Medical-Surgical Nursing: Concepts & Practice 3rd edition Chapter 36 Care of Patients with Pituitary, Thyroid, Parathyroid, and Adrenal Disorders Copyright © 2017, Elsevier Inc. All rights reserved.

Pituitary Tumors Etiology and pathophysiology Signs and symptoms Benign pituitary adenoma Signs and symptoms Local symptoms Systemic symptoms

Progression of Acromegaly See Figure 36-2 on p. 838. From Ignatavicius DD, Workman ML: Medical-surgical nursing: critical thinking for collaborative care, ed 6, Philadelphia, 2010, Saunders.

Pituitary Tumors Diagnosis Treatment Complete history and physical examination Magnetic resonance imaging (MRI) High-resolution computed tomography (CT) with contrast media Treatment Hormone therapy Irradiation Surgery—hypophysectomy

Transsphenoidal Surgical Approach for Hypophysectomy See Figure 36-1 on p. 837. From Ignatavicius DD, Workman ML: Medical-surgical nursing: critical thinking for collaborative care, ed 6, Philadelphia, 2010, Saunders.

Postoperative Nursing Care Semi-Fowler’s position Note any change in vision, mental status, level of consciousness, or strength Diabetes insipidus Nasal packing Patient teaching

Hypofunction of the Pituitary Gland Etiology and pathophysiology Autoimmune disorders, infections, or destruction of the pituitary gland Sheehan syndrome, postpartum hemorrhage Decrease in growth hormone and gonadotropins Signs and symptoms

Diagnosis History and physical examination Levels of pituitary hormones MRI and CT

Treatment and Nursing Management Hormone replacement Surgery and radiation Patient teaching

Diabetes Insipidus Etiology and pathophysiology Central diabetes insipidus (DI): associated with brain tumors, head injury, neurosurgery, or central nervous system (CNS) infections Nephrogenic DI: caused by drug therapy (lithium) or kidney disease Dispogenic DI: caused by excessive water intake (sometimes associated with schizophrenia)

Signs and Symptoms Diuresis Thirst, weakness, and fatigue, often from nocturia (urination at night) Deficient fluid volume Signs of shock and CNS manifestations

Diagnosis Complete history and physical examination Urine and plasma osmolality and urine specific gravity Water deprivation test

Treatment and Nursing Management Replacement of fluid and electrolytes Hormone therapy Early detection, maintenance of fluid and electrolyte balance, and patient education

Syndrome of Inappropriate Antidiuretic Hormone Signs and symptoms Confusion, seizure, loss of consciousness, weight gain, and edema Hyponatremia, muscle cramps, and weakness Diminished urine output

Pathophysiology See Concept Map 36-2 on p. 841.

Diagnosis Urine and serum osmolality tests Blood urea nitrogen (BUN), hemoglobin, hematocrit, and creatinine clearance

Treatment and Nursing Management Correct the underlying cause. Restrict fluids to 500 to 1000 mL/day. Administer sodium chloride, diuretics, and demeclocycline.

Regulation of Thyroid Hormone Secretion See Concept Map 36-3 on p. 842.

Goiter Etiology and pathophysiology Signs, symptoms, and diagnosis Treatment Nursing management

Goiter (Cont.) See Figure 36-3 on p. 842. From Ignatavicius DD, Workman ML: Medical-surgical nursing: critical thinking for collaborative care, ed 9, Philadelphia, 2016, Saunders.

Hyperthyroidism Etiology and pathophysiology Signs and symptoms Primary hyperthyroidism—Graves’ disease or toxic goiter Secondary hyperthyroidism Signs and symptoms Earliest symptoms Older adults and atypical presentation

Exophthalmos of Graves’ Disease See Figure 36-4 on p. 843. From Lewis SL, Heitkemper MM, Dirksen SR, et al: Medical-surgical nursing: assessment and management of clinical problems, ed 7, St. Louis, 2007, Mosby.

Hyperthyroidism Diagnosis Treatment and nursing management Clinical manifestations Heart rate while sleeping Electrocardiography, CT, or MRI Treatment and nursing management Radioactive iodine and antithyroid drugs Mild sedatives, and beta-adrenergic blocking agents

Treatment of Hyperthyroidism Thyroid crisis (thyroid storm) Antithyroid drugs Thyroidectomy Preoperative nursing care, including thyroid crisis Postoperative nursing care Thyroid storm (TS; also known as thyroid crisis or thyrotoxicosis) is caused by a sudden increase in the output of thyroxine caused by manipulation of the thyroid as it is being removed. Another cause of TS may be improper reduction of thyroid secretions before surgery. In a patient with hyperthyroidism, TS also can be triggered by other factors unrelated to surgery; TS can also be caused by a patient with hypothyroidism who consumes an overdose of levothyroxine. The symptoms of TS are produced by a sudden and extreme elevation of all body processes. The temperature may rise to 106° F (41.1° C) or more, the pulse increases to as much as 200 beats/min, respirations become rapid, and the patient exhibits marked apprehension and restlessness. Unless the condition is relieved, the patient quickly passes from delirium to coma to death from heart failure.

Common Causes of Thyroid Storm Administration of drugs or dyes containing iodine Childbirth (immediately postpartum) Congestive heart failure Diabetic ketoacidosis Inadequate hormone replacement Infection Pulmonary embolism Severe emotional distress Stroke Trauma or surgery See Box 36-1 on p. 844.

Treatment of Thyroid Storm Reduce the temperature. Cardiac drugs to slow the heart rate Sedatives such as a barbiturates to reduce restlessness and anxiety

Hypothyroidism Etiology and pathophysiology Signs and symptoms Congenital hypothyroidism   Signs and symptoms Myxedema Older adult considerations Diagnosis and treatment Clinical signs and symptoms Serum levels of thyroid hormones and thyroid-stimulating hormone

Nursing Management Managing hypothyroidism Nurses should increase awareness of look-alike, sound-alike products and help patients to recognize the exact name and purpose of their medications. Myxedema coma—cause, signs and symptoms, and treatment Myxedema coma is life threatening. It can be precipitated by abrupt withdrawal of thyroid therapy, acute illness, anesthesia, use of sedatives or narcotics, surgery, or hypothermia in a patient with hypothyroidism. Signs and symptoms are loss of consciousness along with hypotension, hypothermia, respiratory failure, hyponatremia, and hypoglycemia. Treatment is administration of levothyroxine intravenous (IV) sodium, fluid replacement, maintenance of an airway and respiration, IV glucose administration, corticosteroids, and provision of warmth.

Thyroiditis Etiology and pathophysiology Signs and symptoms Diagnosis Acute, subacute, or chronic Autoimmune thyroiditis (Hashimoto’s thyroiditis) Signs and symptoms Diagnosis Treatment Nursing management

Thyroid Cancer Etiology and pathophysiology Signs and symptoms Diagnosis Treatment Nursing management

Hypoparathyroidism Etiology and pathophysiology Signs and symptoms Chvostek sign Trousseau sign Tetany Convulsions, cardiac dysrhythmias, and spasms of the larynx Diagnosis Treatment and nursing management

Hyperparathyroidism (Von Recklinghausen’s Disease) Etiology and pathophysiology Signs and symptoms Diagnosis Serum calcium and phosphate Serum parathyroid hormone Serum albumin Treatment Nursing management

Causes of Hyperparathyroidism Parathyroid tumor (benign or malignant) Congenital enlargement Neck trauma or irradiation Vitamin D deficiency Chronic renal failure with hypocalcemia Lung, kidney, or gastrointestinal (GI) tract cancers See Box 36-2 on p. 849.

Comparison of Hyperparathyroidism and Hypoparathyroidism Serum calcium levels Serum phosphate levels Bone resorption Calcium and phosphate in urine Neuromuscular irritability See Table 36-2 on p. 850.

Pheochromocytoma Etiology and pathophysiology Signs, symptoms, and diagnosis Treatment Surgical removal Nursing management Hypertensive crisis

Adrenocortical Insufficiency (Addison’s Disease) Etiology and pathophysiology Primary insufficiency Secondary insufficiency Signs and symptoms Diagnosis Nursing management

Expected findings Weight loss Craving for salt Hyperpigmentation Weakness and fatigue Nausea and vomiting Abdominal pain Constipation or diarrhea Dizziness, hypotension dehydration

Adrenocortical Insufficiency (Addison’s Disease) (Cont.) Provide intensive care and support during Addisonian crisis. Prevent problems related to fatigue and orthostatic hypotension. Alleviate GI problems. Provide patient teaching.

Acute Adrenal Insufficiency or Addisonian Crisis Etiology Treatment and nursing management Monitor vital signs, glucose, and potassium. Fluid replacement Kayexalate, diuretics, insulin, and glucagon Hormone replacement

Addisonian crisis A sudden drop in corticosteroids due to: Sudden tumor removal Stress of illness, trauma, or surgery Abrupt withdrawal of steroid medication

Nursing management Transfer to ICU for close monitoring of cardiopulmonary status Administer glucocorticoids Monitor vital signs and glucose levels Monitor electrolytes Safety precautions, as patient is weak and dizzy

Excess Adrenocortical Hormone (Cushing Syndrome) Causes Excessive secretion of adrenocorticotropic hormone (ACTH) by the pituitary, which may result from faulty release of corticotropin-releasing factor (CRF) from the hypothalamus A secreting tumor of the adrenal cortex Ectopic production of ACTH by tumors outside the pituitary, such as lung cancer Iatrogenic Cushing syndrome from prolonged use of steroid therapy

Excess Adrenocortical Hormone (Cushing Syndrome) (Cont.) Signs and symptoms Diagnosis Plasma cortisol 24-Hour urine test Dexamethasone suppression test Treatment Nursing management

Common Characteristics of Cushing Syndrome See Figure 36-5 on p. 855.