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Lewis: Medical-Surgical Nursing, 9th Edition

Chapter 50

Nursing Management: Endocrine Problems

KEY POINTS

ANTERIOR PITUITARY GLAND DISORDER
Acromegaly
•  Acromegaly is a rare condition resulting from excess
secretion of growth hormone (GH).
•  In adults, bones increase in thickness and width but not
length.
•  Manifestations include enlargement of hands and feet,
thickening and enlargement of face and head bony and soft
tissue, sleep apnea, diabetes mellitus, heart failure, and
hypertension.
•  Treatment focuses on returning GH levels to normal
through surgery, radiation, and drug therapy. Prognosis is
dependent on the age at onset, when treatment is initiated,
and tumor size.
•  Nursing care for the patient following transsphenoidal
hypophysectomy includes avoidance of vigorous coughing,
sneezing, and straining at stool; elevating the head of bed to
a 30-degree angle at all times; and monitoring neurologic
status. Mild analgesia is used for headaches. Teeth-brushing
is avoided for at least 10 days.
•  If hypophysectomy is done or pituitary is damaged,
antidiuretic hormone (ADH), cortisol, and thyroid hormone
replacement are needed for life. Patient teaching is essential
with hormone therapy.
HYPOFUNCTION OF PITUITARY GLAND
Hypopituitarism
•  Hypopituitarism is rare and involves a decrease in
one or more of the tropic hormones, the pituitary hormones

nephrogenic. and normal renal function. •  Signs and symptoms vary with the type and degree of pituitary dysfunction. severe fluid volume deficit results as manifested by poor tissue turgor. followed by lifelong hormone therapy. concentrated urine in presence of normal or increased intravascular volume. dilutional hyponatremia. and primary. •  Treatment consists of surgery or radiation for tumor removal. •  Treatment is directed at the underlying cause with a goal to restore normal fluid volume and osmolality. •  There are three types of DI: central (neurogenic). With chronic SIADH. patients must learn self-management. DI may be transient or a chronic lifelong condition. daily weight reductions. which is most common. DISORDERS OF POSTERIOR PITUITARY GLAND Syndrome of Inappropriate Antidiuretic Hormone •  Syndrome of inappropriate antidiuretic hormone (SIADH) results from abnormal production or sustained secretion of ADH. Fluid restriction results in gradual. hypotension. The increased urinary output and plasma osmolality can cause severe fluid and electrolyte imbalances. Diabetes Insipidus •  Diabetes insipidus (DI) is associated with a deficiency of production or secretion of ADH or decreased renal response to ADH. Depending on cause. serum hypoosmolality. such as lung cancer. The most common cause is a hormone- secreting tumor. Manifestations are related to hyposecretion of tropic hormones to the target glands. •  SIADH is characterized by fluid retention. and symptomatic improvement. most often an adenoma. and hypovolemic shock. hypochloremia. that are sent as messengers to endocrine glands. progressive rise in serum sodium concentration and osmolality. •  DI is characterized by a dilute urine with urine output at . •  Most deficiencies with hypopituitarism are due to a pituitary tumor. •  DI is characterized by polydipsia and polyuria. If oral fluid intake cannot keep up with urinary losses.

Hyperthyroidism •  Hyperthyroidism is hyperactivity of the thyroid gland with sustained increase in synthesis and release of thyroid hormones. DISORDERS OF THYROID GLAND Goiter •  A goiter is an enlarged thyroid gland. tenderness. A goiter is present in Hashimoto’s thyroiditis. •  Thyroid-stimulating hormone (TSH) and T4 levels are measured to determine the level of thyroid function associated with the goiter. •  Subacute and acute forms of thyroiditis have an abrupt onset with fever. •  For central DI. Identification of cause as central neurogenic DI often requires a water deprivation test. •  Treatment may involve therapy with thyroid hormone to prevent further thyroid enlargement or surgery to remove large goiters. maintenance of adequate hydration. fluid and hormone therapy is the cornerstone of treatment. greater than 200 mL per hour and specific gravity of less than 1. •  Nursing care includes early detection. and enlargement of the thyroid gland. and patient teaching for long-term management.005. •  In a person with a goiter the thyroid cells are stimulated to grow (process of hyperplasia). Thyroiditis •  Thyroiditis is an inflammatory process in the thyroid gland. •  Hashimoto’s thyroiditis (chronic autoimmune thyroiditis) is the most common cause of hypothyroidism. •  Thyrotoxicosis refers to physiologic effects or clinical syndrome of hypermetabolism resulting from excess . which may result in an overactive thyroid (hyperthyroidism) or an underactive gland (hypothyroidism). •  Diagnostic test results and treatment depend on the type of thyroiditis.

Thyrotoxic Crisis •  Thyrotoxic crisis. is an acute. •  The clinical manifestations of hyperthyroidism are related to the effect of excess thyroid hormone. •  The two primary laboratory findings used to confirm the diagnosis of hyperthyroidism are decreased TSH levels and elevated free thyroxine (free T4) levels. abdominal pain. •  Most cases of hyperthyroidism are the result of Graves’ disease. •  Treatment focuses on reducing circulating thyroid hormone levels by drug therapy. T3. and subtotal thyroidectomy. a goiter may be noted. delirium. shock. •  The primary treatment options are antithyroid medications. or thyroid storm. •  Manifestations include severe tachycardia. rare condition in which all hyperthyroid manifestations are heightened. death is rare when treatment is vigorous and initiated early. •  The overall goals are that the patient with hyperthyroidism will experience relief of symptoms. have no serious complications related to the disease or treatment. and coma. •  It may be primary (related to destruction of thyroid tissue or defective hormone synthesis) or secondary (related to pituitary disease with decreased TSH secretion or . Hypothyroidism •  Hypothyroidism is a deficiency of thyroid hormone that causes a general slowing of the metabolic rate. circulating levels of T4. maintain nutritional balance. hyperthermia. diarrhea. When the thyroid gland is large. seizures. Excess circulating hormone directly increases metabolism and increases tissue sensitivity to stimulation by the sympathetic nervous system. radioactive iodine therapy. or both. and cooperate with the therapeutic plan. A classic finding is exophthalmos. and auscultation of thyroid gland may reveal bruits. Although it can be a life-threatening emergency. protrusion of eyeballs from the orbits.

tranquilizers. hypothalamic dysfunction with decreased thyrotropin- releasing hormone secretion). •  A myxedema coma can be precipitated by infection.. an accumulation of hydrophilic mucopolysaccharides in dermis and other tissues. and barbiturates). •  Hypothyroidism has systemic effects characterized by a slowing of body processes. drugs (especially opioids. puffiness. hypotension. Thyroid Nodules and Cancer •  A palpable deformity of the thyroid gland may be benign or malignant. •  Thyroid cancer is the most common endocrine-related cancer. and masklike affect). vital functions are supported and IV thyroid hormone therapy is administered. This mucinous edema causes characteristic facies of hypothyroidism (i. •  Patients with severe long-standing hypothyroidism may display myxedema. •  A major sign of thyroid cancer is the presence of a hard. lethargy. . and discontinuance of thyroid hormone therapy. Manifestations include fatigue. •  Overall treatment in hypothyroidism is restoration of euthyroid state as safely and rapidly as possible with hormone replacement therapy. •  Patient teaching is imperative and need for lifelong hormone therapy is stressed. related Hashimoto’s thyroiditis and Graves’ disease. and trauma. anemia. When iodine intake is adequate. common causes include thyroid gland atrophy. and hypoventilation. and constipation. To survive. Myxedema coma is characterized by subnormal temperature. painless nodule or nodules on enlarged thyroid gland. decreased cardiac output. Levothyroxine (Synthroid) is the drug of choice. •  Benign nodules are usually not dangerous but can cause tracheal compression if they become too large. personality and mental changes. exposure to cold. periorbital edema. •  Iodine deficiency is the most common cause worldwide.e.

Drug therapy with agents that lower calcium levels. . loss of appetite. Hypoparathyroidism •  Hypoparathyroidism results from inadequate circulating PTH resulting in hypocalcemia. •  Nursing care for thyroid cancer is similar to care for patients who undergo thyroidectomy. a high fluid intake. •  A thyroidectomy is usually recommended for thyroid cancer. oral phosphates. diuretics. medications to block excess hormones. and kidney stones. and shortened attention span. •  The most effective treatment is a parathyroidectomy. constipation. mainly characterized by hyperparathyroidism. such as bisphosphonates. •  Clinical manifestations include muscle weakness. DISORDERS OF PARATHYROID GLANDS Hyperparathyroidism •  Hyperparathyroidism involves increased secretion of parathyroid hormone (PTH) that leads to hypercalcemia and hypophosphatemia. Those with type 2 may also develop pheochromocytoma. •  The two major types include type 1. may be helpful. •  The most common cause is iatrogenic from accidental removal of parathyroid glands or damage to these glands during neck surgery (usually thyroidectomy). •  Nonsurgical treatment involves the avoidance of immobility. and calcimimetics. emotional disorders. •  Treatment includes conservative management approach (watchful waiting). Surgical procedures may range from unilateral total lobectomy to near-total thyroidectomy with bilateral lobectomy. Multiple Endocrine Neoplasia •  Multiple endocrine neoplasia is an inherited condition characterized by presence of hormone-secreting tumors. fractures. and surgery. Major signs include osteoporosis. and moderate calcium intake. and type 2 with manifestations of medullary thyroid carcinoma. Radioactive iodine therapy and external beam radiation may be given after surgery. estrogen.

risk of injury. •  Treatment is dependent on the underlying cause and includes surgery and drug therapy to normalize hormone levels.g. nutrition. •  Key manifestations include central or generalized obesity. or Addison’s disease. and increased muscle tension with paresthesias and stiffness. •  The most common cause is the administration of exogenous corticosteroids (e. which is tingling of lips. and impaired skin integrity. purplish-red striae below the skin surface.. Adrenocortical Insufficiency •  Primary hypofunction of the adrenal cortex. •  Lifetime hormone therapy is required by patients who undergo adrenalectomy or hypophysectomy. including drug therapy. •  The patient requires instruction about lifelong treatment. Emergency treatment of tetany requires IV calcium. prednisone). •  Sudden decreases in serum calcium cause tetany. and monitoring of calcium levels. hirsutism in women. Care instructions are based on patient’s inability to react physiologically to a stressor. and prevent long-term complications. . DISORDERS OF ADRENAL CORTEX Cushing Syndrome •  Cushing syndrome is a clinical condition that results from chronic exposure to excess corticosteroids. maintain normal serum calcium levels. Most cases of endogenous Cushing syndrome are due to an adrenocorticotropic hormone (ACTH) secreting pituitary tumor (pituitary adenoma or adrenal tumor). •  Focus is to treat tetany. disturbed self-esteem. fingertips. “moon facies” (fullness of face). particularly glucocorticoids. hypertension. and unexplained hypokalemia. results in a reduction of all three classes of adrenal corticosteroids (glucocorticoids. •  Nursing care revolves around the risk of infection. imbalanced nutrition. A positive Chvostek’s sign and Trousseau’s sign are usually present.

g.. •  It is triggered by stress (e. •  Treatment is hormone therapy. and anorexia. frequent nursing assessment is necessary. surgery. psychologic distress). sudden withdrawal of corticosteroid hormone therapy. •  The serious nature of the disease and the need for lifelong hormone therapy necessitate a carefully presented teaching plan. protection against infection. trauma. •  Manifestations have a slow onset and include weakness. •  Mineralocorticoid replacement with fludrocortisone acetate (Florinef) is given daily with increased dietary salt. corticosteroid administration. glucocorticoid dosage is increased to prevent Addisonian crisis. and androgens). and techniques for stress management. NURSING MANAGEMENT: ADDISON’S DISEASE •  When the patient with Addison’s disease is hospitalized. and postadrenal surgery. a life-threatening emergency caused by a sudden decrease in adrenocortical hormones. Focus your care on helping the patient maintain hormone balance while managing the medication regimen. recognizing the need for extra medication. mineralocorticoids. •  It is critical that the patient wear an identification bracelet and carry an emergency kit at all times. During times of stress. and in palmar creases. and assistance with daily hygiene. It is important to include daily weights. . Addisonian Crisis •  Patients with Addison’s disease are at risk for acute adrenal insufficiency. at pressure points. the most commonly used form of hormone therapy. where the adrenal cortex is destroyed by autoantibodies. Due to increased ACTH. skin hyperpigmentation is seen in exposed and unexposed areas of the body. Hydrocortisone. over joints. •  The most common cause in the United States is autoimmune. Secondary disease results from pituitary dysfunction. has both glucocorticoid and mineralocorticoid properties. weight loss.

Calcium . dehydration. and conditions in which short-term therapy is likely to produce remission or recovery. and oral corticosteroids should be tapered. hyperkalemia. •  Corticosteroids taken longer than 1 week will suppress adrenal production. •  The preferred treatment is surgical removal of adenoma (adrenalectomy). tachycardia. •  Patients with bilateral adrenal hyperplasia are treated with drugs including potassium–sparing diuretics. gastric ulceration. •  The danger of abrupt cessation of corticosteroid therapy must be emphasized to patients and significant others. and confusion. •  Therapy is reserved for diseases in which there is a risk of death or permanent loss of function. Large volumes of 0. osteoporosis. and alteration in fluid and electrolytes balance. HYPERALDOSTERONISM •  Hyperaldosteronism is characterized by excessive aldosterone secretion commonly caused by small solitary adrenocortical adenoma. Complications Associated with Corticosteroid Therapy •  The use of long-term corticosteroids in therapeutic doses often leads to serious complications and side effects such as risk of infection. resulting in hypertension with hypokalemic alkalosis. •  The main effects are sodium retention and potassium and hydrogen ion excretion. hypoglycemia. •  Manifestations include postural hypotension. fever. weakness. •  Ensure that increased doses of corticosteroids are prescribed in acute care or home care situations with increased physical or emotional stress. hyponatremia.9% saline solution and 5% dextrose are given to reverse hypotension and electrolyte imbalances until blood pressure (BP) normalizes. •  Treatment is shock management and high-dose hydrocortisone replacement. Potential treatment benefits must always be weighed against risks.

radiologic contrast media. and (3) unexplained abdominal or chest pain. resulting in severe hypertension. cardiomyopathy. and death. . (2) tachycardia with palpitations and profuse sweating. •  Attacks may be provoked by many medications. pounding headache. pheochromocytoma may lead to diabetes mellitus. and tricyclic antidepressants. including antihypertensives. channel blockers may be used to control BP. opioids. PHEOCHROMOCYTOMA •  A pheochromocytoma is a rare condition characterized by an adrenal medulla tumor that produces excessive catecholamines (epinephrine. norepinephrine). •  Patients are taught to monitor their own BP along with the importance of monitoring. •  Treatment consists of surgical removal of tumor. •  Manifestations include severe. •  If undiagnosed and untreated. episodic hypertension accompanied by classic triad of (1) severe.