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NUR 342

UNIT I
Assessment and
Management of Patients
With Endocrine Disorders

Endocrine System
Effects almost every cell, organ, and function of the body
The endocrine system is closely linked with the nervous
system and the immune system
Negative feedback mechanism
Hormones
Steroid: act inside the cell
Peptide (protein): act on cell surface
Amine
Fatty acid derivative
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Hypothalamus
Hormones
CRH
TRH
GHRH
GnRH
Somatostatin
Control the release pituitary hormones

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Major Hormone Secreting Glands of


the Endocrine System

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Hormones of the Pituitary Gland


Posterior (Neurohypophysis)
Vasopressin (Antidiuretic Hormone [ADH])
Oxytocin
Anterior (Adenohypophysis)
Follicle Stimulating Hormone (FSH)
Luteinizing Hormone (LH)
Prolactin
Adrenocorticotropic Hormone(ACTH or Corticotropin)
Thyroid-Stimulating Hormone (TSH)
Growth Hormone (GH) or Somatotropin
Melanocyte-Stimulating Hormone
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The Pituitary Gland and its Hormones

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The Pituitary Gland and its Hormones

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Disorders of the Posterior Pituitary


Gland
Diabetes Insipidus
Definition
Etiology
Clinical manifestations
Diagnostic findings
Medical Management
Pharmacologic therapy: Desmopressin
(DDAVP) intranasal; Vasopressin tannate IM
Nursing Management
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Disorders of the Posterior Pituitary


Gland
Syndrome of Inappropriate Antidiuretic

Hormone Secretion

Definition
Etiology
Assessment
Management
Eliminate cause
Fluid restriction
Diuretics (furosemide,Lasix)
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Thyroid gland diagram


Thyroid Gland

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HPT axis
Hypothalamic-Pituitary-Thyroid Axis

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Thyroid Hormones
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 Diagnostic Tests


TSH
Serum free T4
T3 and T4
T4 resin uptake
Thyroid antibodies
Radioactive iodine uptake
Fine-needle biopsy
Thyroid scan, radioscan, or scintiscan
Serum thyroglobulin
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Thyroid Disorders
Hypothyroidism- myxedema,
Hashimotos disease
Hyperthyroidism- Graves Disease
Thyroiditis
Thyroid Tumors
Endemic (Iodine-Deficient) Goiter
Nodular Goiter- hyperplasia
Thyroid Cancer
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Hypothyroidism
Cretinism: Inadequate secretion of thyroid

hormone in fetal and neonatal development


Myxedema: Advanced form in adults
Common cause in adults: Autoimmune
thyroiditis or Hashimotos disease
Previous hyperthyroid who is now
hypothyroid r/t treatment with surgery,
medications, or RAI for hyperthyroidism
Aging Atrophy of thyroid gland
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Hypothyroidism
Hypothyroidism
Causes: Autoimmune thyroiditis; Hashimotos disease (most
common cause)
(See Chart 42-2)
Affects women 5X more frequently than men
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 may progress to stupor, coma, and death
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Hypothyroidism: Medical
Management
Medical Management of Hypothyroidism
Synthetic levothyroxine-replacement therapy
Medication interactions
Effects of hypnotic and sedative agents; reduce dosage
Support of cardiac function and respiratory function
Prevention of complications

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Hyperthyroidism
Hyperthyroidism
The second most prevalent endocrine disorder
Excessive output of thyroid hormone
Graves disease (most common cause)
Affects women 8X more frequently than men
Manifestationsthyrotoxicosisnervousness;
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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Exophthalmos with Graves


Disease

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Thyroid Storm

Manifestations:
High fever, extreme tachycardia, exaggerated
symptoms of hyperthyroidism, delirium, coma,
somnolence.
Treatment
Hypothermia blanket, ice packs, cool
environment, Tylenol, humidified O2, ABGs, IVF
with dextrose, PTU, hydrocortisone to treat shock
or adrenal insufficiency, Iodine, Beta Blocker,
propranolol + digoxin for cardiac rhythm

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Medical Management of
Hyperthyroidism
Radioactive 131I therapy
Medications

(See Table 52-3), p. 1481

Propylthiouracil and methimazole


Sodium or potassium iodine solutions
Dexamethasone
Beta-blockers

Surgery; subtotal thyroidectomy


Relapse of disorder is common
Disease or treatment may result in hypothyroidism

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Medical Management of
Hyperthyroidism
Radioactive 131I therapy
Medications

(See Table 52-3), p. 1481

Propylthiouracil and methimazole


Sodium or potassium iodine solutions
Dexamethasone
Beta-blockers

Surgery; subtotal thyroidectomy


Relapse of disorder is common
Disease or treatment may result in hypothyroidism

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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-Fowlers position, support head
Assess voice but discourage talking
Potential hypocalcemia related to injury or
removal of parathyroid glands; monitor for
hypocalcemia
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Nursing Management of
Hyperthyroidism : Medical
Assessment
Nursing Diagnoses
Imbalanced nutrition: Less than body requirements
Ineffective coping r/t irritability
Low self-esteem r/t changes in appearance
Altered body temperature
Nursing Interventions
Teaching

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Question
Which medication blocks synthesis of thyroid
hormone?
A. Dexamethasone
B. Methimazole
C. Potassium iodide
D. Sodium iodide

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Answer
B
Methimazole blocks synthesis of thyroid
hormone. Dexamethasone, potassium
iodide, and sodium iodide suppress release
of thyroid hormone.

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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.
Parathormone lowers phosphorus level.

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Location of the Parathyroid


Glands

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Parathyroid Disorders
Hyperparathyroidism-

characterized by bone
decalcification and development of
renal calculi
Hypoparathyroidism- occurs
frequently with thyroidectomy or
radical neck dissection
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Hyperparathyroidism
Primary hyperparathyroidism is 24X more frequent in

women.
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
Encourage mobility reduce calcium excretion
Diet: encourage fluid, avoid excess or restricted calcium

Hypercalcemic crisis
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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
Chvosteks sign
Trousseaus sign
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Management of
Hypoparathyroidism

Increase serum calcium level to 910 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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Question
Is the following statement True
or False?
The patient in acute
hypercalcemic crisis requires
close monitoring for lifethreatening complications and
prompt treatment to reduce
serum calcium levels.

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Answer
True
The patient in acute hypercalcemic crisis
requires close monitoring for lifethreatening complications and prompt
treatment to reduce serum calcium levels.

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Management of Patients with


Adrenal Disorders
Adrenal Medulla
Autonomic nervous system: Catecholamines
Epinephrine
Norepinephrine

Adrenal Cortex
Glucocorticoids
Mineralocorticoids
Androgens

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Location of the Adrenal Glands


and 2 Components

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Adrenal Disorders
Pheochromocytoma- benign tumor
Adrenocortical Insufficiency (Addisons

Disease)- autoimmune or idiopathic


Cushings Syndrome- excessive
administration of corticosteroids or
ACTH or hyperplasia of adrenal cortex
Primary Aldosteronism- hypokalemia,
alkalosis, hypertension
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Pheochromocytoma
Benign (usually) tumor of adrenal medulla
Peak 40-50 years of age
Familial tendency
Clinical manifestations
Headache, palpitations, diaphoresis
Hypertension common; hyperglycemia
Acute, unpredictable attacks of extreme
anxiety, tremulous, weak, air hunger and others
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Pheochromocytoma
Assessment/Diagnostic tests
5 Hs: hypertension, hyperhydrosis,
hypermetabolism, hyperglycemia, headache
Urine & plasma levels of catecholamines
Urine:Metanephrines, Vanillylmandelic acid (VMA)
24 hour urine; restrict coffee, tea, vanilla, chocolate,
bananas, & ASA as may alter test results
Plasma catecholamine measured with patient supine
and at rest for 30 minutes; venous access placed
before start the test
Other tests, p. 1277
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Pheochromocytoma
Management: Bedrest with HOB elevated to

reduce BP
Pharmacologic therapy
Alpha adrenergic blockers: phentolamine (Regitine) or
smooth muscle relaxants: sodium nitroprusside
(Nipride) to lower BP
Long acting alpha blocker: phenoxybenzamine
(Dibenzyline) to reduce BP in preparation for surgery.
Beta adrenergic blockers for cardiac dysrhythmias/
tachycardia and angina (propranolol [Inderal])

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Pheochromocytoma
Surgical management: definitive treatment is

removal of tumor with adrenalectomy


BP controlled with medication pre-op
Hydrated to prevent hypotension
BP control during and after surgery
Bilateral adrenalectomy: Corticosteroid
replacement necessary; IV methylprednisolone
(Solu-Medrol) in perioperative period then oral
prednisone for life-long treatment
Monitor for hypotension and hypoglycemia
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Pheochromocytoma
Nursing Mangement
Monitoring VS, F/E balance, blood glucose
Administer corticosteroids as ordered
Teaching

Medications: Corticosteroids have many implications


Monitor BP at home
Procedure for 24-hour urine collection
Home care nurse: check BP and corticosteroid replacement
treatment and side effects
Follow-up with MD

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Adrenocortical Insufficiency
Addisons disease: may result from autoimmune or idiopathic
atrophy
May be the result of adrenal suppression by exogenous
steroid use
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 lability,
confusion
Addisonian crisis: Circulatory shock, may be precipitated by
low salt intake, surgery, exposure to cold, infection.
Diagnostic tests; adrenocortical hormone levels, ACTH
levels, ACTH stimulation test
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Addisons Disease
Diagnostic tests
Low blood glucose
Hyponatremia
Hyperkalemia
Leukocytosis
Low serum cortisol
ACTH administration No response of plasma
cortisol increase (if adrenal cortex is destroyed)
and urinary 17-hydroxycorticosteroids
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Addisons Disease
Medical Management
Reduce shock: fluids, IV corticosteroids
(Hydrocortisone/Solu-Cortef), recumbent
position with legs elevated.
Treat cause, e.g. infection
Lifelong corticosteroids (prednisone) &
mineralocorticoids (Florinef) may be necessary;
added glucocorticoids with stressor; added salt
during times of fluid loss
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Addisons Disease
Nursing Management
Assessment
Managing Addisonian crisis
Restoring fluid balance (Florinef & prednisone)
Improving activity tolerance
Teaching: Home care checklist, p. 1280
Need written and verbal discharge instructions

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Cushings Syndrome
Definition: Excessive adrenocortical

activity
Etiology
Excessive corticosteroid administration*
Excessive ACTH
Hyperplasia of adrenal cortex

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Cushings Syndrome
Clinical manifestations
Central-type obesity
Buffalo hump: fatty tissue in neck and supraclavicular
areas
Thin extremities
Skin: fragile, ecchymoses, striae,
Weakness
Osteoporosis, compression fractures
Retention of sodium & water (mineralocorticoid)
Moon face, acne, oily skin
Hyperglycemia;increased susceptibility to infection
Weight gain
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Woman with Cushings Syndrome:


Facial hair, Buffalo hump, & Moon Face

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Cushings Syndrome
Diagnostic findings
Increased serum sodium & blood sugar
Decreased K+
Decreased eosinophils, and lymphoid tissue
Dexamethasone suppression test, overnight
Give 1mg of oral dexamethasone at 11PMblood
draw at 8AM. If cortisol suppressed to <5mg/dL,
then the HPA axis is working properly

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Cushings Syndrome
Medical Management
Pituitary tumor as cause
Surgical removal of tumor by transsphenoidal
hypophysectomy: Incision made beneath upper lip to reach
pituitary gland through sphenoid sinus (Chapter 61)
Monitor fluid status: DI can occur
No coughing, blowing nose, or sneezing as may lead to CSF
leak
Assess nasal drainage for glucose, if + CSF
Halo sign on dressing: light yellow at edge of clear drainage:
CSF

Primary adrenal hypertrophy as cause: Adrenalectomy


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Cushings Syndrome
Nursing management
Assessment
Nursing Diagnoses

Risk for injury


Risk for infection
Self-care deficit
Impaired skin integrity
Disturbed body image
Disturbed thought process

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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 52-12)
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Corticosteroid Therapy
Uses- adrenal insufficiency, inflammation,

autoimmune and allergic reactions, rejection, stress


Side Effects- metabolic effects, pituitary and
adrenal suppression
Therapeutic uses- acute conditions, eyes,
dermatologic
Dosages and tapering
Table 52-4: Commonly used corticosteroid
preparations
Table 52-5: Side effects of corticosteroid therapy
and Implications for Practice.
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