Assessment and

Management of
Patients With
Endocrine
Disorders
 release of chemical transmitter substances known
as hormones
Effects almost every cell, organ, and function of the
Anatomic body
The endocrine system is closely linked with the
and nervous system and the immune system

Physiologic Negative feedback mechanism

Overview Chemical messengers of the body

Act on specific target cells

Classification of Hormones

• amines and amino acids

• (e.g., epinephrine, norepinephrine, and thyroid hormones);
• peptides, polypeptides, proteins, and glycoproteins
• (e.g., thyrotropin-releasing hormone [TRH], follicle-stimulating hormone [FSH], and growth
hormone [GH]);
• Steroids
• (e.g., corticosteroids, which are hormones produced by the adrenal cortex or their synthetic
equivalents); and
• fatty acid derivatives
• (e.g., eicosanoid, retinoids)
 • Assessment of changes in:
Health • energy level,
History • tolerance to heat or
cold,
• weight, thirst,
• frequency of urination,
• fat and fluid
distribution, secondary
sexual characteristics
such as loss or growth of
hair,
• menstrual cycle,
• memory,
• concentration,
• sleep patterns,
• mood, as well as
• vision changes,
• joint pain, sexual
dysfunction.
Health History

• the severity of these changes,

• the length of time the patient has experienced these changes,
• the way in which these changes have affected the patient’s ability to carry out activities
of daily living,
• the effect of the changes on the patient’s self-perception, and
• family history.
Physical Assessment
• Vital signs
• Head to toe inspection
• Palpation of the skin, hair and thyroid
• Physical, psychological, and behavioral changes should be noted such as:
• Hirsutism • edema,
• Moon face • thinning of the skin
• Buffalo humps • Truncal obesity
• Exophthalmos • Obesity
• vision changes, • Changes in mood and behavior
 Blood tests

Urine tests

Diagnostic
Additional Diagnostic Studies
Evaluation
• Stimulation test
• Suppression tests
• Imaging studies
• Genetic screening
Hypothalamus

• Sits between the cerebrum and

brainstem
• Houses the pituitary gland and
hypothalamus
• Regulates:
• Temperature
• Fluid volume
• Growth
• Pain and pleasure response
• Hunger and thirst
Hypothalamus Hormones

• Releasing and inhibiting hormones

• Corticotropin-releasing hormone
• Thyrotropin-releasing hormone
• Growth hormone-releasing
hormone
• Gonadotropin-releasing hormone
• Somatostatin-=-inhibits GH and
TSH
Pituitary (hypophysis) Gland

• Sits beneath the hypothalamus

• Termed the “master gland”
• Divided into:
• Anterior Pituitary Gland
• Growth hormone
• adrenocorticotropic hormone
• thyroid-stimulating hormone
• Follicle stimulating hormone and luteinizing hormone
• prolactin
• Posterior Pituitary Gland
• Vasopressin or anti diuretic hormones
• Oxytocin
 Anterior pituitary glands
Disorders in
Pituitary • Cushing syndrome
• Acromegaly
glands • Dwarfism
Posterior Pituitary Glands
• Diabetes insipidus
• SIADH
Diabetes Insipidus

• A disorder of the posterior lobe of the pituitary gland that is characterized

by a deficiency of ADH (vasopressin).
• Excessive thirst (polydipsia) and large volumes of dilute urine.
• It may occur secondary to head trauma, brain tumor, or surgical ablation or
irradiation of the pituitary gland, infections of the central nervous system
or with tumors
• Another cause of diabetes insipidus is failure of the renal tubules to
respond to ADH
Clinical Manifestations

• Polyuria (>250 mL per hour)

• very dilute urine (specific gravity of 1.001 to 1.005)
• Presence of albumin and glucose in the urine
• polydipsia
Assessment and Diagnostic Findings
• fluid deprivation test
• withholding fluids for 8 to 12 hours or until 3% to 5% of the body weight is
lost
• Plasma and urine osmolality studies are performed at the beginning and end
of the test
• inability to increase the specific gravity and osmolality
Medical Management
• to replace ADH (which is usually a long term therapeutic program),
• to ensure adequate fluid replacement, and
• to identify and correct the underlying intracranial pathology.

• Pharmacologic Therapy
• Desmopressin
• Chlorpropamide
• thiazide diuretics
Nursing Management

Physical assessment patient education

Syndrome of Inappropriate Antidiuretic
Hormone Secretion (SIADH)
• excessive ADH secretion from the pituitary gland

• cannot excrete a dilute urine, retain fluids, and develop a sodium

deficiency known as dilutional hyponatremia

• Nonendocrine in origin
• Possible causes:
• Bronchogenic carcinoma
• Lung disorders
• CNS disorders
Medical Management Nursing Management
eliminating the underlying cause I and O monitoring
restricting fluid intake if possible Daily weight monitoring
Diuretics Check for neurologic status
Thyroid Gland
• Butterfly shaped
• Sits on either side of the trachea
• Has two lobes connected with an isthmus
• Functions in the presence of iodine
• Stimulates the secretion of three
hormones
• thyroxine (T4), triiodothyronine (T3), and
calcitonin
• Involved with metabolic rate management
and serum calcium levels
 • Thyroid hormone is comprised of T4 and T3,
• Both are amino acids that contain iodine
molecules
• Iodine is essential to the thyroid gland for
Thyroid synthesis of its hormones
• Secretion of T3 and T4 is controlled by TSH
Hormones (thyrotropin)
• main function is to control cellular metabolic
activity
• Calcitonin – storing calcium from blood into
the bones
Diagnostic evaluation
• Serum Thyroid-Stimulating Hormone
• Serum T3 and T4
• T3 -80 to 200 ng/dL (1.2 to 3.1 nmol/L)
• T4 - 5.4 to 11.5 µg/dL (57 to 148 nmol/L)
• T3 Resin Uptake Test
• Radioactive Iodine Uptake
• Fine-Needle Aspiration Biopsy
• Thyroid Scan, Radioscan, or Scintiscan
• Serum Thyroglobulin
Hypothyroidism
• hypothyroidism is the disease state caused by insufficient production of
thyroid hormone by the thyroid gland.
• INCEDENCE
• 30-60 yrs of age
• Mostly women (5 times more than men)
• Causes
• Autoimmune disease (Hashimoto's thyroiditis, post–Graves' disease)
• Atrophy of thyroid gland with aging
• Therapy for hyperthyroidism
• Radioactive iodine (131I)
• Thyroidectomy
• Medications
• Radiation to head and neck
• Infiltrative diseases of the thyroid
 Clinical Manifestations
1. Fatigue. 10. Menstrual disturbances
2. Constipation. 11. Numbness and tingling of fingers.
3. Apathy 12. Tongue, hands, and feet may
4. Weight gain. enlarge
5. Memory and mental impairment 13. Slurred speech
and decreased concentration. 14. Hyperlipidemia.
6. masklike face. 15. Reflex delay.
7. Menstrual irregularities and loss 16. Bradycardia.
of libido. 17. Hypothermia.
8. Coarseness or loss of hair. 18. Cardiac and respiratory
9. Dry skin and cold intolerance. complications .
• Laboratory Test
• T3 T4 TSH

• Treatment
• LIFELONG THYROID HORMONE REPLACEMENT
• levothyroxine sodium (Synthroid, T4, Eltroxin)
• IMPORTANT: start at low does, to avoid hypertension, heart failure and MI Teach about
S&S of hyperthyroidism with replacement therapy
• Administration of high-dose glucocorticoids
MXYEDEMA
• are serious complication of untreated hypothyroidism
• Decreased metabolism causes the heart muscle to become flabby
• Leads to decreased cardiac output
• Leads to decreased perfusion to brain and other vital organs
• Leads to tissue and organ failure
• LIFE THREATENING EMERGENCY WITH HIGH MORTALITY RATE
• Edema changes client’s appearance
• Nonpitting edema appears everywhere especially around the eyes, hands, feet,
between shoulder blades
• Tongue thickens, edema forms in larynx, voice husky
Treatment of Myxedema
• Patent airway Replace fluids with IV.
• Give levothyroxine sodium IV
• Give glucose IV
• Give corticosteroids
• Check temp,
• BP hourly
• Monitor changes LOC hourly
• Aspiration precautions,
• keep warm
 • Hyperthyroidism is the second most
prevalent endocrine disorder, after diabetes
mellitus.
• Graves' disease: the most common type of
hyperthyroidism, results from an excessive
output of thyroid hormones.
Hyperthyroidism • May appear after an emotional shock, stress,
or an infection
• Other causes: thyroiditis and excessive
ingestion of thyroid hormone
• Affects women 8X more frequently than men
(appears between second and fourth
decade)
• Clinical Manifestations (thyrotoxicosis):
• 1.Heat intolerance.
• 2. Palpitations, tachycardia, elevated systolic BP.
• 3. Increased appetite but with weight loss.
• 4. Menstrual irregularities and decreased libido.
• 5. Increased serum T4, T3.
• 6. Exophthalmos (bulging eyes)
• 7. Perspiration, skin moist and flushed ; however, elders’ skin may be dry and pruritic
• 8. Insomnia.
• 9. Fatigue and muscle weakness
• 10. Nervousness, irritability, can’t sit quietly.
• 11. Diarrhea.
Medical Management
• Radioactive 131I therapy
• Medications
• 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
Thyroid Storm (Thyrotoxic Crisis)
• form of severe hyperthyroidism, usually of abrupt onset.
• it is almost always fatal, but with proper treatment the mortality rate
is reduced substantially
• requires astute observation and aggressive and supportive nursing
• usually precipitated by stress, such as injury, infection, thyroid and
nonthyroid surgery, tooth extraction, insulin reaction, diabetic
ketoacidosis, pregnancy, digitalis intoxication, abrupt withdrawal of
antithyroid medications, extreme emotional stress, or vigorous
palpation of the thyroid
Clinical
Manifestations
 • A hypothermia mattress or blanket
• ice packs
• a cool environment
• hydrocortisone, and acetaminophen
(Tylenol)
Management • Oxygen therapy
• Dextrose IV
• Propylthiouracil (PTU) or methimazole
• Hydrocortisone
• Iodine
Thyroiditis
• Inflammation of the thyroid gland.
• Can be acute, subacute, or chronic (Hashimoto's Disease)
• Each type of thyroiditis is characterized by inflammation, fibrosis, or
lymphocytic infiltration of the thyroid gland.
• Characterized by autoimmune damage to the thyroid.
• May cause thyrotoxicosis, hypothyroidism, or both
Parathyroid Glands
• Embedded within the posterior lobes
of the thyroid gland
• Secretion of one hormone
• Maintenance of serum calcium levels
• (Parathormone) Parathyroid hormone—
regulates serum calcium
Hyperparathyroidism
• caused by overproduction of parathormone
• characterized by:
• bone decalcification
• development of renal calculi (kidney stones) containing calcium.
• 2 to 4X more frequent in women
• 60 and 70 years of age
• Diagnostic Tests:
• Serum calcium
• double-antibody parathyroid hormone tes
Manifestations
• elevated serum calcium, • nausea,
• bone decalcification, • vomiting,
• renal calculi, • constipation,
• apathy, • hypertension,
• fatigue, • cardiac dysrhythmias,
• muscle weakness, • psychological manifestations
Treatment

Parathyroidectomy

Hydration therapy

Encourage mobility reduce calcium excretion

Diet: encourage fluid, avoid excess or restricted calcium

Hypoparathyroidism
• Deficiency of parathormone usually due to surgery
• Results in hypocalcaemia and hyperphosphatemia
• Manifestations include
• tetany, • anxiety,
• numbness and tingling in extremities, • Irritability,
• stiffness of hands and feet, • depression,
• bronchospasm, • delirium,
• laryngeal spasm, • ECG changes
• carpopedal spasm, • Trousseau’s sign and Chvostek’s sign
Management
• 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
• Aluminum hydroxide is administered after meals to bind with phosphate
and promote its excretion through the gastrointestinal tract.
Adrenal glands
• Pyramid-shaped organs that sit on top of the
kidneys
• Each has two parts:
• Adrenal Cortex (outer)
• Mineralocorticoid—aldosterone
• Affects sodium absorption, loss of potassium by kidney
• Glucocorticoids—cortisol
• Affects metabolism, regulates blood sugar levels, affects growth,
anti-inflammatory action, decreases effects of stress
• Adrenal androgens—testosterone
• Adrenal Medulla (inner)
• Epinephrine
• Norepinephrine
Disorders in the Adrenal Glands
• Adrenal Medulla
• Pheochromocytoma
• Adrenal Cortex
• Addison’s Disease
• Cushing’s syndrome
 Uncommon tumor in the
adrenal medulla w/c is usually
benign

High Blood Pressure is the

Pheochromocytoma most common cause

Peak: 40 and 50 years old

Assessment and Diagnostic Findings
• Five “Hs”
• Headache
• Hyperhidrosis
• Hypertension
• Hypermetabolism
• Hyperglycemia
• Diagnostic findings:
• Presence of vanillylmandelic acid and metanephrine in the 24hr urine sample
Management
• Bed rest with head elevated during attacks
• Blood pressure monitoring
Pharmacologic
• alpha-adrenergic blocker (phenoxybenzamine) 10-14 days preop
• Calcium channel blocker
• Surgical
• adrenalectomy
Addison Disease
• primary adrenal insufficiency (PAI)
• occurs when the adrenal glands are damaged and cannot produce
sufficient amounts of cortical hormones
• Autoimmune or idiopathic
• Causes:
• Therapeutic use of corticosteroids – most common
• Infections (Tuberculosis and histoplasmosis – most common)
• Medications (anticoagulants, anticonvulsants, rifampicin)
Clinical Manifestations
• muscle weakness;
• anorexia;
• GI symptoms;
• fatigue;
• emaciation;
• dark pigmentation of the mucous membranes and the skin, especially of the
knuckles, knees, and elbows;
• hypotension;
• low blood glucose,
• low serum sodium, and high serum potassium levels.
• Depression
Addisonian Crisis
• Develops as the disease progress
• Manifestations:
• hypotension, cyanosis, fever, nausea, vomiting, and signs of shock

• Even slight overexertion, exposure to cold, acute infection, or a

decrease in salt intake may lead to circulatory collapse, shock, and
death, if untreated
Assessment and Diagnostic Findings
• Laboratory lab results:
• hypoglycemia
• hyponatremia
• hyperkalemia
• Leukocytosis
• Combined measurement of early morning serum cortisol and plasma
ACTH
Medical Management
• Immediate treatment of shock:
• restoring blood circulation,
• administering fluids and corticosteroids,
• monitoring vital signs, and
• placing the patient in a recumbent position with the legs elevated.
• Hydrocortisone (Solu-Cortef) is administered by IV,
• Vasopressors may be required if hypotension persists
• Antibiotics may be given if infection
Cushing Syndrome
• Due to excessive adrenocortical activity or corticosteroid medications
• Women between the ages of 20 and 40 years are five times more
likely than men to develop Cushing's syndrome.
Clinical Manifestations
• Hyperglycemia
• weight gain,
• central type obesity with “buffalo
hump,”
• heavy trunk and thin extremities,
• fragile thin skin,
• ecchymosis,
• striae,
• weakness,
• metabolic alkalosis
• lassitude, sleep disturbances,
• osteoporosis, muscle wasting,
• Diagnosis: Dexamethasone suppression test,
• hypertension
• “moon-face”,
• acne,
• increased susceptibility to infection,
• slow healing,
• virilization in women,
• loss of libido,
• mood changes,
• increased serum sodium,
• decreased serum potassium
• ↑ Na+ ↑ glucose, ↓ K+,
• metabolic alkalosis
Medical management
• If caused by pituitary tumors – transsphenoidal hypophysectomy
• If caused by adrenal tumors – adrenalectomy
• radiation of the adrenal gland
• Adrenal enzyme inhibitors
• Mitotane
• Ketoconazole
• Tapering of cortecosteroids