Endocrine Disorders

The University of Jordan Faculty of Nursing
Chapter 52
Assessment and Management of Patients
with Endocrine Disorders
Dr. Ahmad Aqel RN, PhD

Endocrine System
Affects most cell, organ, and body functions
Closely linked with neurologic and immune systems
Negative feedback mechanism
Classification of hormones,
Amines and amino acids (e.g., epinephrine, nor-epinephrine,
nor and thyroid hormones)
Peptide (protein): act on cell surface (e.g., e.g., follicle-stimulating
follicle hormone [FSH])
Steroid: act inside the cell (e.g., corticosteroids)
Fatty acid derivative
Dr. Ahmad Aqel 2

Major Hormone-Secreting
Secreting Glands
Dr. Ahmad Aqel 3

Pituitary Gland: Hypophysis

Anterior Pituitary Gland Posterior Pituitary Gland
1. Follicle Stimulating Hormone (FSH), 1. ADH, vasopressin
2. Luteinizing Hormone (LH), 2. Oxytocin
3. Prolactin, Hyper: SIADH
4. Adenocorticotrophic Hormone (ACTH) Hypo: DI
5. Thyroid Stimulating Hormone( TSH),
Tumors: 95% benign
6. Growth Hormone ( GH)
Surgery: hypophysectomy
Hyper: Cushing syndrome, gigantism
(Childhood), acromegaly (adulthood)
Hypo: dwarfism, panhypopituitarism
Dr. Ahmad Aqel 4

specific gravity of urine: 1.015-1.030 (lower=dilute, higher=concentrated
Hyper secretion of GH Giganticism (childhood)

Acromegaly (adulthood)
Hypo secretion of GH Dwarfism

Hyper secretion of ADH SIADH
Hypo secretion of ADH Diabetes insipidus
Hyper secretion of ACTH Cushing's
Hypo of ACTH Addison's
Dr. Ahmad Aqel 5

Acromegaly
Excess GH, enlargement of peripheral body parts without height. In children is
Gigantism. can be caused by eosinophilic tumors.
Symp:: large hands, feet in adults, but in all organs if in the child.
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Dwarfism
caused by low GH. limited growth.
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Pituitary Gland and Hormones Secreted
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Pituitary Tumors
95% are benign.
Early in life result in Gigantism (
) .
The affected person are large in all proportions, weak (hardly stand). (in
( height).
During adult life, the excessive skeletal growth occurs only in the feet, the
hands, called Acromegaly (
) . (no height ).
Many suffer from severe headaches and visual disturbances because of
pressure on the optic nerves.
May give rise to Cushing syndrome (ACTH,
( hyperadrenalism) leading to
Masculinization and Amenorrhea ( ) in females.
Dr. Ahmad Aqel 9

Diabetes Insipidus
A disorder of the posterior lobe of the pituitary gland that is
characterized by A deficiency of ADH (vasopressin), excessive thirst
(polydipsia)) & large volumes of dilute urine.
May occur secondary to head trauma, brain tumor, or surgical ablation
or irradiation of the pituitary gland, failure of the renal tubule to
respond to ADH
Management: ADH replacement (Vasopressin), Fluid replacement,
identify and correct underlying intracranial pathology.
Monitor patient for electrolytes imbalances.
Patients with diabetes insipidus produce an enormous daily output of very dilute urine with a
specific gravity of 1.001 to 1.005.
Dr. Ahmad Aqel 10

Syndrome of Inappropriate Anti-diuretic

Anti Hormone
Secretion (SIADH)
Excessive ADH secretion from the pituitary gland even in case of subnormal
serum osmolality.
Patients cannot excrete a dilute urine, retain fluids, and develop a sodium
deficiency known as dilutional hyponatremia.
hyponatremia
SIADH is often of nonendocrine origin; for instance, the syndrome may occur
in patients with bronchogenic carcinoma in which malignant lung cells
synthesize and release ADH.
Dr. Ahmad Aqel 11

Syndrome of Inappropriate Anti-diuretic

Anti Hormone
Secretion (SIADH)
SIADH has also occurred in patients with severe pneumonia,
pneumothorax,, and other disorders of the lungs, as well as malignant
tumors that affect other organs.
Interventions include eliminating the underlying cause, if possible,

and restricting fluid intake
Dr. Ahmad Aqel 12

Thyroid
Thyroid hormones: T3, T4, calcitonin
Iodine is contained in thyroid hormone (T3,
(T T4)
TSH from the anterior pituitary controls the release of thyroid hormone
Controls cellular metabolic activity
T3 is more potent and rapid-acting
acting than T4
Thyroid hormones affect every major organ and tissue function, including
the basal metabolic rate, tissue thermogenesis,
thermogenesis serum cholesterol levels,
and vascular resistance.
Calcitonin is secreted in response to high plasma calcium level and increases
calcium deposit in bone
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Thyroid Gland
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HypothalamicPituitaryThyroid
Thyroid Axis
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Thyroid Diagnostic Tests

TSH stimulates thyroid to release T3 and T4 Fine-needle biopsy
Serum-free T4 Thyroid scan (radioscan, or scintiscan)
- free T4 tests used to evaluate thyroid function and Serum thyroglobulin
diagnose thyroid diseases, usually after TSH level is
abnormal. Refer to Chart 52-2 for medications that can
alter test results
T3 and T4
T4 resin uptake
Thyroid antibodies
Radioactive iodine uptake
Dr. Ahmad Aqel 16

Thyroid Disorders
Cretinism:
- stunted physical and mental growth due to untreated congenital deficiency of thyroid
hormones due to maternal hypothyroidism
Hypothyroidism
Hyperthyroidism
Thyroiditis
Goiter : non cancer enlargement of thyroid gland.
Thyroid cancer
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Hypothyroidism
Hashimotos disease (autoimmune thyroiditis) (most common cause):
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Hypothyroidism
Affects women 5X X more frequently than men
Early symptoms may be nonspecific. May include ( ( HR, Temp, Menstrual
disturbances, feels cold, fatigue)
Severe hypothyroidism is associated with an elevated serum cholesterol
level, atherosclerosis, coronary artery disease, and poor left ventricular
function.
Complications: myxedema (severe deficincy)
deficincy , may progress to stupor, coma, and
death. Myxedema refers to the accumulation of mucopolysaccharides in
subcutaneous and other interstitial tissues ( ( thick skin) .
Dr. Ahmad Aqel 19

Myxedema coma:
occurs most often among older women in the winter months and appears to be
precipitated by cold.
In myxedema coma, , the patients respiratory drive is depressed, resulting in
alveolar hypoventilation, progressive carbon dioxide retention, narcosis, and
coma.
In addition patients with myxedema coma can also exhibit hyponatremia,
hypoglycemia, hypoventilation, hypotension, bradycardia, and hypothermia.
Mortality rate is high at 30% to 40%.
Refer to Plan of Nursing Care, Chart 52-4
4 (Very important).
The major use of iodine in the body is by the thyroid.
Iodized table salt is a source of iodine.
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Dr. Ahmad Aqel 21

Medical Management of Hypothyroidism

Synthetic levothyroxine replacement therapy
Medication interactions; Oral thyroid hormones interact with many
other medications.
Effects of hypnotic and sedative agents; reduce dosage
Support of cardiac function and respiratory function
Prevention of complications
Dr. Ahmad Aqel 22

Hyperthyroidism
Second most prevalent endocrine disorder
Affects women 8x than men
Graves disease
autoimmune disorder result from excessive thyroid hormones caused by abnormal stimulation of
the thyroid gland by circulating immunoglobulin
most common cause
Thyrotoxicosis:
excessive output of thyroid hormone (thyroid storm)
Clinical Manifestations
Nervousness; rapid pulse; heat intolerance;
intolerance tremors; skin flushed, warm, soft, and
moist; exophthalmos; increased appetite (encourage small frequent meal, high in
protein); weight loss;; elevated systolic BP; cardiac dysrhythmias
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Exophthalmos
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Hyperthyroidism
Assessment and Diagnostic Findings
Thyroid gland is enlarged; it is soft and may pulsate; a thrill may be
felt and a bruit heard over thyroid arteries.
Laboratory tests show a decrease in serum TSH, increased free T4,
and an increase in radioactive iodine uptake.
Dr. Ahmad Aqel 26

Medical Management of Hyperthyroidism

Radioactive 131I therapy (destroys thyroid cells)
Medications: Refer to Table 52-3
52
Propylthiouracil and methimazole
Sodium or potassium iodine solutions
Dexamethasone
Beta-blockers (to decrease heart rate, systolic blood pressure, muscle weak-ness,
weak
nervousness, tremor, anxiety, and heat intolerance. )
Surgery; subtotal thyroidectomy
Disease or treatment may result in hypothyroidism
Dr. Ahmad Aqel 27
Hyperthyroidism
Assessment
Obtain a health history, including family history of hyperthyroidism, and
note reports of irritability or increased emotional reaction and the impact
of these changes on patients interaction with family, friends, and
coworkers.
Assess stressors and patients ability to cope with stress.
Evaluate nutritional status and presence of symptoms; note excessive
nervousness and changes in vision and appearance of eyes.
Assess and monitor cardiac status periodically (heart rate, blood pressure,
heart sounds, and peripheral pulses).
Assess emotional state and psychological status.
Dr. Ahmad Aqel 28

Hyperthyroidism
Nursing Diagnoses
Imbalanced nutrition: Less than body requirements related to exaggerated metabolic
rate, excessive appetite, and increased gastrointestinal activity
Ineffective coping related to irritability, hyperexcitability,
hyperexcitability apprehension, and emotional
instability
Low self-esteem related to changes in appearance, excessive appetite, and weight loss
Altered body temperature Goals
improved nutritional status,
Potential Complications improved coping ability,
improved self-esteem,
Thyrotoxicosis or thyroid storm Maintenance of normal body temperature, and
Hypothyroidism absence of complications.
Dr. Ahmad Aqel 29

Hyperthyroidism
Nursing Interventions
Improving Nutritional Status
Provide several small, well-balanced
balanced meals (up to six meals a day) to
satisfy patients increased appetite.
Replace food and fluids lost through diarrhea and diaphoresis, and
control diarrhea that results from increased peristalsis.
Reduce diarrhea by avoiding stimulants such as coffee, tea, cola, and
alcohol; encourage high-calorie,
calorie, high-protein
high foods.
Provide quiet atmosphere during mealtime to aid digestion.
Record weight and dietary intake daily.
Dr. Ahmad Aqel 30
Hyperthyroidism / Nursing Intervention

Enhancing Coping Measures
Reassure the patient that the emotional reactions being experienced are a result
of the disorder and that with effective treatment those symptoms will be
controlled.
Reassure family and friends that symptoms are expected to disappear with
treatment.
Maintain a calm, unhurried approach, and minimize stressful experiences.
Keep the environment quiet
Provide information regarding thyroidectomy and preparatory pharmacotherapy
to alleviate anxiety.
Assist patient to take medications as prescribed and encourage adherence to the
therapeutic regimen.
Provide written instructions
Dr. Ahmad Aqel 31

Improving Self-Esteem
Convey to patient an understanding of concerns regarding problems with
appearance, appetite, and weight, and assist in developing coping
strategies.
Provide eye protection if patient experiences eye changes secondary to
hyperthyroidism; instruct regarding correct instillation of eyedrops or
ointment to soothe the eyes and protect the exposed cornea. Discourage
smoking.
Arrange for patient to eat alone, if desired and if embarrassed by the large
meals consumed due to increased metabolic rate. Avoid commenting on
intake.
Dr. Ahmad Aqel 32


Maintaining Normal Body Temperature
Provide a cool, comfortable environment and fresh bedding and gown
as needed.
Give cool baths and provide cool fluids;
fluids monitor body temperature.
Dr. Ahmad Aqel 33

Thyroid storm (thyrotoxic crisis)

A form of severe hyperthyroidism,
A life-threatening condition, abrupt onset
characterized by:
high fever (hyperpyrexia), extreme tachycardia, and altered mental state(delirium).
Precipitated by stress (injury,, infection, surgery, tooth extraction, DKA,
pregnancy, digitalis intoxication,, abrupt withdrawal of antithyroid drugs,
extreme emotional stress, or vigorous palpation of the thyroid.
These factors precipitate thyroid storm in the partially controlled or
completely untreated patient with hyperthyroidism.
Dr. Ahmad Aqel 34

Thyroid storm (Clinical Manifestations)

Manifestations
High fever (hyperpyrexia) above 38.5C
38
Extreme tachycardia (more than 130 beats/min)
Exaggerated symptoms of hyperthyroidism (weight loss, diarrhea,
abdominal pain) or (edema, chest pain, dyspnea, palpitations)
Altered neurologic or mental state, which frequently appears as
delirium psychosis or coma.
Dr. Ahmad Aqel 35

Thyroid storm (Medical

Medical Management)
Immediate objectives: to reduce temp, HR and prevent vascular collapse.
A hypothermia mattress or blanket, ice packs, cool environment, and acetaminophen
(Tylenol).
Humidified oxygen to improve tissue oxygenation and meet high metabolic demands,
Intravenous fluids (dextrose) to replace glycogen stores.
Hydrocortisone to treat shock or adrenal insufficiency.
Propylthiouracil (PTU) or methimazole to prevent formation of thyroid hormone.
Hydrocortisone to treat shock or adrenal insufficiency.
insufficiency
Iodine to decrease output of thyroxine (T4)) from thyroid gland.
Propranolol, combined with digitalis for cardiac problems.
Salicylates are not used in the management of thyroid storm because they displace
thyroid hormone from binding proteins and worsen the hypermetabolism.
Dr. Ahmad Aqel 36

Thyroid storm (Nursing Management)

Observe patient carefully and provide aggressive and supportive
nursing care during and after acute stage of illness.
Care provided for the patient with hyperthyroidism is the basis for
nursing management of patients with thyroid storm.
Dr. Ahmad Aqel 37

Question
Which medication blocks synthesis
of thyroid hormone?
A. Dexamethasone
B. Methimazole
C. Potassium iodide
D. Sodium iodide
Methimazole blocks synthesis of thyroid hormone.
Dexamethasone, potassium iodide, and sodium
iodide suppress release of thyroid hormone.
Dr. Ahmad Aqel 38

Thyroid Tumors
Might be benign or malignant.
If the enlargement is sufficient to cause a visible swelling in the neck, the
tumor is referred to as a goiter.
If goiter is associated with hyperthyroidism it is described as toxic. If it is not,
it is described as non-toxic.
Causes: Iodine deficiency, Graves' disease, Hashimoto's disease, ... etc
The introduction of iodized salt has been the single most effective means of
preventing goiter in at-risk
risk populations.
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Dr. Ahmad Aqel 40

Cancer of the thyroid

Less prevalent than other forms of cancer.
cancer
The most common type, papillary adenocarcinoma
Accounts for more than half of thyroid malignancies; it starts in childhood
or early adult life, remains localized, and eventually metastasizes.
When papillary adenocarcinoma occurs in an elderly patient, it is more
aggressive.
Risk factors include female gender and external irradiation of the head,
neck, or chest in infancy and childhood.
Lesions that are single, hard, and fixed on palpation or associated with cervical
lymphadenopathy suggest malignancy.
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Cancer of the thyroid/ Assessment and Diagnostic

Needle biopsy or aspiration biopsy of thyroid gland
Thyroid function tests
Ultrasound,, MRI, CT scan, thyroid scans, radioactive iodine uptake
studies, and thyroid suppression tests
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Cancer of the thyroid/ Medical Management

Treatment of choice is surgical removal (total or near-total thyroidectomy).
Modified or extensive radical neck dissection is done if lymph nodes are
involved.
Radioactive iodine is used to eradicate residual thyroid tissue.
Thyroid hormone is administered in suppressive doses after surgery to
lower the levels of thyroid-stimulating
stimulating hormone (TSH) to a euthyroid state.
Lifelong thyroxin is required if remaining thyroid tissue is inadequate to
produce sufficient hormone.
Radiation therapy.
Chemotherapy is used only occasionally.
Dr. Ahmad Aqel 43

Cancer of the thyroid/ Nursing Management

Inform the patient about
the purpose of any preoperative tests,
what preoperative preparations to expect; teaching includes demonstrating to the patient how to support the neck
with the hands after surgery to prevent stress on the incision.
Provide postoperative care
assess and reinforce surgical dressings, observe for bleeding, monitor pulse and BP for signs of internal bleeding,
assess respiratory status, assess pain and administer analgesics as prescribed).
Monitor and observe for potential complications (hemorrhage, hematoma formation, edema of
the glottis, and injury to the recurrent laryngeal nerve).
Explains to the patient and family the need for rest, relaxation, and nutrition; patient can resume
former activities and responsibilities once recovered from surgery.
Dr. Ahmad Aqel 44

Thyroidectomy
Treatment of choice for thyroid cancer
Modified or radical neck dissection, possible radioactive iodine to minimize
metastasis
Preoperative goals: reduction of stress and anxiety to avoid precipitation of
thyroid storm
Preoperative education: dietary guidance to meet patient metabolic needs,
avoidance of caffeinated beverages and other stimulants, explanation of
tests and procedures, and head and neck support used after surgery
Dr. Ahmad Aqel 45

Postoperative Care
Monitor respirations; potential airway impairment
Monitor for potential bleeding and hematoma formation; check posterior
dressing
Assess pain and provide pain relief measures
Semi-Fowlers position,, with the head elevated and supported by pillows.
Assess voice, discourage talking
Potential hypocalcaemia related to injury or removal of parathyroid glands;
refer to Chart 52-6
Dr. Ahmad Aqel 46

Parathyroid Glands
Four glands on the posterior
thyroid gland
Parathormone regulates calcium
and phosphorus balance
Increased parathormone elevates
blood calcium by increasing
calcium absorption from the
kidney, intestine, and bone
Parathormone lowers phosphorus
level
Dr. Ahmad Aqel 47

Hyperparathyroidism (Overproduction
Overproduction of Parathormone)
Primary hyperparathyroidism: Management:
Management
Two to four times more frequent in Parathyroidectomy,
women than men
Hydration therapy (2L daily) [help
Secondary hyperparathyroidism prevent renal calculi],
Occurs in patients with chronic kidney Encourage mobility as tolerated (Bones
failure as a result of phosphorus
retention, increased stimulation of the subjected to the normal stress of walking
parathyroid gland give up less calcium).
Clinical manifestations: Encourage fluid, restrict calcium
Elevated serum calcium, bone decalcification,
renal calculi, apathy, fatigue, muscle Hypercalcemic crisis (> 13 mg/dl); results in
weakness, nausea, vomiting, constipation, neurologic, cardiovascular, and kidney
hypertension, cardiac dysrhythmias,
psychological manifestations symptoms that can be life threatening.
threatening
Dr. Ahmad Aqel 48

Hypoparathyroidism
Parathormone deficiency caused by surgery
surgery thyroidectomy,
parathyroidectomy,, or radical neck dissection
Results in hypocalcaemia and hyperphosphatemia.
hyperphosphatemia
Tetany,, numbness, tingling in extremities, stiffness of hands and feet,
bronchospasm, laryngeal spasm, carpopedal spasm, anxiety, irritability,
depression, delirium, ECG changes
Positive Chvosteks and Trousseaus signs
Care of postoperative patients having a parathyroidectomy is directed toward detecting early signs of
hypoparathyroidism and subsequent hypocalcemia and anticipating signs of tetany, seizures, and
respiratory difficulties
Dr. Ahmad Aqel 49

Chvosteks signs Trousseaus signs
Dr. Ahmad Aqel 50


Tetany is suggested by a positive Trousseaus sign or
a positive Chvosteks sign (tetany noted with serum calcium
5 to 6 mg/dL [1.2 to 1/5 mmol/L]/L] or lower).
increased serum phosphate
Dr. Ahmad Aqel 51

Medical Management of Hypoparathyroidism

Goal: to Raise Serum calcium level to 9 to 10 mg/dL
When hypocalcemia and tetany occur after thyroidectomy,
IV calcium gluconate is given immediately. Sedatives (pentobarbital
pentobarbital) may be administered.
Parenteral parathormone may be given if osteoporosis occur,
watching for an allergic reaction and changes in serum calcium levels.
Neuromuscular irritability is reduced by providing quite environment that is free of noise, bright lights
Tracheostomy or mechanical ventilation may become necessary if the patient develops respiratory distress.
Diet high in calcium and low in phosphorus.
Patient should avoid milk, milk products, egg yolk, because they contain high level of phosphorus and avoid spinach because it
contain oxylate which would form insoluble calcium .
Oral calcium tablets and vitamin D
Aluminum hydroxide or aluminum carbonate after meals to bind phosphorus and promote its excretion from the GIT.
Thiazide diuretics (hydrochlorothiazide) to decrease urinary calcium excretion
Dr. Ahmad Aqel 52

Nursing Management of Hypoparathyroidism

Detecting early signs of hypocalcemia and anticipate signs of tetany, seizures, and
respiratory difficulties.
Keep calcium gluconate at the bedside; if patient has a cardiac disorder, is subject
to dysrhythmias, or is receiving digitalis,, the calcium gluconate is administered
slowly and cautiously.
Provide continuous cardiac monitoring and careful assessment;
calcium and digitalis increase systolic contraction and also potentiate each other; this can
produce potentially fatal dysrhythmias
Teach patient about medications and diet therapy
Dr. Ahmad Aqel 53

Question
Is the following statement true or false?
A patient in acute hypercalcemic crisis requires close monitoring for
life-threatening
threatening complications and prompt treatment to reduce serum
calcium levels. (True)
Dr. Ahmad Aqel 54

Adrenal Glands
Adrenal medulla
Functions as part of the autonomic
nervous system
Catecholamines: (epinephrine and
norepinephrine)
Adrenal cortex
Glucocorticoids (cortisol)
Mineralocorticoids (aldosterone)
Androgens (male sex hormones)
Dr. Ahmad Aqel 55

Adrenocortical Insufficiency/Addisons disease

Hyposecretion of Aldosterone & Cortisol
occurs when the adrenal cortex function is inadequate to meet the patients need for
cortical hormones.
Autoimmune or idiopathic atrophy of the adrenal glands is responsible for the vast
majority of cases.
Other causes include:
surgical removal of both adrenal glands or infection (tuberculosis
( or histoplasmosis) of
the adrenal glands.
Inadequate secretion of adrenocorticotropic hormone (ACTH) from the primary pituitary
gland also results in adrenal insufficiency.
Therapeutic use of corticosteroids is the most common cause of adrenocortical
insufficiency.
Symptoms may also result from sudden cessation of exogenous adrenocortical hormonal
therapy,, which interferes with normal feedback mechanisms.
Dr. Ahmad Aqel 56

Muscle weakness, anorexia,, GI symptoms, fatigue, dark pigmentation
of the skin and mucous membranes, hypotension, low blood glucose,
low serum sodium, and high serum potassium.
The onset usually occurs with nonspecific symptoms. Mental changes
(depression, emotional lability,, apathy, and confusion) are present in
60% to 80% of patients.
In severe cases, disturbance of sodium and potassium metabolism
may be marked by depletion of sodium and water and severe, chronic
dehydration.
Dr. Ahmad Aqel 57

Addisonian Crisis
This medical emergency develops as the disease progresses.
Signs and symptoms include the following:
Cyanosis and classic signs of circulatory shock: pallor, apprehension,
rapid and weak pulse, rapid respirations, and low blood pressure.
Headache,, nausea, abdominal pain, diarrhea, confusion, and
restlessness.
Slight overexertion, exposure to cold, acute infections, or a decrease
in salt intake may lead to circulatory collapse, shock, and death.
Stress of surgery or dehydration from preparation for diagnostic tests
or surgery may precipitate addisonian or hypotensive crisis.
Dr. Ahmad Aqel 58


Greatly increased plasma ACTH (more than 22.0 pmol/L)
serum cortisol level lower than normal (less than 165 nmol/L) or in
the low-normal range
decreased blood glucose (hypoglycemia
hypoglycemia) and sodium (hyponatremia)
levels, increased serum potassium concentration (hyperkalemia), and
increased WBC count (leukocytosis).
Dr. Ahmad Aqel 59

Medical Management
Immediate treatment is directed toward combating circulatory shock:
Restore blood circulation, administer fluids and corticosteroids, monitor
vital signs, and place patient in a recumbent position with legs elevated.
Administer IV hydrocortisone, followed by 5% dextrose in normal saline.
Vasopressor may be required if hypotension persists.
Antibiotics may be administered if infection has precipitated adrenal crisis.
Oral intake may be initiated as soon as tolerated.
If adrenal gland does not regain function, lifelong replacement of
corticosteroids and mineralocorticoids is required.
Dietary intake should be supplemented with salt during times of GI losses
of fluids through vomiting and diarrhea.
Dr. Ahmad Aqel 60

The development of edema

or weight gain may signify
too high a dose of hormone;
postural hypotension
(decrease in systolic blood
pressure, light-headedness,
dizziness on standing) and
weight loss may indicate too
low a dose.
Dr. Ahmad Aqel 61

Nursing Management
Assessment focuses on fluid imbalance and stress.
Monitor BP and pulse to assess for inadequate fluid volume.
Assess skin color and turgor.
Assess Hx of weight changes, muscle weakness, and fatigue.
onset of illness or increased stress that may have precipitated crisis.
Dr. Ahmad Aqel 62

Monitoring and Managing Addisonian Crisis

Monitor for S&S indicative of addisonian crisis (shock;
(shock hypotension; rapid, weak pulse;
rapid respiratory rate; pallor; and extreme weakness).
Avoid stressors (cold exposure, overexertion, infection, and emotional distress).
Treat addisonian crisis with IV fluid,, glucose, and electrolytes, especially sodium; steroid
hormones; and vasopressors.
Dr. Ahmad Aqel 63

Restoring Fluid Balance

Consume foods and fluids to maintain fluid and electrolyte balance .
select foods high in sodium during GI tract disturbances and in very hot weather.
administer hormone replacement as prescribed
Provide written and verbal instructions about the administration of
mineralocorticoid (Florinef) or corticosteroid (prednisone)
(prednisone as prescribed.
Dr. Ahmad Aqel 64

Improving Activity Tolerance

Avoid unnecessary activities and stress that might precipitate a
hypotensive episode.
Detect signs of infection or presence of stressors that may have
triggered the crisis.
Explain rationale for minimizing stress during acute crisis.
Dr. Ahmad Aqel 65

Teaching Patients Self-Care

verbal and written instructions about the rationale for replacement therapy and
proper dosage.
Teach patient and family how to modify drug dosage and increase salt intake in
times of illness, very hot weather, and stressful situations.
Instruct patient to modify diet and fluid intake to maintain fluid and electrolyte
Provide instructions on single-injection
injection syringes of corticosteroid for use in
emergencies.
Advise patient to inform health care providers (eg,
( dentists) of steroid use.
Dr. Ahmad Aqel 66

Cushing Syndrome
(Excessive
Excessive adrenocortical activity or corticosteroid medications)
Remember the mnemonic: STRESSED (remember there is too
much of the STRESS hormone CORTISOL)
Skin fragile, Weakness, Lassitude (lack of energy), acne
Trunk obesity & thin extremities, Osteoporosis, muscle wasting
Round face (moon-face)
Ecchymosis, elevated BP (hypertension)
Striae on extremities and abdomen,
Sugar (hyperglycemia), susceptible to infection; slow healing
Excessive body hair especially in womenand Hirsutism (women
starting to have male characteristics), loss of libido, Electrolytes
imbalance: hypokalemia, hypernatremia
Dorsocervical fat pad (Buffalo hump), Depression, disturbance in
sleep, mood changes
Dr. Ahmad Aqel 67

Dr. Ahmad Aqel 68

Cushing Syndrome
Diagnosis:
serum cortisol, urinary cortisol,
Dexamethasone suppression test.
Dexamethasone (1 mg or 8mg) mg) is administered orally at 11 pm, and a plasma
cortisol level is obtained at 8 AM the next morning , less than 5mg indicate
hypothalamic-pituitary adrenal
adrenal axis is functioning properly
Dr. Ahmad Aqel 69

Cushing Syndrome
Management:
Surgical removal of the tumor
Radiation
Adrenalectomy
Postoperative symptoms of adrenal insufficiency may appear.
Temporary replacement therapy with hydrocortisone may be
necessary for several months
Dr. Ahmad Aqel 70

Cushing Syndrome/Nursing Care

Assessment
Activity level and ability to carry out self-care
self
Skin assessment
Changes in physical appearance and patient responses to these changes
Mental function
Emotional status
Medications
Dr. Ahmad Aqel 71

Cushing Syndrome/ Nursing Diagnosis

Risk for injury related to weakness (the highest priority)
Risk for infection
Self-care deficit
Impaired skin integrity
Disturbed body image
Disturbed thought processes
Dr. Ahmad Aqel 72

Collaborative Problems and Complications

Addisonian crisis
Adverse effects of adrenocortical activity
Dr. Ahmad Aqel 73

Nursing Care of the Patient With Cushing Syndrome

Syndrome
Planning and Interventions
Goals may include: Patient and family education
Present information about Cushing syndrome verbally and in
decreased risk of injury,
writing
decreased risk of infection, Stress on stopping corticosteroid use abruptly can result in adrenal
increased ability to carry out insufficiency and reappearance of symptoms.
self-care activities, Emphasize the need to keep an adequate supply of the
improved skin integrity, corticosteroid to prevent running out or skipping a dose, because
this could result in addisonian crisis.
improved body image,
improved mental function, Stress the need for dietary modifications to ensure adequate
calcium intake without increasing risk for hypertension,
absence of complications hyperglycemia, and weight gain.
: Teach patient and family to monitor blood pressure, blood glucose
levels, and weight.
weight
Dr. Ahmad Aqel 74
Corticosteroid Therapy
Suppress inflammation and autoimmune response, control allergic
reactions, and reduce transplant rejection
Medications: refer to Table 52-4
Patient education: refer to Table 52-5
5
Timing of doses (at 8 am, when the adrenal gland is most active. This is the physiological time of
corticosteriods).
Need to take as prescribed, tapering required to discontinue or reduce therapy (to
allow normal adrenal function to return and to prevent steroid-induced
steroid adrenal insufficiency).
Potential side effects and measures to reduce side effects (Table 52-5)
Dr. Ahmad Aqel 75

Question
Is the following statement true or false?
Oversecretion of adrenocorticotropic hormone (ACTH) or the growth

hormone results in Graves disease.
Dr. Ahmad Aqel 76

Answer
False
Oversecretion of ACTH or growth hormone results in Cushing disease.

Graves disease results from an excessive output of thyroid hormones
caused by abnormal stimulation of the thyroid gland by circulating
immunoglobulins.
Dr. Ahmad Aqel 77

Endocrine Disorders

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Endocrine Disorders

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The University of Jordan Faculty of Nursing

Dr. Ahmad Aqel RN, PhD

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Pituitary Gland: Hypophysis

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specific gravity of urine: 1.015-1.030 (lower=dilute, higher=concentrated

Hyper secretion of GH Giganticism (childhood)

Hypo secretion of GH Dwarfism

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Pituitary Gland and Hormones Secreted

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Syndrome of Inappropriate Anti-diuretic

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Syndrome of Inappropriate Anti-diuretic

Interventions include eliminating the underlying cause, if possible,

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Thyroid Diagnostic Tests

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Medical Management of Hypothyroidism

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Medical Management of Hyperthyroidism

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Hyperthyroidism / Nursing Intervention

Hyperthyroidism / Nursing Intervention

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Hyperthyroidism / Nursing Intervention

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Thyroid storm (thyrotoxic crisis)

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Thyroid storm (Clinical Manifestations)

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Thyroid storm (Medical

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Thyroid storm (Nursing Management)

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Cancer of the thyroid

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Cancer of the thyroid/ Assessment and Diagnostic

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Cancer of the thyroid/ Medical Management

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Cancer of the thyroid/ Nursing Management

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