Nursing Care of Clients with Endocrine Disorders

I. Multiple problems when caring for clients with endocrine disorders

A. Multiple diagnostic tests that can be exhausting
B. Changing physical appearance and emotional responses
C. Permanent lifestyle changes
II. Disorders of the Thyroid land
A. !ystems affected
". Metabolism
#. Cardio$ascular
%. astrointestinal
&. 'euromuscular
B. Clients with (yperthyroidism )Thyrotoxicosis*
". Definition+ excessi$e deli$ery of thyroid hormone to peripheral tissues
#. Pathophysiology
a. Autoimmune reactions )ra$e,s disease*
b. -xcess secretion of T!( from pituitary gland
c. 'eoplasms )toxic multinodular goiter*
d. Thyroiditis
e. -xcessi$e inta.e of thyroid medications
%. !igns and symptoms
a. Metabolism
". (ypermetabolism
#. Increased appetite with weight loss
%. (eat intolerance/ increased sweating
b. Cardio$ascular
". !ystolic hypertension
#. Tachycardia/ atrial fibrillation
%. Dysrhythmias/ palpitations
&. Possibly angina/ congesti$e heart failure
c. astrointestinal
". Increased peristalsis with diarrhea
#. (yperacti$e bowel sounds
d. 'euromuscular
". 'er$ousness/ restlessness
#. Insomnia
%. 0ine tremor
&. -motional lability )mood swings*
e. 1ther
". 0ine hair
#. !mooth and warm s.in
&. !pecific conditions
a. ra$es, disease
". Most common cause of hyperthyroidism
Melchor !al$osa/ 2'
"34"54#3"&
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#. Antibody against T!( receptor site
%. Cause un.nown/ but hereditary lin.
&. More common in females aged #3 6 &3
7. !igns and symptoms
a. !igns of hyperthyroidism plus
b. -nlarged thyroid gland )goiter*
c. Proptosis )forward displacement of eyes*
causing blurred $ision/ diplopia/ lacrimation/
photophobia
d. -xophthalmos )forward protrusion of eyes*
causing corneal dryness/ irritation/ ulceration
e. Changes in menstruation
b. Toxic Multinodular oiter
". 'odules in thyroid tissue secrete excessi$e thyroid
hormone
#. 8sually female in 93 6 :3,s/ has had goiter for a
number of years
c. Thyroiditis
". ;iral infection of thyroid
#. May become chronic and lead to hypothyroidism
d. Thyroid Crisis )Thyroid storm*
". -xtreme state of hyperthyroidism< rare now
#. 1ccurs with untreated hyperthyroidism or hyperthyroid
person with stressor li.e infection/ trauma<
manipulation of thyroid during surgery
%. =ife>threatening condition with excess metabolic
symptoms such astemperature ele$ation to "3# 6 "39/
hypertension/ tachycardia/ and agitation ad$ancing to
sei?ures/ psychosis/ delirium
&. Treatment includes reducing thyroid secretion/
stabili?ing cardio$ascular system/ and managing
respiratory distress
7. Diagnostic tests
a. !erum thyroid antibodies )TA*+ antibodies in ra$es, disease
b. T!( test+ )from pituitary* suppressed with primary
hyperthyroidism
c. T% and T&+ ele$ated for diagnosis of hyperthyroidism/
thyroiditis
d. T% upta.e test< ele$ated with hyperthyroidism
e. 2AI upta.e test
". 1ral or intra$enous dose of radioacti$e iodine )"%"I*
gi$en to client
#. Thyroid scan after #& hours
%. !i?e and shape of gland re$ealed
&. 8pta.e is increased with ra$e,s disease
f. Thyroid suppression test
Melchor !al$osa/ 2'
"34"54#3"&
#
". 2AI and T& measured and then remeasured after client
ta.es thyroid hormone
#. 'o suppression with hyperthyroid
9. Treatment of hyperthyroidism
a. Medications
". Antithyroid medications+ bloc. synthesis of thyroid
hormones
a. Propylthiouracil )PT8*
b. Methima?ole )Tapa?ole*
#. Beta>adrenergic bloc.ers+ control symptoms
)tachycardia/ tremor/ etc.*
a. Propanolol )Inderal*
b. Atenolol )Tenormin*< for those with cardiac or
asthma problems
b. 2adioacti$e Iodine Therapy
". Process+
a. Iodine is ta.en up by thyroid
b. Concentrates in the thyroid gland and destroys
cells
c. =ess hormone is produced
d. Dose gi$en orally
e. 2esults occur in 9 to @ wee.s
#. 'ot to be gi$en to pregnant women
%. Client often hypothyroid after treatment
c. !urgery
". !ubtotal thyroidectomy+ only part of thyroid remo$ed
#. Total thyroidectomy to treat cancer of thyroid+ client
will need life>long thyroid replacement
%. Prior to surgery+ get client into euthyroid state
&. Iodine )Potassium Iodide* gi$en prior to surgery to
decrease si?e and $ascularity of thyroid
7. Post>op concerns
a. Airway+ maintain airway< oxygen/ suction/
tracheostomy set a$ailable
b. (emorrhage+ chec. nec. dressing including
posteriorly< could compress trachea
c. (ypocalcemia+ parathyroid glands may be
remo$ed or damaged< resulting in low calcium<
ha$e Calcium Chloride or Calcium luconate
a$ailable
:. 'ursing Diagnoses
a. 2is. for Decreased Cardiac 1utput
b. Disturbed !ensory Perception+ ;isual
". Inter$entions to protect eye from corneal irritation and
to maintain moisture
#. =ubricants and taping eyes shut at night
Melchor !al$osa/ 2'
"34"54#3"&
%
c. Imbalanced 'utrition>=ess than body reAuirements+ Diet high
in protein and calories
d. Disturbed Body Image+ -xophthalmos may continue post
treatment
@. 'ursing Care+ Client teaching regarding
a. Medications
b. !igns and symptoms of altered thyroid function
c. (yperthyroid client at ris. for hypothyroid post treatment
C. Clients with (ypothyroidism
". Definition
a. Thyroid gland produces insufficient amount of thyroid
hormone
b. Myxedema+ characteristic accumulation of nonpitting edema in
connecti$e tissues throughout body< water retention in
mucoprotein deposits in interstitial spaces
c. More common females aged %3 6 93
#. Pathophysiology
a. Primary )more common*
". Defect in thyroid gland
#. Congenital defects
%. Post treatment of hyperthyroidism
&. Thyroiditis
7. Iodine deficiency
b. !econdary
". Deficiency in T!( )pituitary gland*
#. Peripheral resistance to thyroid hormones
%. !igns and !ymptoms+ !low onset o$er months to years
a. Metabolism+ slowed
". Intolerance to cold
#. !leepiness
%. 0atigue/ wea.ness
b. Cardio$ascular
". Bradycardia/ alterations in blood pressure
#. Tendency for de$elopment of congesti$e heart failure/
myocardial infarction
c. astrointestinal
". -nlarged tongue/ anorexia/ $omiting
#. Constipation
d. 'euromuscular+ Apathy/ slow mo$ement and thin.ing
e. 1ther
". oiter+ thyroid gland enlarges in attempt to produce
more hormone
#. -dema in hands/ feet/ face< dry s.in and hair
& !pecific Conditions
a. Iodine Deficiency
". Dietary foods grown in iodine poor soil
Melchor !al$osa/ 2'
"34"54#3"&
&
#. 8se of non>iodi?ed salt
%. Medications/ such as lithium carbonate/ amiodarone
)Cordarone*
b. (ashimoto,s Thyroiditis
". Autoimmune disorder
#. Antibodies produced against thyroid tissue
c. Myxedematous coma
". =ife>threatening complication of long>standing and
untreated hypothyroidism
#. (yponatremia/ hypoglycemia/ acidosis
%. Precipitated by stressors/ failure to ta.e thyroid
replacement meds
&. Treatment includes restoring balance throughout
systems and increasing thyroid hormone le$els
7. Diagnostic Tests
a. !erum thyroid antibodies )TA*+ antibodies in (ashimoto,s
Thyroiditis
b. T!( test+ )from pituitary* ele$ated with primary
hypothyroidism
c. T% and T&+ decreased for diagnosis of hypothyroidism
d. T% upta.e test< decreased with hypothyroidism
e. 2AI upta.e test
". 1ral or intra$enous dose of radioacti$e iodine )"%"I or
"#%I* gi$en to client
#. Thyroid scanned after #& hours
%. 8pta.e decreased with hypothyroidism
&. !i?e and shape of gland re$ealed
f. !erum cholesterol is ele$ated
9. Treatment of hypothyroidism
a. Medication
". Thyroid hormone replacement life long
#. !ynthroid/ =e$othroid
b. !urgery+ partial thyroidectomy/ if goiter large enough to
interfere with breathing or swallowing
:. 'ursing Diagnoses
a. Decreased Cardiac 1utput
b. Constipation
c. 2is. for Impaired !.in Integrity+ due to o$er all edema high
ris. for s.in brea.down+ pre$entati$e inter$entions
D. Client with Cancer of Thyroid )relati$ely rare*
". Types
a. Papillary thyroid carcinoma
". More common in female in &3,s
#. 8sually single nodule
%. 2is.s+ exposure of area to xray/ nuclear fallout/ family
history
Melchor !al$osa/ 2'
"34"54#3"&
7
b. 0ollicular thyroid cancer+ more common in female in 73,s
#. Diagnosis
a. Palpable firm nontender nodule in thyroid
b. 8sually no ele$ation in thyroid hormones
c. Thyroid scans/ needle biopsy of nodule
%. Treatment
a. !ubtotal or total thyroidectomy
b. 2adioacti$e iodine therapy with "%"I
c. Client will need continued medical followup< thyroid
replacement
d. 57B sur$i$al rate without metastasis
III. Disorders of Parathyroid
A. Clients with hyperparathyroidism
". Definition
a. Increased secretion of parathyroid hormone )PT(* affecting
.idneys/ bones
b. 1ccurs rarely and results in increased serum calcium
#. Pathophysiology+ may be due to tumor or hyperplasia of parathyroid/
resulting in hypercalcemia/ hypophosphatemia
%. !igns and !ymptoms
a. 8sually clients are asymptomatic
b. Beha$iors result from hypercalcemia+ Cbones/ stones/
abdominal groansD
". Bone decalcification )increased of bone fractures*
#. 2enal calculi
%. Abdominal pain/ constipation
c. Clients may also ha$e metabolic acidosis/ hypo.alemia/
dysrhythmias/ muscle wea.ness
&. Collaborati$e care
a. Diagnostic tests
". -xclude other causes of hypercalcemia
#. !erum calcium/ phosphorus/ magnesium/ electrolytes/
bone xrays and scans
b. Treatment
". 0ocus on decreasing calcium le$els
#. Increase fluid inta.e/ remain acti$e
%. A$oid calcium supplements/ thia?ide diuretics
&. Medications to inhibit bone reabsorption+ Alendronate
)0osamax*/ Pamidronate )Aredia*
7. 2emo$al of parathyroid gland/ if tumor exists
9. !e$ere hypercalcemia in$ol$es hospitali?ation and
intra$enous saline
B. Clients with hypoparathyroidism
". Definition
Melchor !al$osa/ 2'
"34"54#3"&
9
a. Abnormal low parathyroid hormone le$els
b. 1ccurs rarely and results in decreased serum calcium
#. Pathophysiology
a. 1ften due to damage or remo$al of parathyroid glands during
thyroidectomy
b. (ypocalcemia/ ele$ated blood phosphate le$els/ decreased
acti$ation of ;itamin D in intestines
%. !igns and !ymptoms of (ypocalcemia
a. 'umbness
b. Tingling around mouth/ fingertips
c. Muscle spasms of hands and feet
d. Tetany
e. =aryngospasms
&. Collaborati$e Care
a. Diagnostic tests
". Calcium and phosphorus le$els/ assess for Ch$oste.
and Trousseau,s signs
#. 2ule out other causes of hypocalcemia )renal failure/
absorption or nutritional disorders*
b. Treatment
". Treat hypocalcemia
#. Intra$enous calcium gluconate in se$ere cases
%. =ong term therapy with supplemental calcium
&. Dietary teaching
7. ;itamin D therapy
I;. Disorders of Adrenal lands
A. Client with (ypercortisolism )Cushing,s !yndrome*
". Definition
a. Chronic disorder hyperfunction of adrenal cortex producing
excessi$e amounts of ACT( or cortisol
b. More common in females between the ages of %3 and 73
c. 1ccurs in persons on high>dose steroids for long periods of
time
#. Pathophysiology
a. Tumors in pituitary cause hypersecretion of ACT(< some
cancerous tumors secrete ACT( )e.g. small>cell lung cancer*
b. Tumors/ either benign or malignant/ in adrenal cortex cause
excessi$e production of cortisol and suppress ACT(
production/ causing atrophy of other unin$ol$ed adrenal cortex
c. Iantrogenic form/ clients who are on long>term glucocorticoid
therapy
%. !igns and !ymptoms
a. Pattern related to adrenal cortex functions
". -ffect functions of adrenal cortex Csugar/ sex/ and saltD
Melchor !al$osa/ 2'
"34"54#3"&
:
#. lucose metabolism/ secondary sex characteristics/ and
mineralcorticoid le$els
b. 1besity and redistribution of body fat+ central obesity/ fat pads
under cla$icles/ upper bac. )Cbuffalo humpD*/ rounded face
c. lucose and electrolyte abnormalities
". (yperglycemia
#. !odium retention
%. (ypo.alemia causing hypertension
d. Thinning of s.in/ bruises easily/ abdominal striae
e. Altered immunity/ delayed healing/ prone to infection
f. Altered calcium absorption increasing osteoporosis and ris. for
fractures
g. Increased gastric acid secretion increasing ris. for ulcers
h. -motional changes from depression to psychosis
i. Changes in secondary sexual characteristics e.g. hirsuitism in
females/ gynecomastia in males
E. Menstrual irregularities
&. Collaborati$e Care
a. =ong>term !teroid Therapy
". Clients with iatrogenic Cushing,s syndrome due to long
term steroid therapy for another condition must be
aware of potential problems and remain under medical
treatment
#. Clients are maintained at lowest le$el of steroids
needed for adeAuate treatment and efforts are made to
minimi?e untoward effects
b. Diagnostic tests
". Measurement of plasma cortisol/ ACT(+ Alterations in
normal diurinal alteration+ higher in mornings/ lower in
afternoons and e$enings
#. #&>hour urine collections for measurements of
hormones
a. ":>.etosteroids and ":>hydroxycorticosteroids/
which are ele$ated
b. Important that collections are done properly
with correct additi$es in specimens
%. -lectrolytes/ calcium/ and glucose le$els )ele$ated 'a/
glucose< decreased F/ Ca*
&. ACT( suppression+ synthetic cortisol )dexamethasone*
gi$en and plasma cortisol le$els measured
c. Treatment+ tumors may be treated with surgery/ radiation/
medications/ or a combination
". !urgery
a. Adrenalectomy+ remo$al of adrenal gland if
tumor is in the adrenal gland< if both glands are
Melchor !al$osa/ 2'
"34"54#3"&
@
remo$ed/ client will need to be on lifelong
hormone replacement
b. (ypophysectomy )remo$al of pituitary gland*+
remo$al of pituitary gland through
transphenoidal )through nostril* route or
craniotomy
#. Medications+ for clients whose pituitary or adrenal
tumors are inoperable
a. !uppress adrenal cortex/ decrease cortisol
synthesis
b. -xamples+ Mitotane/ Metyrapone/ Fetocona?ole
d. 'ursing Diagnoses for clients with Cushing,s syndrome
". 0luid ;olume -xcess
#. 2is. for InEury+ potential for falls/ fractures
%. 2is. for Infection
&. Disturbed Body Image )changes re$ert when Cushing,s
syndrome is treated*
e. 'ursing Care
". Post>operati$ely/ clients being treated for adrenal or
pituitary surgery need intensi$e care and are usually in
large medical centers
#. Clients who ha$e undergone treatment often need to be
on life>long hormone replacement< must wear medical
identification bracelet
%. Clients must not abruptly stop hormone replacement or
could de$elop Addisonian crisis
B. Client with Chronic Adrenocortical Insufficiency )Addison,s !yndrome*
" Definition
a. Dysfunction of adrenal cortex
b. Chronic deficiency of cortisol/ aldosterone/ adrenal androgens
c. More common in women and those adults under 93
#. Pathophysiology
a. Autoimmune destruction of adrenal/ accounts for @3B of
spontaneous cases< occurs alone or with polyglandular
autoimmune syndrome
b. 8ntoward effect from anticoagulant/ trauma in which client has
bilateral adrenal hemorrhage
c. Pituitary dysfunction from tumors/ surgery/ radiation/
exogenous steroid
d. Abrupt withdrawal of from long>term/ high>dose corticosteroid
therapy
%. !igns and !ymptoms
a. !low onset< relate to decreased le$els of cortisol and
aldosterone
Melchor !al$osa/ 2'
"34"54#3"&
5
b. 2elate to lac. of functions of adrenal cortex or decrease in
Csugar/ salt and sexD
c. (yponatremia/ hyper.alemia/ low circulating blood $olume
d. Postural hypotension/ syncope/ and possibly hypo$olemic
shoc.
e. Di??iness/ confusion/ cardiac dysrhythmias
f. (ypoglycemia/ nausea/ $omiting/ wea.ness/ lethargy/ diarrhea
g. (yperpigmentation due to increased ACT( le$els )bron?ed
appearance in Caucasians*
&. !pecific condition+ Addisonian Crisis
a. =ife>threatening response to acute adrenal insufficiency
b. 1ccurs in clients with Addison,s disease in response to maEor
stressors
c. MaEor symptoms are high fe$er/ wea.ness/ abdominal pain/
se$ere hypotension/ circulatory collapse/ shoc./ coma
d. Treatment is rapid intra$enous replacement of fluids and
glucocorticoids
7. Collaborati$e Care
a. Diagnostic tests
". !erum cortisol and urine ":>.etosteroids and ":>
hydroxycorticosteroids are decreased
#. Plasma ACT( is increased/ if cause is from adrenal
dysfunction
%. ACT( stimulation test
&. -lectrolytes show hyponatremia/ hyper.alemia
7. !erum glucose is decreased
9. (ematocrit and hemoglobin are ele$ated< B8' is
ele$ated as with dehydration
:. CT scan of head may be done to determine if
intracranial lesion affecting pituitary
b. Medications
". (ydrocortisone
#. 0ludrocortisone )0lorinef*/ a mineralcorticoid
replacement
c. Diet with increased sodium
d. 'ursing Care
". Clients must continue under medical care and should
wear medical identification bracelet
#. Client and family must be aware of need to continue
medications and signs and symptoms of insufficient
hormone le$els
%. Care must be ta.en whene$er client will face stressor
such as surgery/ serious illness
&. Any client on long>term/ high>dose corticosteroid
therapy must be gradually tapered from cortisone to
allow adrenals to regain functioning
Melchor !al$osa/ 2'
"34"54#3"&
"3
e. 'ursing Diagnoses
". Deficient 0luid ;olume
#. 2is. for Ineffecti$e Therapeutic 2egimen Management
C. Clients with tumors of Adrenal Medulla )Pheochromocytoma*
". Definition
a. Adrenal medulla produces catecholamines )epinephrine/
norephinephrine*
b. Tumors of adrenal medulla produce excessi$e le$els of
catecholamines
#. !igns and !ymptoms
a. Paroxysmal se$ere hypertension )systolic+ #33 6 %33< diastolic
"73 6 ":7* with tachycardia
b. Can be life>threatening and stressor induced
%. Diagnostic tests+ Catecholamine le$els )serum and urine* are ele$ated
&. Treatment+ Adrenalectomy to remo$e tumor
;. Disorders of Pituitary land
A. Disorders of anterior pituitary gland
". (yperfunction of anterior pituitary gland
#. Pathophysiology+ Most often benign adenoma producing excess
hormones< growth hormone )(*/ Prolactin )P2=*/ or ACT(
%. !pecific Conditions
a. igantism+ rowth hormone hypersecretion occurs prior to
puberty resulting in person becoming excessi$ely tall )o$er :
feet tall*
b. Acromegaly+ rowth hormone hypersecretion occurs after
puberty resulting in bone and connecti$e tissue continuing to
grow/ resulting in enlargement of face/ hands/ and feet
c. 1$erproduction of Prolactin secretion+ 2esults in decreased
reproducti$e and sexual function+
d. Cushing,s !yndrome
&. Treatment+ !urgical remo$al or irradiation of pituitary tumor
B. Disorders of Posterior Pituitary land
". -xcessi$e or deficiency in antidiuretic hormone )AD(*
#. AD( is secreted in response to changes in serum osmolality
)hypothalamus*
%. !pecific Conditions
a. !yndrome of Inappropriate AD( !ecretion )!IAD(*
". Definition
a. (igh le$els of AD( is absence of
hypoosmolality
b. 2esults in hyponatremia and water intoxication
#. Pathophysiology
a. Malignant tumors )e.g. oat cell or small cell
lung cancer* which secret AD(/
Melchor !al$osa/ 2'
"34"54#3"&
""
b. Post head inEury/ side effect of some
medications including diuretics and anesthetics
%. !igns and !ymptoms+ neurologic symptoms including
decreased le$el of consciousness/ confusion/ muscle
twitches/ sei?ures
&. Treatment+ correction of 'a deficit/ restriction of fluids/
treat underlying cause
b. Diabetes Insipidus
". Definition+ AD( insufficiency from neurogenic or
nephrogenic origin
#. Pathophysiology+ Brain tumors/ closed head trauma/
other brain conditions/ renal failure
%. !igns and !ymptoms+ excretes large amounts of dilute
urine< client at ris. for dehydration and hypernatremia
&. Treatment+ administer intra$enous hypotonic fluids/
oral fluids and replace AD( hormone )Desmopressin
acetate*
Melchor !al$osa/ 2'
"34"54#3"&
"#