Endocrine Disorders
Endocrine Disorders
Endocrine Disorders
Chapter 52
Assessment and Management of Patients
with Endocrine Disorders
Endocrine System
Affects most cell, organ, and body functions
Closely linked with neurologic and immune systems
Negative feedback mechanism
Classification of hormones,
Amines and amino acids (e.g., epinephrine, nor-epinephrine,
nor and thyroid hormones)
Peptide (protein): act on cell surface (e.g., e.g., follicle-stimulating
follicle hormone [FSH])
Steroid: act inside the cell (e.g., corticosteroids)
Fatty acid derivative
Major Hormone-Secreting
Secreting Glands
Acromegaly
Excess GH, enlargement of peripheral body parts without height. In children is
Gigantism. can be caused by eosinophilic tumors.
Symp:: large hands, feet in adults, but in all organs if in the child.
Dwarfism
caused by low GH. limited growth.
Pituitary Tumors
95% are benign.
Early in life result in Gigantism (
) .
The affected person are large in all proportions, weak (hardly stand). (in
( height).
During adult life, the excessive skeletal growth occurs only in the feet, the
hands, called Acromegaly (
) . (no height ).
Many suffer from severe headaches and visual disturbances because of
pressure on the optic nerves.
May give rise to Cushing syndrome (ACTH,
( hyperadrenalism) leading to
Masculinization and Amenorrhea ( ) in females.
Diabetes Insipidus
A disorder of the posterior lobe of the pituitary gland that is
characterized by A deficiency of ADH (vasopressin), excessive thirst
(polydipsia)) & large volumes of dilute urine.
May occur secondary to head trauma, brain tumor, or surgical ablation
or irradiation of the pituitary gland, failure of the renal tubule to
respond to ADH
Management: ADH replacement (Vasopressin), Fluid replacement,
identify and correct underlying intracranial pathology.
Monitor patient for electrolytes imbalances.
Patients with diabetes insipidus produce an enormous daily output of very dilute urine with a
specific gravity of 1.001 to 1.005.
Thyroid
Thyroid hormones: T3, T4, calcitonin
Iodine is contained in thyroid hormone (T3,
(T T4)
TSH from the anterior pituitary controls the release of thyroid hormone
Controls cellular metabolic activity
T3 is more potent and rapid-acting
acting than T4
Thyroid hormones affect every major organ and tissue function, including
the basal metabolic rate, tissue thermogenesis,
thermogenesis serum cholesterol levels,
and vascular resistance.
Calcitonin is secreted in response to high plasma calcium level and increases
calcium deposit in bone
Dr. Ahmad Aqel 13
The University of Jordan Faculty of Nursing
Thyroid Gland
HypothalamicPituitaryThyroid
Thyroid Axis
Thyroid Disorders
Cretinism:
- stunted physical and mental growth due to untreated congenital deficiency of thyroid
hormones due to maternal hypothyroidism
Hypothyroidism
Hyperthyroidism
Thyroiditis
Goiter : non cancer enlargement of thyroid gland.
Thyroid cancer
Hypothyroidism
Hashimotos disease (autoimmune thyroiditis) (most common cause):
Hypothyroidism
Affects women 5X X more frequently than men
Early symptoms may be nonspecific. May include ( ( HR, Temp, Menstrual
disturbances, feels cold, fatigue)
Severe hypothyroidism is associated with an elevated serum cholesterol
level, atherosclerosis, coronary artery disease, and poor left ventricular
function.
Complications: myxedema (severe deficincy)
deficincy , may progress to stupor, coma, and
death. Myxedema refers to the accumulation of mucopolysaccharides in
subcutaneous and other interstitial tissues ( ( thick skin) .
Myxedema coma:
occurs most often among older women in the winter months and appears to be
precipitated by cold.
In myxedema coma, , the patients respiratory drive is depressed, resulting in
alveolar hypoventilation, progressive carbon dioxide retention, narcosis, and
coma.
In addition patients with myxedema coma can also exhibit hyponatremia,
hypoglycemia, hypoventilation, hypotension, bradycardia, and hypothermia.
Mortality rate is high at 30% to 40%.
Refer to Plan of Nursing Care, Chart 52-4
4 (Very important).
The major use of iodine in the body is by the thyroid.
Iodized table salt is a source of iodine.
Hyperthyroidism
Second most prevalent endocrine disorder
Affects women 8x than men
Graves disease
autoimmune disorder result from excessive thyroid hormones caused by abnormal stimulation of
the thyroid gland by circulating immunoglobulin
most common cause
Thyrotoxicosis:
excessive output of thyroid hormone (thyroid storm)
Clinical Manifestations
Nervousness; rapid pulse; heat intolerance;
intolerance tremors; skin flushed, warm, soft, and
moist; exophthalmos; increased appetite (encourage small frequent meal, high in
protein); weight loss;; elevated systolic BP; cardiac dysrhythmias
Dr. Ahmad Aqel 23
The University of Jordan Faculty of Nursing
Exophthalmos
Hyperthyroidism
Assessment and Diagnostic Findings
Thyroid gland is enlarged; it is soft and may pulsate; a thrill may be
felt and a bruit heard over thyroid arteries.
Laboratory tests show a decrease in serum TSH, increased free T4,
and an increase in radioactive iodine uptake.
Hyperthyroidism
Assessment
Obtain a health history, including family history of hyperthyroidism, and
note reports of irritability or increased emotional reaction and the impact
of these changes on patients interaction with family, friends, and
coworkers.
Assess stressors and patients ability to cope with stress.
Evaluate nutritional status and presence of symptoms; note excessive
nervousness and changes in vision and appearance of eyes.
Assess and monitor cardiac status periodically (heart rate, blood pressure,
heart sounds, and peripheral pulses).
Assess emotional state and psychological status.
Hyperthyroidism
Nursing Diagnoses
Imbalanced nutrition: Less than body requirements related to exaggerated metabolic
rate, excessive appetite, and increased gastrointestinal activity
Ineffective coping related to irritability, hyperexcitability,
hyperexcitability apprehension, and emotional
instability
Low self-esteem related to changes in appearance, excessive appetite, and weight loss
Altered body temperature Goals
improved nutritional status,
Potential Complications improved coping ability,
improved self-esteem,
Thyrotoxicosis or thyroid storm Maintenance of normal body temperature, and
Hypothyroidism absence of complications.
Hyperthyroidism
Nursing Interventions
Improving Nutritional Status
Provide several small, well-balanced
balanced meals (up to six meals a day) to
satisfy patients increased appetite.
Replace food and fluids lost through diarrhea and diaphoresis, and
control diarrhea that results from increased peristalsis.
Reduce diarrhea by avoiding stimulants such as coffee, tea, cola, and
alcohol; encourage high-calorie,
calorie, high-protein
high foods.
Provide quiet atmosphere during mealtime to aid digestion.
Record weight and dietary intake daily.
Dr. Ahmad Aqel 30
The University of Jordan Faculty of Nursing
Question
Which medication blocks synthesis
of thyroid hormone?
A. Dexamethasone
B. Methimazole
C. Potassium iodide
D. Sodium iodide
Methimazole blocks synthesis of thyroid hormone.
Dexamethasone, potassium iodide, and sodium
iodide suppress release of thyroid hormone.
Thyroid Tumors
Might be benign or malignant.
If the enlargement is sufficient to cause a visible swelling in the neck, the
tumor is referred to as a goiter.
If goiter is associated with hyperthyroidism it is described as toxic. If it is not,
it is described as non-toxic.
Causes: Iodine deficiency, Graves' disease, Hashimoto's disease, ... etc
The introduction of iodized salt has been the single most effective means of
preventing goiter in at-risk
risk populations.
Thyroidectomy
Treatment of choice for thyroid cancer
Modified or radical neck dissection, possible radioactive iodine to minimize
metastasis
Preoperative goals: reduction of stress and anxiety to avoid precipitation of
thyroid storm
Preoperative education: dietary guidance to meet patient metabolic needs,
avoidance of caffeinated beverages and other stimulants, explanation of
tests and procedures, and head and neck support used after surgery
Postoperative Care
Monitor respirations; potential airway impairment
Monitor for potential bleeding and hematoma formation; check posterior
dressing
Assess pain and provide pain relief measures
Semi-Fowlers position,, with the head elevated and supported by pillows.
Assess voice, discourage talking
Potential hypocalcaemia related to injury or removal of parathyroid glands;
refer to Chart 52-6
Parathyroid Glands
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
Hyperparathyroidism (Overproduction
Overproduction of Parathormone)
Primary hyperparathyroidism: Management:
Management
Two to four times more frequent in Parathyroidectomy,
women than men
Hydration therapy (2L daily) [help
Secondary hyperparathyroidism prevent renal calculi],
Occurs in patients with chronic kidney Encourage mobility as tolerated (Bones
failure as a result of phosphorus
retention, increased stimulation of the subjected to the normal stress of walking
parathyroid gland give up less calcium).
Clinical manifestations: Encourage fluid, restrict calcium
Elevated serum calcium, bone decalcification,
renal calculi, apathy, fatigue, muscle Hypercalcemic crisis (> 13 mg/dl); results in
weakness, nausea, vomiting, constipation, neurologic, cardiovascular, and kidney
hypertension, cardiac dysrhythmias,
psychological manifestations symptoms that can be life threatening.
threatening
Hypoparathyroidism
Parathormone deficiency caused by surgery
surgery thyroidectomy,
parathyroidectomy,, or radical neck dissection
Results in hypocalcaemia and hyperphosphatemia.
hyperphosphatemia
Tetany,, numbness, tingling in extremities, stiffness of hands and feet,
bronchospasm, laryngeal spasm, carpopedal spasm, anxiety, irritability,
depression, delirium, ECG changes
Positive Chvosteks and Trousseaus signs
Care of postoperative patients having a parathyroidectomy is directed toward detecting early signs of
hypoparathyroidism and subsequent hypocalcemia and anticipating signs of tetany, seizures, and
respiratory difficulties
Question
Is the following statement true or false?
A patient in acute hypercalcemic crisis requires close monitoring for
life-threatening
threatening complications and prompt treatment to reduce serum
calcium levels. (True)
Adrenal Glands
Adrenal medulla
Functions as part of the autonomic
nervous system
Catecholamines: (epinephrine and
norepinephrine)
Adrenal cortex
Glucocorticoids (cortisol)
Mineralocorticoids (aldosterone)
Androgens (male sex hormones)
Clinical Manifestations
Muscle weakness, anorexia,, GI symptoms, fatigue, dark pigmentation
of the skin and mucous membranes, hypotension, low blood glucose,
low serum sodium, and high serum potassium.
The onset usually occurs with nonspecific symptoms. Mental changes
(depression, emotional lability,, apathy, and confusion) are present in
60% to 80% of patients.
In severe cases, disturbance of sodium and potassium metabolism
may be marked by depletion of sodium and water and severe, chronic
dehydration.
Addisonian Crisis
This medical emergency develops as the disease progresses.
Signs and symptoms include the following:
Cyanosis and classic signs of circulatory shock: pallor, apprehension,
rapid and weak pulse, rapid respirations, and low blood pressure.
Headache,, nausea, abdominal pain, diarrhea, confusion, and
restlessness.
Slight overexertion, exposure to cold, acute infections, or a decrease
in salt intake may lead to circulatory collapse, shock, and death.
Stress of surgery or dehydration from preparation for diagnostic tests
or surgery may precipitate addisonian or hypotensive crisis.
Medical Management
Immediate treatment is directed toward combating circulatory shock:
Restore blood circulation, administer fluids and corticosteroids, monitor
vital signs, and place patient in a recumbent position with legs elevated.
Administer IV hydrocortisone, followed by 5% dextrose in normal saline.
Vasopressor may be required if hypotension persists.
Antibiotics may be administered if infection has precipitated adrenal crisis.
Oral intake may be initiated as soon as tolerated.
If adrenal gland does not regain function, lifelong replacement of
corticosteroids and mineralocorticoids is required.
Dietary intake should be supplemented with salt during times of GI losses
of fluids through vomiting and diarrhea.
Nursing Management
Assessment focuses on fluid imbalance and stress.
Monitor BP and pulse to assess for inadequate fluid volume.
Assess skin color and turgor.
Assess Hx of weight changes, muscle weakness, and fatigue.
onset of illness or increased stress that may have precipitated crisis.
Cushing Syndrome
(Excessive
Excessive adrenocortical activity or corticosteroid medications)
Remember the mnemonic: STRESSED (remember there is too
much of the STRESS hormone CORTISOL)
Skin fragile, Weakness, Lassitude (lack of energy), acne
Trunk obesity & thin extremities, Osteoporosis, muscle wasting
Round face (moon-face)
Ecchymosis, elevated BP (hypertension)
Striae on extremities and abdomen,
Sugar (hyperglycemia), susceptible to infection; slow healing
Excessive body hair especially in womenand Hirsutism (women
starting to have male characteristics), loss of libido, Electrolytes
imbalance: hypokalemia, hypernatremia
Dorsocervical fat pad (Buffalo hump), Depression, disturbance in
sleep, mood changes
Cushing Syndrome
Diagnosis:
serum cortisol, urinary cortisol,
Dexamethasone suppression test.
Dexamethasone (1 mg or 8mg) mg) is administered orally at 11 pm, and a plasma
cortisol level is obtained at 8 AM the next morning , less than 5mg indicate
hypothalamic-pituitary adrenal
adrenal axis is functioning properly
Cushing Syndrome
Management:
Surgical removal of the tumor
Radiation
Adrenalectomy
Postoperative symptoms of adrenal insufficiency may appear.
Temporary replacement therapy with hydrocortisone may be
necessary for several months
Corticosteroid Therapy
Suppress inflammation and autoimmune response, control allergic
reactions, and reduce transplant rejection
Medications: refer to Table 52-4
Patient education: refer to Table 52-5
5
Timing of doses (at 8 am, when the adrenal gland is most active. This is the physiological time of
corticosteriods).
Need to take as prescribed, tapering required to discontinue or reduce therapy (to
allow normal adrenal function to return and to prevent steroid-induced
steroid adrenal insufficiency).
Potential side effects and measures to reduce side effects (Table 52-5)
Question
Is the following statement true or false?
Answer
False