1. 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.

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

3. 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.

5. 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

6. 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.

7. 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

8. 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

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

10. Treatment and Nursing Management
Hormone replacement
Surgery and radiation
Patient teaching

11. 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)

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

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

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

15. 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

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

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

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

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

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

21. 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.

22. 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

24. 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.

25. 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

26. 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.

27. 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.

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

29. 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

31. 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.

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

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

34. 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

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

36. 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.

37. 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.

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

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

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

42. 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.

44. 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

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

46. 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

47. 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

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

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