CARE OF THE CLIENTS WITH ENDOCRINE DISORDERS

PITUITARY GLAND (HYPOPHYSIS)

Anterior Pituitary (Adenohypophysis)
a.) Growth Hormone (Somatotropin)
- Growth of tissues and bones
- Hypersecretion: children (gigantism), adult (acromegaly)
- Hyposecretion: dwarfism
b.) Prolaction (Mammotropic/ Lactotropic/ Leutotropic Hormone)
- Mammary tissue growth and lactation
- Hypersecretion: galactorrhea
- Hyposecretion: absence of milk during lactation
c.) ACTH (Adrenocortocotropic Hormone)
- Stimulates adrenal cortex
- Hypersecretion: secondary Cushings disorder
- Hyposecretion: secondary Addisons disorder
d.) TSH (Thyroid Stimulating Hormone)
- Stimulates thyroid gland
- Hypersecretion: secondary hyperthyroidism
- Hyposecretion: secondary hypothyroidism
e.) Gonadotropin ( Follicle- Stimulating Hormone/ Luteinizing Hormone)
- Affects growth, maturity and functioning of primary and secondary sex
characterisitics
- Hypersecretion: precocious puberty
- Hyposecretion:
Males

Females

Small phallus and testicles

Failure to develop breasts

No growth of body hair

No growth of body hair

Decrease libido

No ovulation

Impotence

No menstruation

Aspermia

Infertility

f.) MSH (Melanocyte- Stimulating Hormone)

- Stimulates adrenal cortex; affect oigmentation
- Hypersecretion: eternal tan, bronze appearance of skin
- Hyposecretion: albinism (hypopigmentation)
Posterior Pituitary (Neurohypophysis)
ADH (Antideuretic Hormone/ Vasopressin)
- Retains water in the renal tubules
- Hypersecretion: SIADH
Characterized by excessive retention of water by the renal tubules, edema,
weight gain, HPN, dilutonal hyponatremia: excessive retention of water is
not accompanied by proportionate retention of sodium

Hyposecretion: Diabetes Insipidus

Inability of the renal tubules to retain water, polyuria (20L of urin/day),
retarded growth, dehydration, constipation, dilute, water-like urine, decrease
specific gravity
Diagnostic test: water deprivation test ( no fluids for 4 to 18 hours= no
increase in urine concentration)
Hyperpituitarism
Hyperfunction of the anterior pituitary resulting in oversecretion of one or more of the
anterior pituitary hormones
Frequently caused by benighn pituitary adenoma, may result also from hyperplasia of
pituitary tissue
Prolactinomas (prolactin- secreting tumors) account for 60 to 80 % of pituitary tumors
Assessment:
- Overproduction of GH results in acromegaly in adult; gigantism in children
- Hormonal imbalances
- Neurologic
Hemianopsia or scotomas or blindness, headache, somnolence, s and sx of increase
ICP, behavioural changes, seizures, disturbance in appetite, sleep, temperature
regulation and emotional balance due to hypothalamic involvement
Diagnostic tests: skull x-ray, CT scan, MRI
- Endocrine
Irregular menses, anovulatory periods, oligomenorrhea, amenorrhea, infertility,
galactorrhea, dypareunia, vaginal mucosal atrophy, decreased vaginal regulation,
decreased libido due to ovarian steroid deficit, impotence, reduce sperm count,
infertility and gynecomastia in males.
Collaborative Management:
Medical Management:
- Surgery: transphenoidal hypophysectomy
- Radiation, pharmacotherapy ( Bromocriptine/ parlodel) to lower GH levels and
prolaction levels
Hypopituitarism
Hypofunction of anterior pituitary gland causing deficiencies in both the pituitary
hormones and the hormones of the target glands.
Causes: trauma, tumor, vascular lesions, surgery/ radiation of pituitary gland
Assessment: hemianopsia/ headache (if due to tumor), weight loss, emaciation, hair loss,
impotence, amenorrhea, hypometabolism (hypothyroidism), adrenal insufficiency,
atrophy of all endocrine glands and hormones
Collaborative Management:
Surgery, radiation, HRT (hormonal replacement therapy)
Panhypopituitarism (Simmonds Disease) is total absence of all pituitary secretions
Sheehans syndrome- postpartum pituitary necrosis. Occurs in women with severe
bleeding, hypovolemia and hypotension at the time of delivery.
Medical Management of Acromegaly or Pituitary Tumors

 Hypophysectomy- removal of pituitary gland

Transphenoidal hypophysectomy- surgical removal of pituitary tumor; made under the
upper lip.
Nsg Intervention Post Transphenoidal Hypophysectomy
HOB elevated to promote venous drainage atleast for 2 weeks post op.
Maintain nasal packing in place and reinforce if needed
Provide frequent oral care with toothettes
Avoid blowing of nose and activities that increases ICP
Report output above 900ml/2hurs or sp.gr. below 1.004 (DI)
Medical Management of Diabetes Insipidus
Vasopressin replacement (desmpressin)
Clofibrate has an antideuretic effect on clients with DI
Chlorpropamide (diabenese) and thiazide diuretics potentiates the action of vasopressin
Thyroid Gland
T3 (Triidothyronine)- metabolism and growth
T4 (Thyrxine)- catabolism, body heat production
Thyrocalcitonin
Regulates serum Ca levels
Increase calcium
Thyrocalcitonin
Deposits Ca into the bones
Decrease Serum Ca Levels
Diagnostic tests:
T3 T4 levels
- Increase: hyperthyroidism
- Decrease: hypothyroidism
Protein- Bound Iodine (PBI)
Preparation: no food, drugs, tests dyes with iodine 7-10 days before the test.
Radioactive Iodine Uptake (RAIU)
- Tracer dose of I131,p.o.
- 2, 6, 24 degrees exposure to scintillation camera
- No food, drugs, tests with iodine 7- 10 days before the test
- Temporary discontinue contraceptive pills. These may increase metabolic rate
Increase uptake= hyperthyroidism
Decrease uptake= hypothyroidism
Thyroid Scan
- Radioisotope/ IV
- Exposure to scintillation camera
FNB ( Fine Needle Biopsy) to assess for malignant cells
BMR (Basal Metabolic Rate)

-measures O2 consumption at the lowest cellular activity

-preparation: NPO 10-12H, Night sleep 8-10H, do not get up from bed the following
morning until the test is done, a device with a noseclip and a mouthpiece is used; the
client performs DBE. Normal: 20%(euthyroid)
Reflex testing (Kinemometry) (Tendon of Archilles reflex)
- Hyperthyroidism (hypoCa) hyperactive TAR
- Hypothyroidism (hyperCa) hypoactive TAR
Goiter is an enlargement of the thyroid gland. This is due to increased amount of TSH. It can be
associated with hyperthyroidism, hypothyroidism, or euthyroidism.
Hyperthyroidism
Graves disorder/ parrys disorder/ basedows disorder/ exophthalmic goiter/ toxic diffuse
goiter
Increase in females below 40yo
Severe emotional stress
Autoimmune disorder
3 basic Concepts:
Increase metabolic rate (due to hypersecretion of T3?
Increase body heat production ( due to hypersecretion of T4)
Hypocalcemia ( due to hypersecretion of thyrocalcitonin)
Assessment:
Thyroidal disturbances
Restlessness, nervousness, irritability, agitation
Fine tremors
Tachycardia
Hypertension
Increase appetite
Weight loss
Diaphoresis
Diarrhea
Heat intolerance
Amenorrhea
Fine silky hair
Pliable nails
Ophthalmopathy
Exophthalmus
Accumulation of fluids at the fatpads behind the eyeballs pushing eye forward
Corneal Ulceration, Ophthalmitis, Blindness
o Von Graefes sign (LID LAG)
- Long and deep palpebral fissure is still evident when one looks down
o Jeffreys sign
- Forehead remains smooth when one looks up

Dalirymples sign
- Bright- eyed stare
- Infrequent blinking
o Dermopathy
- Warm flushed sweaty skin
- Thickened hyperpigmented skin at the pretibial area
Collaborative Mgt:
- Rest, non stimulating cool environment
- Diet: inc calorie, inc CHON; vit and mineral supplement; decrease fiber (if with
diarrhea); no stimulants
- Promote safety
- Protect the eyes; artificial tears at intervals; wear dark sunglasses when going out of
the sun
- Replace fluid electrolyte losses
Pharmacotherapy
- Beta- blockers: inderal (to control tachycardia, HPN)
- Iodides: Lugols solution
SSKI ( saturated solution of potassium iodide)
To inhibit release of thyroid hormone
Mix with fruit juice with ice or glass of water to improve its palatability
Provide drinking straw to prevent permanent staining of teeth
Side effects: allergic reaction, increased salivation, coryza
- Thioamides:
PTU (Propylthiuracil) and Tapazole (Methimazole)- to inhibit synthesis of
thyroid hormone
Side effects: Agranulocytosis/ Neutropenia, fever, sore throat, skin rashes
- Dexamethasone- inhibit the action of thyroid hormones.
Radiation Therapy
- I131; isolation for few days, body secretions are radioactive contaminated
- Not to be used in pregnant women because of potential teratogenic effects. Pregnancy
should be delayed for 6 months after therapy
Surgery
- Subtotal thyroidectomy- 5/6 of the gland is removed
- Preop Care:
Promote euthyroid state (control of thyroid disturbances, stable VS)
Administer Iodides as ordered- to recue the size and vascularity of thyroid
gland preventing postop hemorrhage
ECG
- Postop Care
Position: semi fowlers
Prevent hemorrhage- ice collar on the neck. Check back of the neck for
blood
Tracheostomy set available for the first 48H postop
Parathyroid damage hypocalcemialaryngospasmairway obstruction

Ask the patient to speak every hour (to assess for laryngeal damage)
Keep Ca gluconate readily available
Monitor temp- hyperthermia is initial sign of thyroid crisis
Monitor BP- to assess for Trousseaus sign
Steam inhalation to soothe irritated airways
Advise to support neck with interlaced fingers when getting out of bed
Observe for signs and symptoms of potential complications (hemorrhage,
airway obstruction, tetany, laryngeal damage, thyroid crisis)
- Client teaching
ROM exercises for the neck 3-4 times a day after discharge
Massage incision site with coa butter lotion to minimize scarring
Regular ff up care
Thyroid Crisis/ Storm
- Uncontrolled and potentially life- threatening hyperthyroidism
- Causes: stress, infection, unprepared thyroid surgery
- Assessment:
Elevated temp (initial sign)
Tachycardia, dysrythmias
Tremors, apprehension
Delirium, psychotic state, coma
Inc.BP and RR
- Collaborative mgt:
Monitor temp, I and O, neurologic status, cardiovascular state every hour
Administer increasing dose of oral PTU (200 to 300 mg every 6H) as rdered,
following a loading dose of 800- 1,200mg po as ordered
Administer iodine preparation as ordered
Administer dexamethasone to help inhibit the release of thyroid hormone
Administer propanolol to control HTN and tachycardia
Implement measures to lower fever
O2 as ordered
Maintain quiet, cool, private environment until crisis is over
Hypothyroidism
- Results from deficiency of thyroid hormones
- Myedema (adult)
- Cretinism (children)
- Causes:
Autoimmune
Surgery
Radiation therapy (radioactive iodine)
Antithyroid drugs
- Basic Concepts
Decreased metabolic rate ( due to hyposecretion of T3)
Decreased body heat production ( due to hyposecretion of T4)
Hypercalcemia ( due to hyposecretion of thyrocalcitonin)

Assessment
Slowed physical, mental reactions, apathy
Dull, expressionless, masklike face
Anorexia
Obesity
Bradycardia
Hyperlipidemia, atherosclerosis
Cold intolerance, subnormal temp
Constipation
Coarse, dry, sparse hair
Brittle nails
Irregular menstruation ( menorrhagia, amenorrhea)
Husky, hoarse voice
Extreme fatigue
Slow speech
Enlarged tongue
Increased sensitivity to sedatives, narcotics and anesthetics
Collaborative Mgt:
Monitor VS. Be alert for signs and symptoms of cardiovascular disorders
Monitor daily weights
Diet: low calorie, high fiber
Provide warm environment during climate
Pharmacotherapy:
Proloid ( thyroglobulin)
Synthroid ( levothyroxine)
Dessicated Thyroid Extract
Cytomel ( Liothyronine)- BP, RR before administration, start with low dose,
gradually increase

Myxedema coma- is extreme, severe stage of hypothyroidism, in which the client is hypothermic
and unconscious
IV thyroid hormones
Correction of hypothermia
Maintenance of vital functionstreat precipitating factors
Parathyroid Gland
- Produce parathormone which regulates calcium and phosphorous balance
PTH (Parathormone)

Decrease Calcium levels

PTH release

Withdraws Ca from the bones

Increase Ca levels
Therefore; Hyperparathyroidism: Hypercalcemia
Hypoparathyroidism: Hypocalcemia

Pancreas
Glucagon
- Alpha cells of islets of langerhans
- Increase glucose levels ( gluconeogenesis)
Insulin
- Beta celss of islets of langerhans
- Decrease glucose levels
Transcellular membrane transport of glucose
Inhibits breakdown of fats and CHON
Requires sodium for transport of CHO
Requires K for production
Somatostatin
Inhibits action of GH
Polypeptides
Diabetes Mellitus (DM)
- A chronic systemic disease characterized by disorder of carbohydrates, fats and
protein metabolism
- Classic signs: polyuria, polydipsia, polyphagia
Diagnostic Tests:
- FBS: 80-120 mg/dl; DML above 140mg/dl for 2 readings
- OGTT/GTT (oral glucose tolerance test)
Initial urine and blood specimen are collected:
30min
1H
2H- S. CHO returns to normal
3H, 4H, 5H as required
Done when results of FBS are borderline
- Glycosylated Hgb: most accurate; reflects s. CHO levels for the past 3-4 mos
Predisposing factors:
Stress. Stimulates secretion of epinephrine, norepinephrine, glucocorticoids= inc s. CHO
Heredity. Strongly associated with type 2 DM
Obesity. Adipose tissue are resistant to insulin, therefore glucose uptake by the cells is
poor
Viral infection. Increase risk to autoimmune disorders
Autoimmune disorders. More assoc with type 1 DM
Women: multigravida with large babies

Types:
Type I
-

IDDM, juvenile- onset

Brittle DM, Unstable DM
Onest is 30yrs
Absolute insulin deficiency. Pancreas do not have islets of langerhans
Thin
Prone to DK

Mgt:
Diet, activity/ exercise
Insulin (always a component of type 1 DM mgt)
Type II
- NIDDM
- Maturity- onset
- Stable DM
- Ketosis- resistant DM
- Onset is 40yrs
- With insulin secretion but demands are increased
- Obesed
- Prone to HHNC (hyperglycaemic, hyperosmolar, non- ketotic coma)
Mgt:
Diet, activity/ exercise
OHA if uncontrolled
Education for self- care:
Diet: decrease caloric intake
20%CHON, 30%HCHO, 50%CHO
Increase fiber to diet. This inhibit glucose absorption in the diet
Activity/ exercise:
Increase CHO uptake by the cells
Decrease insulin requirements
Maintains IBW, s. CHO and lipids
Medications:
OHA
- Stimulates islets of langerhans to secrete insulin
- Indicated only in type 2 DM
- Hypoglycemia may occu
Insulin
Rapid- Acting: clear insulin
- Regular
- Humulin R
- Semilente
- Crystalline zinc
- Actrapid

- Onset: 30min to 1 H
- Peak: 2-4H
- Duration: 6-8H
Intermediate- acting: cloudy
-NPH
- Humulin N
- Lente
- Monotard
-Onset: 1-2H
- Peak: 6-8H
- Duration: 18- 24H
Long Acting: Cloudy
- PZI
- Ultralente
- Onset: 3-4H
- Peak: 16-20H
- Duration: 30- 36H
Nursing responsibilities in Insulin Therapy:
Route: SQ- slow absorption, less painful; IV for DKA (emergency); do not massage site of
injection
Administer at room tem; Cold insulin= lipodystophy
Rotate site of injection
Store vial of insulin in current use at room temperaturegently roll vial in between the palms to
redistribute insulin particles. Do not shake, bubbles makes it difficult to aspirate exact amount
Dawns Phenomenon- normal glucose at night (12MN to 3 am) and hyperglycemia in the morning
(6-8am)
Hypoglycemia ( Insulin Shock)
Causes: omission of meals, overdose of insulin, strenuous exercises, GI upset
Assessment:
Restlessness, hunger pangs, yawning, weakness, tremors, pallor, diapjoresis, cold clammy
skin, headache, faintness, tachycardia, abd pain, blurred vision, altered LOC
Mgt:
Simple sugars p.o.
3-4 oz regular softdrinks
8oz fruit juice
5-7 pcs lifesavers candy
1 tbsp sugar
5mls pure honey/ Karo syrup
10-15 gms CHO
D50W 20-50 ml IV push
Monitor BS

Hyperglycemia (DKA)
Causes: infections, overeating, underdose of insulin, stress, surgery
Assessment:
Polyuria, polydipsia, polyphagia, warm flushed skin, soft eyeballs, tachycardia, abd pain,
Kussmauls breathing, fruity odor of breath, altered LOC Urine (+) for CHO
Mgt:
Patent AW
O2 therapy
NSS + regular insulin/ IV
D10W once s.CHO reaches 250 mg/dl level
Monitor BS (blood sugar)
Foot Care
Inspect the feet daily
Wash feet with warm water and mild soap
Pat dry the feet- do not rub
Wear comfortable properly- fitted pair of shoes (leather or canvass)
Use white cotton socks
Do not go barefooted
Trim the toenails straight across. Do not cut at lateral edges, ingrown may develop
Apply lotion on the feet (not interdigital spaces)
Exercise/ massage the feet
Do not wear knee- high stay up stockings
Consult a podiatrist for signs of injury
Adrenal Glands
Cushings Syndrome
Hypersecretion of adrenal cortext hormones (glucocortocoid, mineralocorticoid,
androgen, and estrogen)
Causes: Tumor (adrenal cortex/ pituitary), prolonged steroid therapy
Muscle weakness, fatigue, apathy (hypoK)
Obesed trunk, thin arms and legs
Moon face
Buffalo hump
Purple striae on trunk
Mood swings, irritability
Acne
Musculinization (women
Osteoporosis
Low resistance to infection/ poor wound healing
HPN, edema
Hyperglycemia, hypokalemia
Implementation:
Adrenalectomy

 Hypophysectomy for pituitary gland tumor

Radiation therapy
Addisons Disease
Hyposecretion of adrenal cortex hormones
Causes: autoimmune, TB, fungal
Signs and symptoms: fatigue, muscle weakness (hyperK), anorexia, n&v, weight loss,
hypoglycaemia, hypotension, weak pulse, bronze pigmentation of skin (eternal tan), inability to
cope with stress
Implementation:
Cortisone/ Florinef
Monitor VS, IO, Wt
Rest, avoid exposure to infection
Diet: high CHON, CHO, K, low Na
Administer after meals or with antacid
Monitor urine and blood glucose levels
Gradual withdrawal to prevent Addisonian crisis, severe weakness, psychologicletdown
Pheochromocytoma
- A tumor that is usually benign and originates from the chromaffin cells of the adrenal
medulla
- Peak incidenceis ages 20 to 50 years
- Stimulates hypersecretion of catecholamines (epinephrine and norepinephrine)
Diagnostic tests:
Vanillymandelic Acid test
- 24H urine specimen
- Avoid coffee, tea, bananas, chocolate, vanilla, aspirin
Total Plasma Catecholamine Concentration
- Client should lie supine and rest for 30 min
- Butterfly needle is inserted 30 minutes before blood specimen is collected to prevent
catecholamine leves to increase caused by stress of venipuncture
- Normal values: epinephrine 100pg/ml (590 pmol/L); norepinephrine 100-550 pg/ml
(590-3240 pmol/L)
Clonidine Suppression Test
- Clonidine suppresses release of cathechoamines
- In pheochromocytoma, 2-3H after a signle dose of conidine the total plasma
cathecholamine value decreases atleast 40% from baseline
CT Scan, MRI, UTZ
Collaborative Mgt:
Medical mgt
- Bedrest, HOB elevated during episode of HTN, tachycardia and anxiety. To provide
orthostatic decrease in BP

Pharmacotherapy
Phentolamine (regitine), Na Nitroprusside (nipride) to lower the BP quickly
- Surgery: adrenalectomy
Removal of single gland requires corticosteroid therapy for first few days or weeks
postop
Bilateral removal requires lifetime corticosteroid therapy
Nursing Mgt:
- Teach self- care, periodic ff up, instruction on corticosteroid therapy, teach on how to
measure BP