2Overview of Anatomy and Physiology Endocrine glands and hormonesThe endocrine system is composed of a series of ductless glandsIt communicates through the use of hormonesHormones are chemical messengers that travel though the bloodstream to their target organThe body’s glands are divided into two categories: endocrine and exocrine. Review how these two types differ.
3Overview of Anatomy and Physiology Pituitary gland—“master gland”Anterior pituitary glandPosterior pituitary glandThyroid glandParathyroid glandAdrenal glandAdrenal cortexAdrenal medullaPancreasThe pituitary gland is known as the “master gland.” Why has this moniker been applied?
4Figure 11-2 Pituitary hormones. The pituitary gland is responsible for the secretion of eight different hormones. Hormones play a vital function in the human body.What is the definition of hormones and the roles they play?(From Thibodeau, G.A., Patton, K.T. . Structure and function of the body. [13th ed.]. St. Louis: Mosby.)Pituitary hormones.
5Overview of Anatomy and Physiology Female sex glandsOvariesPlacentaMale sex glandsTestesThymus glandPineal glandThe endocrine glands are responsible for the regulation of numerous physiological processes in the body, including reproductive functions. The ovaries, located in the lower abdomen, secrete estrogen, which is responsible for the development of secondary sexual characteristics.The placenta is a unique organ. It is present in the woman only during pregnancy. What are the functions of the placenta? What hormones are secreted by the placenta?What hormone is secreted by the testes? What bodily changes result from this substance?
6Location of the endocrine glands in the female and male bodies. Figure 11-1(From Thibodeau, G.A., Patton, K.T. . Structure and function of the body. [13th ed.]. St. Louis: Mosby.)Location of the endocrine glands in the female and male bodies.
7Disorders of the Pituitary Gland AcromegalyEtiology/pathophysiologyOverproduction of growth hormone in the adultIdiopathic hyperplasia of the anterior pituitary glandTumor growth in the anterior pituitary glandChanges are irreversibleAcromegaly is a relatively rare disorder. Onset of the disorder is usually in the third or fourth decade of life.
8Disorders of the Pituitary Gland Acromegaly (continued)Clinical manifestations/assessmentEnlargement of the cranium and lower jawSeparation and malocclusion of the teethBulging foreheadBulbous noseThick lips; enlarged tongueGeneralized coarsening of the facial featuresEnlarged hands and feetEnlarged heart, liver, and spleenThe characteristic clinical manifestations of acromegaly occur throughout the body. When collecting information from patients, what subjective data should be obtained?What questions should be asked of this patient?
9Disorders of the Pituitary Gland Acromegaly (continued)Clinical manifestations/assessment (continued)Muscle weaknessHypertrophy of the joints with pain and stiffnessMales—impotenceFemales—deepened voice, increased facial hair, amenorrheaPartial or complete blindness with pressure on the optic nerve due to tumorSevere headachesThe significant changes in appearance associated with acromegaly have the potential to have psychosocial implications. What nursing diagnoses may be applicable to the psychosocial needs of the patient diagnosed with acromegaly?
10(Courtesy of the Group for Research in Pathology Education.) Figure 11-6The photograph on the left represents the individual prior to the diagnosis of acromegaly. The physiological impact of the disease is apparent in the photograph on the right side.(Courtesy of the Group for Research in Pathology Education.)Right: Coarse facial features typical of acromegaly. Left: Patient’s face several years before she developed the pituitary tumor.
11Disorders of the Pituitary Gland Acromegaly (continued)Medical management/nursing interventionsPharmacological managementParlodelSandostatinAnalgesicsCryosurgeryTranssphenoidal removal of tissueProton beam therapySoft, easy-to-chew dietThe patient experiencing acromegaly will often experience 7 to 9 years between the diagnosis of the disorder and the onset of clinical manifestations. What factors could be associated with this delay in a definitive diagnosis?When acromegaly is suspected, the diagnosis will be made based upon the patient’s health history, clinical manifestations, and the results of screening tests. What tests can be anticipated? What findings will support a positive diagnosis?Why are analgesics prescribed for the patient with acromegaly?After diagnosis and treatment, what prognosis can the acromegalic patient anticipate?
12Disorders of the Pituitary Gland GigantismEtiology/pathophysiologyOverproduction of growth hormoneCaused by hyperplasia of the anterior pituitary glandOccurs in a child before closure of the epiphysesThe secretion of growth hormone is responsible for the growth and development of the body’s tissues. When growth hormone is produced in excess, gigantism can result.Review the epiphyses. What are they, and why is gigantism impacted by their development?
13Disorders of the Pituitary Gland Gigantism (continued)Clinical manifestations/assessmentGreat heightIncreased muscle and visceral developmentIncreased weightNormal body proportionsWeaknessMedical management/nursing interventionsSurgical removal of tumorIrradiation of the anterior pituitary glandClinical manifestations associated with gigantism resemble an “overgrowth.” Despite their large size, the affected patients experience weakness.What causes this weakness?What nursing care will be needed for the patient diagnosed with gigantism?
14Disorders of the Pituitary Gland DwarfismEtiology/pathophysiologyDeficiency in growth hormone; usually idiopathicSome cases attributed to autosomal recessive traitClinical manifestations/assessmentAbnormally short heightNormal body proportionAppear younger than ageDental problems due to underdeveloped jawsDelayed sexual development`A deficiency in growth hormone can result in dwarfism. Dwarfism is associated with the expected short stature. What other body systems will be affected?
15Disorders of the Pituitary Gland Dwarfism (continued)Diagnostic testsMedical management/nursing interventionsGrowth hormone injectionsRemoval of tumor, if presentWhen a deficiency of growth hormone occurs, what diagnostic workup can be anticipated?What psychosocial implications are associated with a diagnosis of dwarfism?When diagnosed and treated, what is the long-term prognosis?
16Disorders of the Pituitary Gland Diabetes insipidusEtiology/pathophysiologyTransient or permanent metabolic disorder of the posterior pituitaryDeficiency of antidiuretic hormone (ADH)Primary or secondaryDiabetes insipidus results when antidiuretic hormone secretion or function goes awry. What physiological function does antidiuretic hormone have in the body?What factors can cause this dysfunction?
17Disorders of the Pituitary Gland Diabetes insipidusClinical manifestations/assessmentPolyuria; polydipsiaMay become severely dehydratedLethargicDry skin; poor skin turgorConstipationMedical management/nursing interventionsADH preparationsLimit caffeine due to diuretic propertiesPatients experiencing diabetes insipidus might feel the need to consume several liters of fluid and then void thousands of milliliters daily.Review the physiological significance caused by this massive fluid output. Which electrolytes are most compromised with the condition?If the patient wishes to drink so much fluid, what are the dangers of being allowed to do so?
18Disorders of the Thyroid and Parathyroid Glands HyperthyroidismEtiology/pathophysiologyAlso called Graves’ disease, exophthalmic goiter, and thyrotoxicosisOverproduction of the thyroid hormonesExaggeration of metabolic processesExact cause unknownHyperthyroidism occurs more commonly in women than men.It results when there is an elevation in thyroid hormone secretion.Although there is no exact known cure, there are supported theories in existence. Discuss these circulating theories.
19Disorders of the Thyroid and Parathyroid Glands Hyperthyroidism (continued)Clinical manifestations/assessmentEdema of the anterior portion of the neckExophthalmosInability to concentrate; memory lossDysphagiaHoarsenessIncreased appetiteWeight lossNervousnessWhen collecting data, what subjective data should be solicited? Provide examples of questions to include in the patient interview.
20Disorders of the Thyroid and Parathyroid Glands Hyperthyroidism (continued)Clinical manifestations/assessment (continued)InsomniaTachycardia; hypertensionWarm, flushed skinFine hairAmenorrheaElevated temperatureDiaphoresisHand tremors
21Disorders of the Thyroid and Parathyroid Glands Hyperthyroidism (continued)Medical management/nursing interventionsPharmacological managementPropylthiouracilMethimazoleRadioactive iodineSubtotal thyroidectomyWhen hyperthyroidism is suspected, a full diagnostic workup is warranted. What tests can be anticipated? What findings will support a positive diagnosis for the condition?The condition can be managed with the use of medications as well as surgical intervention. When medications are prescribed, what is their mode of action?
22Disorders of the Thyroid and Parathyroid Glands Hyperthyroidism (continued)Medical management/nursing interventions (continued)PostoperativeVoice rest; voice checksAvoid hyperextension of the neckTracheotomy tray at bedsideAssess for signs and symptoms of internal and external bleedingAssess for tetanyChvostek’s and Trousseau’s signsAssess for thyroid crisisSurgical intervention is indicated for those cases for which drug therapy is not appropriate.When surgery is planned, what are the preoperative goals for the patient?During the postoperative period the patient’s environment is monitored. What characteristics are desired for the patient’s care environment? Why?Outline the critical elements in the postoperative assessment.Demonstrate the assessment for Chvostek’s and Trousseau’s signs.
23Disorders of the Thyroid and Parathyroid Glands HypothyroidismEtiology/pathophysiologyInsufficient secretion of thyroid hormonesSlowing of all metabolic processesFailure of thyroid or insufficient secretion of thyroid-stimulating hormone from pituitary glandHypothyroidism is a common disorder. What populations are affected most?What conditions can cause hypothyroidism?
24Disorders of the Thyroid and Parathyroid Glands Hypothyroidism (continued)Clinical manifestations/assessmentHypothermia; intolerance to coldWeight gainDepressionImpaired memory; slow thought processLethargicAnorexiaConstipationHypothyroidism can affect both newborns and adults. What medical terminology is used to refer to the condition in newborns? In adults?
25Disorders of the Thyroid and Parathyroid Glands Hypothyroidism (continued)Clinical manifestations/assessmentDecreased libidoMenstrual irregularitiesThin hairSkin thick and dryEnlarged facial appearanceLow, hoarse voiceBradycardiaHypotensionThe reduction of thyroid hormone will result in a generalized slowing of metabolic processes. All systems are implicated in the condition.In addition to determining the physical signs and symptoms, what psychosocial factors should be assessed?What nursing care will be indicated to meet both the physical and psychological needs of the patient?
26Disorders of the Thyroid and Parathyroid Glands Hypothyroidism (continued)Medical management/nursing interventionsPharmacological managementSynthroidLevothyroidProloidCytomelSymptomatic treatmentWhen hypothyroidism is suspected, a series of tests will be performed to make a diagnosis. What tests can be anticipated? What results will support a diagnosis of hypothyroidism?When medications are prescribed to treat the disorder, what patient teaching is indicated?
27Disorders of the Thyroid and Parathyroid Glands Simple goiterEtiology/pathophysiologyEnlarged thyroid due to low iodine levelsEnlargement is caused by the accumulation of colloid in the thyroid folliclesUsually caused by insufficient dietary intake of iodineA simple goiter is also known as a colloid goiter. What does the term colloid mean?Explain the interrelationship between the T3 levels and TSH secretion.
28Disorders of the Thyroid and Parathyroid Glands Simple goiter (continued)Clinical manifestations/assessmentEnlargement of the thyroid glandDysphagiaHoarsenessDyspneaMedical management/nursing interventionsPharmacological managementPotassium iodideDiet high in iodineSurgery—thyroidectomyThe diagnosis is usually made based upon the clinical presentation of the patient.What are potential topics for patient education concerning the diagnosis?When considering a diet high in iodine, what should be encouraged in the patient’s intake?What is the prognosis for a simple goiter?
29Figure 11-10(Courtesy of L. V. Bergman & Associates, Inc., Cold Springs, New York.)Simple goiter.
30Disorders of the Thyroid and Parathyroid Glands Cancer of the thyroidEtiology/pathophysiologyMalignancy of thyroid tissue; very rareClinical manifestations/assessmentFirm, fixed, small, rounded mass or nodule on thyroidMedical management/nursing interventionsTotal thyroidectomyThyroid hormone replacementIf metastasis is present: radical neck dissection; radiation, chemotherapy, and radioactive iodineWhile there are few cases of thyroid cancer in the United States, there is an anticipated increase on the horizon. To what factors is this expected increase attributed?There are populations in which thyroid cancer occurs more frequently: females and whites.When thyroid cancer is suspected, diagnostic tests are used to make a positive diagnosis. What results will confirm a diagnosis?Review the prognosis associated with a diagnosis of thyroid cancer.
31Disorders of the Thyroid and Parathyroid Glands HyperparathyroidismEtiology/pathophysiologyOveractivity of the parathyroid, with increased production of parathyroid hormoneHypertrophy of one or more of the parathyroid glandsHyperparathyroidism results when the parathyroid gland produces the parathyroid hormone in excess. This disorder affects women between the ages of 30 and 70 years of age.What underlying conditions can cause this to occur?
32Disorders of the Thyroid and Parathyroid Glands Hyperparathyroidism (continued)Clinical manifestations/assessmentHypercalcemiaSkeletal pain; pain on weight-bearingPathological fracturesKidney stonesFatigueDrowsinessNauseaAnorexiaHypercalcemia is the primary manifestation. What series of events will accompany hypercalcemia?Why is there pain associated with this disease?The cardiovascular system may be impacted by hyperparathyroidism. What will occur if this system becomes involved?
33Disorders of the Thyroid and Parathyroid Glands Hyperparathyroidism (continued)Medical management/nursing interventionsRemoval of tumorRemoval of one or more parathyroid glandsWhen hyperparathyroidism is suspected, a series of diagnostic tests will be performed. A radiographic examination of the skeleton might be ordered. What results would be anticipated to support a positive diagnosis?Additional tests will include serum alkaline phosphate and calcium levels.
34Disorders of the Thyroid and Parathyroid Glands HypoparathyroidismEtiology/pathophysiologyDecreased parathyroid hormoneDecreased serum calcium levelsInadvertent removal or destruction of one or more parathyroid glands during thyroidectomyA reduction of parathyroid hormones will result in hypoparathyroidism.What will cause this disorder to occur?
35Disorders of the Thyroid and Parathyroid Glands Hypoparathyroidism (continued)Clinical manifestations/assessmentNeuromuscular hyperexcitabilityInvoluntary and uncontrollable muscle spasmsTetanyLaryngeal spasmsStridorCyanosisParkinson-like syndromeChvostek’s and Trousseau’s signsThe signs and symptoms of this disorder occur when the serum levels of calcium become compromised.In addition to the objective manifestations, what subjective signs might be present?
36Disorders of the Thyroid and Parathyroid Glands Hypoparathyroidism (continued)Medical management/nursing interventionsPharmacological managementCalcium gluconate or intravenous calcium chlorideVitamin DThe management of hypoparathyroidism involves the administration of calcium gluconate or calcium chloride. What nursing implications accompany these medications?When developing a plan of care for this patient, what dietary recommendations should be made?
37Disorders of the Adrenal Glands Adrenal hyperfunction (Cushing’s syndrome)Etiology/pathophysiologyPlasma levels of adrenocortical hormones are increasedHyperplasia of adrenal tissue due to overstimulation by the pituitary glandTumor of the adrenal cortexAdrenocorticotropic hormone (ACTH) secreting tumor outside the pituitaryOveruse of corticosteroid drugsThe adrenal cortex consists of three layers. A specific hormone is secreted by each layer.The hormones secreted by the adrenal cortex are steroids.Identify the hormones produced by the adrenal cortex.
38Disorders of the Adrenal Glands Adrenal hyperfunction (Cushing’s syndrome) (continued)Clinical manifestations/assessmentMoonfaceBuffalo humpThin arms and legsHypokalemia; proteinuriaIncreased urinary calcium excretionSusceptible to infectionsDepressionLoss of libidoThe changes exhibited by an oversecretion of adrenal hormones often cause a drastic change in appearance.In addition to the outward manifestations exhibited, there are blood imbalances. The blood glucose is elevated. What causes this to occur?Discuss the changes in electrolyte balance.
39Disorders of the Adrenal Glands Adrenal hyperfunction (Cushing’s syndrome) (continued)Clinical manifestations/assessmentEcchymoses and petechiaeWeight gainAbdominal enlargementHirsutism in womenMenstrual irregularitiesDeepening of the voice
40Disorders of the Adrenal Glands Adrenal hyperfunction (Cushing’s syndrome) (continued)Medical management/nursing interventionsTreat causative factorAdrenalectomy for adrenal tumorRadiation or surgical removal for pituitary tumorsLysodrenDietary recommendations:Low-sodiumHigh-potassiumThe diagnosis of Cushing’s syndrome is made by combining the patient’s physical symptoms with diagnostic tests for confirmation.The diagnostic tests that might be performed include serum levels and scanning tests. What tests can be anticipated to confirm a diagnosis?What are the goals of nursing care for the Cushing’s syndrome patient in the initial period after diagnosis?
41Disorders of the Adrenal Glands Adrenal hypofunction (Addison’s disease)Etiology/pathophysiologyAdrenal glands do not secrete adequate amounts of glucocorticoids and mineralocorticoidsMay result fromAdrenalectomyPituitary hypofunctionLong-standing steroid therapyWhat populations have the greatest incidence of Addison’s disease?
42Disorders of the Adrenal Glands Adrenal hypofunction (Addison’s disease) (continued)Clinical manifestations/assessmentRelated to imbalances of hormones, nutrients, and electrolytesNausea; anorexiaPostural hypotensionHeadacheDisorientationAbdominal pain; lower back painAnxietyPatients experiencing hypofunction of the adrenal glands present with a broad range of symptoms.What electrolytes are imbalanced? What manifestations will be noted with these imbalances?Anxiety is a chief concern for these patients. What should the nurse assess to determine the coping abilities of the patient?
43Disorders of the Adrenal Glands Adrenal hypofunction (Addison’s disease) (continued)Clinical manifestations/assessmentDarkly pigmented skin and mucous membranesWeight lossVomitingDiarrheaHypoglycemiaHyponatremiaHyperkalemiaAssess for adrenal crisisThe patient suspected of Addison’s disease can present with integumentary changes. Hyperpigmentation often results. What causes this to occur? When assessing the patient for these changes, where should the nurse focus the observations?Assessment of vital signs is also important as the patient could experience alterations in body temperature.Review the physiological changes that cause an adrenal crisis to occur.
44Disorders of the Adrenal Glands Adrenal hypofunction (Addison’s disease) (continued)TreatmentRestore fluid and electrolyte balanceReplacement of adrenal hormonesDiet high in sodium and low in potassiumAdrenal crisisIV corticosteroids in a solution of saline and glucoseAfter diagnosis, the patient with Addison’s disease will require close nursing assessments. Identify the primary patient-centered goals.
45Disorders of the Adrenal Glands PheochromocytomaEtiology/pathophysiologyChromaffin cell tumor; usually found in the adrenal medullaCauses excessive secretion of epinephrine and norepinephrineClinical manifestations/assessmentHypertensionMedical management/nursing interventionsSurgical removal of tumorPheochromocytoma is a rare occurrence.The tumor may be benign or malignant. Most are benign.What complications may result from this condition?
46Disorders of the Pancreas Diabetes mellitusEtiology/pathophysiologyA systemic metabolic disorder that involves improper metabolism of carbohydrates, fats, and proteinsInsulin deficiencyRisk factorsHeredityEnvironment and lifestyleVirusesMalignancy or surgery of pancreasDiabetes is a chronic metabolic disorder.The exact cause of diabetes is unknown, although there are several factors that are associated with its development.
47Disorders of the Pancreas Diabetes mellitus (continued)Types of diabetes mellitusType I—insulin dependent (IDDM)Type II—non-insulin dependent (NIDDM)Clinical manifestations/assessmentType I and type II“3 Ps”PolyuriaPolydipsiaPolyphagiaThere are several types of diabetes mellitus. Although each type is different, the common theme involves the body’s inability to adequately metabolize glucose.The two most common types of DM are type I diabetes mellitus (IDDM) and type II (noninsulin dependent) diabetes mellitus.How do these types differ in presentation?
48Disorders of the Pancreas Diabetes mellitus (continued)Clinical manifestations/assessment (continued)Type ISudden onsetWeight lossHyperglycemiaUnder 40 years oldTypically Type I diabetes mellitus demonstrates a rapid onset. It is characterized by a progressive destruction of beta-cell function. What theories explain potential causes of this type of DM?This type of DM is significantly less common than type II.
49Disorders of the Pancreas Diabetes mellitus (continued)Clinical manifestations/assessment (continued)Type IISlow onsetMay go undetected for years“3 Ps” are usually mildIf untreated, may have skin infections and arteriosclerotic conditionsWhat populations are most affected by type II diabetes?
50Disorders of the Pancreas Diabetes mellitus (continued)Diagnostic testsFasting blood glucose (FBG)Oral glucose tolerance test (OGTT)2-hour postprandial blood sugarPatient self-monitoring of blood glucose (SMBG)Glycosylated hemoglobin (HbA1c)C-peptide testWhen making a diagnosis for diabetes mellitus, both the patient’s clinical manifestations and the diagnostic screening test results will be utilized.What glucose screening results signify a probable diagnosis of diabetes?When tests are scheduled, what patient education is required to ensure preoperative compliance and dependable results?
51Disorders of the Pancreas Diabetes mellitus (continued)Medical management/nursing interventionsDietA goal of nutritional therapy is to achieve a blood glucose level of <126 mg/dLBalanced diet should include proteins, carbohydrates, and fatsType II—may be controlled by diet aloneType I—diet is calculated and then the amount of insulin required to metabolize it is establishedOne of the largest components of diabetic management involves the diet. The diet will need to be individualized.What factors should be assessed concerning individual dietary preferences? What role will culture play?
52Disorders of the Pancreas Diabetes mellitus (continued)Medical management/nursing interventions (continued)Diet (continued)American Diabetes Association (ADA) dietSeven exchangesQuantitative dietNeed three regular meals with snacks between meals and at bedtime to maintain constant glucose levelsThe exchange system is a common means of developing a diet for patients. What are the underlying principles to this type of diet?
53Disorders of the Pancreas Diabetes mellitus (continued)Medical management/nursing interventions (continued)ExercisePromotes movement of glucose into the cellLowers blood glucoseLowers insulin needsStress of acute illness and surgeryExtra insulin may be requiredIncreased risk of ketoacidosis (hyperglycemia)Glucose must be monitored closelySuccessful diabetes management involves control of a series of interrelated factors. In addition to diet, exercise, illness, and stress play a role in the body’s glucose levels.What advice should be given to patients regarding the incorporation of exercise into their plan of care?
54Disorders of the Pancreas Diabetes mellitus (continued)Medical management/nursing interventions (continued)MedicationsInsulinClassified by action: Regular; Lente and NPH; UltralenteClassified by type: beef/pork: Humulin/NovolinInjection sites should be rotated to prevent scar tissue formationSliding scaleInsulin administration is needed to sustain the lives of type I diabetes mellitus patients. The type of insulin prescribed will be based upon the individual needs of the patients.Review the types of insulin.
55Figure 11-16 A, Rotation of sites for insulin injections. Insulin is administered via subcutaneous injection. The selection of the site for administration is vital for a diabetic. Where in the body can insulin be injected? How do these sites differ?Discuss the means to rotate injection sites.(From Potter, P.A., Perry, A.G. . Basic nursing: essentials for practice. [5th ed.]. St. Louis: Mosby.)A, Rotation of sites for insulin injections.B, Injection diagram to track rotation of injection sites.
56Disorders of the Pancreas Diabetes mellitus (continued)Medical management/nursing interventions (continued)MedicationsOral hypoglycemic agentsStimulate islet cells to secrete more insulinOnly for type II diabetes mellitusOral hypoglycemic medications are used by those diagnosed with type II diabetes mellitus. How do these medications work?In what patient populations are they contraindicated?
57Disorders of the Pancreas Diabetes mellitus (continued)Medical management/nursing interventions (continued)Patient teachingGood skin careReport any skin abnormalities to physicianSpecial foot care is crucialDo not trim toenails—go to podiatristNo hot water bottles or heating padsAssess for symptoms of hypoglycemiaSuccessful management of diabetes requires patient teaching. The patient must be assessed for readiness to learn. Education is best completed with an emphasis on repetition. What behaviors signal a readiness to learn?How can learning be evaluated?
58Disorders of the Pancreas Diabetes mellitus (continued)Medical management/nursing interventions (continued)Acute complicationsComaDiabetic ketoacidosisHyperglycemic hyperosmolar nonketoticHypoglycemic reactionInfectionWhen diabetes is not successfully managed, life-threatening complications can result. What are the signs and symptoms of each complication?
59Disorders of the Pancreas Diabetes mellitus (continued)Medical management/nursing interventions (continued)Long-term complicationsDiabetic retinopathyCardiovascular problemsRenal failureThe longer an individual lives with diabetes, the greater the risk of complications. Discuss the ways a patient can reduce long-term complications.
60Nursing Process Nursing diagnoses Knowledge, deficient Self-esteem, risk for situational lowSensory and perceptual alterations: visualFluid volume, deficient, risk forInfection, risk forSexual dysfunctionBody image, disturbedCoping, ineffectiveNutrition, imbalancedActivity intolerance