Nursing Management of Patients with Endocrine Disorders

Disorders of the Thyroid Gland

I.

II.

Disorders
a. Hyperthyroidism
i. Graves Disease
ii. Toxic Multinodular Goiter
iii. Thyroid Crisis (AKA Thyroid Storm)
iv. Pituitary Adenoma (rare)
b. Hypothyroidism
i. Myxedema
ii. Myxedema Coma
iii. Hashimotos Thyroiditis
c. Simple Goiter
i. Endemic
ii. Sporadic
d. Thyroiditis
Hyperthyroidism:Graves disease
a. manifestations of Graves Disease
i. Hyperthyroidism
ii. Exopthalmus
iii. Goiter
iv. Also agitation, restlessness, weight loss, diarrhea, heat intolerance,
diaphoresis, tachycardia, tremors.
b. Laboratory findings: all TH levels are elevated, TSH is decreased, serum
cholesterol is decreased
c. Complications:
i. Exopthalmus (not always reversible; may loose vision if severe)
ii. Heart disease (tachycardia, a-fib, CHF)
iii. Thyroid storm (thyrotoxicosis; potentially fatal)
d. Hyperthyroidism: Thyroid Storm
i. Characterized by high fever, severe tachycardia, delirium,
dehydration, and extreme irritability
ii. Precipitated by inadequate preparation for thyroid surgery,
undiagnosed hyperthyroidism, trauma, infection, MI
iii. Management:
1. Re-hydration with IV fluids, blockade of TH release with
IV sodium iodide, oral steroids, and beta-blockers
e. Hyperthyroidism: Management
i. Goal is to curtail secretion of TH and prevent/treat complications
ii. Includes
1. Anti-thyroid medications (most commonly
propylthiouracil/PTU; methimazole/Tapazole)
2. Radioactive Iodine Therapy (destroys thyroid tissue)
3. Surgery (thyroidectomy; total or subtotal)
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f. Hyperthyroidism: Nursing care

i. Nursing diagnoses:
1. Imbalance nutrition: less than body requirements
2. Activity intolerance
3. Risk for injury
4. Hyperthermia
5. Impaired social interaction
6. Hyperthyroidism: Nursing care
ii. Exopthalmus:
1. Diuretics, prednisone, eye drops, surgery
2. Instruct to wear dark sunglasses, avoid getting dust in eyes,
wear sleep mask, elevate head of bed at night, restrict salt
intake
iii. Cardiac complications:
1. Propranolol to lessen palpitations and tachycardia
(contraindicated in CHF or asthma); instruct on s/s heart
disease and when to seek medical attention
2. Hyperthroidism: Nursing Care
iv. Hyperthermia
1. Cool environment, lightweight sheet for cover; frequent
changes for diaphoresis; avoid overexertion which raises
body temp and metabolic rate
v. Diet therapy
1. High-calorie, high-protein diet to compensate for
hypermetabolic state; sometimes up to 4000-5000 calories
vi. Radioactive Iodine Therapy
1. Indicated for older clients; done on an outpatient basis
2. Dissolved in water and admin. orally
3. No risk for radioactive contamination, unless very large
doses are given
4. Assess for hypothyroidism
5. Instruct will need periodic follow-up, condition may
reoccur years after therapy
g. Thyroidectomy: Nursing Care
i. Preoperative iodine and anti-thyroid drugs to reach euthyroid state;
may take up to 2-3 months
ii. Immediate post-op: place in semi-fowlers, immobilize neck with
sandbags; trach set at bedside
iii. Post-op assessment: s/s of thyroid storm, hemorrhage,
hypocalcemia/tetany, respiratory obstruction, laryngeal edema, and
vocal cord injury
iv. Instruct on voice rest, s/s hypocalciemia and medications (total
thyroidectomy will require ongoing TH replacement)
III.

Hypothyroidism
a. Manifestations
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i. Mild: may be asymptomatic. Sensitive to cold, lethargy, dry

skin/hair, forgetfulness, depression, weight gain
ii. Severe (Myxedema): dry waxy swelling, especially in the pretibial
and facial areas; hypercholesterolemia, hyperlipidemia,
proteinemia
iii. Complicated (Myxedema coma):
b. Hypothyroidism: laboratory values
i. T3, T4 (thyroid hormone)
1. Low
ii. Thyroid Stimulating Hormone (TSH)
1. High in primary hypothyroidism
2. Low in secondary hypothyroidism
c. Hypothyroidism: Management
i. Myxedema and myxedema coma are medical emergencies; reverse
TH deficiency, reverse manifestations, and prevent further cardiac
damage
ii. Hypothyroidism is a lifelong chronic condition; requires
medication (levothyroxine), dietary compliance, and ongoing
follow up (labs: TSH, T3, T4)
d. Hypothyroidism: Nursing Care
i. Nursing diagnoses:
1. Imbalanced nutrition: More than body requirements
2. Activity intolerance
3. Constipation
ii. Teaching:
1. Manifestations of the disorder
2. Importance of following medication regime and diet
3. Need to seek medical attention appropriately
IV.

Thyroid disorders: Goiter

a. Management
i. Iodine preparations and thyroid medications
ii. Increase dietary intake of iodine
iii. surgery
b. Education
i. Use of iodized salt
c. Thyroiditis
i. Acute: abrupt unilateral neck pain, fever, diaphoresis
ii. Subactue: pain or no pain, low-grade fever, sudden onset of goiter
iii. Chronic: painless goiter, dysphagia
d. Thyroiditis: Management
i. Medical: IV antibiotics, anti-inflammatory medications (NSAIDs
or prednisone), sometimes I&D of gland; thyroid/anti-thyroid meds
generally not indicated for acute/subacute
ii. Nursing: medication teaching, instruct on need for ongoing
monitoring of thyroid function
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I.

II.

III.

Disorders of the Parathyroid Gland

Disorders
a. Hyperparathyroidism
i. Primary
ii. Secondary
iii. Tertiary
b. Hypoparathyroidism
i. Iatrogenic
ii. Idiopathic
Hyperparathyroidism
a. Manifestations
i. Bone disease -joint/ bone pain, pathologic fractures
ii. renal -polyuria, polydipsia, calculi, HTN
iii. GI -peptic ulcer, constipation, N/V, GI bleeding)
iv. Neurologic abnormalities
v. Laboratory findings:
1. elevated serum calcium,
2. decreased serum phosphate,
3. urine calcium and phosphates both high
b. Hyperparathyroidism: Management
i. Lower elevated calcium levels: re-hydration with NS, then
diuretics (furosemide) to rid excess calcium
ii. Increase bone reabsorption of calcium: medications (plicamycin,
gallium nitrate, calcitonin)
iii. Parathyroidectomy: only definitive treatment; cure rate is >95%.
c. Hyperparathyroidism: Nursing care
i. Nursing diagnoses
1. Risk for injury (prevent falls and fractures, assist with
activity; monitor for drug reactions- administer digoxin
cautiously)
2. Impaired urinary elimination (encourage fluid intake to
decrease renal stones, observe for hematuria, strain urine)
3. Imbalanced nutrition: Less than body requirements (low
calcium diet, avoid dairy products to relieve GI upset
4. Constipation (increase fluids and fiber)
Hypoparathyroidism:
a. Manifestations related to hypocalcemia/tetany
i. Chvosteks sign
ii. Trousseaus sign
iii. Hyperactive DTRs
iv. Circumoral paresthesia
v. Numbness/tingling of fingers
vi. calcification of brain and ocular lens
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b. Hypoparathyroidism: Management
i. Medical:
1. Acute IV calcium gluconate
2. Chronic oral calcium supplements and vitamin D
supplements; PTH replacement; high calcium/low
phosphate diet
ii. Nursing:
1. Careful assessment for tetany and need for emergency
intervention
2. Instruct on medications; may take a week or more for
symptoms to improve
3. Diet: omit cheese and milk (high phosphorus content)
4. Check serum Calcium levels 3 x year.
I.

II.

Disorders of the Adrenal Gland

Disorders
a. Hyperfunction of the Adrenal Cortex
i. Cushings Syndrome (hypercortisolism)
ii. Conns Syndrome (primary hyperaldosteronism)
b. Hypofunction of the Adrenal Cortex
i. Addisons Disease (Chronic or primary adrenal insufficiency)
ii. Secondary adrenal insufficiency
iii. Addisonian Crisis (adrenal crisis)
c. Hyperfunction of the Adrenal Medulla
i. Pheochromocytoma
ii. Neuroblastoma (pediatric condition)
Cushings Syndrome
a. Manifestations
i. Hyperglycemia
ii. K+ depletion
iii. Na/H2O retention
iv. Hypertension
v. Muscle wasting, weakness
vi. Osteoporosis, fractures
vii. Abnormal fat distribution
viii. Increased susceptibility to infection
ix. Increased production of androgens cause masculine characteristics
in women
x. Mental changes: memory loss, poor concentration, euphoria,
depression
1. Cushings Syndrome: Management
xi. Laboratory tests: elevated plasma cortisol without the normal
variation; ACTH levels to determine if adrenal or pituitary tumor;
24-hour urine tests for free cortisol and androgens. Also elevated

serum sodium, decreased serum potassium, and elevated serum

glucose.
b. Management
i. Surgery: adrenalectomy for adrenal tumor; transsphenoidal
hypophysectomy for most pituitary tumors
ii. Radiation therapy: concurrently with surgery or medication
iii. Medications: adrenal blocking agents; ACTH-reducing agents. Not
curative
c. Cushings Syndrome: Nursing Care
i. Nursing diagnoses:
1. Risk for injury: fractures, HTN, DM
2. Risk for infection
3. Fluid volume excess
4. Disturbed thought processes
ii. Education:
1. Explain disease, cause if overuse of steroids
2. Encourage diet low in calories, carbs, and sodium and
ample protein and potassium; may need fluid restriction
3. Adrenalectomy: Nursing Care
iii. Pre-op
1. electrolyte and glucose imbalance are corrected
2. Cortisol is given day of surgery and post-op to replace loss
of hormones
iv. Post-op
1. Assess for adrenal insufficiency. Addisonian crisis and
hypovolemic shock may occur
2. Lifelong hormonal replacement necessary if both adrenals
are removed
III.

Adrenal Insufficiency: Addisons Disease

a. Manifestations
i. Mild fatigue, irritability, weight loss, N/V, postural hypotension are
early symptoms;
ii. hyperpigmentation of skin and mucosa from elevated ACTH and
MSH;
iii. Electrolyte imbalance may cause confusion and dizziness.
iv. Laboratory tests:
1. decreased plasma cortisol
2. elevated plasma ACTH levels
3. 24-hour urine tests show decreased or absent free cortisol
and androgens
4. decreased serum sodium
5. increased serum potassium
6. Possibly anemia.
b. Adrenal Cortex Hypofunction: Secondary Adrenal Insufficiency
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i. Most commonly caused by chronic use of corticosteroids followed

by abrupt discontinuation
ii. Other causes: hypopititarism, pituitary tumor, radiation
iii. Lab results are similar to primary, except for low ACTH, and
aldosterone remains normal
iv. When corticosteroids are tapered down gradually, adrenals return
to normal
c. Adrenal Cortex Hypofunction: Acute Adrenal Insufficiency (Addisonian
Crisis)
i. a medical emergency; fatal if not corrected
ii. occurs when under stress without proper hormone replacement or
when steroids are abruptly stopped after long term use.
iii. Manifestations include sudden penetrating pain in back, abdomen,
or legs; change in mental status; volume depletion; electrolyte
imbalance; hypotension, loss of consciousness and shock.
d. Adrenal Insufficiency: Management
i. Addisonian Crisis
1. Correct fluid and electrolyte imbalance; rapid rehydration
with an isotonic solution; Kayexalate (oral or enema) to
treat hyperkalemia
2. Correct hypoglycemia with IV fluids
3. Replace steroids with IV hydrocortisone or solu-cortef
ii. Addisons disease
1. Ongoing glucocorticoid (hydrocortisone) and
mineralcorticoid (Florinef) replacement
2. Must be evaluated for complications of long term steroid
use (osteoporosis, for example)
e. Adrenal Insufficiency: Nursing Care
i. Nursing diagnoses:
1. Risk for injury: Addisonian Crisis
ii. Education:
1. Medical alert bracelet and emergency kit with injectable
hydrocortisone
2. Medications lifelong, take exactlly as directed. Florinef
and 2/3 of cortisone dose in the AM and 1/3 of cortisone
dose in the afternoon; this simulates the bodys normal
rhythm. Must use IM if unable to tolerate oral (as with
N/V). Will need to adjust dose in times of stress.
IV.

Adrenal Medulla Hyperfunction:Pheochromocytoma

a. Manifestations
i. Catecholemine (epi and norepi) secreting tumor in the adrenal
medulla
ii. Rare, usually benign
iii. Effects of excessive epinephrine and norepinephrine cause severe
symptoms and can lead to death
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iv. Manifestations: diabetes, severe HTN, hyperthyroidism, and

psychoneurosis
b. Management: Adrenalectomy
Disorders of the Pituitary Gland
I.
Disorders
a. Hyperfunction of the Anterior Pituitary
i. hyperpituitarism
b. Hypofunction of the Anterior Pituitary
i. hypopituitarism
c. Disorders of the Posterior Pituitary
i. SIADH excess ADH
ii. Diabetes Insipidus deficiency of ADH
II.
Hyperfunction of the Anterior Pituitary: Hyperpituitarism
a. Associated Syndromes
i. Gigantism/Acromegaly
ii. Hyperprolactinemia (amenorrhea, galactorrhea)
iii. Cushings and Hyperthyroidism
b. Treatment of a pituitary tumor requires surgery
c. Acromegaly: Manifestations
III.
Hypofunction of the anterior pituitary: Hypopituitarism
a. Manifestations:
i. Syndrome of short stature,
ii. sexual and reproductive disorders,
iii. hypothyroidism,
iv. secondary adrenal insufficiency,
v. prolactin deficiency.
b. Usually related to a tumor
IV. Transsphenoidal Hypophysectomy:Nursing Care
a. Risk for injury
i. Monitor neuro status, I/O balance, s/s increased ICP, s/s
meningitis, s/s hormonal insufficiency
b. Provide oral hygeine
i. Use gauze sponge; no tooth brushing for 2 weeks
c. Monitor for CSF leakage
i. Packing for 2-5 days; rhinorrhea or post-nasal drainage can
indicate CSF leak
ii. Avoid coughing, sneezing, and bending
iii.
Summary
I.
Disorders of the Endocrine System: Ongoing Care
a. Endocrine disorders range from acute to chronic
b. Parathyroid, adrenal, and pituitary disorders are relatively rare and
complex
c. Patients require a high level of assessment, intervention and education