CHAPTER 48 Endocrine System

TABLE 48-8

1213

DIAGNOSTIC STUDIES

Endocrine System
STUDY
Pituitary Studies
Blood Studies

PURPOSE AND DESCRIPTION*

NURSING RESPONSIBILITY

Growth hormone (GH)

(somatotropin)

Evaluates GH secretion. Used to identify GH deficiency or GH

excess. GH levels are affected by time of day, food intake, and
stress.
Male: <4 ng/mL (<4.0 mcg/L)
Female: <18 ng/mL (<18 mcg/L)
Values >50 ng/mL (>50.0 mcg/L) suggest acromegaly.

Make sure that patient has been fasting and has not
recently been emotionally or physically stressed.
Indicate patient fasting status and recent activity level
on the laboratory slip. Send blood sample to laboratory
immediately.

Somatomedin C
(insulin-like growth
factor 1 [IGF-1])

Evaluates GH secretion. Provides a more accurate reflection of

mean plasma concentration of GH because it is not subject
to circadian rhythm and fluctuations. Low levels indicate GH
deficiency; high levels indicate GH excess.
Reference interval: 135-449 ng/mL

Overnight fasting is preferred but not necessary.

Growth hormone (GH)

stimulation

Insulin tolerance test: Regular insulin (0.05-0.15 U/kg) given

IV and blood drawn at 30, 0, 30, 45, 60, and 90 min for
measurement of glucose and GH.
Reference interval: GH >5 mcg/L
Arginine-GHRH test: GHRH bolus followed by 30-min
infusion of L-arginine.
Reference interval: GH >4.1 mcg/L
Useful in distinguishing primary gonadal problems from pituitary
insufficiency. In women, there are marked differences during
menstrual cycle and in postmenopausal period. Levels are low
in pituitary insufficiency and high in primary gonadal failure.
FSH
Female:
Follicular phase: 1.37-9.9 mU/mL
Ovulatory phase: 6.17-17.2 mU/mL
Luteal phase: 1.09-9.2 mU/mL
Postmenopause: 19.3-100.6 mU/mL
Male: 1.42-15.4 mU/mL
LH
Female:
Follicular phase: 1.68-15 IU/L
Ovulatory phase: 21.9-56.6 IU/L
Postmenopause: 14.2-52.3 IU/L
Male: 1.24-7.8 IU/L
Used to differentiate causes of diabetes insipidus, including
central diabetes insipidus (DI), nephrogenic DI, and psychogenic polydipsia.
ADH (vasopressin) is administered.
Reference interval: After ADH administration, urine osmolality
shows no further increase.
In patients with central DI, urine osmolality increases after ADH.
In patients with nephrogenic DI, there is no or minimal response
to ADH.

Patient must be NPO after midnight. Water is permitted

on morning of test. IV access is established for administration of medications and frequent blood sampling.
Continually assess for hypoglycemia and hypotension.
50% dextrose and 5% dextrose IV solution should
be kept at the bedside in case severe hypoglycemia
occurs.
There is no special preparation of the patient. Only one
blood tube is needed for both FSH and LH. Note on
the laboratory slip time of menstrual cycle or whether
female is postmenopausal.

Examination of choice for radiologic evaluation of the pituitary

gland and hypothalamus. Useful in identification of tumors
involving the hypothalamus or pituitary.
Used to detect tumor and size of tumor. Oral and/or IV contrast
medium may be used.

Inform patient of the need to lie as still as possible during

the test; explain that tests are painless and noninvasive.

Measures levels of TSH. Considered the most sensitive

diagnostic test used for evaluating thyroid dysfunction.
Reference interval: 0.4-4.2 U/mL (0.4-4.2 mU/L)
Measures total serum level of T4. Useful in evaluating thyroid
function and monitoring thyroid therapy.
Reference interval: 4.6-11.0 mcg/dL (59-142 nmol/L)

Explain blood draw procedure to the patient. No specific

preparations are necessary.

Gonadotropins
Follicle-stimulating
hormone (FSH)
Luteinizing hormone
(LH)

Water deprivation
(ADH stimulation)

Caution: Severe dehydration may occur with central or

nephrogenic DI during this test.
Should only be performed if serum sodium is normal and
urine osmolality is <300 mOsm/kg.
The test lasts 6 hr, usually from 6 AM to 12 noon. Obtain
baseline weight and urine and plasma osmolality.
Assess urine hourly for volume and specific gravity. Send
hourly samples or urine osmolality.
Discontinue test and rehydrate if patients weight drops
more than 2 kg at any time. Rehydrate with oral fluids.
Check orthostatic BP and pulse after rehydration to
ensure adequate fluid volume.

Radiologic Studies
Magnetic resonance
imaging (MRI)
Computed tomography (CT) scan with
contrast media

Inform patient of procedure. Patient must lie still during the

procedure. If IV contrast is used, check for iodine allergy.

Thyroid Studies
Blood Studies
Thyroid-stimulating
hormone (TSH)
(thyrotropin)
Thyroxine (T4), total

ADH, Antidiuretic hormone; GHRH, growth hormonereducing hormone.

See above.

Continued

1214

SECTION 10 Problems Related to Regulatory and Reproductive Mechanisms

TABLE 48-8

DIAGNOSTIC STUDIEScontd

Endocrine System
STUDY
PURPOSE AND DESCRIPTION*
Thyroid Studiescontd
Blood Studiescontd

NURSING RESPONSIBILITY

Measures active component of total T4. Because level remains

constant, considered better indication of thyroid function than
total T4.
Reference interval: 0.8-2.7 ng/dL (10-35 pmol/L)
Measures serum levels of T3. Helpful in diagnosing
hyperthyroidism if T4 levels are normal.
Ages 20-50: 70-204 ng/dL (1.08-3.14 nmol/L)
Ages >50: 40-181 ng/dL (0.62-2.79 nmol/L)
Measures active component of total T3.
Reference interval: 260-480 pg/dL (4.0-7.4 pmol/L)
Indirectly measures binding capacity of thyroid-binding globulin.
Reference interval: 24%-34%
Measures levels of thyroid antibodies. Assists in the diagnosis
of an autoimmune thyroid disease and separates it from
thyroiditis. One or more antibody tests may be ordered
depending on symptoms.

See above.

Assesses anterior pituitary function via secretion of TSH in

response to TRH administration.
Reference interval: Baseline TSH <10 U/mL; stimulated
TSH > double baseline
Identifies the presence of functioning thyroid tissue or thyroid
cancer cells; primarily used as a tumor marker for patients
being treated for thyroid cancer.
Reference interval:
Males: 0.5-53 ng/mL
Females: 0.5-43 ng/mL

Patient should discontinue thyroid medications 3-4 wk

before test. After TRH administration, blood is drawn at
intervals and TSH levels are determined.

Ultrasound

Evaluates thyroid nodule(s) to determine if fluid-filled (cystic) or

solid tumor.

Thyroid scan and

uptake

Scan: Used to evaluate nodules of thyroid. Radioactive isotopes

are given orally or IV. Scanner passes over thyroid and makes
graphic record of radiation emitted. Normal thyroid scan
reveals homogeneous pattern with symmetric lobes. Benign
nodules appear as warm spots because they take up
radionuclide; malignant tumors appear as cold spots because
they tend not to take up radionuclide.
Radioactive iodine uptake (RAIU): Provides direct measure of
thyroid activity. Evaluates function of thyroid nodules. Patient
is given radioactive iodine either orally or IV. The uptake by
the thyroid gland is measured with a scanner at several time
intervals such as 2-4 hr and at 24 hr. The values of RAIU are
expressed in percentage of uptake.
Reference interval: For 2-4 hr, 3%-19%; for 24 hr, 11%-30%.

Explain that gel and a transducer will be used over the

neck. The test will last 15 min. No fasting or sedation
required.
Explain procedure to the patient. Check for iodine allergy.
Be sure patient understands that radioactive iodine
taken orally is harmless. No special preparation is
required. Patient should not have supplemental iodine
for several weeks before the test. Thyroid medications
interfere with uptake test results.

Free thyroxine (FT4)

Triiodothyronine (T3),
total

Free triiodothyronine
(FT3)
T3 uptake (T3 resin
uptake)
Thyroid antibodies (Ab)
Thyroid peroxidase
(TPO) Ab
Thyroglobulin Ab
Thyroid-stimulating Ab
Thyrotropin-releasing
hormone (TRH)
(TRH stimulation)
Thyroglobulin

See above.

See above.
See above.
See above.

Explain blood draw procedure to the patient. No specific

preparations are necessary.

Radiologic Studies

Parathyroid Studies
Blood Studies
Parathyroid hormone
(PTH)

Measures PTH level in serum. Must be interpreted in terms of

concomitantly drawn serum calcium level.
Reference interval: 50-330 pg/mL (50-330 ng/L)

Calcium (total)

Used to detect bone and parathyroid disorders. Hypercalcemia

can indicate primary hyperparathyroidism, and hypocalcemia
can indicate hypoparathyroidism.
Reference interval: 8.6-10.2 mg/dL (2.15-2.55 mmol/L)
Free form of calcium unaffected by variable serum albumin levels.
Reference interval: 4.64-5.28 mg/dL (1.16-1.32 mmol/L)
Measures inorganic phosphorus. levels indicate primary
hypoparathyroidism or secondary causes (e.g., renal failure);
levels indicate hyperparathyroidism. Phosphorus and calcium
levels are inversely related.
Reference interval: 2.4-4.4 mg/dL (0.78-1.42 mmol/L)

Calcium (ionized)
Phosphate

Fasting specimen preferred. Inform patient that blood

sample will be drawn. Sample must be kept on ice.
Observe venipuncture site for bleeding or hematoma
formation.
Inform patient that blood sample will be drawn. Observe
venipuncture site for bleeding or hematoma formation.

See above.
Fasting preferred. Inform patient that blood sample will
be drawn. Observe venipuncture site for bleeding or
hematoma formation.

CHAPTER 48 Endocrine System

TABLE 48-8

1215

DIAGNOSTIC STUDIEScontd

Endocrine System
STUDY
PURPOSE AND DESCRIPTION*
Parathyroid Studiescontd
Radiologic Studies

NURSING RESPONSIBILITY

Uses radioactive isotopes that are taken up by cells in

parathyroid glands to obtain an image of the glands and any
abnormally active areas. Assists in identifying the number and
location of parathyroid glands.

Inform the patient that certain foods and medications

need to be restricted for a week before the test,
including thyroid medications and foods containing
iodine.

Cortisol (total)

Measures amount of total cortisol in serum and evaluates status

of adrenal cortex function.
Reference interval: 5-23 mcg/dL (138-635 nmol/L) at 8 AM,
3-16 mcg/dL (83-441 nmol/L) at 4 PM

Aldosterone

Used to assess for hyperaldosteronism.

Reference interval: 7-30 ng/dL (0.19-0.83 nmol/L) (upright
posture) and 3-16 ng/dL (0.08-0.44 nmol/L) (supine position)
Measures plasma level of ACTH. Although ACTH is a pituitary
hormone, it controls adrenal cortex secretion, thus helps to
determine if underproduction or overproduction of cortisol is
caused by dysfunction of the adrenal gland or pituitary gland.
Reference interval: morning: <120 pg/mL (26 pmol/L); evening:
<85 pg/mL (<19 pmol/L)
Used to evaluate adrenal function. After baseline cortisol
sample is drawn, cosyntropin (synthetic ACTH) is given by
IV bolus; cortisol samples are drawn 30 and 60 min after
bolus. Plasma cortisol at 60 min should increase by >7 mcg/dL
from baseline.

Cortisol has diurnal variationlevels are higher in

morning than in evening. Sample should be drawn in
morningevening samples may also be ordered.
Mark time of blood draw on laboratory slip. Patient
anxiety should be minimized.
Usually morning blood sample is preferred. Indicate
patient position (supine, sitting, standing) during
venipuncture.
Patient should be NPO after midnight before morning
blood draw. Minimize stress. Diurnal levels correspond
with variation of cortisol levels; that is, levels are higher
in morning, lower in evening. ACTH is very unstable;
blood tube must be placed on ice and sent to laboratory
immediately.
Obtain baseline cortisol level at beginning of cosyntropin
infusion. Inject cosyntropin with a plastic syringe and
collect blood samples in plastic heparinized tubes.
Administer test with continuous-infusion method.
Monitor site and rate of IV infusion. Ensure sample
collection at appropriate times.
Ensure that patient has fasted. Inform patient that blood
sample will be taken. Observe venipuncture site for
bleeding and hematoma formation. Do not test acutely
ill patients or those under stress. Stress-stimulated
ACTH may override suppression. Screen patient for
drugs such as estrogen and corticosteroids that may
give false-positive results. Ensure accurate timing of
medication and sample collection.
Ask about recent history of vigorous exercise, high
levels of stress, or starvation (may artificially levels).
Ingestion of caffeine, alcohol, levodopa, lithium, nitroglycerin, acetaminophen, and medications containing
epinephrine or norepinephrine can alter test.

Parathyroid scan

Adrenal Studies
Blood Studies

Adrenocorticotropic
hormone (ACTH)
(corticotropin)

ACTH stimulation with

cosyntropin

ACTH suppression
(dexamethasone
suppression)

Metanephrine

Assesses adrenal function, especially helpful if hyperactivity

(Cushing syndrome) is suspected. Overnight method:
Dexamethasone (Decadron) 1 mg (low dose) or 4 mg (high
dose) is given at 11 PM to suppress secretion of corticotropinreleasing hormone. Plasma cortisol sample is drawn at 8 AM.
Reference interval: Cortisol level <3 mcg/dL (<0.08 mol/L) for
low dose and <50% of baseline in high dose indicates normal
adrenal response.
Screens for pheochromocytoma more accurately than urinary
vanillylmandelic acid (VMA) and catecholamine measurements.

Urine Studies
17-Ketosteroids

Cortisol (free)

Vanillylmandelic acid

Measures androgen metabolites in urine and evaluates

adrenocortical and gonadal function.
Reference interval:
Male: 6-20 mg/day (20-70 mol/day)
Female: 6-17 mg/day (20-60 mol/day)
Measures free (unbound) cortisol. Preferred test to evaluate
hypercortisolism.
Reference interval: 20-90 mcg/24 hr (55-248 nmol/day)

Measures urinary excretion of catecholamine metabolite. Levels

are increased in pheochromocytoma.
Reference interval: 1.4-6.5 mg/24 hr (7-33 mol/day)

Instruct patient regarding 24-hr urine collection. Tell

patient that specimen must be kept refrigerated or iced
during collection. Determine whether preservative is
required.
Instruct patient about 24-hr urine collection and avoidance
of stressful situations and excessive physical exercise.
Some drugs (e.g., reserpine, diuretics, phenothiazines,
amphetamines) may elevate levels. Ensure that patient
is on low-sodium diet.
Keep 24-hr urine collection at pH <3.0 with HCl acid as
preservative. Keep on ice. Consult with laboratory or
physician about patient discontinuing any drugs 3 days
before urine collection.

Radiologic Studies
Computed
tomography (CT)
Magnetic resonance
imaging (MRI)
HCl acid, Hydrochloric acid.

Abdominal CT is radiologic examination of choice for the adrenal

gland. Used to detect tumor and size or metastatic spread.
Oral and/or IV contrast medium may be used.
Same as MRI above.

Inform patient of procedure. Patient must lie still during

the procedure. If IV contrast is used, check for iodine
allergy.
Same as MRI above.
Continued

1216

SECTION 10 Problems Related to Regulatory and Reproductive Mechanisms

TABLE 48-8

DIAGNOSTIC STUDIEScontd

Endocrine System
STUDY
Pancreatic Studies
Blood Studies

PURPOSE AND DESCRIPTION*

NURSING RESPONSIBILITY

Fasting blood glucose

(FBG)

Measures circulating glucose level.

Reference interval: 70-99 mg/dL (3.9-5.5 mmol/L)

Oral glucose tolerance

test (OGTT)

Used to diagnose diabetes mellitus, especially if FBG is

equivocal. Patient drinks 75 g of glucose; samples for glucose
are drawn at baseline and at 30, 60, and 120 min.
Reference interval: <100 mg/dL (5.5 mmol/L) at baseline,
<200 mg/dL (11.1 mmol/L) at 30 and 60 min, and
<140 mg/dL (7.8 mmol/L) at 120 min.
Values >200 mg/dL (11.1 mmol/L) at 120 min
are considered diagnostic for diabetes mellitus.

Glycosylated
hemoglobin
(Hb A1C)

Indicates the amount of glucose linked to hemoglobin.

Measures degree of glucose control during previous
2-3 mo.
Reference interval: 4.0%-6.0%

Patient should fast for at least 4-8 hr. Water intake is

permitted. If patient has an IV infusion containing
dextrose, test is not considered valid.
Ensure that tests are not done on patients who are
malnourished, confined to bed for over 3 days, or
severely stressed. Instruct patient to refrain from
smoking and caffeine and to fast (except water) for
8-12 hr before test. Ensure that patients diet 3 days
before test includes 150-300 g of carbohydrate with
intake of at least 1500 cal/day. Screen for estrogens,
phenytoin (Dilantin), and corticosteroids, and check for
hypokalemia, which may impair glucose tolerance.
Inform patient that fasting is not necessary and that blood
sample will be drawn. Observe venipuncture site for
bleeding or hematoma formation.

Urine Studies
Glucose

Estimate amount of glucose in urine by using an enzymatic

method. Dipstick is dipped into the urine and read for color
changes after 1 min.
Reference interval: Negative

Ketones

Measures amount of acetone excreted in urine as result

of incomplete fat metabolism. Tested with a dipstick as
described above. Positive result can indicate lack of insulin and
diabetic acidosis.
Reference interval: Negative

Use freshly voided urine specimen collected at appropriate time. Know that many different drugs alter
glucose readings and that errors are great if directions
for timing are not followed exactly. Follow package
directions.
Use freshly voided urine specimen. Test is often done
with glucose test. Directions must be followed exactly.
Certain drugs can produce false-positive and falsenegative results.

Radiologic Studies
Computed
tomography (CT)

Abdominal CT is the radiologic examination of choice for

pancreas. Used to identify tumors or cysts. Oral and/or
IV contrast medium may be ordered.

Inform patient of procedure. Patient must lie still during

the procedure. If IV contrast is used, check for iodine
allergy.

BP, Blood pressure; IV, intravenous; NPO, nothing by mouth.

(e.g., glucose tolerance). In these situations, it is often necessary

to obtain IV access to administer medications and fluids and to
draw multiple blood samples.
Pituitary Studies. Disorders associated with the pituitary
gland can manifest in a wide variety of ways because of the number of hormones produced. There are many diagnostic studies
that evaluate these hormones either directly or indirectly (see
Table 48-8).
Thyroid Studies. A number of tests are available to evaluate
thyroid function. The most sensitive and accurate laboratory
test is measurement of TSH; thus it is often recommended
as a first diagnostic test for evaluation of thyroid function.10
Common additional tests ordered in the presence of abnormal TSH include total T4, free T4, and total T3. Free T4 is the
unbound thyroxine and is a more accurate reflection of thyroid
function than total T4. Less common tests that help in the differentiation of various types of thyroid disease include T3, T3
uptake, thyroid antibodies, thyroglobulin, thyroid scanning,
ultrasound, and biopsy. These tests are done to help differentiate
various types of thyroid disorders.

Parathyroid Studies. The only hormone secreted by the parathyroid glands is PTH. Because the function of PTH is to regulate serum calcium and phosphate levels, abnormalities in PTH
secretion are reflected in the calcium and phosphate levels. For
this reason, diagnostic tests for the parathyroid gland typically
include PTH, serum calcium, and serum phosphate levels.
Adrenal Studies. Diagnostic tests associated with the adrenal
glands focus on the three types of hormones secreted: glucocorticoids, mineralocorticoids, and androgens. These hormone
levels can be measured both in blood plasma and in urine. If
urine studies are done, these will usually be done as 24-hour
urine collection. The major advantage of a 24-hour urine sample is that the short-term fluctuations in hormone levels seen in
plasma samples are eliminated.11
Pancreatic Studies. The tests found in Table 48-8 are used to
evaluate the metabolism of glucose. They are important in the
diagnosis and management of diabetes. (Diagnostic studies for
diabetes are also discussed in Chapter 49.)