Chapter 52

p1502
Assessment and
Management of Patients
With Endocrine Disorders
by Besher Gharaibeh

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 Overview

• Glands: Endocrine, Exocrine, Autocrine, Apocrine.

• Effects:regulate organ functions.
• The endocrine system is closely linked with the nervous
system and the immune system

• Hormones
– Peptide + Amine (protein): act on receptors on cell surface. cAMP
e.g. epinephrine
– Fatty acid derivative + Steroid: act inside the cell. mRNA e.g cortisol.

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Figure 52-1 p 1504

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Pituitary Gland and Its Hormones

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 Diagnostic Evaluation
• Stimulation test: administering hormone that is
normally produced by hypothalamus or pituitary.
• Suppression Test: to test the –ve feedback mechanism;
administering exogenous dose of the hormone
• Genetic screening: for gene mutation
• Imaging studies: MRI, CT, Ultrasound, Positron
Emission (PET), DEXA (Dual-energy x-ray
absorptiometry, or DEXA, is an enhanced form of x-ray
technology used for measuring bone mineral density)

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 Assessment:

1. Health history:
• Fatigue and changes in the energy level and its effect on the daily activity
• Changes in the heat and cold tolerance
• Recent changes in Weight ( increase or decrease)
• Fluid loss or retention
• Changes in sexual functions
• Changes in mood, memory, ability to concentrate and alteration in sleep
2. Physical assessment:
• Skin changes (texture)
• Eye changes (exophthalmos)
• Changes in physical appearance ( such as facial hear in women, moon face, buffalo hump,
increase size of the hand and the feet)
• Vital signs ( hypertension in hyperfunction of adrenal gland)
3. Diagnostic Evaluation:
• Hormonal levels
• Urine test for the presence of hormones such as epinephrine and norepinephrine in the tumor
of adrenal gland
• Stimulation and suppression test
• CT, MRI, Genetic screening.

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 Pituitary gland disorders
• Pituitary tumors:
– Eosinophilic (gigantism), basophilic (Cushing),
chromophobic (90%of tumors) (distroys the pituitary
causing hypopituitarism)
– functional or nonfunctional tumor.
– Rx: hypophysectomy (transsphenoidal) radiation,
meds (inhibit GH). Hypophysectomy (Cushing)

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 Diabetes Insipidus (DI):
Causes: tumor, trauma, infection, kidney not
responding to ADH
Dx: fluid deprivation tes, hypernatremia,
dehydration.
Rx: treat cause, fluid therapy, Atromid, thiazide
& ibuprofen (treat nephrogenic form of DI)
Desmopressin: Transnasal, IM. CI head injury,
caution with heart diseases
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 SIADH:

– Excessive ADH:hyponatremia
– Trauma, tumor, inf (pneumonia, pneumothorax), some
meds (nicotine, tricyclic AD, Vincristine, thiazide).
– Most cases are non-pituitary
– Rx: treat cause, restrict fluid, Lasix
– Nursing care: I&O, daily weight, teaching

– Note: increase BP and blood volume in the heart stimulates releasing

of Atrial Natreuretic Peptide which stimulates water and Na loss
through the kidney
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 Thyroid

• Thyroid hormones: T3, T4 also produces calcitonin

• Iodine is contained in thyroid hormone
• TSH from the anterior pituitary controls the release of
thyroid hormone
• TRH from the hypothalamus controls the release of TSH
• Thyroid hormone controls cellular metabolic activity
• T3 is more potent and more rapid-acting than T4
• Calcitonin is secreted in response to high plasma calcium
level and increases calcium deposition in bone
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Thyroid Gland

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 Assessment and diagnostic findings:

• Physical Exam of the thyroid gland:

1. Inspection for swelling and symmetry
2. Palpation for size, shape, consistency, symmetry, and
tenderness
3. Auscultation for bruits which indicate high blood flow
to the thyroid gland ( should be reported)

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 Thyroid Diagnostic Tests

• TSH
• Serum free T4 to confirm abnormal TSH
• T3 and T4
• T4 resin uptake: to determine the amount of thyroid hormone bound to
thyroxine-binding globulin (TBG) and the number of available binding sites
(normal 25-35%)
• Thyroid antibodies: auto-immune conditions
• Radioactive iodine uptake: high uptake in hyperthyrodism
• Fine-needle biopsy
• Thyroid scan, radioscan, or scintiscan: identify hot area and cold
areas
• Serum thyroglobulin to detect persistence or recurrence of
thyroid carcinoma
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Other tests:
Ultrasonography, CT and MRI
Test such as ALT, SGPT, and LDH, ECG

• Nursing implication to thyroid tests:

Allergy to iodine.
Assess the patient if taken medication or agents that may contain Iodine and thus
affect test results. ( Chart 52-2 p1514 shows list of medications that may
alter thyroid test results)

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 Thyroid Disorders
• Cretinism congenital hypothyrodism result in
stunted physical and mental growth.
• Hypothyroidism Myxedema due to Hashimoto’s
disease (autoimmune thyroditis) and cretinism
(present at birth
• Hyperthyroidism Grave’s disease
• Thyroiditis
• Goiter (Iodine-Deficient)
• Thyroid cancer
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 Hypothyroidism
• Causes: Autoimmune thyroiditis; Hashimoto’s disease (most common
cause)
• Affects women 5X more frequently than men
• Types of hypothyroidism:
1. Primary or thyroidal hypothyroidism (95%): dysfunction of
thyroid it self (decreased T3,T4, Increased TSH, Goiter)
2. Central Hypothyroidism : or hypothalamic hypothyroidism
(tertiary) or pituitary hypothyroidism (Secondary) or both
( Decreased T3, T4 Results from decreased TRH and /or
Decreased TSH, No goiter)

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 Manifestations:

– Early symptoms may be nonspecific

– Fatigue; hair, skin and nail changes; numbness and tingling
of fingers; menstrual disturbances, subnormal
temperature and pulse; weight gain; subdued emotional
and mental responses; slow speech; tongue, hands, and
feet may enlarge; personality and cognitive changes;
cardiac and respiratory complications
– Myxedema diminished cognitive status, may progress to
stupor, coma, and death

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 Manifestations

• Edema caused by infiltration of the skin with complex retaining

carbohydrate molecules as a result of altered metabolism
( Myxedema….. Sever degree of hypothyroidism) cause thickening of
the skin enlarged tongue, hands, and feet , hairs fall from the eye
brows, facemask, usually patient complaining of cold even in warm
environment, frequently complain of constipation, Deafness may occur
• Sever hypothyroidism is associated with elevated cholesterol,
atherosclerosis, coronary artery disease, and poor left ventricular
function
• Myxedema Coma: most extreme hypothyroidism ( Hypothermic and
unconscious), coma following lethargy which progress to stupor and
then coma

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 Medical management
• Pharmacologic Rx
• Levithyroxine: dosage based on TSH
• In coma:T3,T4 IV till stable
• Hydrocorisone
• O2 therapy (after improving atherosclerosis)
• Levithyroxine therapy increases risk of Angina
Prevent meds interaction (e.g.
anticoagulant,magnesium, sedatives, hypnotics.
ABGs
Avoidheat: cause hypotension and increase O2 demand

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 Medical Management of Hypothyroidism

- Phenytoin and tricyclic antidepressants

- Thyroid hormone may increase the effect of
digitalis glycosides and indomethacin.
- adjust insulin
- Monitor blood glucose
- Monitor fluid overload
- Prevention of cardiac dysfunction: cholesterol
- Levothyroxine till consciousness is restored
- Teach self care (meds and nutrition)
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 Nursing Management:
page 1516 careplan

1. Modifying activity: Assisting with care and hygiene because the patient
energy levels are low and the pt is having a problem cardiac and respiratory
function
2. Monitoring of vital signs and cognitive level: detect deterioration in mental
status, s/s indicating that medication has increased metabolic rate beyond
the body’s capacity to response( cardiac and respiratory) and limitation and
decrease the complication of myxedema
3. Promoting physical comfort: such as cold intolerance by providing patient
with extra clothing and blankets
4. Provide emotional support: changes in body image and appearance, feeling
of guilt and depression
5. Promoting home and community-Based care: By teaching patient self-care

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 Hyperthyroidism

• The second most prevalent endocrine disorder

• Excessive output of thyroid hormone
• Graves disease (most common cause): A.bodies stimulate TSH receptors.
• Affects women 8X more frequently than men
• Manifestations—thyrotoxicosis—nervousness; palpitations; rapid
pulse; tolerate heat poorly; tremors; skin is flushed, warm, soft,
and moist; however, elders’ skin may be dry and pruritic;
exophthalmos, increased appetite and dietary intake; weight loss;
elevated systolic BP; may progress to cardiac dysrhythmias and
failure
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 Assessment and diagnostic findings:
• Enlarged, soft, pulsate thrill, bruit heard over thyroid arteries
• Increased T4, and increased Iodine uptake by the thyroid
gland in excess of 50%
• exophthalmos

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 Medical Management of Hyperthyroidism

• Radioactive 131I therapy: 95% cured after 1 dose

• With I 121 :
– Thyroid storm is possible: due to release of stored thyroid hormones.
– Euothyrod in 3-4 weeks
– 20% hypothyroid in 2 years

• Medications: anti thyroid agents: affects synthesis or release of T3 T4.

30 min before meal on empty stomach.
(p1521)
– Propylthiouracil (PTU) and methimazole
– Sodium or potassium iodine solutions
– Dexamethasone
– Beta-blocker
*D/C therapy before it is complete causes relapse in 6 months
* side effect uncommon, Agranulocytosis; infection
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 Surgical management:

• Before surgery: Propylthiouracil is given to relieve signs of

hyperthyroidism
• Beta-blockers (propranolol used to reduce heart rate)
• Deep breathing and coughing with splinting of neck ( support neck and
avoid strain on suture line)
• Observe signs of respiratory distress and laryngeal stridor causes by
tracheal edema ( keep tracheostomy set available)
• Semi-fowler without pillows
• Observe dressing at operative site and back of neck and shoulders for
signs of hemorrhage.

• Potential complications: Hypoparathyroidism, Vocal cord paralysis result

from tracheal intubation or laryngeal nerve damage.

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 Thyroidectomy

• Treatment of choice for thyroid cancer

• Cancer surgery may include modified or radical neck dissection,
and may include treatment with radioactive iodine to minimize
metastasis
• Preoperative goals include the reduction of stress and anxiety
to avoid precipitation of thyroid storm
• Preoperative teaching includes dietary guidance to meet
patient metabolic needs and avoidance of caffeinated
beverages and other stimulants, explanation of tests and
procedures, and demonstration of support of head to be used
postoperatively
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 Postoperative Care

• Monitor dressing for potential bleeding and

hematoma formation; check posterior dressing
• Monitor respirations; potential airway impairment
• Assess pain and provide pain relief measures
• Semi-Fowler’s position, support head
• Assess voice but discourage talking
• Potential hypocalcaemia related to injury or removal
of parathyroid glands; monitor for hypocalcaemia
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 Thyroid Storm:

• Thyrotoxicosis: Sever hyperthyroidism of abrupt onset. And it is fatal if not

treated
• Causes: due to stress result from injury, infection, thyroid and non-thyroid
surgery, tooth extraction, insulin reaction, diabetes acidosis, pregnancy, abrupt
antithyroid medication, extreme emotional stress, vigorous palpation of the
thyroid.
• Manifestations:
- High fever above 38.5
- Extreme tachycardia > 130 bpm
- Exaggerated symptoms of hyperthyroidism: irritability with disturbances of a
major system ( GI: Wt loss, diarrhea, abd pain; cardiac: edema, chest pain,
dyspnea, palpitation )
- Altered neurological or mental state, as delirium, psychosis, and coma

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 Management of thyrotoxicosis

• Improve nutrition
• Enhance coping
• Self esteem
• Reduce body temperature
• Reduce complications
• Reduce heart rate and prevent vascular collapse
• O2 administration to improve tissue oxygenation
• Monitoring O2 saturation and blood gases to assess respiratory status.
• IVF containing glucose to replace liver glycogen
• Antithyroid medications
• Hydrocortisone to treat shock or adrenal insufficiency.

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 Parathyroid
• Four glands on the posterior thyroid gland
• Parathormone regulates calcium and
phosphorus balance
– Increased parathormone elevates blood calcium
by increasing calcium absorption from the kidney,
intestine, and bone through stimulating the
kidneys to release CALCITRIOL.
– Parathormone lowers phosphorus level.

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 Hyperparathyroidism

• Primary hyperparathyroidism is 2–4X more frequent in women.

• Increase PTH=increase S. Ca+2 = decrease excitation potential
• Manifestations include elevated serum calcium, bone decalcification, renal
calculi, apathy, fatigue, muscle weakness, nausea, vomiting, constipation,
hypertension, cardiac dysrhythmias, psychological manifestations
• Treatment
– Parathyroidectomy:
– Hydration therapy:2L
– Encourage mobility reduce calcium excretion
– Diet: encourage fluid, avoid excess or restricted calcium. Manage Anorexia
• Complications: high risk of peptic ulcer and pancreatitis
• Hypercalcemic crisis: Rx=rehydration, phosphate therapy, dialysis,
calcitonin+cortisone
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 Hypoparathryoidism
• Deficiency of parathormone usually due to surgery—
thyroidectomy, parathyroidectomy, or radical neck
dissection
• Results in hypocalcaemia and hyperphosphatemia
• Manifestations include tetany, numbness and tingling
in extremities, stiffness of hands and feet,
bronchospasm, laryngeal spasm, carpopedal spasm,
anxiety, irritability, depression, delirium, ECG changes
– Chvostek’s sign
– Trousseau’s sign

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Management of Hypoparathyroidism
• Increase serum calcium level to 9—10 mg/dL
• Calcium gluconate IV
• May also use sedatives such as pentobarbital
to decrease neuromuscular irritability
• Parathormone may be administered; potential
allergic reactions
• Environment free of noise, drafts, bright lights,
sudden movement
• Diet high in calcium and low in phosphorus
• Vitamin D

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 Adrenal Glands
• Adrenal medulla
– Functions as part of the autonomic nervous
system
– Catecholamines; epinephrine and norepinephrine
• Adrenal cortex
– Glucocorticoids
– Mineralocorticoids
– Androgens

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 The Adrenal Glands:
1. glucocorticoids (cortisole):
- play important role in glucose, protein, and fat metabolism and have role
in stress adaptation
- Elevate blood glucose level - inhibit the inflammatory response to tissue
injury
- Suppress allergic reaction -
- Side effects: Develop DM, Osteoporosis, Peptic ulcer, Muscle wasting,
poor wound healing, Redistribution of body fat and increase body Wt.
- Large amount of exogenous cortisol inhibit release of ACTH and
endogenous cortisol, lead to adrenal atrophy and sudden withdrawal of
cortisole leads to adrenal insufficiency

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 Cont….
2. Mineralocoticoids (Aldosterone):
- Influence electrolyte balance and blood pressure hmeostasis.
- Retain sodium and excrete potassium and hydrogen ions
3. Adrenal Sex hormones: (Androgens) (Male sex
hormones)
- May secret small amount of female sex hormones (Estrogen)
- Excess secretion can lead to Masculinization (adrenogenetal
syndrome)

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Adrenal Glands

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 Adrenocortical Insufficiency

• Addison’s disease
May be the result of adrenal suppression by exogenous steroid use-
Autoimmune or idiopathic atrophy of the adrenal gland (Cortex) (80%)
- Surgical remove of both glands
- Infection including TB and histoplasmosis
- Sudden cessation of exogenous adrenocortical hormone therapy
• Manifestations include muscle weakness, anorexia, GI symptoms, fatigue,
dark pigmentation of skin and mucosa, hypotension, low blood glucose, low
serum sodium, high serum potassium, mental changes, apathy, emotional
liability, confusion
• Addisonian crisis
• Diagnostic tests; adrenocortical hormone levels, ACTH levels, ACTH
stimulation test
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 Addisonian Crisis: (hypotensive crisis)

• Cyanosis and classic signs of circulatory shock: pallor, hypotension, rapid, weak
pulse, rapid respiration

• Headache, nausea, abdominal pain and diarrhea

• slight overexertion, exposure to cold, acute infection or decreased salt intake

can lead to circulatory collapse

• Sign of confusion and restlessness.

• Stress or surgery or dehydration and preparation for diagnostic tests can

precipitate crisis.

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 Assessment and diagnostic Findings:

• Hypoglycemia and hyponatremia and hyperkalemia

• Increased WBC’s ( leukocytosis)
• Diagnosis confirmed with low levels of:
- Adrenocortical hormones in the blood or urine
- Decreased serum cortisol levels
Medical management:
• Combat shock ( addisonian crisis) by:
- Restoring blood circulation
- Administering fluids and corticosteroids
- monitoring vital signs
= placing the patient in recumbent position with leg elevated

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 Cont…
• Administering Hydrocortisone ( solu-cortef)
followed by D5NS.
• Vasopressor amines for hypotention
• Antibiotic if infection presented
• Oral intake as tolerated
• Replacement of cortical hormones if gland
doesn’t regain function
• Salts and fluid supplement during GI losses

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 Nursing Management:

• Monitor vital signs and signs of infection, dehydration

• Monitor signs of electrolyte imbalance
• I/O daily, assess skin turgor
• Administer steroids with milk or antacids to prevent ulcer
• Prevent contact with other patient who have infection,
limit visitors
• Monitor for Addison's crisis: ( shock , hypotension, rapid
weak pulse, rapid respiration, pallor, extreme weakness:

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 Cont…
• Avoid physical and psychological stressors to prevent circulatory
collapse
• Improving activity tolerance ( avoid unnecessary activity and stress,
maintain quit, non stressful environment, assist in daily activity)
• Restoring fluid balance:
- instruct pt. to report increased thirst, monitor signs of dehydration
- Lying, sitting, and standing BP: decreased systolic pressure of
20mmHg may indicate fluid depletion
- Encourage foods and fruits that restore F and E balance
- Administer hormonal replacement as ordered

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 Nursing Process: The Care of the Patient with
Adrenocortical Insufficiency— Assessment

• Level of stress; note any illness or stressors that may

precipitate problems
• Fluid and electrolyte status
• VS and postural blood pressures
• Note signs and symptoms related to adrenocortical
insufficiency such as weight changes, muscle weakness, and
fatigue
• Medications
• Monitor for signs and symptoms of Addisonian crisis
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 Nursing Process: The Care of the Patient
with Adrenocortical Insufficiency—
Diagnoses
• Risk for fluid volume deficit
• Activity intolerance and fatigue
• Knowledge deficit

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 Interventions

• Risk for fluid deficit; monitor for signs and symptoms of fluid
volume deficit, encourage fluids and foods, select foods high
in sodium, administer hormone replacement as prescribed
• Activity intolerance; avoid stress and activity until stable,
perform all activities for patient when in crisis, maintain a
quiet nonstressful environment, measures to reduce anxiety
• Teaching
(See Chart 42-10)

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 Cushing’s Syndrome

• Due to excessive adrenocortical activity or corticosteroid

medications
• Manifestations include hyperglycemia which may develop
into diabetes, weight gain, central type obesity with “buffalo
hump,” heavy trunk and thin extremities, fragile thin skin,
ecchymosis, striae, weakness, lassitude, sleep disturbances,
osteoporosis, muscle wasting, hypertension, “moon-face”,
acne, increased susceptibility to infection, slow healing,
virilization in women, loss of libido, mood changes,
increased serum sodium, decreased serum potassium
(See Chart 42-11)
• Dexamethasone suppression test
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Nursing Process: The Care of the Patient
with Cushing’s Syndrome—Assessment
• Activity level and ability to carry out self-care
• Skin assessment
• Changes in physical appearance and patient
responses to these changes
• Mental function
• Emotional status
• Medications

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Nursing Process: The Care of the Patient
with Cushing’s Syndrome—Diagnoses
• Risk for injury
• Risk for infection
• Self-care deficit
• Impaired skin integrity
• Disturbed body image
• Disturbed thought processes

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 Collaborative Problems/Potential
Complications
• Addisonian crisis
• Adverse effects of adrenocortical activity

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 Nursing Process: The Care of the Patient with
Cushing’s Syndrome—Planning
• Goals may include decreased risk of injury,
decreased risk of infection, increased ability to
carry out self-care activities, improved skin
integrity, improved body image, improved
mental function, and absence of complications

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 Interventions
• Decrease risk of injury; establish a protective
environment; assist as needed; encourage diet high in
protein, calcium, and vitamin D.
• Decrease risk of infection; avoid exposure to
infections, assess patient carefully as corticosteroids
mask signs of infection.
• Plan and space rest and activity.
• Meticulous skin care and frequent, careful skin
assessment.
• Explanation to the patient and family about causes of
emotional instability.
• Patient teaching.
(See Chart 42-12) 54
 Corticosteroid Therapy
• Widely used drugs to treat adrenal insufficiency, suppress inflammation
and autoimmune response, control allergic reactions, and reduce
transplant rejection
• Common corticosteroids
(See Table 42-5)
• Patient teaching
– Timing of doses
– Need to take as prescribed, tapering required to discontinue or reduce
therapy
– Potential side-effects and measures to reduction of side-effects
(See Table 42-6)

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