:

Outer Ear: Scaly patches, pearly white lumps, ulcers that bleed, changes in skin texture.
Ear Canal: Lumps, hearing loss, ear pain, numbness, drainage.
Inner Ear: Ear pain, dizziness, hearing loss, tinnitus (ringing in the ear), headache.

Causes of Ear Tumors:

Sun Exposure: Prolonged and unprotected sun exposure significantly increases the risk of skin cancers in the ear.
Genetic Predisposition: Certain genetic conditions can increase the risk of developing various types of ear tumors.
Chronic Ear Infections: Repeated ear infections can potentially contribute to the development of some ear tumors, particularly squamous cell carcinoma.
Age: Some types of ear tumors are more common in older individuals.
Trauma: Ear injuries or trauma can increase the risk of certain types of tumors.
Exposure to Loud Noises: Prolonged exposure to loud noises may increase the risk of certain types of tumors, particularly acoustic neuromas.
Lifestyle Factors: Smoking and alcohol consumption can increase the risk of some ear tumors.

Investigations:

Physical Examination: A thorough examination of the ear by a doctor is essential.
Biopsy: A sample of tissue is taken for microscopic examination to determine the type of tumor.
Imaging Studies: CT scans and MRI scans provide detailed images of the ear and surrounding structures to assess the extent of the tumor.
Audiometry: Hearing tests are used to evaluate hearing loss.
Facial Nerve Testing: Testing is done to assess facial nerve function, which can be affected by some ear tumors.

Treatment:

Surgery: Surgical removal of the tumor is the most common treatment for benign and malignant ear tumors.
Radiation Therapy: Used to shrink or destroy tumors, especially when surgery is not possible or to prevent recurrence.
Chemotherapy: May be used to treat widespread or advanced ear tumors.
Targeted Therapy: Newer therapies that target specific proteins or pathways in tumor cells are being developed and may become more common.

Prevention:

Sun Protection: Protect your ears from prolonged sun exposure by wearing a hat, sunglasses, and sunscreen with a high SPF.
Ear Hygiene: Practice good ear hygiene to prevent infections.
Hearing Protection: Wear earplugs or protective headphones when exposed to loud noises.
Regular Checkups: Schedule regular checkups with a doctor to detect potential ear tumors early.

NOSE

1. External Nose: The external nose includes the nasal bones and cartilages covered by skin.

It helps in filtering, warming, and moistening inhaled air.

2. Nasal Cavity: The nasal cavity is a hollow space behind the external nose that extends from the nostrils to the back of the throat (nasopharynx).

It is lined with mucous membranes and contains the nasal septum (dividing the cavity into left and right sides), nasal turbinates (bony structures that increase the surface area and help with air filtration), and openings to the paranasal sinuses.
At the entrance, Little’s area (also known as Kiesselbach’s plexus) is found on the anterior nasal septum, where epistaxis usually originates because of its vascular delicate structure.

3. Paranasal Sinuses: There are four pairs of paranasal sinuses: frontal, ethmoid, sphenoid, and maxillary sinuses.

These air-filled cavities are connected to the nasal cavity and play a role in producing mucus, providing resonance to the voice, and reducing the weight of the skull bones.

Types of Tumors of the Nose:

Benign Tumors:

1. Nasal Polyps: Benign, soft, teardrop-shaped growths that develop in the nasal lining. These are not true tumors but rather an overgrowth of the tissue lining the nasal cavity.

Causes:

Chronic inflammation due to allergies, sinusitis, aspirin sensitivity/drug sensitivity or immune disorders, cystic fibrosis, recurrent nasal sinus infections and other conditions.

Clinical Presentation:

Nasal obstruction: Difficulty breathing through the nose, feeling like the nose is blocked.
Anosmia/Loss of smell: Reduced or complete inability to smell.
Postnasal drip: Mucus dripping down the back of the throat.
Discharge: There may be nasal discharge which may be yellowish, mucoid or pus.
Facial pain: Aching or pressure in the face, especially around the sinuses.
Frequent headaches: Headaches that may be related to sinus pressure.
Snoring: Loud breathing during sleep, often due to nasal obstruction.
Sleep apnea: Pauses in breathing during sleep, which can be caused by obstruction.
Facial pressure or fullness: A feeling of tightness or pressure in the face.
Recurrent sinus infections: Frequent infections in the sinuses, often associated with inflammation.
There may be signs and symptoms of allergy like Nasal congestion, runny nose/stuffy nose, sneezing, loss of taste or smell.

Diagnosis & Investigations:

Physical examination: Through inspection of the nasal cavity and Grey freshly masses from nasal cavities which look like skinned grapes may be seen.
Nasal endoscopy: A thin, flexible tube with a camera is inserted into the nose to visualize the polyps.
CT scan or MRI: Imaging tests can show the size and location of the polyps and any associated sinus problems.

Management of Nasal Polpys:

Medical:

Treat the cause: Addressing underlying conditions like allergies, sinusitis, or aspirin sensitivity.
Antrum washout or antrostomy: Procedures to clear out the sinuses and improve drainage.
Nasal corticosteroids: Reduce inflammation and shrink polyps. (e.g., betamethasone 50mg instilled twice daily into each nostril for 4 weeks, with the patient lying flat for 3 minutes after instillation).
Antihistamines: Used to manage allergy-related inflammation.
Saline irrigation: Using saline solution to flush out the nasal passages.
Antibiotics: Prescribed for any bacterial infections.

Surgical:

Polypectomy: Removal of the polyps through surgery. This may be necessary if polyps are large, recurrent, or unresponsive to medical treatment.

Procedure:

Local anesthesia: Spray lignocaine 2% into the nose and adrenaline 1:100,000, wait for 5 minutes.
Open nostrils: Use a nasal speculum to open the nostrils under good lighting.
Pass a polypectomy snare: Maneuver the snare to catch the polyp and remove its base.
Repeat process: Repeat the procedure until all polyps are removed.
Bleeding control: Pack the nose if excessive bleeding occurs.

General anesthesia: This may be used for more complex polypectomies or in cases where the patient is unable to tolerate local anesthesia.

Prevention:

Avoiding triggers: Identifying and avoiding allergens and irritants, such as dust mites, pollen, smoke, and strong odors.
Managing underlying conditions: Treating sinusitis, allergies, and other conditions that contribute to inflammation.
Regular nasal hygiene: Using saline sprays, nasal irrigation, and other methods to keep the nasal passages clear.

2. Nasal Angiofibroma: Benign, vascular tumor that originates from the nasal cavity, most commonly in adolescent males. This tumor is made of blood vessels and connective tissue.

Causes: The exact cause is unknown, but hormonal influences are suspected. It may be related to puberty in males.

Clinical Presentation:

Nasal obstruction: Difficulty breathing through the nose.
Epistaxis (nosebleeds): Frequent and often heavy nosebleeds.
Facial swelling: Swelling around the nose and face.
Headache: Pain in the head, often caused by pressure from the tumor.
Snoring: Loud breathing during sleep, often due to nasal obstruction.
Sleep apnea: Pauses in breathing during sleep, which can be caused by obstruction.
Difficulty breathing through the nose: Feeling like you can’t breathe comfortably through your nose.
Repeated nosebleeds: Frequent and sometimes severe nosebleeds.

Diagnosis & Investigations:

Physical examination: Inspect the nasal cavity
Nasal endoscopy: A thin, flexible tube with a camera is inserted into the nose to visualize the tumor.
CT scan or MRI: Imaging tests can show the size and location of the tumor.
Haemogram: Blood tests

Management:

Surgical: Removal of the tumor, often via an endoscopic approach.
Radiation therapy: May be used as an adjunct to surgery or as a primary treatment in cases where surgery is not possible.

3. Nasal Papilloma: Benign, wart-like growth on the nasal lining, often caused by HPV (human papillomavirus). These are usually small but can grow larger.

Causes: HPV infection, specifically types 6 and 11.

Clinical Presentation:

Nasal obstruction: Difficulty breathing through the nose.
Epistaxis: Nosebleeds, which may be frequent or severe.
Nasal discharge: Clear or white mucus coming from the nose.
Smell disturbances: Reduced or complete inability to smell.
Repeated nosebleeds: Frequent and sometimes severe nosebleeds.
Postnasal drip: Mucus dripping down the back of the throat.

Diagnosis & Investigations:

Physical examination: Visual inspection of the nasal cavity.
Nasal endoscopy: A thin, flexible tube with a camera is inserted into the nose to visualize the papilloma.
Biopsy: A small sample of the papilloma is taken for examination under a microscope to confirm the diagnosis.

General Management:

Surgical: Removal of the papilloma, often with electrocautery or laser surgery.
Antiviral medication: May be used for some types of HPV-related papillomas, but generally not as effective as surgery.

General Prevention:

Avoiding exposure to HPV: This means practicing safe sexual practices and avoiding close contact with people who have HPV-related warts.

ADENOIDS AND ADENOIDITIS

Adenoids, also known as pharyngeal tonsils, are lymphatic tissues located in the nasopharynx, the area at the back of the nose. Important in the immune system by trapping and destroying pathogens, particularly bacteria and viruses.

Adenoiditis is the inflammation and enlargement of the adenoids. This condition is common in children under 7 years old and often follows an episode of acute tonsillitis. The most frequent culprit behind adenoiditis is Group A beta-hemolytic streptococcus, the same bacteria often responsible for strep throat.

Symptoms of Adenoiditis:

Nasal Obstruction: The enlarged adenoids block the nasal passages, leading to mouth breathing, difficulty breathing through the nose, and a stuffy feeling.
Difficulty Eating: Pain caused by inflammation can make eating difficult, particularly for children.
Snoring: Adenoid enlargement can obstruct the airway during sleep, resulting in noisy breathing and snoring.
Jaw Deformities: Prolonged mouth breathing due to nasal obstruction can lead to changes in jaw development.
Hearing Loss: The adenoids are located near the openings of the Eustachian tubes, which connect the middle ear to the back of the throat. Inflammation can block these tubes, leading to fluid buildup in the middle ear and hearing loss.
Glue Ear: The accumulation of fluid in the middle ear behind the eardrum, known as glue ear, is a common consequence of adenoiditis.
Recurrent Cough: Adenoiditis can trigger a persistent cough, often accompanied by drainage.
Discharging Cough: Mucus from the inflamed adenoids can drain down the throat, causing a post-nasal drip and a cough with phlegm.
Sleep Apnea: In severe cases of adenoid hypertrophy, the enlarged adenoids can completely block the airway during sleep, leading to episodes of apnea, where breathing temporarily stops.

Diagnosis of Adenoiditis:

History and Physical examination: The diagnosis of adenoiditis relies on a thorough medical history and physical examination. A careful assessment of the patient’s symptoms and examination of the throat can reveal the presence of enlarged adenoids.
Imaging: In some cases, imaging tests may be necessary to confirm the diagnosis and assess the severity of the adenoid enlargement. X-rays of the neck soft tissue, particularly a lateral view, can demonstrate narrowing of the nasopharynx due to enlarged adenoids.

Management of Adenoiditis:

The approach to managing adenoiditis depends on the severity of the symptoms and the patient’s age.

Mild Cases: If symptoms are mild and not significantly impacting daily life, conservative treatment may be sufficient. This includes:

Antihistamines: Chlorphenamine, an antihistamine, can help reduce inflammation and congestion. The dosage is 4 mg orally t.d.s, adjusted according to age, for a period of 7 days.
Topical Nasal Steroids: Nasal sprays containing corticosteroids like betamethasone can effectively reduce inflammation and improve nasal breathing.
Underlying Infection: If an underlying bacterial infection is suspected, antibiotics may be prescribed. Ampicillin, a common antibiotic, is often used at a dosage of 500mg-1g every 6 hours.
Pain Management: Pain relief can be achieved with analgesics like paracetamol (PCT) 500mg-1g three times a day or tramadol 75 mg for severe pain.
Mouth Care: Encouraging good oral hygiene practices, such as regular brushing and flossing, can help prevent secondary infections and promote healing.
Surgery (Adenoidectomy): If conservative treatment fails to alleviate symptoms, or if the adenoids significantly obstruct breathing or cause recurrent ear infections, surgery may be recommended. Adenoidectomy, the surgical removal of the adenoids, is typically performed after the age of one year.
- Note: Adenoids usually shrink as a child grows older, so surgery is considered as a last resort.

Complications of Adenoiditis:

While adenoiditis is usually a temporary condition, it can lead to complications if left untreated:

Otitis Media (Ear Infection): Blocked Eustachian tubes can result in recurrent ear infections.
Recurrent Infections: Persistent inflammation can increase susceptibility to repeated infections, particularly in the respiratory system.
Quinsy (Peritonsillar Abscess): A rare complication where an abscess forms around the tonsils, requiring drainage.
Mastoiditis: In severe cases, infection can spread to the mastoid bone behind the ear, causing mastoiditis.

Cancerous Tumors:

4. Nasal Carcinoma/Sinus Cancer: Malignant tumor arising from the nasal lining, usually squamous cell carcinoma. This is a serious condition that can spread to other parts of the body if left untreated.

Causes: Exposure to tobacco smoke, industrial chemicals, radiation, and certain viruses (including HPV) are all risk factors.

Clinical Presentation:

Nasal obstruction: Difficulty breathing through the nose.
Epistaxis: Nosebleeds, which may be frequent or severe.
Facial pain: Pain in the face, often related to pressure from the tumor.
Nasal discharge: Mucus coming from the nose, which may be thick, bloody, or foul-smelling.
Loss of smell: Reduced or complete inability to smell.
Facial swelling: Swelling around the nose and face.
Headache: Pain in the head, often caused by pressure from the tumor.
Sinus pain: Pain and pressure in the sinuses.
Facial pressure or fullness: A feeling of tightness or pressure in the face.
Pain in the teeth: Pain in the teeth, especially the upper teeth.
Loss of teeth: Loss of teeth due to tumor growth or pressure.
Weight loss: Unexplained weight loss, which can be a sign of cancer.
Fatigue: Feeling tired and weak.
Neck mass: A lump in the neck, which can be a sign of cancer spreading to the lymph nodes.

General Diagnosis & Investigations:

Physical examination: Visual inspection and examination of the nose, sinuses, and neck.
Nasal endoscopy: A thin, flexible tube with a camera is inserted into the nose to visualize the tumor.
Biopsy: A small sample of the tumor is taken for examination under a microscope to confirm the diagnosis.
CT scan or MRI: Imaging tests can show the size, location, and spread of the tumor.

Management:

Surgery: Removal of the tumor, often with radiation therapy or chemotherapy.
Radiation therapy: May be used as primary treatment or as an adjunct to surgery.
Chemotherapy: May be used to shrink the tumor before surgery or to treat advanced disease.

General Prevention:

Avoiding tobacco use: The most important thing that can reduce the risk of nasal cancer.
Limiting exposure to industrial chemicals: Wear appropriate safety gear when handling chemicals and avoid unnecessary exposure.
Wearing appropriate safety gear: Wear protective gear such as respirators, masks, and gloves when exposed to hazardous materials.
Regular dental check-ups: See your dentist regularly for check-ups and to identify any early signs of oral cancer, which can sometimes be related to nasal cancer.

THROAT:

a. Pharynx: The pharynx is a muscular tube located behind the nasal cavity and mouth.

It is divided into three parts: nasopharynx (behind the nasal cavity), oropharynx (behind the mouth), and laryngopharynx (above the esophagus and larynx). The pharynx serves as a passage for both air and food.

b. Larynx: The larynx, commonly known as the voice box, is situated at the top of the trachea (windpipe).

It houses the vocal cords, which are responsible for voice production. The larynx also helps protect the airway during swallowing by closing the epiglottis.

c. Tonsils and Adenoids: The tonsils (palatine tonsils) are located on each side of the back of the throat, while the adenoids (pharyngeal tonsils) are located in the upper part of the throat, behind the nose.

They are part of the immune system and help fight infection.

Tumors of the Throat:

Benign Tumors:

1. Papilloma: A benign, wart-like growth that occurs on the mucous membrane of the throat, often caused by human papillomavirus (HPV).

Causes: HPV infection, especially types 6 and 11.

Clinical Presentation:

Hoarseness: A change in voice quality, often described as raspy or rough.
Dysphagia/Difficulty swallowing: A feeling of food getting stuck in the throat or discomfort when swallowing.
Sore throat: A painful sensation in the throat that may be constant or intermittent.
Cough: A dry or productive cough that may be persistent.
Change in voice: A noticeable difference in how the voice sounds, such as hoarseness, breathiness, or a loss of vocal range.
Sensation of something in the throat: A feeling of a lump or obstruction in the throat.
Frequent throat clearing: A constant need to clear the throat to relieve a feeling of blockage.
Dyspnea/Difficulty breathing: Shortness of breath, wheezing, or a feeling of being unable to take a full breath.

Diagnosis & Investigations:

Physical examination: Visual assessment of the throat and neck for any visible signs of a papilloma.
Laryngoscopy: A thin, flexible tube with a camera is inserted into the throat to visualize the papilloma.
Biopsy: A small sample of the papilloma is taken for examination under a microscope to confirm the diagnosis and rule out cancer.

Management:

Surgical: Removal of the papilloma using laser surgery, electrocautery, or cryosurgery. These procedures are usually minimally invasive and performed under local anesthesia.
Antiviral medication: May be used for some types of HPV-related papillomas, but it is not always effective.

Prevention:

Avoiding exposure to HPV: This involves practicing safe sexual practices, using condoms, and avoiding close contact with people who have HPV-related warts.

Cancerous Tumors:

2. Laryngeal Cancer: Malignant tumor arising from the larynx (voice box), usually squamous cell carcinoma.

Causes:

Tobacco use (smoking and chewing): The most significant risk factor, both for developing and worsening laryngeal cancer.
Heavy alcohol consumption: Increases the risk of developing laryngeal cancer, particularly when combined with tobacco use.
Exposure to industrial chemicals: Certain chemicals like asbestos, formaldehyde, and nickel can increase the risk.
HPV infection: Some types of HPV can contribute to the development of laryngeal cancer.

Clinical Presentation:

Hoarseness: A persistent change in voice quality, often the first and most noticeable symptom.
Difficulty swallowing: Pain or discomfort when swallowing, sometimes accompanied by a feeling of food getting stuck.
Sore throat: A persistent sore throat, often described as scratchy or burning.
Cough: A chronic or persistent cough that may be dry or produce phlegm.
Neck pain: Pain in the neck, especially when swallowing or moving the head.
Ear pain: Pain in the ear, often on the same side as the tumor.
Difficulty breathing: Shortness of breath, wheezing, or a feeling of being unable to take a full breath.
Fatigue: A feeling of persistent tiredness and weakness.
Change in voice: Noticeable alteration in how the voice sounds, such as hoarseness, breathiness, or a loss of vocal range.
Sensation of something in the throat: A feeling of a lump or obstruction in the throat.
Frequent throat clearing: A constant need to clear the throat to relieve a feeling of blockage.
Pain when swallowing: Discomfort or pain when swallowing food or liquids.
Difficulty breathing: Shortness of breath, wheezing, or a feeling of being unable to take a full breath.
Neck mass: A lump or swelling in the neck, often on one side.
Loss of appetite: A decrease in appetite or a feeling of fullness quickly after eating.
Unexplained weight loss: Significant weight loss without trying to lose weight.
Chronic cough: A persistent cough that lasts for weeks or months.

Diagnosis & Investigations:

Physical examination: Examination of the throat and neck for any visible signs of a tumor.
Laryngoscopy: A thin, flexible tube with a camera is inserted into the throat to visualize the tumor.
Biopsy: A small sample of the tumor is taken for examination under a microscope to confirm the diagnosis and determine the type of cancer.
Imaging studies (CT scan, MRI, PET scan): These scans provide detailed images of the tumor and its location, helping to assess its size and spread. A positron emission tomography (PET) scan is a type of imaging test. It uses a radioactive substance called a tracer to look for disease in the body.

Management:

Surgery: Removal of the tumor, often with radiation therapy or chemotherapy, depending on the stage and location of the cancer.
Radiation therapy: May be used as primary treatment or as an adjunct to surgery to destroy any remaining cancer cells.
Chemotherapy: May be used to shrink the tumor before surgery or to treat advanced disease that has spread to other parts of the body.

Prevention:

Avoiding tobacco use: This is the most important step to reduce the risk of laryngeal cancer.
Limiting alcohol consumption: Moderate alcohol consumption can reduce the risk, but heavy drinking significantly increases it.
Avoiding exposure to industrial chemicals: Wear appropriate protective gear when handling hazardous substances.
Receiving the HPV vaccine: Vaccination can help protect against certain types of HPV that can contribute to laryngeal cancer.

3. Pharyngeal Cancer/Throat cancer: Malignant tumor arising from the pharynx (throat), commonly squamous cell carcinoma.

Causes:

Tobacco use (smoking and chewing): The primary risk factor.
Heavy alcohol consumption: Increases the risk, particularly when combined with tobacco use.
Exposure to industrial chemicals: Certain chemicals can increase the risk.
HPV infection: Some types of HPV can contribute to the development of pharyngeal cancer which can be obtained through oral sex.

Clinical Presentation:

Difficulty swallowing: Pain or discomfort when swallowing, sometimes accompanied by a feeling of food getting stuck.
Sore throat: A persistent sore throat, often described as scratchy or burning.
Ear pain: Pain in the ear, often on the same side as the tumor.
Neck pain: Pain in the neck, especially when swallowing or moving the head.
Hoarseness: A change in voice quality, often described as raspy or rough.
Nasal obstruction: Difficulty breathing through the nose.
Weight loss: Unexplained weight loss without dietary changes.
Fatigue: A feeling of persistent tiredness and weakness.
Sensation of something in the throat: A feeling of a lump or obstruction in the throat.
Frequent throat clearing: A constant need to clear the throat to relieve a feeling of blockage.
Earache: Pain in the ear, often on the same side as the tumor.
Neck mass: A lump or swelling in the neck, often on one side.
Chronic cough: A persistent cough that lasts for weeks or months.

Diagnosis & Investigations:

Physical examination: Examine the throat and neck for any visible signs of a tumor.
Laryngoscopy: A thin, flexible tube with a camera is inserted into the throat to visualize the tumor.
Biopsy: A small sample of the tumor is taken for examination under a microscope to confirm the diagnosis and determine the type of cancer.
Imaging studies (CT scan, MRI, PET scan): These scans provide detailed images of the tumor and its location, helping to assess its size and spread.

Management:

Surgery: Removal of the tumor, often with radiation therapy or chemotherapy, depending on the stage and location of the cancer.
Radiation therapy: May be used as primary treatment or as an adjunct to surgery to destroy any remaining cancer cells.
Chemotherapy: May be used to shrink the tumor before surgery or to treat advanced disease that has spread to other parts of the body.

Prevention:

Avoiding tobacco use: This is the most important step to reduce the risk of pharyngeal cancer.
Limiting alcohol consumption: Moderate alcohol consumption can reduce the risk, but heavy drinking significantly increases it.
Avoiding exposure to industrial chemicals: Wear appropriate protective gear when handling hazardous substances.
Receiving the HPV vaccine: Vaccination can help protect against certain types of HPV that can contribute to pharyngeal cancer.
Avoid Oral sex: Avoid engaging in oral sexual intercourse.

ADENOID HYPERTROPHY

Adenoid hypertrophy is a condition characterized by enlarged adenoids, a collection of lymphatic tissue located at the back of the nasal cavity.

This enlargement can lead to nasal obstruction, impacting breathing, sleep, and overall well-being.

Adenoids and Their Function

The adenoids, also known as the pharyngeal tonsils, are part of the body’s immune system, acting as a first line of defense against infections.
They are usually larger in children, playing a role in protecting them from respiratory infections.
By the age of five, adenoids usually begin to shrink, becoming less prominent in the immune system’s function.

The adenoids are small masses of lymphatic tissue located in the upper airway, between the nose and the back of the throat. Along with the tonsils, the adenoids form part of the lymphatic system, which works to defend the body against microbes, absorb nutrients, maintain proper fluid levels, and eliminate certain waste products. The anatomical position of the adenoids allows them to help fight infection by preventing germs from entering the body through the mouth or nose.

Causes of Adenoid Hypertrophy

Adenoid enlargement can be attributed to various factors, including:

Infections: Viral infections, such as Epstein-Barr virus, and bacterial infections, like group A Streptococcus, can trigger inflammation and swelling of the adenoids.
Chronic Inflammation: Repeated acute infections or persistent infections can lead to chronic adenoid inflammation, resulting in hypertrophy.
Allergies and Irritants: Allergens or irritants, when exposed to the adenoid tissue, can trigger an inflammatory response, causing enlargement.
Gastroesophageal Reflux (GERD): Stomach acid refluxing into the esophagus can irritate the adenoid tissue, leading to inflammation and hypertrophy.
Bacterial Infections: Several aerobic bacterial species have been implicated in adenoid hypertrophy, including:

Alpha-, beta-, and gamma-hemolytic Streptococcus species
Hemophilus influenzae
Moraxella catarrhalis
Staphylococcus aureus
Neisseria gonorrhoeae
Corynebacterium diphtheriae
Chlamydophila pneumoniae
Mycoplasma pneumoniae

Classifying Adenoid Hypertrophy

Adenoid hypertrophy can be classified based on its anatomical relationship with adjacent structures:

Grade 1: No contact between adenoid tissue and vomer, soft palate, or torus tubaris.
Grade 2: Adenoid tissue contacts the torus tubaris.
Grade 3: Adenoid tissue contacts the torus tubaris and vomer.
Grade 4: Adenoid tissue contacts the torus tubaris, vomer, and soft palate in resting position.

Additionally, adenoid hypertrophy can be classified based on its size in relation to surrounding tissues:

Grade 1: Adenoid occupies less than 25% of the choanal area.
Grade 2: Adenoid occupies 25-50% of the choanal area.
Grade 3: Adenoid occupies 50-75% of the choanal area.
Grade 4: Adenoid occupies 75-100% of the choanal area.

Clinical Features of Adenoid Hypertrophy

The symptoms of adenoid hypertrophy can vary depending on the severity of the condition. Common signs include:

Nasal Obstruction: Difficulty breathing through the nose, leading to mouth breathing.
Mouth Breathing: Dry lips and bad breath due to continuous breathing through the mouth.
Nasal Congestion: Feeling like the nose is pinched or stuffed.
Frequent Sinus Symptoms: Recurrent sinus infections, headaches, and facial pain.
Snoring: Loud snoring, especially during sleep.
Sleep Apnea: Restless sleep, frequent awakenings, and potentially obstructive sleep apnea.

Diagnosis of Adenoid Hypertrophy

Physical Examination: Examine the nose and throat for signs of adenoid enlargement.
Lateral Neck X-Ray: An X-ray of the neck can help visualize the size and shape of the adenoids.
Palpation: Gently feeling the adenoids through the roof of the mouth.
Nasal Endoscopy: A thin, flexible tube with a camera is inserted into the nose to visualize the adenoids.
Transnasal Endoscopy: An otolaryngologist (ENT doctor) performs this procedure for a definitive diagnosis.

Management of Adenoid Hypertrophy

Treatment for adenoid hypertrophy depends on the severity of the symptoms:

Minimal Symptoms: No treatment may be needed.

Mild to Moderate Symptoms:

Nasal Sprays: Saline or steroid nasal sprays can help reduce swelling and improve breathing.
Antibiotics: If the condition is caused by a bacterial infection, antibiotics may be prescribed.

Severe Symptoms:

Adenoidectomy: Surgical removal of the adenoids may be recommended if conservative measures are ineffective.

Complications of Adenoid Hypertrophy

If left untreated, adenoid hypertrophy can lead to various complications:

Obstructive Sleep Apnea (OSA): Enlarged adenoids can block the airway during sleep, leading to frequent awakenings, daytime sleepiness, and other health issues.
Chronic Otitis Media: The hypertrophied adenoids can block the Eustachian tube, leading to recurrent ear infections and fluid buildup in the middle ear.
Recurrent Sinus Infections: Obstruction of the nasal passages can lead to frequent sinus infections.
Mouth Breathing and Dental Issues: Continuous mouth breathing can cause dry mouth, bad breath, and dental malocclusions over time.
Speech and Swallowing Problems: Enlarged adenoids can interfere with speech and swallowing, potentially causing nasal speech and difficulty swallowing.
Failure to Thrive: In severe cases, the obstruction can lead to poor weight gain and growth in children.

Post-operative Care for Adenoidectomy

After surgery to remove the adenoids, nurses play a vital role in providing comprehensive care:

Pain Management: Administering pain medication and providing comfort measures.
Hydration and Nutrition: Encouraging fluid intake and offering soft, easy-to-swallow foods.
Monitoring for Complications: Observing for signs of bleeding, infection, and respiratory distress.
Rest and Recovery: Advise on adequate rest and gradual return to normal activities.

Common tumors of ear nose and throat (ENT) Read More »

Partograph

Partograph is a graph or tool used to monitor fetal condition, maternal condition and labour progress during the active 1st stage of labour so as to be able to detect any abnormalities and be able to take action.
It’s only used during 1st stage of labour. It is used for recording salient conditions of the mother and the fetus.

USES OF A PARTOGRAPH

To detect labour that is not progressing normally.
To indicate when augmentation of labour is appropriate.
To recognize CPD when obstruction occurs.
It increases the quality of all observations on the mother and fetus in labour.
It serves as an “early warning system”
It assists on early decision of transfer and augmentation.

Who should not use a partograph?
Women with problems which are identified before labour starts or during labour which needs special attention.
Women not anticipating vaginal delivery (elective C/S).

A partograph has 3 parts i.e. –
fetal part
maternal part
labour progress part

Observations charted on a partograph:

The progress of labour
> Cervical dilatation 4 hourly
> Descent 2 hourly
> Uterine contractions
Fetal condition
> Fetal heart rate ½ hourly
> Membranes and liquor 4 hourly
> Moulding of the fetal skull 4 hourly.
Maternal condition
> Pulse ½ hourly
> Blood Pressure 2 hourly
>Respiration and > temperature 4 hourly
Urine; – volume 2 hourly, acetone, proteins and sugars.
> Drugs
> I.V fluids 2 hourly and Oxytocin regimen

Starting a partograph:

The partograph should be started only when a woman is in active phase of labour.
Contractions must be 1 or more in 10 minutes.
Cervical dilatation should be 4cm or more.

FETAL CONDITION

Fetal heart;
It is taken 1/2 hourly unless there is need to check frequently i.e. if abnormal every 15 minutes and if it remains abnormal over 3 observations, take action. The normal fetal heart rate is 120-160b/m. below 120b/m or above 160b/m indicates fetal distress.
Molding;
This is felt on VE. It is charted according to grades.
State of moulding Record
Absence of moulding. (-)
Bones are separate and sutures felt (0)
Bones are just touching each other (+)
Bone are over lapping but can be Separated (++)
Bones are over lapping but cannot be separated (+++)
Liquor amnii;
This is observed when membranes are raptured artificially or spontaneously.
It has different colour with different meaning and meconium stained liquor has grades.
State of liquor Record
Clear (normal) (C)
Light green in colour (m+) Moderate green, more slippery (m++) Thick green, meconium stained (m+++) Blood stained (B)
Membranes;

State of membranes Record
Membranes intact (I)
Membranes raptured (R)

LABOUR PROGRESS

5. Cervical dilatation,
The dilatation of the cervix is plotted with an “X”. Vaginal examination is done at admission and once in 4 hours. Usually we start recording on a partograph at 4cm.
Alert line starts at 4cm of cervical dilation to a point of expected full dilatation at a rate of 1cm per hour
Action line– parallel and at 4 hours to the right of the alert line.

6. Descent of presenting part.
Descent is assessed by abdominal palpation. It is measured in terms of fifths above the brim.
The width of five fingers is a guide to the expression in the fifth of the head above the brim.
A head that is ballotable above the brim will accommodate the full width of five fingers.
As the head descends, the portion of the head remaining above the brim will be represented by fewer fingers.
It is generally accepted that the head is engaged when the portion of the head above the brim is represented by 2 or less fingers.
Descent is plotted with an “O” on the graph

7. Uterine contractions This is done ½ hourly for every 30 minutes. The duration, frequency and strength of contraction is observed. Observe the contractions within 10 minutes.

-Mild contractions last for less than 20 seconds.
-Moderate contractions last for 20-40 seconds.
-Strong contractions last for 40 seconds and above.
When plotting and shedding contractions use the following symbols.
Dots for mild contractions
Diagonal lines for moderate contractions
Shade for strong contractions

MATERNAL CONDITION

Pulse; this is checked every 30 minutes. The normal pulse is 70-90b/min.
The raised pulse may indicate maternal distress, infection especially if she had rapture of membranes for 8-12 hours and in case of low pulse, it can be due to collapse of the mother.
Blood pressure; it is taken 2 hourly. The normal is 90/60-140/90mmHg. Any raise of 30mmHG systolic and 20mmhg diastolic from what is regarded as normal or if repeated over 3 times and remains high, test urine for albumen to rule out pre-eclampsia.
Temperature; this is taken 4 hourly. The normal range is between 37.2 0 c to 37.5 0 c. Any raise in temperature may be due to infections, dehydration as a sign of maternal distress or if a mother had early rapture of membranes.
Urine; the mother should pass urine atleast every after 2 hours and urine should be tested on admission.
Fluids; she should be encouraged to take atleast 250-300 mls every 30 minutes. Any type of
fluid can be given hot or cold except alcohol. Thefluid should be sweetened in order to give her
strength.

Further mgt in the normal 1st stage of labour- nursing care

Emotional support:

Midwife should rub the mothers backto relieve pain.
Allow the mother to move around or sit in bed if membranes are still intact.
Re-assure the mother and keep her informed about the progress of labour to relieve anxiety.
Allow her to talk to relatives and husband.
Allow her to read or do knitting.

2. Nutrition;
Encourage mother to take light and easily digested food like bread, soup and sweet tea to rehydrate her and provide energy.

3. Elimination;
Taking care of the bladder and bowel. Encourage mother to empty bladder every 2 hours during labour. Every specimen is measured and tested for acetone, albumen, sugars and findings interpreted and recorded.
Pass catheter if mother is unable to pass urine.

4. Personal hygiene;
Allow mother to go for bath in early labour or on admission if condition allows. If membranes rapture, give a clean pad and ask mother to change frequently to prevent infections.
VE should be done only after aseptic technique.

5. Ambulation and position:
In early labour, mother is encouraged to walk around to aid descent of presenting part.
During contractions, ask mother to lean forward supporting herself on a chair or bed to reduce discomfort.
Allow mother to adopt a position of her choice except supine position.
Mother should be confined to bed when membranes rapture in advanced stage of labour.

6. Prevention of infections
Strict aseptic technique should be maintained when doing a VE and vulval swabbing.
When membranes rapture early, vulval toileting should be done 4 hourly to reduce the risk of infections. Put mother on antibiotics to avoid risk of ascending infections in early raptured of membranes.
Frequent sponging is done, bed linen changed when necessary when a mother is confined in bed.
The midwife should pay attention to her own hygiene and be careful to wash her hands before and after attending to the mother.

7. Sleep and rest
Mother is encouraged to rest when there is no contraction (rest in between contractions).

What to report

Abnormality found in urine.
Failure to pass urine.
Rise in temperature, pulse and BP.
Hypertonic uterine contractions.
Rapture of membranes with meconium stained liquor grade 2 and 3.
Failure of presenting part to descend despite good uterine contractions.
Tenderness of abdomen.
Bleeding per vagina.
Fall in BP.
Raise in fetal heart rate.

Complications

Infections
Early rapture of membranes
Cord prolapse
Supine hypotensive syndrome
Fetal distress
Maternal distress
APH
PET and eclampsia
Prolonged labour
Obstructed labour

Partograph Read More »

Cushing’s Syndrome

CUSHING’S SYNDROME

Cushing’s syndrome results from secretion of excessive cortisol either in response to excess ACTH production by the pituitary tumors and adrenal adenoma or nodular hyperplasia.

Cushing’s syndrome is simply defined as a hormonal disorder associated with excessive production of corticosteroids by the adrenal gland or the pituitary gland and/or prolonged use of corticosteroids.

Hypersecretion of ACTH. (disease)

Hypersecretion of ACTH by the anterior pituitary-causes increased release of both cortisol and androgenic hormones

Hypersecretion of Cortisol. (syndrome)

… too much cortisol secreted by the adrenal cortex organ itself.

Causes of Cushing’s Syndrome

Cushing’s syndrome arises from excessive cortisol production, which can be caused by;

Pituitary Adenoma (Cushing’s Disease): This is the most common cause, involving a non-cancerous tumor in the pituitary gland. The tumor produces excessive amounts of adrenocorticotropic hormone (ACTH), which in turn stimulates the adrenal glands to produce excess cortisol.
Adrenal Adenoma (Primary Adrenal Hyperplasia): A non-cancerous tumor within the adrenal glands themselves. The tumor directly produces excess cortisol, bypassing the regulation of ACTH.
Adrenal Carcinoma: A cancerous tumor in the adrenal gland. The cancerous cells uncontrollably produce large amounts of cortisol.
Iatrogenic Cushing’s Syndrome: This type is caused by long-term use of corticosteroid medications. Corticosteroids, such as prednisone, are synthetic versions of cortisol, and long-term use can lead to similar symptoms as Cushing’s syndrome.

Classifications of Cushing’s Syndrome:

Cushing’s syndrome can be classified based on the underlying cause of excess cortisol production:

1. ACTH-Dependent Cushing’s Syndrome:

Cause: Excess cortisol production is driven by high levels of ACTH. This can occur due to:

Pituitary Adenoma (Cushing’s Disease): Most common cause, with a tumor in the pituitary gland producing ACTH.
Ectopic ACTH Syndrome: A tumor outside the pituitary gland produces ACTH, such as in the lungs, pancreas, or thymus.

2. ACTH-Independent Cushing’s Syndrome:

Cause: Excess cortisol production is not driven by ACTH, but rather by the adrenal glands themselves. This can occur due to:

Adrenal Adenoma (Primary Adrenal Hyperplasia): A benign tumor in the adrenal gland directly producing cortisol.
Adrenal Carcinoma: A malignant tumor in the adrenal gland producing excessive cortisol.
Iatrogenic Cushing’s Syndrome: Long-term use of corticosteroid medications.

Signs and Symptoms of Cushing’s Syndrome:

Cushing’s syndrome is a condition caused by prolonged exposure to high levels of cortisol, a hormone produced by the adrenal glands. This can be due to an adrenal tumor, pituitary tumor, or external medications.

Weight Gain: Cortisol promotes fat deposition, especially in the face, abdomen, and upper back. Increased cortisol levels lead to increased fat storage in these areas.
Moon Face: A round, puffy face due to fat deposition. Cortisol stimulates fat accumulation in the face, resulting in a characteristic rounded appearance.
Buffalo Hump: Fat deposition in the upper back between the shoulders, creating a hump. Similar to moon face, cortisol leads to fat accumulation in this specific area.
Thinning Skin: The skin becomes thinner and more fragile due to protein breakdown. Cortisol promotes protein breakdown, leading to thinner skin, making it more prone to tearing and bruising.
Easy Bruising: Bruising occurs more easily due to the thinning of the skin and increased fragility of blood vessels. Thin skin and increased fragility of blood vessels make it easier for the capillaries to leak, causing bruising.
Striae (Stretch Marks): Stretch marks appear on the abdomen, thighs, and breasts due to rapid skin stretching and thinning. Cortisol weakens the collagen fibers in the skin, making it more prone to tearing, leading to striae.
Purple Striae (Purple Stretch Marks): Stretch marks appear purple or red due to increased blood vessel fragility and rupture. Similar to regular striae, but the increased vascular fragility leads to discoloration.
Acne: Cortisol stimulates oil production in the skin, leading to acne. Increased oil production clogs pores, promoting bacterial growth and causing acne.
Hirsutism (Excessive Hair Growth): Excessive hair growth on the face, chest, and back, particularly in women. Cortisol can change the way the body processes androgens, leading to increased hair growth in areas typically affected by androgens.
Muscle Weakness and Fatigue: Muscle breakdown and weakness due to protein catabolism. Cortisol promotes protein breakdown, weakening muscles and contributing to fatigue.
High Blood Pressure: Cortisol increases blood pressure by constricting blood vessels and increasing sodium retention. Increased cortisol levels directly affect blood pressure regulation, causing vasoconstriction and increased sodium retention.
High Blood Sugar: Cortisol inhibits insulin’s action, leading to high blood sugar levels. Cortisol’s interference with insulin function leads to impaired glucose uptake and utilization, resulting in high blood sugar.
Mood Changes and Depression: Cortisol can affect mood and lead to depression. Chronic exposure to high cortisol levels can disrupt neurotransmitters involved in mood regulation, leading to mood swings and depression.
Increased Thirst and Frequent Urination: Increased thirst and urination due to increased fluid loss and sodium excretion. Cortisol’s influence on fluid balance leads to increased sodium excretion and water loss, causing thirst and frequent urination.
Osteoporosis: Increased bone loss and decreased bone density due to protein breakdown and calcium excretion. Cortisol’s effect on protein and calcium metabolism weakens bones, increasing the risk of fractures.
Menstrual Irregularities: Irregular periods or amenorrhea (absence of periods) in women. High cortisol levels can interfere with the hormone regulation of the menstrual cycle.
Impotence: Erectile dysfunction in men due to hormonal imbalances and reduced testosterone levels. Cortisol’s influence on hormone balance can lead to reduced testosterone levels, contributing to impotence.
Delayed Wound Healing: Wounds heal more slowly due to impaired immune function and tissue repair. Cortisol’s immunosuppressive effect inhibits the body’s natural healing response, delaying wound healing.

Diagnosis and Investigations of Cushing’s Syndrome

1. Clinical Evaluation:

History and Physical Examination: Detailed medical history focusing on symptoms like weight gain, fatigue, muscle weakness, skin changes, and hypertension. Physical examination to assess for signs of Cushing’s, such as moon face, buffalo hump, purple striae, and high blood pressure.

2. Laboratory Tests:

24-Hour Urine Free Cortisol: Measures the total amount of cortisol excreted in urine over 24 hours. A high level is suggestive of Cushing’s syndrome.
Overnight Dexamethasone Suppression Test: A low dose of dexamethasone (a synthetic corticosteroid) is given at bedtime. Ideally, this should suppress cortisol production in a healthy individual. In Cushing’s, cortisol levels remain high, indicating the problem is not responsive to feedback suppression.
ACTH Levels: Measured to distinguish between ACTH-dependent and ACTH-independent Cushing’s.
Cortisol Levels: Blood tests can measure serum cortisol levels, particularly in the morning when they should be high.

3. Imaging Studies:

MRI of the Pituitary Gland: To visualize the pituitary gland and detect any tumors (for Cushing’s disease).
CT or MRI of the Adrenal Glands: To detect tumors in the adrenal glands (for primary adrenal hyperplasia or carcinoma).

Management of Cushing’s Syndrome

Treatment is dependent on the site of the disease.

If pituitary source, may need transsphenoidal hypophysectomy(surgery done to remove the pituitary gland)
Radiation of pituitary also appropriate
Adrenalectomy may be needed in case of adrenal hypertrophy
Adrenal enzyme reducers may be indicated if source if ectopic and inoperable. Examples include: ketoconazole, mitotane and metyrapone.
If cause is related to excessive steroid therapy, tapering slowly to a minimum dosage may be appropriate.

Assessment:

Patient History: Obtain a detailed medical history focusing on:

Symptoms: Weight gain, fatigue, muscle weakness, skin changes (striae, acne, hirsutism), hypertension, menstrual irregularities, mood swings, depression, sleep disturbances, etc.
Family History: Any history of Cushing’s or other endocrine disorders.
Medication History: Current medications, especially corticosteroid use, and previous treatments.

Physical Examination: Thoroughly assess for signs of Cushing’s, including:

Moon Face: Round, puffy face.
Buffalo Hump: Fat deposit on the upper back.
Purple Striae: Stretch marks on the abdomen, thighs, and breasts.
Thinning Skin and Easy Bruising: Due to collagen breakdown.
Hypertension: Elevated blood pressure.
Proximal Muscle Weakness: Weakness in the arms and legs.

Investigations:

Laboratory Tests:

24-Hour Urine Free Cortisol
Overnight Dexamethasone Suppression Test
ACTH Levels
Serum Cortisol Levels
Other Hormonal Tests: (TSH, Thyroid Function, etc.)

Imaging Studies:

MRI of the Pituitary Gland: For Cushing’s disease.
CT or MRI of the Adrenal Glands: For primary adrenal hyperplasia or carcinoma.

Reassurance and Explanation:

Communicate Clearly: Explain the diagnosis and treatment plan in a way that the patient understands.
Address Concerns: Answer any questions the patient may have.
Empathy and Support: Emphasize that Cushing’s can be effectively managed.
Provide Educational Resources: Offer reliable information about Cushing’s and its management.

Medical Management:

Treatment Goals:

Control Excess Cortisol: Reduce cortisol levels to a normal range.
Manage Symptoms: Address specific symptoms like hypertension, diabetes, and osteoporosis.
Prevent Complications: Minimize long-term risks associated with Cushing’s.

Treatment Strategies:

ACTH-Dependent Cushing’s:

Surgery: Pituitary tumor removal (transsphenoidal surgery).
Radiation Therapy: Used if surgery is not possible or unsuccessful.
Medical Therapy: Drugs like ketoconazole or pasireotide to suppress ACTH production.

ACTH-Independent Cushing’s:

Surgery: Removal of adrenal tumors.
Medical Therapy: Drugs like metyrapone, aminoglutethimide, or mitotane to block cortisol production.

Iatrogenic Cushing’s (Corticosteroid-Induced):

Tapering the Corticosteroid: Slowly reducing the dose under close monitoring.
Alternatives: Exploring non-corticosteroid treatments if possible.

Nursing Care:

Monitoring for Complications: Regularly assess for signs of hyperglycemia, hypertension, infection, electrolyte imbalance, and other potential complications.
Education and Support: Provide ongoing education about the disease and treatment plan.
Symptom Management: Assist with managing symptoms like weight gain, fatigue, skin problems, and mood changes.
Promote Self-Care: Encourage healthy lifestyle practices, including diet, exercise, and stress management.

Follow-up Care:

Regular Checkups: Schedule routine visits for monitoring and adjustments to treatment.
Laboratory Tests: Monitor cortisol levels and other relevant markers.
Imaging Studies: Periodic imaging to assess the tumor status if applicable.
Long-Term Management: Focus on controlling symptoms, preventing complications, and maintaining quality of life.

Hypophysectomy

Nursing care plan for Cushing’s syndrome:

Assessment	Nursing Diagnosis	Goals/Expected Outcomes	Interventions	Rationale	Evaluation
1. Patient presents with central obesity, moon face, and buffalo hump.	Distrupted Body Image related to changes in physical appearance as evidenced by patient expressing dissatisfaction with appearance.	The patient will verbalize acceptance of body changes and demonstrate positive body image behaviors.	– Provide emotional support and encourage the patient to express feelings about body image changes. – Involve the patient in grooming and self-care activities to enhance self-esteem. – Refer to a counselor or support group specializing in chronic illness and body image issues.	Emotional support helps the patient cope with body changes. Involvement in self-care promotes a sense of control and improves self-esteem. Counseling and support groups offer a space for shared experiences and coping strategies.	The patient expresses acceptance of body changes and participates in self-care activities.
2. Patient reports fatigue, muscle weakness, and difficulty with physical activities.	Activity Intolerance related to muscle weakness and fatigue as evidenced by patient’s inability to perform daily activities without exhaustion.	The patient will demonstrate improved activity tolerance and participate in daily activities with minimal fatigue.	– Encourage rest periods between activities to conserve energy. – Assist with activities of daily living (ADLs) as needed. – Gradually increase physical activity as tolerated.	Rest periods prevent exhaustion and allow for energy conservation. Assistance with ADLs reduces the physical strain on the patient. Gradual increase in activity helps build endurance without overwhelming the patient.	The patient reports increased energy and is able to participate in daily activities with minimal fatigue.
3. Patient presents with hypertension, edema, and weight gain.	Excess Fluid Volume related to sodium and water retention as evidenced by edema, hypertension, and rapid weight gain.	The patient will demonstrate reduced edema and stable weight, with blood pressure within normal limits.	– Monitor daily weight, intake and output, and blood pressure regularly. – Administer diuretics as prescribed and monitor for effectiveness. – Restrict sodium intake as prescribed and educate the patient on a low-sodium diet. – Elevate edematous limbs to promote venous return.	Monitoring helps detect fluid retention and assess intervention effectiveness. Diuretics reduce fluid overload. Sodium restriction helps prevent further fluid retention. Elevation of limbs reduces edema and promotes circulation.	The patient shows reduced edema, stable weight, and blood pressure within normal limits.
4. Patient has elevated blood glucose levels and history of diabetes mellitus.	Risk for Unstable Blood Glucose Levels related to increased cortisol production as evidenced by hyperglycemia.	The patient will maintain blood glucose levels within the normal range.	– Monitor blood glucose levels regularly and adjust insulin or oral hypoglycemic agents as prescribed. – Educate the patient on the importance of adhering to prescribed diabetic diet and medication regimen. – Teach the patient to recognize signs and symptoms of hyperglycemia and hypoglycemia. – Collaborate with a dietitian to develop an appropriate meal plan.	Regular monitoring helps manage blood glucose levels. Adherence to diet and medication prevents blood glucose fluctuations. Early recognition of symptoms allows for prompt intervention. A meal plan supports stable blood glucose levels.
5. Patient reports difficulty sleeping, restlessness, and increased stress.	Disrupted Sleep Pattern related to elevated cortisol levels as evidenced by patient verbalizing difficulty sleeping and feeling restless.	The patient will experience improved sleep patterns and report feeling well-rested.	– Establish a regular sleep routine and create a restful environment. – Encourage relaxation techniques before bedtime, such as deep breathing or meditation. – Limit caffeine and fluid intake in the evening. – Administer prescribed sleep aids if needed and monitor their effectiveness.	A regular sleep routine promotes better sleep. Relaxation techniques help reduce stress and promote sleep. Limiting caffeine and fluids prevents sleep disturbances. Sleep aids may be necessary to manage sleep disturbances.	The patient reports improved sleep quality and feels more rested.
6. Patient presents with thin, fragile skin, bruises, and delayed wound healing.	Risk for Impaired Skin Integrity related to thinning of the skin and delayed wound healing as evidenced by bruising and skin tears.	The patient will maintain intact skin with no further breakdown or injury.	– Assess skin condition daily and document any changes. – Protect skin from injury by using padding on bony prominences and gentle handling. – Encourage a high-protein diet to promote skin healing. – Apply prescribed topical treatments to any wounds and monitor for signs of infection.	Daily assessment helps identify early signs of skin breakdown. Protecting the skin prevents injury and tears. A high-protein diet supports tissue repair and wound healing. Topical treatments aid in wound healing and prevent infection.

Cushing’s Syndrome Read More »

Pheochromocytoma

Pheochromocytoma is a tumor that produces excessive amounts of catecholamines, including adrenaline (epinephrine) and noradrenaline (norepinephrine).

Pheochromocytoma is a type of neuroendocrine tumor that grows from cells called chromaffin cells. These cells produce hormones needed for the body and are found in the adrenal glands.

It is usually benign but can be malignant in some cases.

Pheochromocytomas can occur at any age but are commonly diagnosed in adults between the ages of 30 and 50.

Pathophysiology

Pheochromocytomas arise from chromaffin cells, which are specialized cells in the adrenal medulla that produce and release catecholamines into the bloodstream. In pheochromocytoma, there is uncontrolled and excessive secretion of catecholamines, leading to episodic or sustained hypertension(high blood pressure). The excess catecholamines can stimulate adrenergic receptors in various organs and tissues, resulting in a wide range of symptoms.

Effects on Blood Pressure:

Catecholamines have potent effects on blood vessels and the heart. They can cause vasoconstriction, leading to elevated blood pressure. They can increase heart rate and cardiac contractility, further contributing to elevated blood pressure.

Clinical Presentation of Pheochromocytoma

Pheochromocytomas can cause a variety of symptoms, often due to the excessive release of catecholamines (epinephrine and norepinephrine). These symptoms can be sporadic or persistent.

Common Signs and Symptoms:

Headaches: Often severe and can be throbbing.
Sweating (Hyperhidrosis): Profuse and generalized sweating episodes.
Tachycardia: A rapid or racing heartbeat. Palpitations may also be present.
Hypertension: High blood pressure, which can be sustained or occur in sudden spikes (paroxysmal hypertension).
Pallor: A pale face, often accompanying episodes of high blood pressure.
Nausea and Vomiting: Feeling sick to the stomach.
Anxiety and Panic: Feelings of intense anxiety, nervousness, and impending doom.
Tremor: Shakiness or trembling, often in the hands.
Agitation: Feeling restless, irritable, and uneasy.
Chest Pain or Discomfort: May mimic angina.

Less Common Symptoms:

Visual Disturbances: Blurred vision.
Abdominal Pain: Less frequent, but possible.
Constipation: Due to the effects of catecholamines on the digestive system.
Weight Loss: Unexplained weight loss can occur.
Hyperglycemia: High blood sugar.
Orthostatic Hypotension: Drop in blood pressure upon standing.
Seizures: In rare cases, very high blood pressure can lead to seizures.

Diagnosis and Investigations:

History and Physical Examination: A careful medical history, focusing on symptom onset, duration, and severity, is crucial. Physical examination may reveal signs of hypertension, tachycardia, and tremor.

Biochemical Testing:

Plasma and Urine Catecholamine Levels: Measurement of epinephrine, norepinephrine, and metanephrines (breakdown products of catecholamines) in plasma and urine is the primary diagnostic tool.
Plasma Free Metanephrines: This test is highly sensitive and specific for pheochromocytoma.

Imaging Studies:

Abdominal Computed Tomography (CT) Scan: Used to visualize the adrenal glands and identify any tumors.
Magnetic Resonance Imaging (MRI) Scan: Provides detailed anatomical images, particularly helpful in differentiating tumors from other adrenal masses.

Genetic Testing: Recommended in cases with a family history of pheochromocytoma or associated genetic syndromes.

How the tumor affects the adrenal glands
The adrenal glands make the hormones adrenaline and noradrenaline, which are released into the bloodstream when needed. These hormones control heart rate, blood pressure and metabolism (the chemical processes that keep your organs working).

A phaeochromocytoma can cause the adrenal glands to produce too much of these hormones, which often results in problems such as heart palpitations and high blood pressure.

Management of Pheochromocytoma

Aims of management

The primary goals of managing pheochromocytoma are;

to control symptoms
stabilize blood pressure
ultimately remove the tumor.

1. Pre-operative Management (Medical Management)

Alpha-Adrenergic Blockers: These are the cornerstone of pre-operative management.

Mechanism: Alpha-blockers (e.g., phenoxybenzamine, doxazosin, prazosin) block the effects of norepinephrine on blood vessels, preventing vasoconstriction and reducing blood pressure.
Duration: Typically administered for 1-3 weeks before surgery to allow for adequate blood pressure control and expansion of blood volume.
Goal: To achieve adequate blood pressure control (target usually <130/80 mmHg) and minimize the risk of hypertensive crisis during surgery.

Beta-Adrenergic Blockers:

Use: Beta-blockers (e.g., propranolol, metoprolol) are only initiated after adequate alpha-blockade has been established.
Mechanism: Beta-blockers help control tachycardia (rapid heart rate) and arrhythmias caused by excess catecholamines.
Caution: Starting beta-blockers before alpha-blockers can lead to unopposed alpha-adrenergic stimulation, resulting in a dangerous hypertensive crisis.

Calcium Channel Blockers:

Use: May be used as adjunctive therapy or in patients who cannot tolerate alpha-blockers.
Mechanism: They help relax blood vessels and lower blood pressure.

Metyrosine:

Use: An alternative or adjunct to alpha and beta blockers.
Mechanism: Inhibits tyrosine hydroxylase, an enzyme involved in catecholamine synthesis.
Benefit: Can help reduce catecholamine levels and improve blood pressure control.

High-Sodium Diet and Fluid Intake:

Rationale: Pheochromocytomas can cause chronic vasoconstriction and reduced blood volume.
Goal: To expand blood volume and prevent hypotension after tumor removal.

Patient Education:

Importance: Patients need to understand the importance of medication adherence and monitoring blood pressure regularly.
Symptom Management: Educate patients on how to recognize and manage symptoms of catecholamine excess.

2. Surgical Management

Surgical Resection: The definitive treatment for pheochromocytoma.

Laparoscopic Adrenalectomy (“Keyhole” Surgery):

Approach: Preferred approach for most pheochromocytomas.
Advantages: Smaller incisions, less pain, shorter hospital stay, faster recovery.

Open Adrenalectomy:

Indications: Larger tumors, suspicion of malignancy, or when laparoscopic surgery is not feasible.
Approach: Requires a larger incision in the abdomen or flank.

Bilateral Adrenalectomy:

Indication: For bilateral pheochromocytomas (tumors in both adrenal glands).
Considerations: Requires lifelong hormone replacement therapy (glucocorticoids and mineralocorticoids).

Intraoperative Management:

Anesthesia: Requires careful monitoring and management by an experienced anesthesiologist.
Medications: Anesthesiologists use medications to manage blood pressure fluctuations during surgery.
Post-Resection Hypotension: Be prepared for hypotension after tumor removal due to sudden drop in catecholamine levels. Volume expansion and vasopressors may be required.

3. Management of Malignant Pheochromocytoma

Surgery: Resection of primary tumor and any metastases, if feasible.

Radiation Therapy: May be used to control local tumor growth or palliate symptoms.

Chemotherapy:

Regimens: Often involves a combination of cyclophosphamide, vincristine, and dacarbazine (CVD).
Efficacy: Response rates are variable.

Targeted Therapy:

Tyrosine Kinase Inhibitors (TKIs): (e.g., sunitinib) may be used in some cases.

Peptide Receptor Radionuclide Therapy (PRRT):

Mechanism: Uses radiolabeled somatostatin analogs to target tumor cells.

Radiofrequency Ablation (RFA) or Cryoablation:

Use: To treat liver or bone metastases.

4. Nursing Care

Pre-operative Care:

Monitoring: Frequent monitoring of vital signs (blood pressure, heart rate).
Medication Administration: Ensure accurate and timely administration of alpha and beta blockers.
Patient Education: Provide clear instructions about medications and potential side effects.

Post-operative Care:

Monitoring: Continuous monitoring of vital signs.
Fluid Management: Careful management of fluid balance to prevent hypotension or fluid overload.
Pain Management: Administer pain medication as prescribed.
Wound Care: Monitor incision site for signs of infection.
Hormone Replacement: If bilateral adrenalectomy was performed, initiate hormone replacement therapy and educate the patient on how to take the medications.

Long-Term Follow-Up:

Monitoring: Regular monitoring of blood pressure, catecholamine levels, and imaging studies to detect recurrence.
Genetic Counseling: Offer genetic counseling and testing, especially for patients with a family history of pheochromocytoma or associated genetic syndromes.

Nursing Care Plan: Pheochromocytoma

Assessment

Nursing Diagnosis

Goals/Expected Outcomes

Interventions

Rationale

Evaluation

Patient presents with hypertension, palpitations, headaches, excessive sweating, and anxiety. Laboratory results show elevated catecholamines.

Risk for Hypertensive Crisis related to excessive catecholamine secretion as evidenced by severe hypertension, palpitations, and headaches.

– Patient’s blood pressure will be maintained within normal limits.

– Patient will report reduced episodes of palpitations and headaches.

– Patient will avoid triggers that exacerbate symptoms.

1. Monitor blood pressure and heart rate frequently.

2. Administer prescribed antihypertensive medications (alpha-blockers and beta-blockers).

3. Educate patient on avoiding triggers like stress, caffeine, and strenuous activity.

4. Prepare patient for surgical removal of the tumor (adrenalectomy) if indicated.

5. Monitor for signs of hypertensive crisis (severe headache, visual disturbances, seizures).

1. Early detection of hypertensive episodes helps prevent complications.

2. Controls blood pressure and prevents complications.

3. Reduces catecholamine surges and symptom exacerbation.

4. Definitive treatment to remove the source of excessive catecholamine secretion.

5. Prevents life-threatening complications like stroke or myocardial infarction.

– Patient maintains stable blood pressure.

– Patient reports reduced palpitations and headaches.

– Patient adheres to lifestyle modifications.

Patient reports episodes of anxiety, excessive sweating, and restlessness. Patient appears nervous and agitated.

Anxiety related to catecholamine excess as evidenced by restlessness, tachycardia, and diaphoresis.

– Patient will verbalize reduced anxiety and use coping strategies.

– Patient’s vital signs will remain stable.

– Patient will participate in relaxation techniques.

1. Assess level of anxiety and provide a calm environment.

2. Teach relaxation techniques (deep breathing, guided imagery).

3. Administer prescribed anxiolytics if indicated.

4. Reassure the patient and provide psychological support.

5. Educate the patient on the physiological cause of symptoms.

1. Minimizes stress, which can trigger catecholamine release.

2. Helps the patient manage anxiety episodes.

3. Controls severe anxiety and autonomic symptoms.

4. Reduces fear and emotional distress.

5. Enhances understanding and reduces uncertainty.

– Patient verbalizes reduced anxiety.

– Patient demonstrates relaxation techniques.

– Vital signs remain within normal range.

Patient reports headaches, dizziness, and episodes of fainting.

Risk for Decreased Cardiac Output related to excessive catecholamine secretion as evidenced by tachycardia, hypertension, and palpitations.

– Patient will maintain stable cardiac function with normal heart rate and blood pressure.

– Patient will remain free from syncope and dizziness.

– Patient will adhere to prescribed medications and treatments.

1. Monitor ECG for arrhythmias and signs of myocardial strain.

2. Assess for signs of heart failure (dyspnea, edema, chest pain).

3. Administer beta-blockers or calcium channel blockers as prescribed.

4. Encourage adequate hydration and sodium intake (if not contraindicated).

5. Educate the patient about the importance of adherence to treatment.

1. Detects potential cardiac complications early.

2. Prevents worsening of cardiac function.

3. Helps regulate heart rate and blood pressure.

4. Prevents dehydration-related hypotension.

5. Ensures effective symptom management.

– Patient remains hemodynamically stable.

– No episodes of dizziness or syncope.

– Patient follows medication regimen.

Patient is scheduled for surgical tumor removal (adrenalectomy). Patient expresses fear and uncertainty about the procedure.

Deficient Knowledge related to unfamiliarity with pheochromocytoma and its management as evidenced by patient’s questions and concerns.

– Patient will verbalize understanding of the disease and treatment plan.

– Patient will express reduced fear and anxiety about surgery.

– Patient will adhere to preoperative and postoperative care instructions.

1. Explain pheochromocytoma, its effects, and treatment options.

2. Educate patient on preoperative preparation, including medication use (e.g., alpha-blockers).

3. Inform the patient about potential postoperative complications.

4. Provide written educational materials for reinforcement.

5. Encourage patient to ask questions and express concerns.

1. Increases patient understanding and reduces uncertainty.

2. Ensures safe surgery by preventing hypertensive crisis.

3. Helps the patient anticipate and manage postoperative recovery.

4. Supports learning and recall of important information.

5. Promotes active patient participation in care.

– Patient demonstrates understanding of condition and treatment.

– Patient verbalizes reduced fear about surgery.

– Patient follows preoperative and postoperative instructions.

Patient is unable to engage in normal activities due to fatigue, dizziness, and palpitations.

Activity Intolerance related to catecholamine-induced cardiovascular instability as evidenced by fatigue, dizziness, and exertional dyspnea.

– Patient will gradually resume activities without excessive fatigue.

– Patient will report improved tolerance to physical exertion.

– Patient will engage in energy-conserving techniques.

1. Assess activity tolerance and monitor for symptoms of intolerance.

2. Encourage rest periods between activities.

3. Teach energy conservation strategies.

4. Gradually reintroduce physical activity as tolerated.

5. Monitor blood pressure and heart rate during activity.

1. Prevents overexertion and worsening of symptoms.

2. Conserves energy and prevents fatigue.

3. Helps the patient manage limited energy levels.

4. Improves endurance and quality of life.

5. Ensures hemodynamic stability during exertion.

– Patient engages in activities with minimal fatigue.

– Patient reports improved energy levels.

– Vital signs remain stable during exertion.

Pheochromocytoma Read More »

Addison’s disease (Adrenal insufficiency)

Addison’s Disease (Adrenal Insufficiency)

Addison’s disease, also known as primary adrenal insufficiency, is a rare disorder characterized by the insufficient production of hormones by the adrenal glands.

Addison’s disease is a clinical condition characterized by adrenocorticotrophic hormone hyposecretion due to primary disease of the adrenal glands or secondary to pituitary gland disorder.

The adrenal glands, located above the kidneys, produce hormones such as cortisol and aldosterone that are essential for maintaining normal bodily functions.

It’s mostly idiopathic or auto immune but can occur in tuberculosis infection of the gland or obstruction by the adrenal tumor, metastasis / hemorrhage

Hormones Produced by the Adrenal Cortex

Hormone	Examples of the Hormone	Effects of the Hormone
Glucocorticoids	Cortisol, Cortisone, Hydrocortisone	– Protein Breakdown: Enhances the breakdown of proteins, especially in muscle cells, to release amino acids. – Glucose Formation: Promotes gluconeogenesis, converting non-carbohydrate sources into glucose, raising blood sugar levels. – Lipolysis: Stimulates the breakdown of stored fats into fatty acids and glycerol. – Resistance to Stress: Increases blood pressure and blood glucose, providing the body with energy to handle stress. – Anti-inflammatory Effects: Inhibits white blood cells that participate in inflammatory responses, reducing inflammation and allergic reactions. – Depression of Immune Responses: Lowers the activity of the immune system, which can decrease the body’s ability to fight infections.





Mineralocorticoids	Aldosterone	– Electrolyte Balance: Regulates sodium (Na⁺) and potassium (K⁺) ions, maintaining blood pressure and fluid balance. – Blood Pressure Regulation: Adjusts blood pressure and blood volume by increasing sodium retention and water reabsorption in the kidneys. – Acid-Base Balance: Promotes the excretion of hydrogen ions (H⁺) in the urine, preventing acidosis and helping to maintain blood pH.


Androgens	Dehydroepiandrosterone (DHEA), Androstenedione	– Secondary Sexual Characteristics: Influence the development of male secondary sexual characteristics, such as facial hair and deepening of the voice. – Sex Drive: Contribute to libido in both males and females. – Precursor for Estrogen: In postmenopausal women, androgens serve as precursors for estrogen synthesis.

Hormones Produced by the Adrenal Medulla

Hormone	Cells that Produce It	Action of the Hormone
Adrenaline (Epinephrine)	Chromaffin Cells	– Fight or Flight Response: Increases heart rate, blood pressure, and blood glucose levels; dilates airways to prepare the body for stress. – Energy Mobilization: Stimulates the breakdown of glycogen to glucose in the liver, providing quick energy. – Increased Alertness: Enhances alertness and readiness by stimulating the central nervous system.


Noradrenaline (Norepinephrine)	Chromaffin Cells	– Fight or Flight Response: Similar to adrenaline, it constricts blood vessels to increase blood pressure and redirects blood flow to vital organs. – Vasoconstriction: Causes blood vessels to constrict, which increases peripheral resistance and helps maintain blood pressure during stress.

Pathophysiology of Adrenal Insufficiency

Adrenal glands are incapable of producing sufficient cortisol and other steroids . It is distinguished from acute primary adrenocortical insufficiency caused by Waterhouse-Friderichsen syndrome.

Glucocorticoid deficiency: Glucocorticoid deficiency contributes to hypotension and causes severe insulin sensitivity and disturbances in carbohydrate, fat, and protein metabolism. In the absence of cortisol, insufficient carbohydrate is formed from protein; hypoglycemia and decreased liver glycogen result. Weakness follows, due in part to deficient neuromuscular function. Resistance to infection, trauma, and other stress is decreased. Myocardial weakness and dehydration reduce cardiac output, and circulatory failure can occur.

Causes of Addison’s Disease(Can be predisposing Factors too)

Autoimmune Reaction: Addison’s Disease can occur when the body’s immune system mistakenly attacks and damages the adrenal glands. This is known as an autoimmune reaction. In this case, the immune system views the adrenal glands as foreign entities and targets them for destruction, leading to a deficiency in adrenal hormones.
Idiopathic Atrophy of the Adrenal Glands: In some cases, the adrenal glands may undergo atrophy, which means they shrink and lose their function without a clear identifiable cause. This condition is referred to as idiopathic adrenal atrophy.
Surgical Removal of Both Adrenal Glands: Addison’s Disease can result from the surgical removal of both adrenal glands. This usually occurs as a last resort when treating conditions such as Cushing’s syndrome or adrenal tumors. After removal, the individual will need hormone replacement therapy.
Adrenal Carcinoma: Adrenal carcinoma is a rare type of cancer that originates in the adrenal glands. In some instances, the cancerous growth can disrupt the normal functioning of the adrenal glands, leading to adrenal insufficiency and Addison’s Disease.
Infections such as TB: Certain infections, particularly tuberculosis (TB), can infiltrate and damage the adrenal glands. TB-induced damage to the adrenal glands can impair their ability to produce hormones, causing Addison’s Disease.
Abnormal/Malfunction of the Pituitary Gland: The pituitary gland plays a crucial role in regulating adrenal function by secreting adrenocorticotropic hormone (ACTH). If the pituitary gland malfunctions and doesn’t produce an adequate amount of ACTH, the adrenal glands won’t receive the necessary signals to produce hormones, leading to Addison’s Disease.
Prolonged Use of Steroid Medication: Long-term use of corticosteroid medications, which are often prescribed for conditions like autoimmune diseases or inflammation, can suppress the production of ACTH by the pituitary gland. This can lead to adrenal gland atrophy and result in Addison’s Disease.

Additional causes include:

Genetic Factors: While most cases of Addison’s Disease are not inherited, there is a rare genetic form known as familial glucocorticoid deficiency (FGD). In FGD, specific genetic mutations can lead to the inadequate production of adrenal hormones.
Hemorrhage into the Adrenal Glands: Severe bleeding into the adrenal glands, often due to injury or other medical conditions, can damage the glands and impair their hormone production.
Amyloidosis: Amyloidosis is a rare condition in which abnormal proteins (amyloids) build up in various organs, including the adrenal glands. This accumulation can disrupt adrenal function and cause Addison’s Disease.

Clinical Presentation of Addison’s Disease:

Due to Cortisol Deficiency: Addison’s Disease primarily results in the deficiency of cortisol, which is a crucial hormone for various bodily functions.

Common symptoms due to cortisol deficiency include:

Weakness: Individuals with Addison’s Disease often experience significant weakness, making even simple tasks challenging.
Weight Loss: Unexplained weight loss can occur due to a disruption in metabolism.
Fatigue: Profound fatigue and tiredness are typical, even after a full night’s sleep.
Nausea and Vomiting: Persistent nausea and vomiting may be present.
Diarrhea: Chronic diarrhea can develop as a result of gastrointestinal disturbances.

Due to Increased ACTH Production (If the Cause Is in the Adrenal Gland): When Addison’s Disease is caused by issues within the adrenal glands, it can lead to increased production of adrenocorticotropic hormone (ACTH).

Symptoms related to excess ACTH include:

Hyperpigmentation of Skin and Mucous Membranes: A distinctive symptom is the darkening of the skin and mucous membranes, which may appear as tan or bronze patches. This is often referred to as hyperpigmentation.

Due to Mineralocorticoid Deficiency: Addison’s Disease can also lead to the deficiency of mineralocorticoids, particularly aldosterone, which plays a crucial role in regulating electrolyte balance.

Symptoms associated with mineralocorticoid deficiency include:

Very Low Blood Pressure (Hypotension): The absence of aldosterone can result in extremely low blood pressure, leading to dizziness and fainting.
Serum Potassium High, but Sodium and Chloride Are Low: Electrolyte imbalances can manifest as high levels of potassium and low levels of sodium and chloride.

Due to Androgen Deficiency: In some cases, Addison’s Disease may also cause androgen deficiency, which can lead to specific symptoms:

Sparse Hair in Females: Women with Addison’s Disease may experience hair thinning or loss.
General Weakness: Overexertion, exposure to cold, or acute infections can exacerbate the overall weakness and fatigue experienced by individuals with Addison’s Disease.

Other symptoms: Dizziness, headache, and menstrual irregularities in women may also occur.

In severe cases, adrenal crisis can occur, which is a life-threatening condition characterized by

extremely low blood pressure, electrolyte imbalances, and shock.

CLASSIC TRIAD/CARDINAL SIGNS

Hyperpigmentation: A darkening of the skin, MOSTLY in areas exposed to the sun and areas of friction or pressure.

The hyperpigmentation is a result of increased production of melanin due to elevated levels of adrenocorticotropic hormone (ACTH).

Weakness and Fatigue: Individuals with Addison’s disease often experience generalized weakness and fatigue.

This is attributed to the deficiency of glucocorticoids, such as cortisol, which play a crucial role in maintaining energy balance.

Low Blood Pressure (Hypotension): Addison’s disease can lead to decreased production of aldosterone, contributing to low blood volume and hypotension (low blood pressure).

Electrolyte imbalances, particularly low sodium levels, also play a role in hypotension.

DIAGNOSTIC EVALUATION

History collection

History of recent infection, steroid use, or adrenal or pituitary surgery.
History of poor tolerance for stress, weakness, fatigue, and activity intolerance.
Anorexia, nausea, vomiting, or diarrhea as a result of altered metabolism.
Dizziness due to orthostatic hypotension.
History of craving for salt or intolerance to cold.
Presence of altered menses in females and impotence in males.

Physical examination

Signs of dehydration such as tachycardia, altered level of consciousness, dry skin with poor turgor, dry mucous membranes, weight loss, and weak peripheral pulses.
Postural hypotension
Inspect the skin for pigmentation changes
Inspect the patient’s gums and oral mucous membranes to see if they are bluish-black.
Temperature
Any loss of axillary and pubic hair that could be caused by decreased androgen levels.

Investigations

1. ACTH stimulation test

Short test: compares blood cortisol levels before and after 250 mcg of tetracosactide (IM/IV) is given.
Increased ACTH level: Primary insufficiency
Decreased ACTH level: Secondary insufficiency

2. Other investigations

Complete blood count (CBC): Anaemia
Blood urea nitrogen (BUN): Increased
Electrocardiography (ECG): Shows low voltage and peaked T waves caused by hyperkalaemia
Computed Tomography (CT) scan and Magnetic Resonance Imaging (MRI): To assess the adrenal glands
Urine cortisol and aldosterone: Decreased
Hypoglycaemia, hyponatremia, hyperkalaemia, leukocytosis.

Complications of Addison’s Disease:

Renal Failure:

One of the potential complications of Addison’s Disease is renal failure, which refers to the loss of kidney function.
Addison’s Disease can disrupt the balance of electrolytes in the body, particularly causing increased levels of potassium. This imbalance can have a detrimental effect on the kidneys.
High levels of potassium can lead to abnormal heart rhythms (arrhythmias) and, in severe cases, impair kidney function.

Adrenal Hemorrhage:

Adrenal hemorrhage, though rare, is another complication that can occur in individuals with Addison’s Disease.
It involves bleeding into the adrenal glands, typically due to an adrenal crisis or severe stress. This can lead to sudden and severe abdominal or back pain.
Adrenal hemorrhage requires immediate medical attention, as it can be life-threatening.

Addisonian Crisis:

An Addisonian crisis, also known as an adrenal crisis, is a severe and potentially life-threatening complication of Addison’s Disease.
It occurs when the adrenal glands fail to produce enough cortisol to meet the body’s needs, often triggered by stress, illness, trauma, or abrupt cessation of corticosteroid medications.
Symptoms of an Addisonian crisis can include extreme weakness, confusion, low blood pressure, rapid heart rate, and even loss of consciousness.
Prompt emergency medical treatment is essential to stabilize the patient, typically through intravenous administration of cortisol and fluids.

Depression:

Chronic illnesses like Addison’s Disease can lead to emotional and psychological challenges, including depression.
Coping with the demands of managing a chronic condition, along with the physical symptoms and potential complications, can take a toll on a person’s mental health.
It’s essential for individuals with Addison’s Disease to receive comprehensive care that includes addressing emotional well-being and providing support for mental health issues such as depression.

Management of Addison’s Disease

The management of Addison’s disease involves lifelong hormone replacement therapy to compensate for the deficiency of cortisol and aldosterone. Treatment aims to:

Replace missing hormones:

Glucocorticoids: Hydrocortisone is the most commonly used glucocorticoid, administered in divided doses throughout the day to mimic the body’s natural cortisol production. (hydrocortisone-15 mg on waking and 5 mg at 6p.m.)
Mineralocorticoids: Fludrocortisone is the primary mineralocorticoid used to replace aldosterone. (fludrocortisone 0.05 to 0.1mg daily).
If the adrenal gland does not regain function, the patient needs lifelong replacement of corticosteroids and mineralocorticoids to prevent recurrence of adrenal insufficiency.

Manage complications:

Addisonian crisis: A life-threatening emergency caused by severe adrenal insufficiency. It requires immediate medical attention with intravenous fluids, electrolyte replacement, and high doses of hydrocortisone.

Treatment of patient with Addisonian crisis

Administration of fluid, glucose, and electrolytes, especially sodium.
Replacement of missing steroid hormones; and vasopressors(Vasopressors are drugs used to raise blood pressure in people whose blood pressure is very low.)
Large volumes of 0.9% saline solution and 5% dextrose are administered to reverse hypotension and electrolyte imbalances until blood pressure returns to normal.

Electrolyte imbalances: Regular monitoring of electrolytes (sodium, potassium) and prompt correction of imbalances are crucial.

Osteoporosis: Glucocorticoid therapy can increase the risk of osteoporosis. Calcium and vitamin D supplementation, along with weight-bearing exercises, are recommended.

Patient education:

Self-management: Patients need to learn about their condition, medication regimen, and how to recognize and manage symptoms.
Emergency preparedness: Patients should carry an emergency kit containing injectable hydrocortisone and a medical identification card.
Stress management: Patients should avoid excessive stress and learn techniques to manage stress effectively.
Dietary modifications: A balanced diet with adequate salt intake is essential.
Supplement dietary intake with salt during GI losses of fluids through vomiting and diarrhoea.
Regular follow-up: Regular visits with a healthcare provider are necessary to monitor the patient’s condition and adjust medication doses as needed.

Nursing Interventions.

Hormone Replacement Therapy: Collaborate with the healthcare team to ensure the patient receives appropriate hormone replacement therapy, with glucocorticoids (such as hydrocortisone) and mineralocorticoids (such as fludrocortisone). Administer medications as prescribed and monitor for the desired therapeutic response.
Medication Education: Provide education to the patient and their family regarding the importance of adhering to the prescribed medication regimen. Explain the purpose, dosage, timing, and potential side effects of hormone replacement medications.
Stress Management: Educate the patient about the need for increased medication during times of physical or emotional stress, such as illness, injury, or surgery. Instruct them to carry an emergency card or wear a medical alert bracelet to inform others about their condition.
Fluid and Electrolyte Balance: Monitor the patient’s fluid intake and output and assess for signs of dehydration or electrolyte imbalances. Encourage the patient to maintain adequate hydration and offer oral rehydration solutions as needed.
Blood Pressure Monitoring: Regularly measure the patient’s blood pressure to assess for hypotension. Collaborate with the healthcare team to adjust medication dosages if necessary to maintain appropriate blood pressure levels.
Dietary Education: Provide dietary education to the patient, emphasizing the importance of a well-balanced diet with adequate sodium intake. Encourage the patient to include foods rich in sodium in their diet or consult with a dietitian for personalized guidance.
Emotional Support: Provide emotional support and encourage open communication with the patient. Offer a safe space for them to express any concerns, fears, or emotional challenges related to their condition.
Education on Recognizing and Managing Emergencies: Educate the patient and their family about the signs and symptoms of adrenal crisis, a life-threatening condition that can occur in Addison’s disease. Instruct them to seek immediate medical help if symptoms such as severe weakness, dizziness, abdominal pain, or altered consciousness occur. Increase dosage in times of stress.
Collaboration and Referrals: Collaborate with the healthcare team to ensure comprehensive care for the patient. This may involve referrals to specialists such as endocrinologists or social workers who can provide additional support and resources.

Nursing Concerns in Addison’s Disease:

Hypotension and Fluid Balance:

Concern for the patient’s risk of hypotension and dehydration.
Monitoring blood pressure and fluid status, implementing interventions to address imbalances.

Electrolyte Imbalances:

Concern for potential electrolyte imbalances, such as hyponatremia and hyperkalemia.
Regular monitoring of electrolyte levels and interventions to maintain balance.

Adrenal Crisis Risk:

Concern for the risk of adrenal crisis during stress or illness.
Patient education on stress dosing and vigilant monitoring during times of increased stress.

Medication Adherence:

Concern for adherence to medication regimens.
Assessing the patient’s understanding of the importance of medication compliance.

Skin Integrity:

Concern for skin changes and hyperpigmentation.
Regular skin assessments and education on skin care to prevent breakdown.

Medical Management

Restore blood circulation IV fluids NS and Dextrose.
Small dose of fludrocortisones 0.05 – 0.1mg/day is given to maintain BP and electrolytes
Hormone replacement with cortisone daily in divided doses i.e prednisolone 20mg in the morning and 10mg in the evening
Vasopressor amines may be required if hypertension persists.
Antibiotic therapy if infection has precipitated the adrenal crisis
Lifelong replacement of corticosteroids and mineralocorticoids.
ORS for salt replacement.
May need additional salt intake
Treat underlying cause ie TB

Nursing Care

Monitor for BP,P, as patient moves from lying, sitting, and standing position to asses for inadequate fluid volume.
Assess skin color and turgor
Assess history of weight changes, muscle weakness, and fatigue.
Ask patient and family about onset of illness or increased stress that may have precipitated the crisis

Nursing diagnosis

Electrolyte imbalance related to low sodium level as evidenced by craving for salt, vomiting and diarrhea.
Ineffective tissue perfusion related to hyperpigmentation of skin as evidenced by skin tanning.
Risk for fluid volume deficit related to vomiting and diarrhea.

Nursing care plan for Addison’s disease:

Assessment	Nursing Diagnosis	Goals/Expected Outcomes	Interventions	Rationale	Evaluation
1. Patient reports fatigue, muscle weakness, and dizziness.	Activity Intolerance related to fatigue and muscle weakness as evidenced by the patient reporting the inability to perform daily activities without exhaustion.	The patient will demonstrate increased energy levels and participate in daily activities with minimal fatigue.	– Encourage rest periods between activities to conserve energy. – Assist with activities of daily living (ADLs) as needed. – Educate the patient on the importance of balancing activity and rest.	Rest periods prevent exhaustion and allow for energy conservation. Assistance with ADLs reduces the physical strain on the patient. Education promotes effective energy management.	The patient reports increased energy and is able to participate in daily activities with minimal fatigue.
2. Patient presents with hypotension, darkened skin, and weight loss.	Deficient Fluid Volume related to adrenal insufficiency as evidenced by hypotension, weight loss, and decreased skin turgor.	The patient will maintain adequate fluid volume as evidenced by stable blood pressure and normal skin turgor.	– Monitor vital signs, especially blood pressure, regularly. – Administer prescribed corticosteroid therapy (e.g., hydrocortisone). – Encourage increased oral fluid intake, and administer IV fluids as needed. – Educate the patient on recognizing signs of dehydration and the importance of fluid intake.	Monitoring vital signs detects changes in fluid status. Corticosteroid therapy helps manage adrenal insufficiency. Increased fluid intake and IV fluids help maintain fluid balance. Education empowers the patient to prevent dehydration.	The patient maintains stable blood pressure and demonstrates normal skin turgor.
3. Patient expresses concern about skin changes and weight loss.	Disturbed Body Image related to hyperpigmentation and weight loss as evidenced by the patient verbalizing distress about appearance.	The patient will verbalize acceptance of their appearance and demonstrate positive body image behaviors.	– Provide emotional support and counseling to address concerns about appearance. – Encourage participation in self-care and grooming activities. – Refer to a support group or counselor specializing in chronic illness.	Emotional support helps the patient cope with changes in appearance. Self-care activities can enhance self-esteem. Support groups provide a network for shared experiences and coping strategies.	The patient reports acceptance of their appearance and demonstrates positive body image behaviors.
4. Patient reports nausea, vomiting, and decreased appetite.	Imbalanced Nutrition: Less than Body Requirements related to nausea and vomiting as evidenced by weight loss and decreased appetite.	The patient will maintain adequate nutritional intake and demonstrate stable weight.	– Monitor daily weight and nutritional intake. – Offer small, frequent meals with high-calorie, nutrient-dense foods. – Administer antiemetics as prescribed to control nausea. – Collaborate with a dietitian to develop a nutrition plan that meets the patient’s needs.	Monitoring weight and intake helps assess nutritional status. Small, frequent meals are easier to tolerate and help maintain calorie intake. Antiemetics reduce nausea and improve appetite. A dietitian can tailor a nutrition plan to the patient’s needs.	The patient maintains stable weight and reports improved appetite.
5. Patient reports feelings of anxiety about managing the disease and its symptoms.	Anxiety related to chronic illness and potential complications as evidenced by patient verbalizing concerns about managing Addison’s disease.	The patient will verbalize reduced anxiety and demonstrate effective coping strategies.	– Assess the patient’s understanding of Addison’s disease and its management. – Provide education on the disease, including symptom management and when to seek medical help. – Teach stress management techniques, such as deep breathing exercises and relaxation techniques. – Refer the patient to a counselor or support group if needed.	Understanding the disease reduces fear and anxiety. Education empowers the patient to manage their condition effectively. Stress management techniques help reduce anxiety levels. Counseling or support groups provide additional emotional support.	The patient reports reduced anxiety and effectively manages the disease with appropriate coping strategies.
6. Patient presents with a blood glucose level of 60 mg/dL, sweating, and confusion.	Risk for Hypoglycemia related to impaired gluconeogenesis and decreased cortisol levels.	The patient will maintain blood glucose levels within the normal range.	– Monitor blood glucose levels regularly. – Educate the patient on recognizing early signs of hypoglycemia, such as sweating, shaking, and confusion. – Administer glucose or dextrose as prescribed in case of hypoglycemia. – Encourage the patient to carry fast-acting carbohydrates (e.g., glucose tablets) at all times.	Regular monitoring detects hypoglycemia early. Early recognition allows for prompt intervention. Glucose administration rapidly corrects hypoglycemia. Carrying fast-acting carbohydrates ensures the patient can quickly address hypoglycemia.

Addison’s disease (Adrenal insufficiency) Read More »

Dwarfism (Panhypopituitarism)

Dwarfism is a medical condition characterized by short stature.

It is defined as an adult height of 4 feet 10 inches (147 centimeters) or shorter. There are different types of dwarfism, which can be caused by various underlying factors.

It is a condition characterized by the underproduction or deficiency of several hormones produced by the pituitary gland. The primary hormones affected in panhypopituitarism include:

Growth hormone (GH): GH plays a key role in stimulating growth and development in children. Its deficiency can result in impaired growth and short stature.
Thyroid-stimulating hormone (TSH): TSH regulates the function of the thyroid gland, which affects metabolism, energy levels, and growth. Deficiency of TSH can lead to thyroid hormone deficiency.
Adrenocorticotropic hormone (ACTH): ACTH stimulates the production of cortisol by the adrenal glands. Its deficiency can result in adrenal insufficiency.
Gonadotropins (Luteinizing hormone [LH] and Follicle-stimulating hormone [FSH]): These hormones regulate the function of the gonads (testes in males, ovaries in females) and play a crucial role in reproductive function. Deficiency of gonadotropins can lead to infertility and sexual dysfunction.
Prolactin: Prolactin is involved in milk production in females. Its deficiency may result in decreased lactation in breastfeeding women.

Types of Dwarfism

There are two main types of dwarfism — disproportionate and proportionate.

Disproportionate dwarfism: Disproportionate dwarfism is characterized by an average-size torso and shorter arms and legs or a shortened trunk with longer limbs. The most common types of dwarfism, known as skeletal dysplasia’s, are genetic. Skeletal dysplasia’s are conditions of abnormal bone growth that cause disproportionate dwarfism.

Skeletal dysplasia’s include:

1. Achondroplasia: The most common cause of dwarfism which causes disproportionately short stature. This is the most common form of dwarfism, occurs in about one out of 26,000 to 40,000 babies and is evident at birth. People with achondroplasia have a relatively long trunk and shortened upper parts of their arms and legs.

- This disorder usually results in the following:
- An average-size trunk
- Short arms and legs, with particularly short upper arms and upper legs
- Short fingers, often with a wide separation between the middle and ring fingers
- Limited mobility at the elbows
- An adult height around 4 feet (122 cm)
- a large head with a prominent forehead and a flattened bridge of the nose
- protruding jaw
- crowded and misaligned teeth
- forward curvature of the lower spine
- Progressive development of bowed legs

2. Spondyloepiphyseal dysplasia Congenita (SEDC): Another rare cause of disproportionate dwarfism that affects approximately one in 95,000 babies. It refers to a group of conditions characterized by a shortened trunk, which may not become apparent until a child is between ages 5 and 10.

A very short trunk
A short neck
Shortened arms and legs
Average-size hands and feet
Slightly flattened cheekbones
Hip deformities that result in thighbones turning inward
Instability of the neck bones.
Progressive hunching curvature of the upper spine.
Progressive development of swayed lower back
Vision and hearing problems.
Arthritis and problems with joint movement.
Adult height ranging from 3 feet (91 cm) to just over 4 feet (122 cm).
club feet (A foot that’s twisted or out of shape).
Opening in the roof of the mouth (cleft palate).
severe osteoarthritis in the hips
weak hands and feet.
barrel-chested appearance (Broad, rounded chest)

3. Diastrophic dysplasia: A rare form of dwarfism, diastrophic dysplasia occurs in about one in 100,000 births. People who have it tend to have shortened forearms and calves (calf muscles-this is known as mesomelic shortening).

Achondroplasia

Spondyoepipheseal

Diastrophic

Proportionate dwarfism: In Proportionate dwarfism, the body parts are in proportion but shortened. It usually results from medical conditions present at birth or appearing in early childhood that limit overall growth and development. So the head, trunk and limbs are all small, but they’re proportionate to each other. Because these disorders affect overall growth, many of them result in poor development of one or more body systems. Growth hormone deficiency is a relatively common cause of proportionate dwarfism. It occurs when the pituitary gland fails to produce an adequate supply of growth hormone, which is essential for normal childhood growth.

Signs include:

Height below the third percentile on standard pediatric growth charts
Growth rate slower than expected for age
Delayed or no sexual development during the teen years.

Causes of Dwarfism

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 Ovum rather than from either parent’s complete genetic makeup.
Dwarfism can be caused by any of more than 200 conditions. Causes of proportionate dwarfism include metabolic and hormonal disorders such as growth hormone deficiency.
The most common types of dwarfism, known as skeletal dysplasias, are genetic. Skeletal dysplasias are conditions of abnormal bone growth that cause disproportionate dwarfism.

Other causes include;

Deficiency of growth hormone
Malnutrition
Inherited defect i.e. turners syndrome(Turner syndrome, a condition that affects only girls and women, results when a sex chromosome (the X chromosome) is missing or partially missing. A female inherits an X chromosome from each parent. A girl with Turner syndrome has only one fully functioning copy of the female sex chromosome rather than two)
Renal disorders
Congenital heart disease
Chronic infection in childhood

Diagnosis of Dwarfism

Some forms of dwarfism are evident at birth or during infancy and can be diagnosed through X-rays and a physical exam.
A diagnosis of achondroplasia, diastrophic dysplasia, or spondyloepiphyseal dysplasia can be confirmed through genetic testing. In some cases, prenatal testing is done if there is concern for specific conditions.
Sometimes dwarfism doesn’t become evident until later in a child’s life, when dwarfism signs lead parents to seek a diagnosis. Here are signs and symptoms to look for in children that indicate a potential for dwarfism:
- Late development of certain motor skills, such as sitting up or walking.
- Breathing problems
- Curvature of the spine
- bowed legs
- Joint stiffness and arthritis
- Lower back pain or numbness in the legs
- Crowding of teeth.

Measurements. A regular part of a well-baby medical exam is the measurement of height, weight and head circumference. At each visit, they will be plotted on a chart to show the child’s current percentile ranking for each one. This is important for identifying abnormal growth, such as delayed growth or a disproportionately large head. If any trends in these charts are a concern, the health worker may make more-frequent measurements.
Appearance. A child’s appearance may also help to make a diagnosis. Many distinct facial and skeletal features are associated with each of several dwarfism disorders.
Imaging technology. Imaging studies, such as X-rays, may be ordered because certain abnormalities of the skull and skeleton can indicate which disorder a child may have. Various imaging devices may also reveal delayed maturation of bones, as is the case in growth hormone deficiency.
A magnetic resonance imaging (MRI) scan may reveal abnormalities of the pituitary gland or hypothalamus, both of which play a role in hormone function.
Genetic tests. Genetic tests are available for many of the known causal genes of dwarfism-related disorders, but these tests often aren’t necessary to make an accurate diagnosis. If the pediatrician believes the daughter may have Turner syndrome, then a special lab test may be done that assesses the X chromosomes extracted from blood cells.
Family history. The pediatrician may take a history of stature in siblings, parents, grandparents or other relatives to help determine whether the average range of height in the family includes short stature.
Hormone tests. Tests that assess levels of growth hormone or other hormones that are critical for childhood growth and development may be ordered.

Management of Dwarfism

Treatment for Underlying Cause: Focus on addressing the specific cause of dwarfism, if possible.

Growth Hormone Therapy: GH injections can be administered to stimulate growth in children and adolescents.

Physical Therapy:

Improve Mobility: Develop strategies to compensate for mobility limitations.
Strengthen Muscles: Improve overall strength and endurance.

Psychological Support:

Counseling: Address any emotional issues related to self-esteem, body image, and social integration.
Support Groups: Connect with others who have dwarfism to share experiences and build support networks.

Nursing Care:

Education and Support:

Provide comprehensive information about dwarfism, its causes, and treatment options.
Encourage open communication and emotional support for the individual and their family.

Medication Administration:

Administer GH injections accurately and monitor for side effects.
Educate patients and families about proper injection techniques and storage.

Physical Care:

Assess mobility, and provide assistive devices and adaptive techniques as needed.
Promote healthy weight management and encourage regular exercise.

Emotional Support:

Empathize with the challenges of living with dwarfism and provide emotional support.
Facilitate access to counseling and support groups for the individual and their family.

Advocacy:

Advocate for the individual’s needs and rights.
Connect them with resources and support services for people with dwarfism.

Nursing Concerns:

Growth Hormone Therapy: Monitor for side effects of GH treatment, such as fluid retention, joint pain, and increased risk of diabetes.
Mobility and Safety: Assess for potential falls and injuries related to mobility limitations. Provide modifications and adaptations to improve safety in the home and community.
Psychological Well-being: Monitor for signs of depression, anxiety, and social isolation. Promote self-esteem and body image through counseling and support groups.
Accessibility: Advocate for accessible environments and accommodations for individuals with dwarfism.
Long-Term Management: Educate individuals and families about the lifelong implications of dwarfism and the need for ongoing care and support.

Surgical Management

Surgical procedures that may correct problems in people with disproportionate dwarfism include:
Correcting the direction in which bones are growing
Stabilizing and correcting the shape of the spine
Increasing the size of the opening in bones of the spine (vertebrae) to alleviate pressure on the spinal cord
Placing a shunt to remove excess fluid around the brain (hydrocephalus), if it occurs to drain excess fluid and relieve pressure on the brain.

Limb lengthening

Some people with dwarfism choose to undergo surgery called extended limb lengthening. This procedure is controversial for many people with dwarfism because, as with all surgeries, there are risks.
Because of the emotional and physical stress of multiple procedures, waiting until the person with dwarfism is old enough to participate in the decision to have the surgery is recommended.

Ongoing health care

Regular checkups and ongoing care by a doctor familiar with dwarfism can improve quality of life.
Because of the range of symptoms and complications, treatments are tailored to address problems as they occur, such as assessment and treatment for ear infections, spinal stenosis or sleep apnea.
Adults with dwarfism should continue to be monitored and treated for problems that occur throughout life.
In many cases, people with dwarfism have orthopaedic or medical complications. Treatment of those can include:
- A tracheotomy to improve breathing through small airways.
- Corrective surgeries for deformities such as cleft palate, club foot, or bowed legs
- Surgery to remove tonsils or adenoids to improve breathing problems related to large tonsils, small facial structures, and/or a small chest.
- Surgery to widen the spinal canal to relieve spinal cord compression.

Other treatments may include:

Physical therapy to strengthen muscles and increase joint range of motion.
Back braces to improve curvature of the spine
Placement of draining tubes in the middle ear to help prevent hearing loss due to repeated ear infections.
Orthodontic treatment to relieve crowding of teeth caused by a small jaw.
Nutritional guidance and exercise to help prevent obesity, which can aggravate skeletal problems.

Life style and home remedies

Talk with the pediatrician or a specialist about home care. Issues particularly critical for children with disproportionate dwarfism include:
Car seats. Use an infant car seat with firm back and neck supports. Continue using a car seat in the rear-facing direction to the highest weight and height possible (and beyond the recommended age limit).
Infant carriers and play equipment. Avoid infant devices such as swings, umbrella strollers, carrying slings, jumper seats and backpack carriers that don’t support the neck or that curve the back into a C shape.
Adequate support. Support the child’s head and neck when he or she is seated.
Complications. Monitor the child for signs of complications, such as ear infection or sleep apnea.
Posture. Promote good posture by providing a pillow for the lower back and a footstool when the child is sitting.
Healthy diet. Begin healthy eating habits early to avoid later problems with weight gain.
Healthy activities. Encourage participation in appropriate recreational activities, such as swimming or bicycling, but avoid sports that involve collision or impact, such as football, diving or gymnastics.
Coping and support. If a child has dwarfism, a number of steps to help him or her cope with challenges and function independently:
Seek help. Organizations provides social support, information about disorders, advocacy opportunities and resources. Many people with dwarfism stay actively involved in this organization throughout their lives.
Modify the home. Make changes in the home, such as putting specially designed extensions on light switches, installing lower handrails in stairways and replacing doorknobs with levers.
Provide personal adaptive tools. Everyday activities and self-care can be a problem with limited arm reach and problems with dexterity. An occupational therapist also may be able to recommend appropriate tools for home and school use.
Talk to educators. Talk to school personnel about what dwarfism is, how it affects the child, what needs the child may have in the classroom and how the school can help meet those needs.
Talk about teasing. Encourage the child to talk to you about his or her feelings, and practice responses to insensitive questions and teasing.
If the child tells you that bullying occurs in school, seek help from the child’s teacher, principal or the school guidance counselor and ask for a copy of the school’s policy on bullying.

Complications of Dwarfism

Complications of dwarfism-related disorders can vary greatly, but some complications are common to a number of conditions.

Disproportionate dwarfism

The characteristic features of the skull, spine and limbs shared by most forms of disproportionate dwarfism result in some common problems.
Delays in motor skills development, such as sitting up, crawling and walking.
Frequent ear infections and risk of hearing loss.
Bowing of the legs.
Difficulty breathing during sleep (sleep apnea).
Pressure on the spinal cord at the base of the skull.
Excess fluid around the brain (hydrocephalus).
Crowded teeth
Progressive severe hunching or swaying of the back with back pain or problems breathing
Narrowing of the channel in the lower spine (spinal stenosis), resulting in pressure on the spinal cord and subsequent pain or numbness in the legs
Arthritis
Weight gain that can further complicate problems with joints and the spine and place pressure on nerves

Proportionate dwarfism

With proportionate dwarfism, problems in growth and development often result in complications with poorly developed organs. For example, heart problems often present in Turner syndrome can have a significant effect on health.
An absence of sexual maturation associated with growth hormone deficiency
Turner syndrome affects both physical development and social functioning.
Pregnancy: Women with disproportionate dwarfism may develop respiratory problems during pregnancy. A C-section (cesarean delivery) is almost always necessary because the size and shape of the pelvis doesn’t allow for successful vaginal delivery.
Public perceptions
Most people with dwarfism prefer not to be labeled by a condition. However, some people may refer to themselves as dwarfs or little people.
People of average height may have misconceptions about people with dwarfism. And the portrayal of people with dwarfism in modern movies often includes stereotypes.
Misconceptions can impact a person’s self-esteem and limit opportunities for success in school or employment.
Children with dwarfism are particularly vulnerable to teasing and ridicule from classmates. Because dwarfism is relatively uncommon, children may feel isolated from their peers.

Dwarfism (Panhypopituitarism) Read More »

Acromegaly & Gingatism (Hyperpituitarism)

Acromegaly/Gigantism (Hyperpituitarism)

Acromegaly and Gigantism are conditions that result from hyperpituitarism, which is the excessive secretion of growth hormone (GH) by the pituitary gland.

Acromegaly and gigantism can also be referred to as hyperpituitarism and the most common cause is prolonged hypersecretion of growth hormone (GH), usually by a hormone-secreting pituitary tumour. As the tumour increases in size, compression of nearby structures may lead to: hyposecretion of other pituitary hormones of both the anterior and posterior lobes damage to the optic nerves, causing visual disturbances.

Gigantism occurs when there is an overproduction of GH in children or adolescents before the closure of the growth plates in bones. This leads to excessive growth in height and overall large stature.
Acromegaly occurs when GH overproduction happens in adulthood, after the growth plates have closed. Instead of growing taller, individuals with acromegaly experience abnormal growth of the hands, feet, and facial features, leading to a distinct appearance.

The effects of excess GH include:
> excessive growth of bones
> enlargement of internal organs
> formation of excess connective tissue
> enlargement of the heart and raised blood pressure
> reduced glucose tolerance and a predisposition to diabetes mellitus.

Growth hormone stimulates skeletal and soft tissue growth. Growth hormone (GH) excess therefore produces gigantism in children and acromegaly in adults.

Gigantism occur before fusion of the diaphysis and an individual increases in height
reaching 7-8 feet.
Acromegaly occur after fusion of the diaphysis with the epiphysis and there is enlargement of the acral parts
Both are caused due to a pituitary tumor in almost all cases.

Pathophysiology and clinical manifestations of acromegaly/gigantism:

Pituitary adenomas secrete excessive amounts of GH, which stimulates the production of insulin-like growth factor 1 (IGF-1) in the liver and other tissues. IGF-1 is responsible for the growth-promoting effects of GH. The excessive GH and IGF-1 levels result in tissue overgrowth, primarily affecting bones, cartilage, and soft tissues throughout the body.

Clinical manifestations Acromegaly and Gigantism:

The clinical manifestations of acromegaly and gigantism are similar and include gradual enlargement and thickening of the bones and tissues. This can lead to changes in facial features, such as;

Enlarged hands and feet: The bones and soft tissues in the hands and feet can become enlarged, resulting in larger glove and shoe sizes.
Facial changes: This can include a protruding jaw (prognathism), enlarged nose, thickened lips, and a prominent forehead.
Enlarged tongue: The tongue may become larger, potentially causing difficulties with speech and swallowing.
Increased size of internal organs: The heart, liver, and other organs may enlarge, leading to various complications.

The hands and feet may also increase in size. Other manifestations may include

joint pain
limited joint mobility
increased sweating
oily skin
sleep apnea, and enlarged nerves.

In children with gigantism, excessive growth can lead to abnormally tall stature.

Clinical Feature	Acromegaly	Gigantism
Onset	Adulthood (after growth plates have closed)	Childhood or adolescence (before growth plates have closed)
Height	Normal height (since growth plates are closed)	Abnormally increased height (due to prolonged bone growth)
Facial Features	Enlarged jaw, nose, and brow; coarse facial features	Normal facial proportions, but overall larger facial structure
Hand and Foot Size	Enlarged hands and feet, with thickened skin	Large hands and feet relative to body size
Joint Pain	Common due to joint hypertrophy	May occur but less common
Skin Changes	Thick, oily skin; excessive sweating	May have thickened skin
Organ Enlargement (Visceromegaly)	Enlarged organs (heart, liver, kidneys)	Possible, due to overall body enlargement
Cardiovascular Complications	Hypertension, cardiomyopathy	May develop cardiovascular issues due to increased body size
Bone and Soft Tissue Overgrowth	Bone thickening, particularly in the skull and jaw	Generalized overgrowth of bones and soft tissues
Visual Disturbances	Possible due to optic chiasm compression by a pituitary tumor	Possible if tumor compressing optic chiasm
Other Symptoms	Headaches, fatigue, sleep apnea, carpal tunnel syndrome	Headaches, fatigue, may develop other symptoms as they age

Diagnosis and treatment of acromegaly/gigantism:

Clinical Evaluation:

History: Look for symptoms like:

Enlarged hands, feet, and facial features (jaw, nose, forehead)
Headaches, vision problems
Joint pain and stiffness
Sleep apnea, snoring
Excessive sweating, fatigue
Menstrual irregularities in women
Impotence in men
Increased ring size, shoe size, hat size
Thickened skin, enlarged tongue

Physical Exam: Assess for signs of:

Acral enlargement (hands, feet, jaw)
Enlarged tongue
Hypertrophy of the soft tissues
Carpal tunnel syndrome
Enlarged organs (liver, spleen)

Biochemical Tests:

IGF-1 (Insulin-like Growth Factor-1): The most sensitive and reliable test. Elevated levels are highly suggestive of acromegaly or gigantism.
GH levels: Can be measured, but are less reliable than IGF-1 as GH levels fluctuate throughout the day.

Imaging Studies:

MRI (Magnetic Resonance Imaging): The gold standard for visualizing the pituitary gland and identifying a tumor.
CT (Computed Tomography) scan: Can also be used to assess the pituitary gland, but MRI is preferred.

Investigations:

Pituitary Function Tests:

Hormonal evaluation: To assess the function of other pituitary hormones (TSH, ACTH, FSH, LH, prolactin) as other pituitary hormones may be affected by the tumor.

Cardiovascular Evaluation:

Echocardiogram: To assess heart size and function, as acromegaly can lead to cardiomegaly and heart failure.
Electrocardiogram (ECG): To assess heart rhythm and electrical activity.

Management and Treatment

The primary treatment for acromegaly/gigantism is the surgical removal or reduction of the pituitary adenoma through transsphenoidal surgery.

In cases where surgery is not possible or does not fully resolve the condition, other treatment modalities may include medication (such as somatostatin analogs or GH receptor antagonists) to lower GH levels, radiation therapy to target the tumor, or a combination of these approaches.

1. Medical Management:

Somatostatin Analogues: (e.g., octreotide, lanreotide) are synthetic versions of the naturally occurring hormone somatostatin, which inhibits GH release. They are effective in controlling GH levels and reducing tumor size in some patients.
Dopamine Agonists: (e.g., bromocriptine, cabergoline) can be effective in some patients, especially those with GH-secreting tumors that are sensitive to dopamine.
Pegvisomant: A GH receptor antagonist that blocks the action of GH at its target tissues. It is effective in reducing GH levels and improving symptoms, but can be associated with liver toxicity.

2. Surgical Management:

Transsphenoidal Surgery: This involves removing the pituitary tumor through the nose and sinuses. It can be very effective in treating acromegaly, but it is a major surgery with potential risks.

3. Radiation Therapy:

Stereotactic Radiosurgery: This is a non-invasive treatment that delivers a high dose of radiation to the tumor, destroying it gradually. It can be used as a primary treatment or as an adjunct to surgery.

Nursing Care:

Patient Education: Educate the patient about acromegaly, its causes, treatments, and potential complications.
Symptom Management: Help patients manage symptoms like headaches, joint pain, sleep apnea, and fatigue.
Medication Administration: Administer medications as prescribed and monitor for side effects.
Monitoring for Complications: Observe signs and symptoms of complications like cardiovascular disease, diabetes, and vision problems.
Support and Emotional Care: Provide emotional support and guidance to patients and their families as they adjust to the diagnosis and treatment.
Regular Monitoring: Includes regular IGF-1 and GH level monitoring, as well as monitoring for complications.
Lifestyle Modifications: Weight management, exercise, and a healthy diet are important for improving overall health and managing complications.

Nursing interventions for acromegaly/gigantism:

Monitor and assess the patient’s physical and psychological well-being, including symptoms, vital signs, and emotional state.
Educate the patient about the condition, its management, and the importance of treatment compliance.
Assist in the administration of prescribed medications and monitor for potential side effects.
Monitor and manage pain, including joint pain and headaches, through appropriate pain management strategies.
Support the patient in maintaining a healthy lifestyle, including regular exercise and a balanced diet.
Provide emotional support and counseling to address body image concerns and potential psychosocial challenges.
Assess and monitor the patient’s endocrine function, including hormonal levels, to evaluate treatment effectiveness and detect any complications.
Monitor the patient’s cardiovascular health by assessing blood pressure, heart rate, and signs of heart enlargement or dysfunction.
Assist with the management of comorbidities that may arise, such as diabetes, hypertension, and sleep apnea.
Educate the patient on the importance of regular follow-up appointments, including hormone level monitoring, imaging studies, and other necessary investigations.
Collaborate with the healthcare team to provide coordinated care and ensure continuity of treatment.
Help the patient cope with potential psychological and emotional challenges associated with the condition, such as body image changes, anxiety, and depression.
Promote a safe environment by assisting with mobility, falls prevention, and management of joint pain and limited mobility.
Encourage the patient to engage in activities that promote overall well-being and quality of life.
Provide nutritional counseling to ensure a balanced diet that supports bone health.
Foster open communication and a therapeutic relationship with the patient, addressing any concerns or questions they may have.

Complications

Sterility in females and importance in males
Poor learning ability
Lack of sexual development
Poor concentration
Irritability
Heart disease
Diabetes mellitus
Gallstone
Enlargement of internal organs like heart, liver
Cancer
Polyp formation

Nursing Care Plan for Acromegaly and Gigantism

Assessment	Nursing Diagnosis	Goals/Expected Outcomes	Interventions	Rationale	Evaluation
1. Patient verbalizes anxiety over physical appearance changes (thickened skin, enlarged face, hands, and feet).	Disturbed Body Image related to anxiety over thickened skin and enlargement of face, hands, and feet.	The patient will verbalize acceptance of their appearance and demonstrate behaviors to enhance body image.	– Provide emotional support and counseling to address feelings of self-consciousness. – Encourage patient participation in grooming and self-care activities. – Involve the patient in support groups with others experiencing similar conditions.	To reduce anxiety and promote positive coping mechanisms. Engaging in self-care can enhance self-esteem. Support groups offer emotional support and shared experiences.	The patient reports reduced anxiety and increased acceptance of physical changes.
2. Patient shows signs of emotional distress, and expresses feelings of helplessness due to changes in appearance.	Ineffective Coping related to change in appearance.	The patient will demonstrate effective coping strategies and verbalize reduced distress.	– Assess the patient’s current coping mechanisms and provide education on effective coping strategies. – Refer the patient to a psychologist or counselor for additional support. – Encourage participation in activities that the patient enjoys and finds relaxing.	Understanding current coping methods allows for targeted interventions. Professional counseling can help the patient develop healthy coping strategies. Participation in enjoyable activities can reduce stress and improve mood.	The patient demonstrates effective coping strategies and verbalizes reduced emotional distress.
3. Patient reports tingling sensations in the hands and feet, and reduced sensitivity to touch.	Disturbed Sensory Perception related to nerve compression from tissue overgrowth.	The patient will report a reduction in tingling and an improvement in sensory perception.	– Monitor and document changes in sensory perception regularly. – Educate the patient on the importance of avoiding activities that could lead to injury due to decreased sensation. – Collaborate with physical therapy to enhance sensory perception.	Regular monitoring helps in identifying worsening or improving conditions. Educating the patient reduces the risk of injury. Physical therapy can improve sensory function and prevent complications.	The patient reports reduced tingling and improved sensory perception.
4. Patient reports difficulty sleeping due to soft tissue swelling.	Disturbed Sleeping Pattern related to soft tissue swelling.	The patient will report improved sleep quality and reduced nighttime discomfort.	– Elevate the head of the bed to reduce swelling and improve breathing. – Encourage the patient to maintain a regular sleep schedule. – Administer prescribed medications to reduce swelling as needed.	Elevation can help reduce fluid accumulation in tissues. A regular sleep schedule improves sleep quality. Medications can help manage swelling and discomfort.	The patient reports improved sleep and reduced nighttime discomfort.
5. Patient shows signs of dehydration (dry skin, decreased urine output).	Fluid Volume Deficit related to increased metabolic demands and soft tissue growth.	The patient will maintain adequate hydration, as evidenced by normal skin turgor and urine output.	– Monitor daily fluid intake and output, and encourage adequate fluid consumption. – Administer intravenous fluids as prescribed if oral intake is insufficient. – Educate the patient on the importance of hydration and signs of dehydration to watch for.	Monitoring fluid balance helps prevent complications. IV fluids provide hydration when oral intake is insufficient. Education empowers the patient to manage their condition effectively.	The patient maintains normal hydration levels, with normal skin turgor and urine output.
6. Patient expresses anxiety about changes in appearance and possible social implications.	Anxiety related to change in appearance.	The patient will report reduced anxiety and demonstrate relaxation techniques.	– Assess the patient’s level of anxiety and provide reassurance. – Teach relaxation techniques such as deep breathing and progressive muscle relaxation. – Encourage open communication about concerns and fears.	Assessing anxiety levels allows for appropriate interventions. Relaxation techniques help reduce anxiety. Open communication fosters trust and understanding.	The patient reports reduced anxiety and effectively uses relaxation techniques.
7. Patient shows a lack of understanding about their condition and its management.	Knowledge Deficit related to lack of information about acromegaly/gigantism and its management.	The patient will demonstrate an understanding of their condition and engage in appropriate self-care behaviors.	– Provide comprehensive education about acromegaly/gigantism, including causes, symptoms, and treatment options. – Encourage the patient to ask questions and participate in care decisions. – Offer written materials and resources for further learning.	Education empowers the patient to manage their condition effectively. Involving the patient in care decisions increases adherence to the treatment plan. Written materials provide ongoing reference and support learning.	The patient demonstrates understanding of their condition and actively participates in their care.

Acromegaly & Gingatism (Hyperpituitarism) Read More »

Endocrine System

Applied Anatomy and Physiology of the Endocrine System

The endocrine system controls the growth of many tissues, like the bone and muscle, and the degree of metabolism of various tissues, which aids in the maintenance of the normal body temperature and normal mental functions.

The endocrine system comprises glands and tissues that produce hormones for regulating and coordinating vital bodily functions, including growth and development, metabolism, sexual function and reproduction, sleep and mood.

Endocrine system is a system of ductless glands, which secrete hormones that are pored in the blood stream to be transported to the target cells.
The endocrine system is composed of the following

Pituitary gland
Parathyroid gland
Thyroid gland
Adrenal gland
Pancreas
Tests and ovaries

Hormones secreted by these glands act on the specific target tissue away from their site of secretion. Some hormones are protein in nature while others are not.

They act by interacting with specific cell membrane receptors to stimulate the intra cellular Adenylyl cyclase system (membrane-bound enzyme that catalyzes the conversion of Adenosine triphosphate (ATP)-organic compound that provides energy to drive many processes in living cells, such as muscle contraction, nerve impulse to Cyclic adenosine monophosphate (cAMP) – messenger used for intracellular signal induction, which in turn forms ATP to stimulate protein synthesis.

Hormones regulate their own production through a feedback (negative feedback mechanism) system where the increase in concentration of the hormone suppresses its own production.

Structure and function of major endocrine glands:

The endocrine system consists of several major glands that secrete hormones into the bloodstream. These glands include the pituitary gland, thyroid gland, adrenal glands, and pancreas.

The endocrine system plays a big role in regulating numerous body functions by releasing hormones, which are chemical messengers, directly into the bloodstream. These hormones travel to target tissues, influencing various physiological activities.

Exocrine vs. Endocrine Glands

Exocrine glands differ from endocrine glands in that they use ducts to transport their secretions, whereas endocrine glands release hormones directly into the bloodstream.

Pituitary Gland: The Master Gland

The pituitary gland, often termed the “master gland,” is a small structure hanging from the base of the brain. It controls other endocrine glands through hormone production, which is regulated by the hypothalamus.

But, hypothalamus is what controls the pituitary gland, making it the master of the master gland

Pituitary Gland Structure and Function

The pituitary gland is divided into two parts: the anterior and posterior pituitary, each with distinct functions and hormone production.

Posterior Pituitary: Produces oxytocin, which stimulates uterine contractions and milk ejection, and antidiuretic hormone (ADH), which helps the kidneys retain water.
Anterior Pituitary: Produces several hormones including thyroid-stimulating hormone (TSH), growth hormone (GH), adrenocorticotropin (ACTH), follicle-stimulating hormone (FSH), luteinizing hormone (LH), and prolactin.

The pituitary gland secretes hormones like; (Anterior lobe)

Adrenocorticotrophic hormone (ACTH)
Somatotrophic hormone (STH)/(GH)
Thyroid stimulating hormone (TSH)
Follicle stimulating hormone (FSH)
Luteinizing hormone (LH)’
Melanocyte stimulating hormone (MSH)

The Posterior lobe secretes

Anti diuretic hormone (ADH),
Vasopressin
Oxytocin.

Secretion of the anterior lobe is under the control of Hypothalamus which secretes regulatory hormones.

Growth hormone stimulates muscular and skeletal growth either by regulating synthesis of somatomedins by the liver or by directly stimulating incorporation of amino acids into proteins.
Hypoglycemia is a potent stimulant of growth hormone release; obesity blunts its release.
Excess secretion of growth hormone after epiphyseal fusion produces acromegaly where as before epiphyseal fusion causes gigantism

Image showing hormones produced by the anterior lobe.

Thyroid Gland

Located in the neck just below the larynx, the thyroid gland consists of two lobes connected by an isthmus. It produces thyroid hormones (T4 and T3) that regulate metabolism and calcitonin, which lowers blood calcium levels.

Parathyroid Glands

These small glands, usually four in number, are located near the thyroid and regulate calcium levels in the body through the secretion of parathyroid hormone.

Pancreas

The pancreas has both endocrine and exocrine functions, for digestion and blood sugar regulation. The endocrine function occurs in the Islets of Langerhans, which contain alpha, beta, and delta cells.

Alpha Cells: Release glucagon to increase blood glucose levels.
Beta Cells: Produce insulin, which lowers blood glucose by facilitating its uptake into cells.
Delta Cells: Secrete somatostatin, which inhibits both glucagon and insulin.

Adrenal Glands

Situated atop the kidneys, the adrenal glands consist of two parts with distinct functions:

Adrenal Medulla: Secretes catecholamines (norepinephrine and epinephrine), which are involved in the sympathetic nervous system’s response to stress.
Adrenal Cortex: Produces steroid hormones including glucocorticoids (which increase blood glucose), mineralocorticoids (which regulate sodium and potassium), and androgenic hormones.

Gonads

The gonads are the reproductive glands with endocrine functions.

Ovaries: Located in the female abdomen, they produce estrogen and progesterone under the control of FSH and LH from the anterior pituitary.
Testes: Situated in the male scrotum, they produce sperm and testosterone, promoting male growth and secondary sexual characteristics.

Hormones Produced

The pituitary gland is divided into two parts: the anterior pituitary and the posterior pituitary, each producing different hormones with distinct functions.

Anterior Pituitary Hormones

Thyroid-Stimulating Hormone (TSH): Stimulates the thyroid gland to produce thyroid hormones (T3 and T4), which regulate metabolism, energy levels, and overall growth and development.
Growth Hormone (GH): Promotes growth of body tissues, particularly bones and muscles, by increasing protein synthesis, fat metabolism, and cell division.
Adrenocorticotropic Hormone (ACTH): Stimulates the adrenal cortex to release cortisol, a hormone that helps the body respond to stress, maintain blood sugar levels, and regulate metabolism.
Follicle-Stimulating Hormone (FSH): In females, it stimulates the growth and maturation of ovarian follicles; in males, it promotes sperm production in the testes.
Luteinizing Hormone (LH): In females, it triggers ovulation and the production of progesterone; in males, it stimulates the production of testosterone in the testes.
Prolactin: Promotes milk production in the mammary glands after childbirth.

Posterior Pituitary Hormones

Oxytocin: Stimulates uterine contractions during childbirth and promotes the ejection of milk during breastfeeding.
Antidiuretic Hormone (ADH): Helps the kidneys manage the amount of water in the body by increasing water reabsorption, reducing urine volume, and helping maintain blood pressure.

Endocrine System Read More »

Normal First Stage Of Labour

PHYSIOLOGY OF FIRST STAGE OF LABOUR:

UTERINE ACTION

Fundal dominance;
Each uterine contraction starts from the fundus near the cornua and spreads across and down wards.
The contraction lasts longer in the in the fundus where it is most intense but the peak is reached simultaneously over the whole uterus and the contractions fade from all parts together.
This permits the cervix to dilate and the strongly contracting fundus to expel the fetus.

Polarity
This is a neuromuscular harmony that prevails between the two poles of the uterus throughout
labour.
During a contraction, these two poles act harmoneously. The upper uterine segment contracts strongly and retracts to expel fetus and the lower pole contracts slightly and dilates to allow expulsion of the fetus. If polarity is disorganized, labour progress is inhibited.

Contraction and retraction
During labour, a contraction does not pass off entirely but muscle fibres retain some of the shortening contractions instead of becoming completely relaxed. This is termed as retraction. This is a unique property of the uterine muscles and because of this,
the upper uterine segment becomes shorter and thicker and diminishes its cavity assisting in expulsion of the fetus.

Formation of the upper and lower uterine segment
By the end of pregnancy, the body of the uterus has divided into two segments;
> The upper segment is mainly for contraction and is muscular and thicker while the lower uterine segment is for distension and dilatation and is thinner.
> The lower segment develops from the isthmus and is about 8-10cm in length.

Retraction ring

This is a ridge formed between the upper and lower uterine segment.
The physiological retraction ring gradually rises when the upper uterine segment contracts and retracts and lower uterine segment thins out to accommodate the descending fetus.
This ring is not usually visible and when cervix is fully dilated and fetus can leave the uterus, it rises no further.
An exaggerated phenomenon of retraction ring in obstructed labour it becomes visible above the
symphysis pubis. This is termed as a bundle’s ring

2. CERVICAL ACTION

Cervical effacement
This is inclusion of the cervical canal. The muscle fibres surrounding the internal os are drawn upwards by the retracted upper uterine segment and the cervix merges into the lower uterine segment.

Cervical dilatation
This is the process of enlargement of the os from a tightly closed aperture to an opening large enough to permit passage of the fetal head.
It is measured in cm. a full dilatation at term equates to 10cm.
Pressure applied by the bag of fore waters and a well flexed fetal head closely applied to the cervix favors efficient dilatation.

Show
This is blood stained mucus which is seen before or at the onset of labour. The mucus is a thick mucoid substance which forms the cervical plug (opeculum) during pregnancy. Blood comes from raptured capillaries when the chorion has become detouched from the dilating cervix.

3. MECHANICAL FACTORS

Formation of fore waters

As the lower uterine segment stretches, the chorion becomes detouched from it and the increased intra uterine pressure causes this loosened part of the sac of fluid to bulge down wards into the dilating internal os. A well flexed head fits snugly into the cervix and cuts off the fluid in front of the head from that surrounding the body. The water in front is known as fore waters and that
behind is called hind waters.
General fluid pressure
When the membranes are intact, the pressure of the uterine contractions is exerted on the fluid and since the fluid is not compressible, the pressure is applied on the uterus and over the fetal
body. This is termed as general fluid pressure.
When membranes rapture and quantity of fluid escapes, the fetal head, placenta and umbilical cord will be compressed between the uterine wall and body of fetus during contraction resulting in reduced oxygen supply to the fetus.

Rapture of membranes
The optimum physiological moment for membranes to rapture is at the end of 1st stage of labour when the cervix becomes fully dilated and no longer supports the bag of fore water.
The uterine contractions are also applying increasing expulsive force at this time. Membranes may also rapture days before labour begins or during 1st stage of labour especially in a badly
fitting presenting part.
Occasionally, membranes do not rapture even in 2 nd stage and appear at the vulva as a bulging sac covering the fetal head as it is born. This is known as caul(CAL DE SAC)

Fetal axis pressure

During the contraction, the uterus rises forward and the force of fundal contraction is transmitted to the upper pole of the fetus down the long axis of the fetus and is applied to the cervix by the presenting part. This becomes more significant after rapture of membranes and during 2 nd stage of labour.

Descent of the presenting part.

It refers to the downward and outward movement of this part through the pelvis.
The normal well flexed head twists and turns flexes and extends to maneuver through the pelvis.
There are 3 planes or obstacles involved in the process of descent:
– Pelvic inlet/ brim.
When the presenting part is at the level of the ischial spines, a pelvic brim mark, it indicates the largest part of the head has come through the brim. The head is thus engaged.
The presenting part is now at station 0.
– Pelvic cavity.
When the presenting part has descended to the perineum, the largest part has passed the ischial
spines. The head is now at station +2.
– Pelvic outlet.
Delivery of the head brings it past the 3 rd obstacle ( pelvic outlet), which is under the pubic arch, between the ischial tuberosities and over the coccyx.
NB: station is the relationship of the lowermost part of the presenting part to an imaginary line
drawn between the ischial spines and the woman’s pelvis.

MANAGEMENT OF FIRST STAGE OF LABOUR

Aims

To monitor labour progress.
To prevent maternal exhaustion.
To prevent infections.
To give comfort to the mother and maintain patient’s moral.
To relieve pain.
To prevent complications.

Admission of a mother in labour
Welcome the mother and her relatives to allay fear and anxiety, create rapport.
Obtain full history and review the antenatal card while the mother is sitting or lying on
the couch.
The histories taken include;-
-Demographic data
-Date and time of admission
-When contractions started
-Frequency and strength of contractions
-If membranes raptured
Obtain consent from the mother and sign. Make sure mother is given sufficient
information before she decides to give consent.
Vital observations;- pulse ½ hourly if >100b/m indicates pain, anxiety, infections,
ketosis, hemorrhage etc.
– Blood pressure 2 hourly
– Temperature 4 hourly
-Respiration 4 hourly (16-20r/m)
Investigations e.g.- Urinalysis to rule out acetones, glucose and proteins.- Blood for Hb estimation, grouping and cross matching can be obtained depending on mother’s condition.
General examination The midwife examines a mother from head to toe paying more attention to general appearance (health or ill), size, any deformity, signs of anaemia, jaundice, oedema, dehydration, infections, Vericose veins and enlarged glands and veins in the neck. Examine the breasts and notice their suitability for breast feeding.
Abdominal examination: The mother’s bladder should be empty. It’s done following 3 steps.

-Inspection:-for size, shape, scars, signs of pregnancy etc
-Palpation: – Noting tenderness, height of fundus, presentation, lie, position, descent,
contractions, frequency, length and strength.
-Auscultation: – Noting rate, regularity and volume.

Vaginal examination.

This is a sterile procedure carried out on a woman through the vagina to rule out obstetrical or
gynecological abnormalities.

Indications of VE during pregnancy

> To confirm pregnancy
> To exclude abnormalities e.g. fibroids
> For pelvic assessment
> To determine the state of the cervix
> To confirm the type of abortion
> To rule out abnormal discharges
> During labour

During First stage

> To determine cervical dilation

> To exclude cord prolapse when membranes rapture
> To confirm full dilation when mother is bearing down.
> Before induction of labour to determine state of the cervix
> In prolonged labour to rule out obstructed labour.
> To make a positive identification of the presentation.
> To determine if the presenting part is engaged.

–During Second stage
> To confirm full dilation of the cervix
> When there is no descent to determine the delay e.g. face to pubis
> After delivery of the 1st twin to determine the presentation of the 2nd twin.

-During Third stage
> In delayed 3rd stage of labour to know whether the placenta is in the birth canal where it can be
removed quickly.
> To exclude lacerations and expel clots from the birth canal.
> In emergency i.e. manual removal of placenta.
> During puerperium
To find out whether the perineum has healed after 6 weeks.
> To find out whether the reproductive organs have regained their muscle tone and position.
> To obtain a specimen for examination.
> In abnormal vaginal discharge to confirm the type of infection.

Contraindications of VE

In APH and elective caesarian section

Complications of VE
-Infections
-Early rapture of membranes.
-Trauma or lacerations to the birth canal

Requirements
Tray containing;
> Galipot for swabs with antiseptic
> 2 receivers
> Sterile gloves
> Vaginal speculum
> Sterile bowl for lotion.
> Perineal pad/ clean pads
> Sheet and mackintosh.
> Clean gloves.
> Lubricant
At the bed side
> Screen
> Hand washing equipment
> Bed pan

PROCEDURE OF VAGINAL EXAMINATION

Welcome and explain procedure to the mother.
Empty bladder and screen the bed.
Assemble a VE tray.
Ask mother to relax during examination.
Woman’s arms should be down by her sides or across her abdomen to relax her abdominal
muscles.
Assist her into dorsal position and drape her.
Put on clean gloves
Place mackintosh and draw sheet under the buttocks
Remove gloves and wash hands thoroughly and put on sterile gloves.
Observe the external genitalia. Before the midwife cleans the vulva, should observe the
following;-
– Hygiene
– Labia for signs of varicosities.
– Oedema
– Vulval warts
– Sores
– If the perineum has old scars for tears, episiotomy, female circumcision.
– Any discharge from the vaginal opening i.e. blood, raptured membranes, smell of liquor
and colour.
– If liquor smells, it indicates infections. If green or meconium stained, indicates fetal
distress.
Vulva is swabbed using the left hand, swab from the front towards the rectum.
The 2 fingers of the right hand are dipped in the antiseptic cream for lubrication and gently inserted down wards and backwards into the vagina while the labia majora are held apart by the fingers of the left hand.
The fingers are directed along the anterior vaginal wall and should not be withdrawn until the
required information has been obtained. NB: The clitoris should not be touched because it causes discomfort.

Findings:

Condition of the vagina;

The vagina should feel warm and moist. A hot and dry vagina is a sign of obstructed labour and should not be found in modern obstetric care.
If a mother has a high temperature, the vagina will feel correspondingly hot but not dry.
Previous scar from Perineal wound, cystocele or rectocele.

The cervix;
The normal should feel thin and elastic and well applied to the presenting part.
A spongy feeling may show undiagnosed placenta previa.
The midwife should sweep the examining fingers from side to side to locate the os. It is usually felt in the center but sometimes in early labour, it is very posterior.
The length of the cervical canal assessed through a tightly closed cervix shows that labour has not yet started.
In a PG, the cervix can be completely taken up(effaced) but still closed and in this manner, it will be closely applied to the presenting part and it can be confused with a fully dilated cervix. If poorly applied to the presenting part, then it means there is an ill-fitting presenting part.
Assess cervix for; effacement, dilatation, consistency.

Membranes;
When membranes are intact, they can be felt through the dilating os; they feel tenser on contraction. When the fore waters are shallow, it is not easy to feel membranes.
If the presenting part does not fit well in or at the cervix, some of the fluid from the hind waters escapes into the fore waters causing the membranes to bulge or protrude through the cervix and are liable to rapture early.

Level or station of presenting part;
The presenting part is that part of the fetus that lies over the internal os during labour.
In order to assess the descent of the fetus in labour, the level of presenting part is assessed or estimated in relation to maternal ischial spines.

Position;
On feeling the features of the presenting part, the position of the fetus can be detected. The vertex is the normal presentation and the midwife must be familiar with it. Commonly the first feature to be felt even in early labour is the sagittal suture. The sagittal suture should be followed with a finger until a fontanel is reached.
If the head is well flexed, the posterior fontanel will be felt. This can be judged by feeling the amount of overlapping of the skull bones and can give additional information on position.
The parietal bones override the occipital bone to reduce the distance of the presenting diameter.

Pelvic capacity (pelvic assessment);
Although the pelvis was assessed during ANC period, the midwife should take opportunity to assure herself of its adequacy as she completes vaginal examination.
At completion of examination, withdraw fingers from the vagina and note any blood or amniotic fluid, cleans up the mother and removes gloves.
Record all findings of what was observed on admission on a partograph and observation chart.

Normal First Stage Of Labour Read More »

Labour

It is described as the process by which the fetus, placenta and membranes are expelled through the birth canal after 28 weeks of gestation.
OR
It is defined as rhythmic contraction and relaxation of the uterine muscles with progressive effacement (thinning) and dilatation ( opening) of the cervix, leading to expulsion of the products of conception.

Normal labour

Labour is said to be normal when;

It occurs at term.
Spontaneous in onset.
Fetus presenting by vertex.
The process is complete within 12-18 hours.
No complications arise.
Both mother and fetus suffer no injury.
No assistance is given in any way.

THREE P’S OF NORMAL LABOUR

Powers – uterine contractions
Passage – pelvis including the size and shape.
Passenger – Size, position and presentation of the fetus as well as bag of fore waters or amniotic sac.

TYPES OF LABOUR

True labour: This is characterized by regular uterine contractions slight at 1 st but increase in severity and frequency causes the cervix to dilate.
False labour: It is characterized by irregular uterine contractions which do not cause the cervix to dilate. They are painful, appear stronger when a mother is in bed and weaker when she is up and moving around.
> No cervical dilatation.
> No show.
> Pain remains stationary in the lower abdomen.
> Pain is continuous without any rhythm.
> Pain reduces after enema.
> No associated hardening of the abdomen.

Signs of impending labour.

These changes occur in the last weeks of pregnancy. This is termed as pre-labour.

Lightening
About 2-3 weeks before the onset of labour, the lower uterine segment expands and allows the fetal head to sink lower. The symphysis pubis widens and pelvic floor becomes more relaxed and softened, allowing the uterus to descend further into the pelvis.
Cervical changes
As labour approaches, the cervix becomes “ripe”. It becomes softer, like a lower lip and there is some degree of effacement and slight cervical dilatation.
False labour: It consists of painful uterine contractions that have no measurable progressive effect on the cervix and this is an exaggeration of the usually painless Braxton hick’s contractions which have been occurring since about 6weeks of gestation. It may occur for days intermittently even 3-4 weeks before the onset of true labour.
Premature rapture of membranes: Normally, membranes rapture at the end of 1 st stage of labour. When rapture occurs before the onset of labour, it is termed as PROM and occurs in about 12% of women. In 90% of women with PROM, labour begins spontaneously within 24 hours.
Bloody show: A mucus plug created by cervical secretions from proliferation of cervical mucosal glands in early pregnancy serves as protective barrier and closes the cervical canal throughout pregnancy. Bloody show is the expulsion of this mucus plug.
Energy spurt: Many women experience an energy spurt approximately 24-48 hours before the onset of labour. After days or weeks of feeling tired (physically tired and tired of being pregnant) they get up one day to find themselves full of energy and vigor.
G.I.T upset: In the absence of any causative factors for the occurrence of diarrhea, nausea, vomiting and indigestion, it is thought that they might be indicative of impending labour and there is no known explanation for this.

SIGNS OF LABOUR

They are divided into two;

Premonitory signs
Actual signs

Premonitory signs
– Lightening
It occurs 2-3 weeks before onset of labour. The lower uterine segment expands and allows the fetal head to sink further so as to engage. The fundus nolonger crowds the lungs and breathing is easier and the mother experiences relief
– Frequency of micturition
Congestion in the pelvis limits the capacity of the bladder requiring it to be emptied more often
– Effacement of the cervix
This is the taking up of the cervix-the cervix is drawn up and gradually merges into the lower uterine segment.
– Braxton hick’s contractions.
They become exaggerated and mother becomes anxious. She experiences backache or pains while walking due to relaxation of pelvic joints. This makes the mother think that she is in labour.

Actual signs
– Regular uterine contractions.
Mother feels painful, rhythmic uterine contractions slight at first but increase in severity and frequency.
– Dilatation of the cervix.
This is enlargement of the external os from a circular opening large enough to permit passage of the fetus.
– Show.
This is a bloody mucoid discharge which comes from the cervical canal. When it dilates, blood
comes from the raptured capillaries.
– Plus or minus rapture of membranes.
This is not so much relied on because it can occur in late 1 st stage or spontaneously at birth of the baby.

Causes of onset of labour.

The exact cause remains unknown but appears to be a combination of hormonal and mechanical
factors.

Hormonal factors.
Theories regarding the initiation of labour include the following;
1. Oxytocin stimulation theory:
– Although the mechanism is unknown, the uterus becomes increasingly sensitive to oxytocin as the pregnancy progresses.
2. Progesterone withdrawal theory:
– A decrease in progesterone production may stimulate prostaglandin synthesis and enhance the effect of Oestrogen which has stimulating effect on muscles. The fall of progesterone reduces the
relaxing effect of the uterine muscles.
3. Oestrogen stimulation theory: Oestrogen stimulates irritability of uterine muscles and enhances uterine contractions.
The raise in estrogen stimulates the decidua to release prostaglandins. Both prostaglandins and oxytocin cause the uterus to contract.
4. Fetal cortisol theory:
Cortisol may affect the maternal Oestrogen levels.
5. Prostaglandin stimulation theory:
Prostaglandin stimulates smooth muscles to contract.
A combination of the above mechanisms is likely to initiate labour.

Mechanical factors
1. over stretching and over distension of the uterus
2. Pressure from the presenting part on the nerve endings of the cervix stimulates the nerve plexus (cervical ganglion)
3. The increase in the strength and frequency of Braxton hick’s contractions may cause labour to begin.

Stages of labour

First stage
It begins with onset of regular, rhythmic uterine contractions and is complete when the cervix
is fully dilated.
It is a stage of dilation of the cervix.
It’s divided into 3 phases
-Latent phase
-Active phase
-Transitional phase
Latent phase:
This is a period of slow dilation of the cervix from 0-3cm.
It may last 6-8hours in first time mothers
Active phase:
This is the time when the cervix undergoes more rapid dilatation. It begins when the cervix is 4cm dilated and ends when the cervix is 8cm dilated.
Transitional phase
It begins when the cervix is 8cm dilated and is complete when Its fully dilated.
–
Second stage
It’s that stage of expulsion of the fetus. It begins when the cervix is fully dilated and is complete when the baby is completely born.
It also has two phases
– The propulsive phase
– The expulsive phase

Propulsive phase: It starts from full dilatation up to the descent of the presenting part to the pelvic floor.
Expulsive phase:
It is distinguished by maternal bearing down efforts and ends with delivery of the baby.

3. Third stage
It’s that stage of separation and expulsion of the placenta and membranes and involves control of bleeding.
OR
It begins with birth of the baby and ends with expulsion of placenta and membranes.
It takes 5-30 minutes. With active management, its completed within 5-15 minutes.

4. Fourth stage
It is also called recovery stage. It is defined as the 1 st one hour after delivery of the placenta.

Labour Read More »

Peri-Operative Care (Summary)

Pre-Operative Care

Post-Operative Care

Tumors of the Ear

Types of Tumors of the Nose:

Tumors of the Throat:

ADENOID HYPERTROPHY

Causes of Adenoid Hypertrophy

Classifying Adenoid Hypertrophy

Clinical Features of Adenoid Hypertrophy

Diagnosis of Adenoid Hypertrophy

Management of Adenoid Hypertrophy

USES OF A PARTOGRAPH

Starting a partograph:

FETAL CONDITION

LABOUR PROGRESS

MATERNAL CONDITION

Further mgt in the normal 1st stage of labour- nursing care

What to report

Complications

CUSHING’S SYNDROME

Causes of Cushing’s Syndrome

Classifications of Cushing’s Syndrome:

Signs and Symptoms of Cushing’s Syndrome:

Diagnosis and Investigations of Cushing’s Syndrome

Nursing care plan for Cushing’s syndrome:

Pheochromocytoma

Pathophysiology

Clinical Presentation of Pheochromocytoma

Diagnosis and Investigations:

Management of Pheochromocytoma

Nursing Care Plan: Pheochromocytoma

Addison’s Disease (Adrenal Insufficiency)

Causes of Addison’s Disease(Can be predisposing Factors too)

Clinical Presentation of Addison’s Disease:

DIAGNOSTIC EVALUATION

Complications of Addison’s Disease:

Management of Addison’s Disease

Medical Management

Nursing Care

Nursing care plan for Addison’s disease:

Dwarfism (Panhypopituitarism)

Types of Dwarfism

Management of Dwarfism

Acromegaly/Gigantism (Hyperpituitarism)

Pathophysiology and clinical manifestations of acromegaly/gigantism:

Clinical manifestations Acromegaly and Gigantism:

Diagnosis and treatment of acromegaly/gigantism:

Management and Treatment

Nursing interventions for acromegaly/gigantism:

Nursing Care Plan for Acromegaly and Gigantism

Applied Anatomy and Physiology of the Endocrine System

Structure and function of major endocrine glands:

Pituitary Gland: The Master Gland

Thyroid Gland

Parathyroid Glands

Pancreas

Adrenal Glands

Gonads

Hormones Produced

Anterior Pituitary Hormones

Posterior Pituitary Hormones

PHYSIOLOGY OF FIRST STAGE OF LABOUR:

UTERINE ACTION

2. CERVICAL ACTION

3. MECHANICAL FACTORS

Descent of the presenting part.

MANAGEMENT OF FIRST STAGE OF LABOUR

Vaginal examination.

Indications of VE during pregnancy

Contraindications of VE

PROCEDURE OF VAGINAL EXAMINATION

Findings:

Normal labour

THREE P’S OF NORMAL LABOUR

TYPES OF LABOUR

Signs of impending labour.

SIGNS OF LABOUR

Causes of onset of labour.