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Chapter 61 Assessment of the Endocrine System
Mrs. April Page, ARNP MSN FNPC NUR1213C Intermediate Adult Care GCSC A.D.R.N. Program
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Learning Objectives Applies the pathophysiology, clinical manifestations, collaborative care, and nursing management of the patient with an imbalance of hormones produced by the anterior pituitary gland. Applies the pathophysiology, clinical manifestations, collaborative care, and nursing management of the patient with an imbalance of hormones produced by the posterior pituitary gland. Applies the pathophysiology, clinical manifestations, collaborative care, and nursing management of the patient with thyroid dysfunction.
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Learning Objectives Applies the pathophysiology, clinical manifestations, collaborative care, and nursing management of the patient with an imbalance of the hormone produced by the parathyroid glands. Uses common nursing assessments, interventions, rationales, and expected outcomes related to patient teaching for management of chronic endocrine problems
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Learning Objectives(cont’d)
Summarize the functions and effects of the thyroid hormones in Adults. Discuss specific age-related changes of the endocrine system in the older adult.
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INTRODUCTION Endocrine system includes glands found in various locations in the body These glands secrete hormones that act on specific target tissues
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Anatomy & Physiology Overview
Hypothalamus Pituitary glands Adrenal glands Thyroid gland Parathyroid gland Gonads Pancreas
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ANATOMY AND PHYSIOLOGY OVERVIEW (cont’d)
Secretion of hormones is regulated via signals From the nervous system Levels of hormones in the blood Other chemical changes such as glucose, sodium, and potassium levels Hormonal release is controlled by a negative feedback system Increases hormone secretion when circulating levels are decreased
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ANATOMY AND PHYSIOLOGY OVERVIEW (cont’d)
Hypothalamus Small structure located beneath the thalamus Shaped like a flattened funnel Forms the walls and floor of the third ventricle Pituitary gland Located at the base of the brain in the sella turcica Size of a lima bean Communicates directly with the hypothalamus
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ANATOMY AND PHYSIOLOGY OVERVIEW (cont’d)
Adrenal glands are located on top of each kidney Adrenal cortex Comprises 90% of the adrenal gland and secretes 3 types of hormones Mineralocorticoids, glucocorticoids, and sex hormones Adrenal medulla Under control of the sympathetic nervous system (SNS) Catecholamines (epinephrine and norepinephrine) are secreted from the adrenal medulla
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ANATOMY AND PHYSIOLOGY OVERVIEW (cont’d)
Thyroid gland Located in the anterior neck directly below the cricoid cartilage Composed of two lobes, it is connected by a strip of tissue called the isthmus Produces 3 thyroid hormones Triiodothyronine (T3) Thyroxine (T4) Thyrocalcitonin (calcitonin)
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ANATOMY AND PHYSIOLOGY OVERVIEW (cont’d)
Thyroid gland Control of metabolism Calcium and phosphorus balance Parathyroid glands Usually found partially embedded in the thyroid gland May also be found above the hyoid bone or near the aortic arch Secrete parathyroid hormone
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ANATOMY AND PHYSIOLOGY OVERVIEW (cont’d)
Gonads Sexual development and function are controlled by hormones secreted from the ovaries and testes Pancreas Located in upper left quadrant of the abdominal cavity Both exocrine and endocrine functions Insulin Glucagon
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Assessment Methods Patient history Nutrition history Family history and genetic risk Current health problems Changes in energy levels Changes in elimination Sexual and reproductive functions Changes in physical appearance Any other current health problems
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ASSESSMENT History Complete a comprehensive history Evaluating family history for endocrine disorders Physical assessment Inspection Auscultation Palpation
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Physical Assessment Examine for: Prominent forehead or jaw Round or puffy face Dull or flat expression Exophthalmos Vitiligo Striae Hirsutism
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DIAGNOSTIC TESTING Laboratory assessment of urine and blood Tests are related to disorder under investigation Imaging studies Assess for changes in the size or presence of tumor formation in the glands of the endocrine system Computed tomography (CT) Magnetic resonance imaging (MRI) X-rays
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INTERVENTIONS AND THERAPIES
Multidisciplinary care for multiple problems Holistic approach essential component of nursing care Independent therapies Educate client regarding diagnostic testing, disease state, therapies
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INTERVENTIONS AND THERAPIES
Help develop a lifestyle that will limit complications For diabetes educate, coach, advocate to help clients attain optimum health For osteoporosis help client and family ensure safe environment
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INTERVENTIONS AND THERAPIES
Collaborative therapies May work with exercise physiologists and dietitians Behavioral therapy Pharmacologic therapy Replacement therapy Medications for Metabolic and Endocrine Disorders
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AGE-RELATED CHANGES Changes in endocrine function are associated with aging Early detection and treatment can minimize long-term consequences Some of the endocrine changes are secondary to hypoactive function of endocrine glands secondary to downregulation Other changes may be related to an increased incidence of chronic disease
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Care for Patients With Pituitary and Adrenal Gland Problems
Chapter 62 Care for Patients With Pituitary and Adrenal Gland Problems Mrs. April Page, ARNP MSN FNPC NUR1213C Intermediate Adult Care GCSC A.D.R.N. Program
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Disorders of the Adrenal Glands
Hyperfunction and hypofunction of the adrenal cortex Hyperfunction of the adrenal medulla
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INTRODUCTION One adrenal gland is on top of each kidney Each adrenal gland has an inner core, medulla, and a cortex Under control of the anterior pituitary gland the adrenal cortex secretes Glucocorticoids (cortisol) Mineralocorticoids (aldosterone) Sex hormones (androgens and estrogens)
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ADRENAL CORTICAL INSUFFICIENCY
Epidemiology Adrenal insufficiency may result from Destruction of the adrenal glands Primary insufficiency or Addison’s disease Decreased secretion of adrenocorticotropic hormone (ACTH) from the anterior pituitary gland Secondary insufficiency Dysfunction of the hypothalamus Tertiary insufficiency
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ADRENAL CORTICAL INSUFFICIENCY (cont’d)
Pathophysiology Decreased secretion of corticotropin-releasing hormone (CRH) from the anterior pituitary gland Decreased secretion of ACTH from the anterior pituitary gland Decreased secretion of glucocorticoids and mineralocorticoids from the adrenal cortex
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ADRENAL CORTICAL INSUFFICIENCY (cont’d)
Clinical manifestations Adrenal insufficiency usually present after 90% of the adrenal cortex is destroyed or nonfunctional Management Includes tests of the hypothalamic-pituitary axis and adrenal cortex plus serum electrolytes Replacement of cortisol for adrenal insufficiency
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ADRENAL CORTEX HYPERFUNCTION
Epidemiology Adrenal cortex hyperfunction May be secondary to excessive secretion of glucocorticoids (hypercortisolism) Excessive secretion of aldosterone (hyperaldosteronism) Cushing's disease and Cushing's syndrome Pathophysiology Excessive circulating glucocorticoid (cortisol) is the pathophysiological process
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The Patient with Cushing Syndrome
Signs and symptoms Weakness Easily bruised Poor wound healing Glycosuria Psychological manifestations
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Figure - Among the manifestations of Cushing’s syndrome are central obesity; fat deposits around the upper back (A); the face (B); and clavicle; hirsutism; dilation of capillaries; and purple or red striae (due to weight gain). 29
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Pathophysiology Iatrogenic Cushing syndrome Pituitary form (Cushing disease) ACTH hypersecretion leading to hypercortisolism Adrenal form Ectopic form
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Interprofessional Care
Diagnosis Laboratory tests Late night salivary cortisol test CT scan or MRI of abdomen to assess adrenal gland for tumors
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Interprofessional Care
Medications Mitotane Amnioglutethimide or ketoconazole Somatostatin analog
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Interprofessional Care
Surgery Adrenalectomy Lifelong hormone replacement necessary if both adrenal glands removed Hypophysectomy
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Nursing Care Diagnoses, outcomes, and interventions Fluid Volume Excess Risk for Injury Risk for Infection Disturbed Body Image
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Nursing Care Continuity of care Safety measures to prevent falls Taking medications as prescribed Having regular health assessments Wearing a medical ID indicating the patient has Cushing syndrome
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Nursing Care Continuity of care Referrals to social services or community health services Resources The American Association of Clinical Endocrinologists The Endocrine Society
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The Patient with Chronic Adrenal Insufficiency
Addison disease Uncommon Results from destruction, dysfunction of adrenal cortex Chronic deficiency of cortisol, aldosterone, and adrenal androgens Accompanied by skin pigmentation
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Pathophysiology Autoimmune destruction of the adrenals Patients who are taking anticoagulants, have major trauma, sepsis, or are having open heart surgery Adrenoleukodystrophy ACTH deficit Abrupt withdrawal from long-term, high-dose steroid therapy
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Manifestations Experienced after 90% of function of gland is lost Postural hypotension, syncope common Poor tolerance of stress Lethargy, weakness Anorexia, nausea, vomiting, and diarrhea Hyperpigmentation of skin
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Manifestations Addisonian crisis Life-threatening acute adrenal insufficiency Triggers Surgery Acute systemic illness Trauma Abrupt withdrawal of long-term corticosteroid therapy
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Manifestations Addisonian crisis Treatment Rapid intravenous replacement of fluids and glucocorticoids
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Interprofessional Care
Diagnostic tests Serum cortisol levels Blood glucose levels Serum sodium levels Serum potassium levels BUN levels
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Interprofessional Care
Diagnostic tests Urinary 17-hydroxycorticoids and 17-KS levels Plasma ACTH levels ACTH stimulation test CT scans
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Interprofessional Care
Medications Replacement of corticosteroids and mineralcorticoids Hydrocortisone Fludrocortisone Increased sodium in diet
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Nursing Care Health promotion Risks associated with abruptly withdrawing prolonged or high dose corticosteroid drugs Teaching to prevent, treat Addisonian crisis Priorities of care Maintaining fluid and electrolyte balance Compliance with lifelong self-care
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Nursing Care Diagnoses, outcomes, and interventions Deficient Fluid Volume Risk for Ineffective Therapeutic Regimen Management
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Nursing Care Continuity of care Teach self-care at home Refer to social worker, if appropriate Refer to community agencies for continued education and support
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Nursing Care Continuity of care Helpful resources National Institute of Diabetes and Digestive and Kidney Diseases (Addison disease) Endocrine Society American Association of Clinical Endocrinologists
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ADRENAL CORTEX HYPERFUNCTION (cont’d)
Clinical manifestations Hyperglycemia, fluid retention, hypokalemia, abnormal fat distribution, and decreased muscle mass Management Diagnosis of hypercortisolism Medical management of hypercortisolism Surgical management of hypercortisolism
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ADRENAL CORTEX HYPERFUNCTION (cont’d)
Management (cont’d) Diagnosis of hyperaldosteronism Medical management of hyperaldosteronism Surgical management of hyperaldosteronism Complications Hypercortisolism Hyperaldosteronism
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The Patient with Pheochromocytoma
Tumors of chromaffin tissues in adrenal medulla Signs and symptoms Paroxysmal hypertension Increased cardiac output Peripheral vasoconstriction
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PHEOCHROMOCYTOMA Epidemiology Rare catecholamine secreting tumors of the adrenal medulla 50% of cases are diagnosed only upon autopsy Pathophysiology Catecholamine-secreting tumors of the adrenal medulla and are usually unilateral
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PHEOCHROMOCYTOMA (cont’d)
Clinical manifestations Include tachycardia, hypertension, headaches, palpitations, hyperhydrosis, hypermetabolism, and hyperglycemia Management Sudden elevation of blood pressure accompanied by other clinical manifestations of catecholamine excess Adrenalectomy is the definitive treatment
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The Patient with Pheochromocytoma
Diagnosis Increased catecholamine levels in blood Urine by x-rays or surgical exploration Treatment Removal of tumors by adrenalectomy
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The Patient with Disorders of the Anterior Pituitary Gland
Hyperfunction Excess production, secretion of one or more trophic hormones Benign adenoma most common Hypofunction Deficiency in one or more hormone(s) Manifestations Gigantism Acromegaly
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The Patient with Disorders of the Anterior Pituitary Gland
Pathophysiology and manifestations Gigantism When GH hypersecretion begins before puberty Person abnormally tall Acromegaly "Enlarged extremities" Sustained GH and IGF-1 hypersecretion beginning during adulthood
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The Patient with Disorders of the Anterior Pituitary Gland
Interprofessional care Acromegaly treatment Surgical removal or irradiation of pituitary tumor Somatostatin receptor binding drugs (SRBDs) Growth hormone receptor antagonists Radiation therapy
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The Patient with Disorders of the Anterior Pituitary Gland
Nursing care Interventions to help in coping with physical, emotional changes Prevent complications involving other organs and functions of the endocrine system
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Nursing Care Focus on patient problems with fluid and electrolyte balance
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Coordinating Care for Patients With Thyroid and Parathyroid Disorders
Chapter 63 Coordinating Care for Patients With Thyroid and Parathyroid Disorders Mrs. April Page, ARNP MSN FNPC NUR1213C Intermediate Adult Care GCSC A.D.R.N. Program
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Disorders of the Thyroid Gland
Hyperthyroidism Hypothyroidism Cancer of the thyroid
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INTRODUCTION Thyroid and parathyroid glands are integral to normal body functions Metabolic activity and rate are primarily controlled by 2 thyroid gland hormones Triiodothyronine (T3) Thyroxine (T4) Disorders affecting either of these structures can result in hypothyroidism or hyperthyroidism
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The Patient with Hypothyroidism
Common in women between ages of 30 and 60 Myxedema Chronic, untreated hypothyroid state in adults Accumulation of nonpitting edema in connective tissues throughout body
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HYPOTHYROIDISM Epidemiology Caused by disorders affecting the anterior pituitary gland or the hypothalamus Most common type is Hashimoto’s thyroiditis Pathophysiology Primary hypothyroidism Secondary hypothyroidism Tertiary hypothyroidism
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Pathophysiology and Manifestations
Primary hypothyroidism More common Secondary hypothyroidism Pituitary TSH deficiency or peripheral resistance to thyroid hormones Goiter Fluid retention and edema Multisystem effects
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Pathophysiology and Manifestations
Iodine deficiency Iodine necessary for TH synthesis and secretion Use of iodized salt in U.S. has decreased deficiency Hashimoto thyroiditis Most common cause of goiter, hypothyroidism Antibodies destroy thyroid tissue
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Pathophysiology and Manifestations
Myxedema coma Life-threatening complication of long-standing, untreated hypothyroidism Usually occurs in older adults Patients extremely sensitive to opioids Mortality rate high
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Interprofessional Care
Clinical manifestations and decrease in TH, especially T4 Same tests used as for hypothyroidism with opposite results Other tests Elevated serum LDL cholesterol Triglycerides Lipoproteins
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Interprofessional Care
Medications Thyroid hormone is used in the treatment of hypothyroidism. Levothyroxine sodium (Synthroid) Liothyronine sodium (Cytomel) Levothyroxine sodium (Levothroid) Liotrix (Euthroid)
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Interprofessional Care
Surgery When goiter is large enough to cause respiratory difficulties or dysphagia
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Nursing Care Diagnoses, outcomes, and interventions Decreased Cardiac Output Constipation Risk for Impaired Skin Integrity
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Nursing Care Continuity of care Address the need to take medications for the rest of one's life Address the need for periodic dosage reassessments Community resources if patient is older or lacks support system Additional resources are the same as for the patient with hyperthyroidism.
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HYPERTHYROIDISM Epidemiology Commonly diagnosed in women yrs of age 10x more prevalent in women Graves’s disease Pathophysiology Accelerated metabolism is characteristic of hyperthyroidism and affects most body systems
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The Patient with Hyperthyroidism
Caused by excessive delivery of TH to tissues Also known as thyrotoxicosis
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HYPERTHYROIDISM CLINICAL MANIFESTIONS
Increased appetite Weight loss Fatigue Nervousness Insomnia Light to absent menses Hair loss Elevated heart rate Cardiac dysrhythmias Increased heart sounds Thyroid bruit Heat intolerance Increased gastric activity
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HYPERTHYROIDISM (cont’d)
Management Laboratory findings Elevated serum T3 and serum T4 Decreased TSH in primary disorders In goiter patients thyroid scans may be performed Complications Thyroid storm Thyrotoxicosis
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Pathophysiology and Manifestations
Graves disease Autoimmune disorder sometimes associated with myasthenia gravis, diabetes mellitus, celiac, pernicious anemia Goiter Enlarged thyroid gland Proptosis Forward displacement of the eye
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Pathophysiology and Manifestations
Graves disease Exophthalmos Forward protrusion of eyeballs from inflammation by-products in retro-orbital tissues Toxic multinodular goiter Small, discrete, independently functioning nodules in thyroid tissue that secrete excessive TH
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Figure - Exophthalmos in a patient with Graves’ disease
Figure - Exophthalmos in a patient with Graves’ disease. The disease causes edema of fat deposits behind the eyes and inflammation of the extraocular muscles. The accumulating pressure forces the eyes outward from their orbits. Source: Medical-on-Line/Alamy. 79
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Pathophysiology and Manifestations
Thyroiditis Viral infection of thyroid gland Acute disorder that may become chronic Thyroid crisis Also known as thyroid storm Rare, extreme hyperthyroidism Untreated hyperthyroidism People with hyperthyroidism who have experienced a stressor
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Toxic Multinodular Goiter
Figure 19–2 Toxic multinodular goiter. The formation and growth of numerous nodules in the thyroid gland cause the characteristic massive enlargement of the neck. 81
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Diagnosis Elevated levels of TH T3 and T4 Increased radioactive iodine (RAI) uptake
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Medications Administer antithyroid medications that reduce TH production Initial treatment of propanolol or esmolol
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Radioactive Iodine Therapy
Given orally Results in 6–8 weeks Contraindicated in pregnant women Most patients not hospitalized during treatment
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Surgery Thyroidectomy Subtotal Enough gland left in place to produce adequate amount of TH Patient in a nearly euthyroid state before surgery
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Nursing Care Diagnoses, outcomes, and interventions Risk for Decreased Cardiac Output Impaired Vision Imbalanced Nutrition: Less Than Body Requirements Disturbed Body Image and Anxiety
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Nursing Care Continuity of care Teach self-care at home Referral to community healthcare agencies Resources The American Thyroid Association The Thyroid Foundation of Canada The Endocrine Society
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The Patient with Hypothyroidism
Common in women between ages of 30 and 60 Myxedema Chronic, untreated hypothyroid state in adults Accumulation of nonpitting edema in connective tissues throughout body
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THYROID CANCER Thyroid cancer patients usually present with a nodule on the thyroid gland Other than anaplastic, thyroidectomy is the treatment of choice 4 types of thyroid cancer Papillary, follicular, medullary, and anaplastic
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Cancer of the Thyroid Risk factors Exposure to ionizing radiation to the head and neck during childhood Common types Papillary thyroid carcinoma Follicular thyroid cancer Medullary thyroid cancer
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The Patient with Cancer of the Thyroid
Common types Papillary thyroid carcinoma Follicular thyroid cancer Medullary thyroid cancer Manifestations Palpable, firm, non-tender nodule on thyroid
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The Patient with Cancer of the Thyroid
Diagnosis Measure thyroid hormones Thyroid scans Fine-needle biopsy of nodule
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The Patient with Cancer of the Thyroid
Treatment Subtotal or total thyroidectomy TSH suppression therapy with levothyroxine prior to surgery Radioactive iodine therapy (131I) Chemotherapy
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Disorders of the Parathyroid Glands
Hyperparathyroidism Hypoparathyroidism
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HYPOPARATHYROIDISM Epidemiology Idiopathic Acquired Reversible Pathophysiology Hypocalcemia is the primary disorder
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HYPOPARATHYROIDISM (cont’d)
Clinical manifestations Decreased serum calcium levels Numbness/tingling around mouth or hands and feet Muscle cramps, spasms of hands and feet, and tetany Management Treatment based upon whether the presentation is acute or insidious Focuses primarily on raising serum calcium levels .
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The Patient with Hypoparathyroidism
Abnormally low PTH levels Damage to or inadvertent removal of all parathyroid glands during thyroidectomy Pathophysiology and manifestations Tetany Muscle spasms Hyperactive reflexes
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Manifestations of Hypoparathyroidism
Muscle spasms, facial grimacing, carpopedal spasms, tetany or convulsions Brittle nails, hair loss, dry, scaly skin Abdominal cramps, malabsorption Dysrhythmias
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Manifestations of Hypoparathyroidism
Paresthesias, mood disorders, hyperactive reflexes, psychosis, increased intracranial pressure
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Interprofessional Care
Diagnosis Low serum calcium levels and high phosphorous levels in absence of renal failure An absorption disorder Nutritional disorder
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Interprofessional Care
Treatment Increase calcium levels Long-term therapy Supplemental calcium Increased dietary calcium Vitamin D therapy
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HYPERPARATHYROIDISM Epidemiology 85% of the cases of primary hyperparathyroidism 15% of cases are secondary disorders Pathophysiology Causes hypercalcemia secondary to its actions on bone, kidneys, and the bowel
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HYPERPARATHYROIDISM (cont’d)
Clinical manifestations May be asymptomatic Polyuria, anorexia, and constipation Management Direct measurement of intact PTH Treatment focuses primarily on lowering serum levels
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The Patient with Hyperparathyroidism
Increase in secretion of parathyroid hormone (PTH), which regulates normal serum levels of calcium Signs and symptoms Hypertension Psychosis Muscle weakness Renal calculi
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The Patient with Hyperparathyroidism
Pathophysiology and manifestations Primary hyperparathyroidism Hyperplasia, adenoma in parathyroid gland Secondary hyperparathyroidism Response to chronic hypocalcemia Tertiary hyperparathyroidism Patients with chronic renal failure
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Interprofessional Care
Diagnosis Exclude all other possible causes of hypercalcemia by at least a 6-month history of manifestations Laboratory analysis of levels of serum calcium and PTH levels
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Interprofessional Care
Treatment Decrease elevated serum calcium levels Drink fluids Keep active
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Interprofessional Care
Medications Short-term Pamidronate Alendronate Zoledronate Calcitonin, calcimimetic Surgery
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Nursing Care Effects on calcium balance Risk for pathologic fractures Risk for developing kidney stones
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