Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 50: Nursing Management: Endocrine Pro lems !e" Points # Printa le $%S&'$E'S &( )N*E'%&' P%*+%*)', -L)N$ )C'&ME-)L, Acromegaly is a rare condition resulting from excess secretion of growth hormone (GH). In adults, bones increase in thickness and width but not length. anifestations include enlargement of hands and feet, thickening and enlargement of face and head bony and soft tissue, slee! a!nea, signs of diabetes mellitus, cardiomegaly, and hy!ertension. "reatment focuses on returning GH le#els to normal through surgery, radiation, and drug thera!y. $rognosis is de!endent on age at onset, when treatment is initiated, and tumor si%e. &ursing care for surgical !atient !osto!erati#ely includes a#oidance of #igorous coughing, snee%ing, and straining at stool to !re#ent cerebros!inal fluid leakage from where sella turcica was entered. After surgery with a transs!henoidal a!!roach, head of bed is ele#ated to a '() degree angle at all times and neurologic status is monitored. ild analgesia is used for headaches. "eeth brushing is a#oided for at least *( days. If hy!o!hysectomy is done or !ituitary is damaged, antidiuretic hormone (A+H), cortisol, and thyroid hormone re!lacement are needed for life. $atient teaching is essential with hormone re!lacement thera!y. .,P&(+NC*%&N &( P%*+%*)', -L)N$ .,P&P%*+%*)'%SM Hy!o!ituitarism is rare and in#ol#es a decrease in one or more of the !ituitary hormones. ost deficiencies with hy!o!ituitarism are due to a !ituitary tumor. ,igns and sym!toms #ary with the degree and s!eed of onset of !ituitary dysfunction and are related to hy!osecretion of the target glands and-or a growing !ituitary tumor. "he treatment consists of surgery or radiation for tumor remo#al, followed by lifelong hormone re!lacement. $%S&'$E'S &( P&S*E'%&' P%*+%*)', -L)N$ S,N$'&ME &( %N)PP'&P'%)*E )N*%$%+'E*%C .&'M&NE ,yndrome of ina!!ro!riate antidiuretic hormone (,IA+H) results from abnormal !roduction or sustained secretion of A+H and is characteri%ed by fluid retention, serum hy!oosmolality, dilutional hy!onatremia, hy!ochloremia, concentrated urine in !resence of normal or increased intra#ascular #olume, and normal renal function. "he most common cause is lung cancer.
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"reatment is directed at underlying cause with a goal to restore normal fluid #olume and osmolality. 4luid restriction results in gradual, daily weight reductions, !rogressi#e rise in serum sodium concentration and osmolality, and sym!tomatic im!ro#ement. 5ith chronic ,IA+H, !atient must learn self) management.

$%)/E*ES %NS%P%$+S +iabetes insi!idus (+I) is associated with deficiency of !roduction or secretion of A+H or decreased renal res!onse to A+H. +e!ending on cause, +I may be transient or chronic lifelong condition. "here are three ty!es of +I6 central, ne!hrogenic, and !rimary. +I is characteri%ed by !olydi!sia and !olyuria. If oral fluid intake cannot kee! u! with urinary losses, se#ere fluid #olume deficit results as manifested by weight loss, consti!ation, !oor tissue turgor, hy!otension, and shock. "he increased urinary out!ut and !lasma osmolality can cause se#ere fluid and electrolyte imbalances. "reating the !rimary cause is central to management. "hera!eutic goal is maintenance of fluid and electrolyte balance. &ursing care includes early detection, maintenance of ade7uate hydration, and !atient teaching for long)term management. $%S&'$E'S &( *.,'&%$ -L)N$ -&%*E' A goiter is an enlarged thyroid gland. In a !erson with a goiter the thyroid cells are stimulated to grow, which may result in an o#eracti#e thyroid (hy!erthyroidism) or an underacti#e one (hy!othyroidism). "hyroid)stimulating hormone (",H) and "8 le#els are measured to determine the le#el of thyroid function associated with the goiter. "reatment with thyroid hormone may !re#ent further thyroid enlargement. ,urgery to remo#e large goiters may be !erformed. *.,'&%$ N&$+LES )N$ C)NCE' A !al!able deformity of the thyroid gland may be benign or malignant. 9enign nodules are usually not dangerous, but can cause tracheal com!ression if they become too large. "hyroid cancer is the most common endocrine)related cancer. a:or sign of thyroid cancer is !resence of hard, !ainless nodule or nodules on enlarged thyroid gland. ,urgical tumor remo#al is the treatment of choice for cancerous nodules. $rocedures include unilateral total lobectomy with remo#al of isthmus to total thyroidectomy with bilateral lobectomy. &ursing care for thyroid tumors is similar to care for !atients who undergo thyroidectomy. *.,'&%$%*%S "hyroiditis is an inflammatory !rocess in the thyroid gland.

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,ubacute and acute forms of thyroiditis ha#e abru!t onset< the thyroid gland is !ainful and !atients often ha#e systemic manifestations, such as fe#er and chills. Hashimoto=s thyroiditis is a chronic autoimmune disease in which thyroid tissue is re!laced by lym!hocytes and fibrous tissue. It is the most common cause of goiterous hy!othyroidism. +iagnostic test results and treatment de!end on the ty!e of thyroiditis. .,PE'*.,'&%$%SM Hy!erthyroidism is thyroid gland hy!eracti#ity with sustained increase in synthesis and release of thyroid hormones. "hyrotoxicosis refers to !hysiologic effects or clinical syndrome of hy!ermetabolism resulting from excess circulating le#els of "8, "', or both. ost cases of hy!erthyroidism result in Gra#es= disease. "he clinical manifestations of hy!erthyroidism are related to the effect of excess thyroid hormone. 1xcess circulating hormone directly increases metabolism and increases tissue sensiti#ity to stimulation by the sym!athetic ner#ous system. 5hen thyroid gland is large, a goiter may be noted, and auscultation of thyroid gland may re#eal bruits. A classic finding is exo!hthalmos, !rotrusion of eyeballs from the orbits. "he two !rimary laboratory findings used to confirm the diagnosis of hy!erthyroidism are decreased ",H le#els and ele#ated free thyroxine (free "8) le#els. "he !rimary treatment o!tions are antithyroid medications, radioacti#e iodine thera!y, and subtotal thyroidectomy. "he o#erall goals are that the !atient with hy!erthyroidism will ex!erience relief of sym!toms, ha#e no serious com!lications related to the disease or treatment, maintain nutritional balance, and coo!erate with the thera!eutic !lan. Thyrotoxic Crisis "hyrotoxic crisis, or thyroid storm, is an acute, rare condition in which all hy!erthyroid manifestations are heightened. Although a life)threatening emergency, death is rare when treatment is #igorous and initiated early. anifestations include se#ere tachycardia, shock, hy!erthermia, sei%ures, abdominal !ain, diarrhea, delirium, and coma. "reatment focuses on reducing circulating thyroid hormone le#els by drug thera!y. .,P&*.,'&%$%SM Hy!othyroidism, a common medical disorder, results from insufficient circulating thyroid hormone. It may be !rimary (related to destruction of thyroid tissue or defecti#e hormone synthesis) or secondary (related to !ituitary disease with decreased ",H secretion or hy!othalamic dysfunction with decreased thyrotro!in)releasing hormone secretion). Iodine deficiency is the most common cause worldwide. 5hen iodine intake is ade7uate, common causes include thyroid gland atro!hy, related Hashimoto=s thyroiditis and Gra#es= disease, and discontinuance of thyroid hormone thera!y.

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Hy!othyroidism has systemic effects characteri%ed by a slowing of body !rocesses. anifestations include fatigue, lethargy, !ersonality and mental changes, decreased cardiac out!ut, anemia, and consti!ation. $atients with se#ere long)standing hy!othyroidism may dis!lay myxedema, an accumulation of hydro!hilic muco!olysaccharides in dermis and other tissues. "his mucinous edema causes characteristic facies of hy!othyroidism (e.g., !uffiness, !eriorbital edema, and masklike affect). A myxedema coma can be !reci!itated by infection, drugs (es!ecially o!ioids, tran7uili%ers, and barbiturates), ex!osure to cold, and trauma. yxedema coma is characteri%ed by subnormal tem!erature, hy!otension, and hy!o#entilation. "o sur#i#e, #ital functions are su!!orted and I> thyroid hormone re!lacement administered. ?#erall treatment in hy!othyroidism is restoration of euthyroid state as safely and ra!idly as !ossible with hormone re!lacement thera!y. @e#othyroxine (,ynthroid) is the drug of choice. $atient teaching is im!erati#e and need for lifelong drug thera!y is stressed.

$%S&'$E'S &( P)')*.,'&%$ -L)N$S .,PE'P)')*.,'&%$%SM Hy!er!arathyroidism in#ol#es increased secretion of !arathyroid hormone ($"H) that leads to hy!ercalcemia and hy!o!hos!hatemia. Alinical manifestations include muscle weakness, loss of a!!etite, consti!ation, emotional disorders, and shortened attention s!an. a:or signs include osteo!orosis, fractures, and kidney stones. "he most effecti#e treatment is a !arathyroidectomy. &onsurgical treatment in#ol#es the a#oidance of immobility, a high fluid intake, and moderate calcium intake. +rug thera!y with agents that lower calcium le#els, such as bis!hos!honates, estrogen, oral !hos!hates, diuretics, and calcimimetics, may be hel!ful. .,P&P)')*.,'&%$%SM Hy!o!arathyroidism results from inade7uate circulating $"H that results in hy!ocalcemia. "he most common cause is iatrogenic from accidental remo#al of !arathyroid glands or damage to these glands during neck surgery. ,udden decreases in serum calcium cause tetany, which is tingling of li!s, fingerti!s, and increased muscle tension with !aresthesias and stiffness. A !ositi#e Ah#ostek=s sign and "rousseau=s sign are usually !resent. 4ocus is to treat tetany, maintain normal serum calcium le#els, and !re#ent long) term com!lications. 1mergency treatment of tetany re7uires I> calcium. "he !atient re7uires instruction about lifelong treatment, including drug thera!y, nutrition, and monitoring of calcium le#els. $%S&'$E'S &( )$'EN)L C&'*E0 C+S.%N- S,N$'&ME Aushing syndrome is a s!ectrum of clinical abnormalities caused by excessi#e corticosteroids, !articularly glucocorticoids.

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"he most common cause is the administration of exogenous corticosteroids (e.g., !rednisone). ost cases of endogenous Aushing syndrome are due to adrenocorticotro!ic hormone (AA"H) secreting !ituitary tumor. 2ey signs include centri!edal or generali%ed obesity, Bmoon faciesC (fullness of face), !ur!lish)red striae below the skin surface, hirsutism in women, hy!ertension, and unex!lained hy!okalemia. "reatment is de!endent on underlying cause and includes surgery and drug thera!y to normali%e hormone le#els. &ursing care re#ol#es around the diagnoses of risk for infection, imbalanced nutrition, disturbed self)esteem, and im!aired skin integrity. Aare instructions are based on !atient=s inability to react to stressors !hysiologically. @ifetime re!lacement thera!y is re7uired by many !atients.

)$'EN&C&'*%C)L %NS+((%C%ENC, $rimary hy!ofunction of the adrenal cortex, or Addison=s disease, results in a reduction of all three classes of adrenal corticosteroids (glucocorticoids, mineralocorticoids, and androgens). ,econdary disease results from !ituitary dysfunction. "he most common cause is autoimmune where the adrenal cortex is destroyed by autoantibodies. anifestations ha#e a slow onset and include weakness, weight loss, and anorexia. ,kin hy!er!igmentation is seen in sun)ex!osed areas of body, at !ressure !oints, o#er :oints, and in !almar creases. "reatment is re!lacement thera!y. Hydrocortisone, the most commonly used form of re!lacement thera!y, has both glucocorticoid and mineralocorticoid !ro!erties. +uring times of stress, glucocorticoid dosage is increased to !re#ent addisonian crisis. ineralocorticoid re!lacement with fludrocortisone acetate (4lorinef) is gi#en daily with increased dietary salt. N+'S%N- M)N)-EMEN*: )$$%S&N1S $%SE)SE 5hen the !atient with Addison=s disease is hos!itali%ed, fre7uent nursing assessment is necessary. In addition, include daily weights, diligent corticosteroid administration, !rotection against ex!osure to infection, and assistance with daily hygiene. "he serious nature of the disease and the need for lifelong re!lacement thera!y necessitate a well)organi%ed and carefully !resented teaching !lan. 4ocus your care on hel!ing the !atient maintain hormone balance while managing the medication regimen, recogni%ing the need for extra medication and techni7ues for stress management. It is critical that the !atient wear an identification bracelet and carry an emergency kit at all times. Addisonian Crisis

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$atients with Addison=s disease are at risk for acute adrenal insufficiency, a life) threatening emergency caused by insufficient or sudden decrease in adrenocortical hormones. It is triggered by stress (e.g., surgery, trauma, or !sychologic distress)< sudden withdrawal of corticosteroid hormone re!lacement thera!y< and !ostadrenal surgery. anifestations include !ostural hy!otension, tachycardia, dehydration, hy!onatremia, hy!erkalemia, hy!oglycemia, fe#er, weakness, and confusion. "reatment is shock management and high)dose hydrocortisone re!lacement. @arge #olumes of (.DE saline solution and ;E dextrose are gi#en to re#erse hy!otension and electrolyte imbalances until blood !ressure (9$) normali%es. Complications Associated with Corticosteroid Therapy "he use of long)term corticosteroids in thera!eutic doses often leads to serious com!lications and side effects. "hera!y is reser#ed for diseases in which there is a risk of death or !ermanent loss of function, and conditions in which short)term thera!y is likely to !roduce remission or reco#ery. $otential treatment benefits must always be weighed against risks. "he danger of abru!t cessation of corticosteroid thera!y must be em!hasi%ed to !atients and significant others. Aorticosteroids taken longer than * week will su!!ress adrenal !roduction, and oral corticosteroids should be ta!ered. &urses must ensure that increased doses of corticosteroids are !rescribed in acute care or home care situations with increased !hysical or emotional stress. .,PE')L$&S*E'&N%SM Hy!eraldosteronism is characteri%ed by excessi#e aldosterone secretion commonly caused by small solitary adrenocortical adenoma. "he main effects are sodium retention and !otassium and hydrogen ion excretion, resulting in hy!ertension with hy!okalemic alkalosis. "he !referred treatment is surgical remo#al of adenoma (adrenalectomy). $atients with bilateral adrenal hy!er!lasia are treated with drugs. Aalcium channel blockers may be used to control 9$. $atients are taught to monitor their own 9$ and need for monitoring.

P.E&C.'&M&C,*&M) A !heochromocytoma is a rare condition characteri%ed by an adrenal medulla tumor that !roduces excessi#e catecholamines (e!ine!hrine, nore!ine!hrine), resulting in se#ere hy!ertension. anifestations include se#ere, e!isodic hy!ertension accom!anied by classic triad of se#ere, !ounding headache, tachycardia with !al!itations and !rofuse sweating, and unex!lained abdominal or chest !ain.

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Attacks may be !ro#oked by many medications, including antihy!ertensi#es, o!ioids, radiologic contrast media, and tricyclic antide!ressants. If undiagnosed and untreated, !heochromocytoma may lead to diabetes mellitus, cardiomyo!athy, and death. "reatment consists of surgical remo#al of tumor.

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