 ENDOCRIN

E
 SYSTEM
DIABETES MELLITUS
a. Metabolic disorder characterized by
hyperglycemia resulting from lack of insulin,
lack of insulin effect, or both.
b. Four general classifications as recognized:
1. Pre-diabetes (fasting blood glucose >
100 mg/dl and < 126 mg/dl or postprandial
blood glucose > 140mg/dl and 200 < 200
mg/dl) 6
 2. Type 1 (absolute insulin
insufficiency)
3. Type 2 (insulin resistance with
varying degrees of insulin secretory defects)
4. Gestational (develops during
pregnancy)

7
III. Causes
A. Type 1
1. Autoimmune process
triggered by viral or
environmental factors
2. Idiopathic (no evidence 8

of autoimmune process)
B. Type 2
1. Beta cell exhaustion due to lifestyle
choices or hereditary factors
2. Risk factors
a. Obesity
b. Family history
c. Pregnancy ending in birth of neonate
weighing more than 9 lb.
d. Hypertension 9

e. Age
10
IV. Pathophysiologic changes
a. Polyuria and polydipsia
b. Polyphagia
c. Weight loss
d. Headaches, fatigue, lethargy, reduced energy
level
e. Muscle cramps, irritability, and emotional
lability due to electrolyte imbalance
f. Numbness and tingling due to neural tissue
damage
g. Abdominal discomfort
h. Nausea, diarrhea, or constipation
i. Slow-healing skin infections or wounds, itching of 11
skin, and recurrent monilial infections of the vagina or
anus due to hyperglycemia
12
VI. Diagnostic test findings
a. Blood testing
fasting plasma 126 mg/dl or more on at least
two occasions
random blood glucose level of 200 mg/dl
2-hour blood glucose test 200 mg/dl or more
(2 hours after ingesting 75 g of oral dextrose
increased glycosylated hemoglobin (HbA1c),
reflecting glycemic control during the previous
2 to 3 months. 13
VII. Treatment
a. Careful monitoring of blood glucose and
HbA1c levels
b. Regular exercise
c. Type 1
1. Insulin replacement
2. Pancreas transplantation (requires
chronic immunosuppression)
d. Type 2 14

1. Oral antidiabetic drugs

 e. Gestational
1.Medical nutrition therapy
2. Injectable insulin if glucose level
isn’t achieved with diet alone
3. Postpartum counseling to address
the high risk of gestational diabetes in
subsequent pregnancies and type 2 diabetes
later in life.
15
VIII. Nursing considerations
1. Stress the importance of complying with
prescribed treatment program (diet, exercise,
blood glucose monitoring recognition and
treatment of hypoglycemia and hyperglycemia)
2. Teach the patient and his family about possible
adverse effects of medications
3. Watch for complications, especially
hypoglycemia (dizziness, weakness, pallor,
tachycardia, diaphoresis, seizures and 16

coma)
4. Stay alert for signs of ketoacidosis (acetone
breath, dehydration, weak and rapid pulse,
Kussmaul’s respirations) and Hyperosmolar
coma (polyuria, thirst, neurologic abnormalities,
stupor); these hyperglycemic crises require I.V.
fluids and regular insulin.
5. Teach the patient and his family how to recognize
hypoglycemia and ketoacidosis, how to
respond, and when to seek medical attention.
6. Monitor diabetes control by obtaining blood
glucose, HbA1c level, annd blood pressure 17

measurements regularly.
7.Watch for diabetic effects on the cardiovascular
system and the peripheral and autonomic
nervous system
a. Meticulously treat all injuries, cuts, and
blisters
b. Monitor for signs and symptoms of cellulitis
(skin reddening and edema, possible blistering
or ulceration)
c. Stay alert for signs of UTI and renal disease
8.Urge the patient to get regular ophthalmologic
examinations to detect diabetic retinopathy. 18
9.Assess the patient for signs of diabetic
neuropathy (changes in sensation or in
motor strength or agility in an extremity)
a. Stress the need for personal safety
precautions.
b. Minimize complications by maintaining
strict blood glucose control

19
20
A. Hypopituitarism
1. Definition - underactivity of the front
(anterior) pituitary gland
a. classifications of pituitary tumors
i. functioning: hormone present
in insufficient quantities
ii. non-functioning: hormone
absent
iii. if in childhood - decreased
21
growth hormone results in
dwarfism
22
2. Etiology - most common cause:
neoplasms, usually benign as a pituitary
adenoma
3. Findings - result from hormone
deficiency (hypogonadism)
a. hypogonadism, female:
i. amenorrhea
ii. infertility
iii. decreased libido
iv. breast and uterine atrophy
v. loss of axillary and pubic hair 23

vi. vaginal dryness

b. hypogonadism, male
i. decreased libido
ii. impotence
iii. small, soft testicles
iv. loss of axillary and pubic hair
c. hypothyroidism (because pituitary
regulates thyroid glands by thyroid
stimulating hormone (TSH))
24
d. hypoadrenalism (because
pituitary regulates adrenal
glands by ACTH production)
e. may see signs of increased
intracranial pressure (ICP)

25
 Management
a. expected outcome: hormone
deficiency corrected
b. hormone replacement therapy
i. corticosteroid therapy
ii. thyroid hormone replacement
iii. sex hormone replacement
c. surgical removal of tumor
26
 Diagnostics
 a. history and physical exam
 b. neuro-ophthalmological exam
 c. x-rays of pituitary fossa
 d. radioimmunoassays of anterior
pituitary hormones
 e. computerized tomogram (CT) scan

27
• Nursing interventions
a. provide for
i. care of the client with increased
ICP

CARE OF THE CLIENT WITH INCREASED

INTRACRANIAL PRESSURE

1. Monitor neuro vital signs as ordered

2. Maintain fluid restriction as ordered 28

3. Raise head of bed at 30-45 degrees

 4. Prevent any activities that increase
ICP such as straining at stool, coughing,
vomiting, any restrictive clothing around
neck, neck rotation, flexion, extension,
anxiety
 5. Observe for herniation syndrome
 6. Monitor intracranial pressure
 7. Administer oxygen as ordered
29
 8. Seizure precautions
 ii. care of the client undergoing surgery
 b. monitor for desired effects of
administered medications as ordered
 c. provide emotional support with referral
to support groups
 d. teach client
 i.medications desired effects and side
effects
 ii. need for lifelong hormone replacement30

therapy and regular checks of serum levels

31
32
B. Hyperpituitarism
1. Definition - anterior pituitary secretes too
much growth hormone and/or ACTH
2. Etiology
a. usually caused by benign
neoplasm
b. growth hormone overproduction
i. acromegaly - if growth plates
closed
ii. giantism - if growth plates open
c. ACTH overproduction leads adrenal 33
gland to overproduce cortisone: Cushing's
disease
3. Findings
a. may see signs of increased ICP
b. acromegaly: excess longitudinal bone growth,
C. increase in density and size of organs and soft
tissue
d. coarse facial features
e. prominent forehead and orbital ridge
f. large, broad, spade-like hands
g. arthritis, kyphosis
h. prominent tongue
i. change in ring or shoe size drastically over short
34

period of time
 Diagnostics
a. history and physical exam
b. computerized tomogram (CT) scan
c. plasma hormone levels: increased growth
hormone, ACTH

35
 Management
a. expected outcome: remove tumor and
restore hormonal balance
b. surgical removal of tumor
c. irradiation of gland
d. pharmacologic: growth hormone
suppressant: bromocriptine (parlodel)
e. physical changes of acromegaly are
irreversible 36
 Nursing interventions
 a. provide
 i.care of the client with increased ICP
 ii. care of the client undergoing surgery
 iii. care of the client undergoing radiation
therapy
 iv. emotional support

37
 b. assess for signs of diabetes
insipidus, since removal of a pituitary
tumor may injure the posterior pituitary
glands and decrease antidiuretic hormone
(ADH) secretions - drastic fluid loss
 c. teach client that treatment usually
produces hypopituitarism so lifelong
hormone replacement therapy with regular
check-ups are required
38
DIABETES INSIPIDUS
1. Posterior pituitary gland makes too
little antidiuretic hormone (ADH). Body loses
too much water in the urine; plasma
osmolality and sodium levels increase.
2. Etiology can include
tumor,
trauma, inflammation, or
 psychogenic causes. 39
 3. Findings
a. excessive thirst (polydipsia)
b. polyuria: as much as 20 liters
per day with specific gravity
below 1.006
c. nocturia
d. signs of dehydration
e. constipation
40
4. Diagnostics
a. water deprivation tests: inability to
concentrate urine; also
differentiates between primary DI
and nephrogenic DI
b. osmotic stimulation
c. administration of vasopressin
(pitressin) or desmopressin
acetate (stimate)
41

d. computerized tomogram (CT)

Management
A. expected outcomes: to correct
underlying cause and restore hormonal
balance
B. pharmacotherapy
A. desmopressin acetate (stimate)
B. vasopressin (pitressin) -
antidiuretic hormone
C. lypressin (diapid) 42

D. chloropropamide (chloronase)
 E. clofibrate (claripex)
F. carbamazapine (mazepine)
C. IV fluid replacement therapy
D. surgical removal of tumor

43
 Nursing interventions
 A. monitor for findings of dehydration;
measure urine; specific gravity
 B. administer medications as ordered
 C. monitor fluids and give IV fluids as
ordered
 D. measure intake and output
 E. weigh client daily
44
F. care of the client with increased ICP
G. care of the client undergoing surgery
H. teach client
A. to record intake and output
B. about medications and side
effects
C. to check urine specific gravity
D. the need to wear disease
identification jewelry 45
46
B. Syndrome of
Inappropriate Antidiuretic
Hormone (SIADH)-
oversecretion of ADH, results in excessive
water conservation

47
Etiology
1. Central nervous system disorders
2. Stimulation due to hypoxia or decreased
left atrial filling pressure
3. Pharmacologic agents
4. Overuse of vasopressin therapy
5. Ectopic ADH production asociated with
some disorders
6. Nausea or opioid use, which can stimulate
48

ADH secretion
 Signs and symptoms
1. Decreased urine output
2. Weight gain
3. Altered mental status (e.g. headache,
confusion, lethargy, seizures, and coma in
severe hyponatremia)
4. Delayed deep tendon reflexes

49
 Laboratory and diagnostic study findings
1. Plasma osmolality and serum sodium
levels are decreased.
2. Serum ADH level is elevated.

50
 Nursing care
1. Administer prescribed medications, which
may include furosemide (Lasix) to prevent
concentration of urine; isotonic urine is
exreted, achieving a change in water
balance diuretics. Drugs that render the
kidneys less sensitive to ADH may be
prescribed; demeclocycline is preferred,
but lithium may be prescribed.
2. Restrict fluid intake as indicated. 51
52
53
54
I. Hypothyroidism
1. Definition - an underactive thyroid
resulting in a lessened secretion of thyroid
hormone
a. deficiency of thyroid hormones
causing decreased metabolic rate
i. affects more women
ii. age group: 30 to 50 years of 55

age
 b. classifications
i. cretinism: hypothyroidism in
children; leads to mental
retardation
ii. hypothyroidism without
myxedema: mild thyroid failure
iii. hypothyroidism with
myxedema: severe thyroid
failure; usually seen in older adults
56
 iv. myxedema coma
• most severe type of
hypothyroidism
• precipitated by stress
• findings include:
o hypothermia
o bradycardia
o hypoventilation
o altered LOC leading to
coma
• potentially life threatening
57

condition
Etiology
a. thyroid surgery - may cause hypothyroid
state after surgery depending on extent of
thyroid removal
b. treatment for hyperthyroid condition
c. overdosage of thyroid medications
d. deficiency in dietary iodine

58
Findings
a. cognitive impairment
b. constipation, fatigue, depression
c. intolerance to cold
d. coarse, dry skin;
e. bradycardia; increased diastolic pressure
f. menstrual changes - increased menstrual flow
g. loss of the outer one-third of eyebrows
h. weight gain
i. fluid retention
59
 Diagnostic test findings
a. Radioimmunoassay shows low T3 and T4 levels
b. Blood testing reveals increased TSH level when
hypothyroidism is caused by thyroid disorder and
decreased TSH when the cause is hypothalamic or
pituitary disorder
c. Thyroid panel differentiates between primary
hypothyroidism (thyroid gland hypofunction),
secondary hypothyroidism (pituitary hyposecretion of
TSH), tertiary hypothyroidism (hypothalamic
hyposecretion of TRH) 60
 Management
a. expected outcomes: to restore
hormonal balance and prevent
complications
b. administer synthetic thyroid hormone:
levothyroxine sodium (levothroid)
c. myxedema coma:
i. IV fluids as ordered
ii. correct hypothermia 61

iii. give synthetic thyroid hormone

Nursing interventions
a. give medications as ordered
b. watch client for signs of myxedema
c. provide restful environment
d. teach client
i. how to conserve energy
ii. how to avoid stress
iii. about the medications and side effects -
synthyroid is to be taken in the morning on an
empty stomach at least one hour before any
other medications or vitamins or ingestion of milk
iv. the importance of lifelong therapy 62

e. protect client from cold

63
B. Hyperthyroidism (Graves' disease,
thyrotoxicosois)
Definition - overactive thyroid over secretes
hormones, and causes increased basal
metabolic rate or hyperactivity of thyroid as
a primary disease state
Etiology - considered autoimmune
response
 women affected more than men
 age group: 30 to 50 years
64
 3. Findings
a. hyperphagia, weight loss, diarrhea
b. heat intolerance
c. exophthalmos
d. tachycardia
e. Palpitations
f. increased systolic BP
g. difficulty concentrating
65
 h. irritability
i. hyperactivity
j. thin, brittle hair, pliable nails:
plummer's nails (onycholysis)
k. diaphoresis
l. insomnia
m. reduced tolerance for stress

66
 Diagnostics
1. history and physical exam: palpable
thyroid enlargement: (goiter)
2. elevated serum T3 and T4 levels
3. elevated radioactive iodine uptake
4. presence of thyroid autoantibodies
5. decreased TSH (thyroid-stimulating
hormone; comes from pituitary) levels
67
Complication: thyrotoxic crisis (thyroid storm)
1. rare but potentially fatal
2. breakdown of body's tolerance to
chronic hormone excess
3. state of extreme hypermetabolism
4. precipitating factors: stress, infection,
pregnancy
5. findings include:
1. systolic hypertension
2. hyperthermia
3. angina
4. infarction or heart failure 68

5. extreme anxiety
Management
a. expected outcomes: to reduce the excess
hormone secretion and to prevent complications
b. pharmacologic
i. sodium131I
ii. antithyroid agents: propylthiouracil
(PTU)
iii. beta-adrenergic blocking agents:
propranolol (inderol)
iv. iodides: useful adjunct to decrease 69

vascularity of thyroid pre-surgical removal

 c. surgical: thyroidectomy: partial or
total removal of thyroid gland
d. diet high in calories, protein,
carbohydrates

70
A. Hypoparathyroidism
1. Definition - parathyroid produces too little
parathormone; results in hypocalcemia
2. Etiology unknown
 a. possibly an autoimmune disorder
 b.most often results from surgical removal of parathyroid glands

71
3. Findings (mild to severe order)
a. neuromuscular
i. irritability
ii. personality changes
iii. muscular weakness or cramping
iv. numbness of fingers
v. tetany
vi. carpopedal spasms
vii. laryngospasms 72

viii. seizures
B. Hyperparathyroidism
1. Definition - parathyroid secretes too
much parathormone; results in increased
serum calcium (hypercalcemia)
2. Etiology
a. benign growth in parathyroid
b. secondarily as result of
kidney disease or
osteomalacia
c. incidence increases 73

dramatically in both sexes after

3. Findings
a. many clients are asymptomatic
b. gastrointestinal: constipation,
nausea, vomiting, anorexia
c. skeletal: bone pain,
demineralization, pathological
fractures
d. irritability
e. muscle weakness and fatigue 74
 PHARMACOLOGIC INTERVENTIONS
FOR HYPERPARATHYROIDISM
 1. Hydration with 0.9% normal saline
solution
 2. Diuretics
 3. Plicamycin
 4. Didronel
 5. Glucocorticoids
 6. Phosphate as antihypercalcemic agent
75
 7. Calcitonin
 8. Estrogen
 a. expected outcomes: to restore
hormonal balance and prevent
complications
 b. surgery: removal of parathyroid glands
- parathyroidectomy

76
77
78
Disorders of the Adrenal Gland

A.Addison's disease
relatively rare

Etiology - autoimmune adrenalitis

79
adrenal insufficiency
i. vague complaints or findings
ii. fatigue
iii. muscle weakness
iv. vague abdominal complaints:
anorexia, nausea, vomiting
v. personality changes
vi. skin pigmentation darkens 80
Diagnostics
 ACTH stimulation test: low cortisol level
low blood levels of sodium and glucose and
high levels of potassium
24-hour urine collection: decreased levels of
free cortisol

81
 Management
 Pharmacologic Interventions for Adrenal
Insufficiency
 1. Glucocorticoids
 2. Betamethasone (CELESTONE)
 3. Cortisone (CORTONE)
 4. Dexamethasone (DECADRON)
 5. Hydrocortisone
 6. Methylprednisone (MEDROL) 82
83
 Cushing's syndrome
1. Definition: adrenal gland secretes too
much cortisol
2. Etiology
a. average age of onset 20 to 40
years of age
b. affects women more often than
men
c. primary syndrome caused by 84
d. secondary syndrome caused by an
ACTH-producing tumor of pituitary
e. long term steroid therapy

85
86
Diagnostics
a. history and physical exam
b. blood tests show
i. increased levels of cortisol,
ii. increased sodium and glucose,
iii. decreased potassium
c. 24-hour urine collection:
i. elevated free cortisol
ii. elevated 17-ketosteroids 87

iii. elevated 17-hydroxycorticosterone

adrenal enzyme inhibitors that block
enzymes needed for cortisol synthesis
i. aminogluthemide
ii. metyrapone
iii. mitotane

88
CARE OF CLIENT ON STEROID THERAPY
Teach client to:
1. Never discontinue medications abruptly- could
precipitate acute crisis.
2. Take medication with breakfast - corresponds to
biorhythms and reduces gastric irritation.
3. Take higher dose in AM and lower doses in PM.
4. Always take medication with a meal or a snack.
5. Carry extra medication on self during travel.
89
90
Pheochromocytoma
1. Definition
Adrenal medulla secretes too much
epinephrine and norepinephrine (called the
catecholamines). Causes excessive
stimulation of the sympathetic nervous system
2. Etiology
a. generally benign tumor of the
adrenal medulla 91

b. curable, but fatal if untreated

 Diagnostics
 a. increased BMR
 b. computerized tomogram (CT) scan
 c. 24-hour urine collection: increased
urinary catecholamines

92
Management

alpha-adrenergic blocking agent and beta

adrenergic blocking agent (beta blockers):
phentolamine (regitine), nitroprusside (nitropress),
propranolol (inderal)
tyrosine inhibitors: alphamethylparatyrosine
decreases circulating catecholamines
f. antidysrhythmic agents as needed preop

93
94
 1. The nurse recognizes that lowered blood
glucose stimulates the release of which
hormone from the pancreas?
 A. Glycogen
 B. Glucagon
 C. Cortisol
 D. Glucocorticoid

95
 2. In evaluating a patient with suspected
diabetes mellitus (DM), which of the
following clinical manifestations is seen in
type I and not type II DM?
 A. Hyperglycemia
 B. Polydipsia
 C. Polyuria
 D. Weight loss
96
 3. In monitoring a patient response to
insulin therapy, the nurse correlates which
clinical manifestations to hypoglycemia?
 A. Diaphoresis and hunger
 B. Increased urine output and thirst
 C. Dry, flushed skin and confusion
 D. Hyperventilation and tachycardia

97
 4. The nurse correlates which clinical
manifestations with the diagnosis of
hyperthyroidism?
 A. Fatigue, weight gain, cold intolerance
 B. Decreased pulse rate, slurred speech,
anorexia
 C. Abdominal pain, constipation, heat
intolerance
 D. Nervousness, weight loss, tachycardia 98
 5. The nurse monitors for which of the
following as indicative of effective treatment
of hyperthyroidism?
 A. Elevated body temperature
 B. Weight loss
 C. Decreasing heart rate
 D. Increasing blood glucose

99
 6. The nurse monitors for which of the
following as indicative of effective treatment
of hypothyroidism?
 A. Decreased sweating
 B. Weight gain
 C. Decreasing heart rate
 D. Increasing energy level

100
 7. The nurse assesses for which of the
following clinical manifestations in the
patient with hypoparathyroidism?
 A. Hyperactive reflexes
 B. Elevated serum calcium
 C. Muscle weakness
 D. Constipation

101
 8. The client had just undergone thyroid
surgery. Which of the following should urge
the nurse to notify the attending physician?

 A. Frequent swallowing
 B. Persistent laryngeal hoarseness
 C. Bloody nape area
 D. Carpopedal spasms
102
 9 A client receiving propylthiouracil should
be instructed to stop the medication
immediately and call the health care
provider if which sign occurs?
 A. Diarrhea
 B. Palpitations
 C. Fever
 D. Weight gain
103
 10. In assessing parathyroid function, the
nurse monitors which laboratory value?
 A. Calcium
 B. Magnesium
 C. Sodium
 D. Potassium

104
 11. Which statement about analgesic therapy
for a client with hypothyroidism would be
appropriate to use as a basis for developing
the client’s plan?
 A. Increase dosage will be needed because
the client is overweight.
 B. Analgesics are not needed because the
client already is lethargic.
 C. Decreased dosages are needed because
of prolonged drug degradation rates.
 D. Increased dosages will be needed 105

because of the hypermetabolic state.

 12. Which client behavior would support the
nursing diagnosis deficient knowledge for
the client with insulin-dependent diabetes
mellitus?
 A. Recent weight gain of 15lb
 B. Failure to monitor blood glucose level
 C. Skipping insulin doses when feeling ill
 D. Crying whenever diabetes is mentioned
106
 13. Which outcome represents the best
indicator of good overall diabetes control?
 A. The client reports urine glucose levels
indicating no glucosuria.
 B. The client displays a glycosylated
hemoglobin level within normal range.
 C. The client reports urine ketone levels
reflecting no ketonuria
 D. The client records home glucose test 107

results daily.
 14. The results of blood glucose monitoring
for a client with diabetes who takes regular
and NPH insulin in the morning and evening
reveals that the client is hyperglycemic
before breakfast. Which dose of insulin
would the nurse expect to be increased?
 A. Morning dose of regular insulin
 B. Evening dose of NPH insulin
 C. Morning dose of NPH insulin
108

 D. Evening dose of regular insulin

 15. Signs of thyroid storm include all of the
following except:
 A. Bradycardia
 B. Delirium
 C. Dyspnea and chest pain
 D. Hyperpyrexia

109
 16. A patient is diagnosed with type 1
diabetes. The nurse knows that all of the
are probable clinical characteristics except:
 A. Ketosis-prone
 B. Little or endogenous insulin
 C. Obesity at diagnosis
 D. Younger than 30 years of age.

110
 17. The most sensitive test for diabetes
mellitus is the:
 A. Fasting plasma glucose
 B. Glycosylated hemoglobin
 C. Oral glucose tolerance test
 D. Urine glucose

111
 18. The nurse is asked to assess a patient
for glucosuria. The nurse would secure a
specimen of:
 A. Blood
 B. Sputum
 C. Stool
 D. Urine

112
 19. The nurse should expect that insulin
therapy will be temporarily substituted for
oral antidiabetic therapy if the diabetic:
 A. develops an infection with fever
 B. Suffers trauma
 C. Undergoes major surgery
 D. Develops any of the above condition

113