Assessment of the Endocrine

System.
Care of Patients with Problems
of the Thyroid and Parathyroid
Glands.

Dr. Lyudmyla Mazur, PhD

 Concepts
 The priority concepts for this chapter are
 NUTRITION
 ELIMINATION
 The interrelated concept for this chapter is
 FLUID AND ELECTROLYTE BALANCE

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Glands of the Endocrine System
Hypothalamus
Posterior Pituitary
Anterior Pituitary
Thyroid
Parathyroids
Adrenals
Pancreatic islets
Ovaries and testes
 Anatomy and Physiology Review
 Negative feedback—control of hormone
synthesis
 Excesses or deficiencies of hormone secretion
can lead to pathologic conditions.

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Regulation
FEEDBACK:
Hormone secretion → delivery to target cells →
hormone recognition by receptors in target cells →
biologic effect → hormone degradation → signal from
target cells to stop further hormone secretion
 Hypothalamus
 Function—produce regulatory hormones

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Hypothalamus
Releasing and inhibiting hormones
Corticotropin-releasing hormone
Thyrotropin-releasing hormone
Growth hormone-releasing hormone
Gonadotropin-releasing hormone
Somatostatin-=-inhibits GH and TSH
Hypothalamus and Pituitary Glands

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Anterior Pituitary
Growth Hormone--
Adrenocorticotropic hormone
Thyroid stimulating hormone
Follicle stimulating hormone—ovary in female, sperm
in males
Luteinizing hormone—corpus luteum in females,
secretion of testosterone in males
Prolactin—prepares female breasts for lactation
 Posterior Pituitary
Antidiuretic Hormone

Oxytocin—contraction of uterus, milk ejection from

breasts
 Adrenal Glands
 Adrenal cortex
 Mineralocorticoids (aldosterone)
 Glucocorticoids (cortisol)
 Adrenal medulla
 Catecholamines (epinephrine and norepinephrine)

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Adrenal Cortex
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—dehydroepiandrosterone and

androstenedione. Converted to testosterone in the
periphery.
 Adrenal Medulla
Epinephrine and norepinephrine
serve as neurotransmitters for sympathetic system
 Thyroid Gland
 Composed of follicular and parafollicular cells
 Control of metabolism takes place through T3
and T4.
 Calcium and phosphorus balance takes place

partly through the actions of calcitonin.

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 Thyroid
Follicular cells—excretion of triiodothyronine (T3)
and thyroxine (T4)—Increase BMR, increase bone and
calcium turnover, increase response to catecholamines,
need for fetal G&D
Thyroid C cells—calcitonin. Lowers blood calcium
and phosphate levels
 Parathyroid Glands
 Secretion of parathyroid hormone (PTH)
 Regulates calcium and phosphorus metabolism
by acting on bones, kidneys, GI tract
 PTH increases bone resorption.
 Serum calcium levels determine PTH secretion.

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Parathyroid
Parathyroid hormone—regulates serum calcium
 Pancreas
 Exocrine and endocrine functions
 Islet cells
 Glucagon—hormone that increases blood
glucose levels
 Insulin—promotes movement and storage of
carbohydrate, protein, and fat
 Somatostatin—inhibits release of glucagon and
insulin from pancreas

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 Kidney
1, 25 dihydroxyvitamin D—stimulates calcium
absorption from the intestine
Renin—activates the RAAS
Erythropoietin—Increases red blood cell production
 Gonads
 Testes (male)
 Ovaries (female)
 Function is dormant until puberty; then induces
development of secondary sexual
characteristics.

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 Ovaries
Estrogen
Progesterone—inportant in menstrual cycle,*maintains
pregnancy,
 Testes
Androgens, testosterone—secondary sexual
characteristics, sperm production
 Thymus
Releases thymosin and thymopoietin
Affects maturation of T lymphocetes
 Pineal
Melatonin
Affects sleep, fertility and aging
 Prostaglandins
Work locally
Released by plasma cells
Affect fertility, blood clotting, body temperature
 Endocrine Changes
Associated with Aging
 Reduced glandular function
 Decreased hormone secretion

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 Assessment:
Noticing and Interpreting
 Patient history
 Nutrition history
 Family history and genetic risk
 Current health problems
 Changes in energy levels
 Changes in elimination patterns
 Sexual and reproductive functions
 Changes in physical features
 Any other current health problems

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 Assessment
Health history—energy level, hand and foot size
changes, headaches, urinary changes, heat and cold
intolerance, changes in sexual characteristics,
personality changes, others
 Physical Assessment
 Inspect for
Prominent forehead or jaw
Round or puffy face
Dull or flat expression
Exophthalmos
Skin color, pigment loss
Trunk abnormalities in size, symmetry
Hair distribution
Genitalia
Physical assessment—appearance including hair
distribution, fat distribution, quality of skin,
appearance of eyes, size of feet and hands,
peripheral edema, facial puffiness, vital signs

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 Physical Assessment (Cont.)
 Palpation
 Thyroid gland, testes
 Auscultation
 Chest
 Area of thyroid enlargement

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 Psychosocial Assessment
Behaviors, personality, psychological responses may
be affected
Coping skills
Support systems
Health-related beliefs
Self-perception

31 Copyright © 2018 Elsevier Inc. All rights reserved.

 Diagnostic Assessment
Laboratory tests
Assays
Provocative/Suppression tests
Urine tests
Genetic tests
Tests for glucose
Imaging assessment
Other diagnostic assessment

32 Copyright © 2018 Elsevier Inc. All rights reserved.

 Diagnostic Evaluation
Serum levels of hormones
Detection of antibodies against certain hormones
Urinary tests to measure by-products (norepinephrine,
metanephrines, dopamine)
Stimulation tests—determine how an endocrine gland
responds to stimulating hormone. If the hormone
responds, then the problem lies w/hypothalmus or
pituitary
Suppression tests—tests negative feedback systems
that control secretion of hormones from the
hypothalamus or pituitary.
Thyroid
 Concepts
 The priority concept in this chapter is
 CELLULAR REGULATION
• THE CELLULAR REGULATION EXEMPLAR IS
HYPOTHYROIDISM
 The interrelated concept in this chapter is
 NUTRITION

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 ASSESSMENT - NECK

• Symmetry – head and neck

muscles
• ROM
• Ask person to touch chin to chest,
turn head to right and left, try to
touch each ear to shoulder, extend
head backwards
• Note limitation of movement
• Muscle strength
• Test strength by resisting movement
• CN XI – Accessory n. – Trapezius
m.
• Thyroid gland
• Enlargement of lower neck may be
bilateral or a unilateral lump
• Diffuse enlargement or nodular
lump
 PALPATING THE THYROID GLAND

• Posterior approach
• Anterior approach

• Place fingers inferior and

lateral of thyroid cartilage
and ask the person to
swallow
• Usually, you cannot palpate
the normal adult thyroid
• Enlarged lobes are also tender
to palpation
 LYMPH
NODES

• Lymph nodes
• Beginning with the preauricular lymph nodes, palpate the 10 groups of
lymph nodes in a routine order
• Lymphadenopathy - enlargement of lymph nodes due to infection,
allergy, or neoplasm
 Thyroid
T3 and T4
Need iodine for synthesis of hormones—excess will
result in adaptive decline in utilization called the Wolf-
Chaikoff mechanism
Thyroid is controlled by TSH
Cellular metabolism, brain development, normal
growth, affect every organ in the body
T3 is five times as potent as T4
Calcitonin—secreted in response to high levels of
serum calcium, increases deposition in the bone
 Thyroid
Inspect gland
Observe for goiter
Check TSH, serum T3 and T4
T3 resin uptake test useful in evaluating thyroid
hormone levels in patients who have received
diagnostic or therapeutic dose of iodine. Estrogens,
Dilantin, Tagamet, Heparin, amiodarone, PTU,steroids
and Lithium can cloud the accuracy
T3 more accurate indicator of hyperthyroidism
according to text
 Thyroid
Antibodies seen in Hashimoto’s, Grave’s and other
auto-immune problems.
Radioactive iodine uptake test measures rate of iodine
uptake. Patients with hyperthyroidism exhibit a high
uptake, hypothyroidism will have low uptake
Thyroid scan—helps determine the location, size,
shape and size of gland. “Hot” areas (increased
function) and “cold” areas (decreased function) can
assist in diagnosis.
Biopsy
 Nursing Implications
Be aware of meds patient is taking (see list in text) that
can affect accuracy of testing
Also be aware if patient is taking multivitamins and
food supplements
 Hypothyroidism Assessment: Noticing
History
Physical assessment
Signs and symptoms
Psychosocial assessment
Laboratory assessment

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44
 Hypothyroidism
 Most common cause is Hashimoto’s thyroiditis
 Common in those previously treated for hyperthyroidism
 Atrophy of gland with aging
 Medications like lithium, iodine compounds, antithyroid
meds can cause
 Radiation treatments to head and neck
 Infiltrative diseases like amyloidosis, scleroderma
 Iodine deficiency and excess
 Hypothalamic or pituitary abnormality
 More common in women, especially over age 50
 Manifestations
From mild symptoms to myxedema
Myxedema –accumulation of mucopolysaccharides in
sc and interstitial tissues. Is the extreme form of
hypothyroidism. Can progress to shock.
S/S—fatigue, hair loss, dry skin, brittle nails,
numbness and tingling of the fingers, amenorrhea,
weight gain, decreased heart rate and temperature,
lassitude, cognitive changes, elevated cholesterol
levels, constipation, hypotension
 Myxedema

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48
 Analysis: Interpreting
 The priority collaborative problems for patients
with hypothyroidism include
 Decreased gas exchange and oxygenation
 Hypotension and reduced perfusion
 Reduced cognition
 Potential for the complication of myxedema coma

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 Pharmacologic Management of
hypothyroidism
Levothyroxine is preferred agent
Dosage is based on TSH
Desiccated thyroid used infrequently due to
inconsistent dosing
Angina can occur when thyroid replacement is
initiated as it enhances effects of cardiovascular
catecholamines (in pt. w/pre-existent CAD). Start at
low dose.
Hypnotics and sedatives may have profound effects on
sensorium
 Planning and Implementation:
Responding
 Improve gas exchange
 Prevent hypotension
 Support cognition
 Prevent myxedema coma
 Care coordination and transition management

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 Management in Myxedema
Cautious fluid replacement
Glucose to restore to normal glycemic levels
Avoid rapid overheating due to increased oxygen
demands but keep warm
May give levothyroxine intravenously
With recovery,
Modify activity
High fiber foods
Home health for follow-up
 Hyperthyroidism
 Thyrotoxicosis
 Graves’ disease: Goiter, exophthalmos,
pretibial myxedema
 Interprofessional collaborative care
 Assessment: Noticing
 History
 Physical assessment
 Signs and symptoms
 Psychosocial assessment

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 Hyperthyroidism
Extreme form is Grave’s disease
Caused by thyroiditis, excessive amount thyroid
hormone, abnormal output by immunoglobulins
Is more common in women
Manifestations of hyperthyroidism
Thyrotoxicosis—nervousness, irritable, apprehensive,
palpitations, heat intolerance, skin flushing, tremors,
possibly exophthalmos
Have an increased sensitivity to catecholamines
Can occur after irradiation or presence of a tumor
 Assessment and Diagnosis
Thyroid thrill and or bruit may be present
Thyroid may be enlarged
Decreased TSH, increased free T4 and an increased
radioactive iodine uptake
Exophthalmos

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 Goiter

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Eyes sings
 Laboratory Tests
 T3, T4, T3RU, TSH, TSH-RAb
 Thyroid scan
 Ultrasonography
 Electrocardiography (ECG)

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Interprofessional Collaborative Care
 Nonsurgical management
 Monitoring
 Reducing stimulation
 Promoting comfort
 Drug therapy (antithyroid drugs, iodine
preparations, beta-adrenergic blocking drugs)

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 Management
Reduce thyroid hyperactivity—usually use radioactive
iodine, antithyroid meds or surgery)
Beta blockers
Can be relapse with antithyroid meds
 Pharmacologic Therapy
Irradiation with administration of radioisotope iodine
131—initially may cause an acute release of thyroid
hormones. Should monitor for thyroid storm
S/S of thyroid storm—high fever. Tachycardia,
delirium, chest pain, dyspnea, palpitations, weight loss,
diarrhea, abdominal pain
Management of thyroid storm—oxygen, IV fluids
with dextrose, hypothermic measures, steroids to treat
shock or adrenal deficiency, iodine to decrease output
of T4, beta blockers, PTU or Tapazole impedes
formation of thyroid hormone and blocks conversion
of T4 to T3
 Antithyroid Medications
PTU—propylthiouracil—blocks synthesis of
hormones
Tapazole (methimazole)—blocks synthesis of
hormones. More toxic than PTU.
Sodium Iodide-suppresses release of thyroid hormone
SSKI (saturated solution of potassium chloride)–
suppresses release of hormones and decreases
vascularity of thyroid. Can stain teeth
Dexamethazone—suppresses release of thyroid
hormones
 Surgical Management
Reserved for special circumstances, e.g. large goiters,
those who cannot take antithyroid meds, or who need
rapid normalization
Subtotal thyroidectomy
Before surgery, give PTU until s/s of hyperthyroidism
have disappeared
Iodine may be used to decrease vascularity
 Surgical Management
 Total or subtotal thyroidectomy
 Postoperative complications
 Hemorrhage
 Respiratory distress
 Hypocalcemia and tetany
 Laryngeal nerve damage
 Thyroid storm or thyroid crisis
 Eye and vision problems of Graves’ disease

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 Postoperative Monitoring
 Hoarseness or stridor
 Suture line pressure
 Hypocalcemia and tetany
 Thyroid storm

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 Nursing Management
Reassurance r/t the emotional reactions experienced
May need eye care if has exophthalmos
Maintain normal body temperature
Adequate caloric intake
Managing potential complications such as
dysrhythmias and tachycardias
Educate about potential s/s of hypothyroidism
following any antithyroid tx.
 Parathyroid Glands
Parathormone maintains sufficient serum calcium
levels
Excess calcium can bind with phosphate and
precipitate in various organs, can cause pancreatitis
Hyperparathyroidism will cause bone decalcification
and development of renal calculi
More common in women
Secondary hyperparathyroidism occurs in those with
chronic renal failure and renal rickets secondary to
excess phosphorus retention (and increased
parathormone secretion)
 Manifestations of
Hyperparathyroidism
May be asymptomatic
Apathy, fatigue, muscle weakness, nausea, vomiting,
constipation, hypertension and cardiac dysrhythmias
Excess calcium in the brain can lead to psychoses
Renal lithiasis can lead to renal damage and even
failure
Demineralization of bones with back and joint pain,
pain on weight bearing, pathologic fractures
Peptic ulcers and pancreatitis can also occur
Assessment and Diagnostic Findings
Persistent elevated calcium levels
Elevated serum parathormone level
Bone studies will reveal decreased density
Double antibody parathyroid hormone test is used to
distinguish between primary hyperparathyroidism and
malignancy
Ultrasound, MRI, thallium scan, fine needle biopsy
also can be used to localize cysts, adenomas, or
hyperplasia
 Management
 Recommended treatment for hyperparathyroidism is
surgical removal
 Hydration therapy necessary to prevent renal calculi
 Avoid thiazide diuretics as they decrease renal excretion of
calcium
 Increase mobility to promote bone retention of calcium
 Avoid restricted or excess calcium in the diet
 Fluids, prune juice and stool softeners to prevent
constipation
 Watch for s/s of tetany postsurgically (numbness, tingling,
carpopedal spasms) as well as cardiac dysrhythmias and
hypotension
 Hypercalcemic crisis
Seen with levels greater than 15mg/dL
Can result in life-threatening neurologic,
cardiovascular and renal symptoms
Treatments include: hydration, loop diuretics to
promote excretion of calcium, phosphate therapy to
promote calcium deposition in bone and reducing GI
absorption of calcium
Give calcitonin or mithramycin to decrease serum
calcium levels quickly
 Hypoparathyroidism
Seen most often following removal of thyroid gland,
parathyroid glands or following radical neck surgery
Deficiency of parathormone results in increased bone
phosphate and decreased blood calcium levels
In absence of parathormone, there is decreased
intestinal absorption of dietary calcium and decreased
resorption of calcium from bone and through kidney
tubules
 Clinical Manifestations of
Hypoparathyroidism
Irritability of neuromuscular system
Tetany—hypertonic muscle contractions , numbnes,
tingling, cramps in extremities, laryngeal spasm,
bronchospasm, carpopedal spasm ( flexion of the
elbows and wrists, dorsiflexion of the feet), seizures
Assessment and Diagnostic Findings
Trousseau’s sign—can check with a BP cuff
Chvostek’s sign—tapping over facial nerve causes
spasm of the mouth, nose and eye
Lab studies may reveal calcium levels of 5-6 mg/dL or
lower
Serum phosphate levels will be decreased
Management of Hypoparathyroidism
Restore calcium level to 9-10 mg/dL
May need to give IV calcium gluconate for immediate
treatment
Use of parathormone IV reserved for extreme
situations due to the probability of allergic reactions
Monitor calcium levels
May need bronchodilators and even ventilator
assistance
Diet high in calcium and low in phosphorus; thus,
avoid milk products, egg yolk and spinach.
Management of Hypoparathyroidism
Keep calcium gluconate at bedside
Ensure has IV access
Cardiac monitoring
Care of postoperative patients who have undergone
thyroid surgery, parathyroidectomy or radical neck
surgery. Be watchful for signs of tetany, seizures, and
respiratory difficulties
 Thyroiditis
Inflammation of thyroid gland
Three types: Acute; subacute (granulomatous); chronic
(Hashimoto’s disease—most common type)
Thyroiditis vs. hyperthyroidism, hypothyroidism
Nonsurgical management, drug therapy
Surgical management

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79
 Thyroid Cancer
Four types
Papillary
Follicular
Medullary
Anaplastic
Interprofessional collaborative care
Radiation therapy
Surgery

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80
 Hyperparathyroidism
Parathyroid glands—calcium and phosphate balance
Hypercalcemia and hypophosphatemia
Nonsurgical versus surgical management

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81
 Hypoparathyroidism
Decreased function of parathyroid gland
Iatrogenic
Idiopathic
Hypomagnesemia
Interventions: Correcting hypocalcemia, vitamin D
deficiency, hypomagnesemia

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82
Дякую за увагу!
Thank You for
!attention
 Question 1
As the nurse is assessing a patient with Grave’s disease,
which finding requires immediate attention?

A. Elevated temperature
B. Elevated blood pressure
C. Change in respiratory rate
D. Irregular heart rate and rhythm

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84
 Question 2
What is the priority nursing intervention for an older
female patient with a history of hyperparathyroidism?

A. Implement fall precautions.

B. Encourage oral fluid hydration.
C. Encourage small frequent meals.
D. Provide pain medications as prescribed.

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85
 Question 3
When developing a postoperative plan of care for a
patient after a total thyroidectomy, the nurse knows the
plan should include which intervention?

A. Avoiding extending the patient’s neck

B. Assessing the patient’s voice once per shift
C. Encouraging the patient to be out of bed in a
chair
D. Administering oxygen via nasal cannula as
needed

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86