NCLEX-RN: Medical–Surgical Nursing

Medical–Surgical Nursing: Endocrine System

Focus topic: Medical–Surgical Nursing

The endocrine system consists of a series of glands that function individually or conjointly to integrate and control innumerable metabolic activities of the body. These glands automatically regulate various body processes by releasing chemical signals called hormones.

Medical–Surgical Nursing: Anatomy and Physiology

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Function

Focus topic: Medical–Surgical Nursing

A. Maintenance and regulation of vital functions.

  • Response to stress or injury.
  • Growth and development.
  • Reproduction.
  • Fluid, electrolyte, and acid–base balance.
  • Energy metabolism.

B. Endocrine glands.

  • Have specific functions.
  • Influence one another.
  • Secrete hormones directly into the bloodstream.
  • Controlled by autonomic nervous system.
  • Located in various parts of body.

C. Hormones. (See Table 8-11.)

  • Chemical messengers that stimulate or inhibit life processes.
  • Transmitted via the bloodstream to target tissues.
  • Regulated through negative feedback control system (hypothalamic–pituitary axis). For example, the thyrotropin-releasing hormone (TRH) is secreted by the hypothalamus, which causes the pituitary to secrete thyroid-stimulating hormone (TSH). TSH stimulates the thyroid to secrete thyroxine (T4). Thyroxine feeds back on the pituitary and inhibits production of TSH.
  • Also regulated by renin–angiotensin–aldosterone, insulin–glucose, and calcium–parathormone.
  • Endocrine disorders are caused by a deficit or excess in hormone production.

Medical–Surgical Nursing: Structure

Focus topic: Medical–Surgical Nursing

A. Hypothalamus connects pituitary gland to central nervous system.
B. Pituitary gland divided into three lobes.

  • Anterior pituitary control (master gland).
    a. Tropic hormones exert effect through regulation of other endocrine glands—adrenocorticotropic hormone (ACTH), TSH, follicle-stimulating hormone (FSH), luteinizing hormone (LH).
    b. Target tissues: Hormones have direct effect on tissues—growth hormone, prolactin, melanophore-stimulating hormone (MSH).
  • Posterior lobe (neurohypophysis)—antidiuretic hormone (ADH; also called vasopressin), oxytocin, melanophore-stimulating hormone.
  • Intermediate lobe.

C. Adrenal gland—located on the top of each kidney.

  • Cortex produces glucocorticoids, mineralocorticoids, sex hormones.
  • Medulla produces epinephrine and norepinephrine.

D. Thyroid gland—located anterior to the trachea. Produces thyroxine, triiodothyronine (T3), and thyrocalcitonin.
E. Parathyroid gland—located near thyroid. Produces parathormone (PTH).
F. Pancreas—located between stomach and small intestine. Produces insulin and glucagon.
G. Ovaries—located in female pelvic cavity. Produce estrogen and progesterone.
H. Testes—located in male scrotum. Produce testosterone.

Medical–Surgical Nursing: System Assessment

Focus topic: Medical–Surgical Nursing

A. Assess for growth imbalance.

  • Excessive growth.
    a. Pituitary or hypothalamic disorders.
    b. Excess adrenal, ovarian, or testicular hormone.
  • Retarded growth.
    a. Endocrine and metabolic disorders; difficult to distinguish from dwarfism.
    b. Hypothyroidism.

B. Evaluate for obesity.

  • Sudden onset suggests hypothalamic lesion (rare).
  • Cushing’s syndrome (with characteristic buffalo hump).

C. Assess abnormal skin pigmentation.

  • Hyperpigmentation may coexist with depigmentation in Addison’s disease.
  • Thyrotoxicosis may be associated with spotty brown pigmentation.
  • Pruritus is a common symptom in diabetes.

D. Check for hirsutism.

  • Normal variations in body occur on nonendocrine basis.
  • First sign of neoplastic disease.
  • Indicates changes in adrenal status.

E. Evaluate appetite changes.

  • Polyphagia is a common sign of uncontrolled diabetes.
  • Indicates thyrotoxicosis.
  • Nausea and weight loss may indicate Addisonian crisis or diabetic acidosis.

F. Check for polyuria and polydipsia.

  • Symptoms usually of nonendocrine etiology.
  • If sudden onset, suggest diabetes mellitus or insipidus.
  • May be present with hyperparathyroidism or hyperaldosteronism.

G. Assess mental changes.

  • Though often subtle, may be indicative of underlying endocrine disorder.
    a. Nervousness and excitability may indicate hyperthyroidism.
    b. Mental confusion may indicate hypopituitarism, Addison’s disease, or myxedema.
  • Mental deterioration is observed in untreated hypoparathyroidism and hypothyroidism.

H. Assess metabolic status.

  • Changes in energy level.
  • Fatigue.
  • Changes in heat or cold tolerance.
  • Recent weight changes.
  • Changes in sleep pattern.

I. Assess for coma state.

  • Drowsiness.
  • Hyperpnea.
  • Tachycardia.
  • Subnormal temperature.
  • Fruity odor to breath.
  • Acetone in urine.
  • Stupor leading to coma.

J. Assess diagnostic tests (radioactive iodine uptake, T3 and T4, thyroid stimulation, and glucose tolerance test).

Endocrine System

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing

Medical–Surgical Nursing: System Implementation

Focus topic: Medical–Surgical Nursing

A. Administer hormone replacement on time to keep blood level stable.
B. Monitor for side effects of hormone replacement therapy.
C. Identify clinical manifestations indicating hyperfunction or hypofunction of endocrine glands.
D. Monitor for fluid and electrolyte imbalances due to hormone imbalance.
E. Provide appropriate diet specific for endocrine disorder.
F. Promote rest and reduce stress.
G. Prepare client physically and psychologically for surgical removal of endocrine gland.
H. Instruct client on methods to prevent infection.
I. Differentiate diabetic coma from other causes.

  • Urinalysis for sugar and acetone.
  • Blood sugar level.
Medical–Surgical Nursing

Medical–Surgical Nursing: Pituitary Gland Disorders

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Acromegaly (Anterior Pituitary Hyperfunction)

Focus topic: Medical–Surgical Nursing

Definition: The hypersecretion of growth hormone by the anterior pituitary. Occurs in adulthood after closure of the epiphyses of the long bones.

Assessment
A. Assess for excessive growth of short, flat bones.

  • Large hands and feet.
  • Thickening and protrusion of the jaw and orbital ridges that cause teeth to spread.
  • Increased growth of soft tissue.
  • Coarse features.
  • Pain in joints.
  • Forehead enlarges.
  • Tongue enlarges.
  • Hypertension.
  • Peripheral nerve damage.
  • Congestive heart failure.
  • Seizures.

B. Evaluate voice, which becomes deeper.
C. Assess increased diaphoresis.
D. Assess for oily, rough skin.
E. Assess increased hair growth over the body.
F. Evaluate menstrual disturbances; impotence.
G. Assess for symptoms associated with local compression of brain by tumor.

  • Headache.
  • Visual disturbances; blindness.

H. Check any related hormonal imbalances.

  • Diabetes mellitus (growth hormone is insulin antagonist).
  • Cushing’s syndrome.

I. Evaluate laboratory values—increased growth hormone level.

Implementation
A. Provide emotional support.

  • Encourage client’s expression of feelings.
    a. Loss of self-image and self-esteem.
    b. Fears about brain surgery.
    c. Consequences of surgery (sterility and lifetime hormone replacement).
  • Have client avoid situations that may be embarrassing.
  • Encourage support of and communication with family.

B. Provide frequent skin care.
C. Position and support painful joints.
D. Test urine for glucose and acetone.
E. Administer supportive care for irradiation of pituitary.
F. Provide preoperative and postoperative care for hypophysectomy.

Medical–Surgical Nursing: Gigantism (Anterior Pituitary Hyperfunction)

Focus topic: Medical–Surgical Nursing

Definition: The hypersecretion of growth hormone by the anterior pituitary. Occurs in childhood prior to closure of the epiphyses of the long bones.

Assessment
A. Assess for symmetrical overgrowth of the long bones.
B. Evaluate increased height in early adulthood (may be 7–9 feet).
C. Check for deterioration of mental and physical processes, which may occur in early adulthood.
D. Assess for other tissue responses similar to acromegaly.

Implementation
A. Supportive care for irradiation of pituitary.
B. Provide preoperative and postoperative care for hypophysectomy.

Medical–Surgical Nursing: Hypophysectomy

Focus topic: Medical–Surgical Nursing

Definition: The removal of the pituitary gland because of tumor formation. If tumors are small, an adenectomy (surgical excision of the gland) may be performed.

Treatment
A. Surgical procedures.

  • Craniotomy—for large, invasive tumors.
  • Microsurgery—Endoscopic transnasal preferred approach, associated with fewer complications.
  • Cryohypophysectomy.

B. Medical treatment.

  • Radiation therapy.
  • Stereotactic radiosurgery.
  • Drugs.
    a. Somatostatin analogs (Sandostatin [octreotide]).
    b. GH receptor antagonists (Somavert [pegvisomant]).
    c. Dopamine antagonists (Dostinex [cabergoline]).

Implementation
A. Preoperative care.

  • Provide general preoperative care.
  • Provide emotional support.

B. Postoperative care.

  • Administer corticosteroids on time.
  • Elevate the head of the bed.
  • Monitor fluid and electrolyte balance.
    a. Hypernatremic due to ADH disturbance leading to fluid imbalance and diabetes insipidus.
    b. Avoid water intoxication.
    c. Encourage fluid intake of 2500–3000 mL/ day unless otherwise ordered.
  • Carefully monitor vital signs.
  • Monitor blood gas determinations.
  • Provide routine care for craniotomy. Observe for
    a. Vital signs.
    b. Increased intracranial pressure.
    c. Shock.
    d. Level of consciousness (LOC).
  • Initiate client education.
    a. Compensate for altered stress response.
    b. Avoid contact with infectious individuals.
    c. Carry emergency adrenal hormone drugs.
    d. Use Medic-Alert band.

C. Monitor for complications.

  • Craniotomy—bleeding in acromegaly (due to excessive growth of frontal bones). ↑ ICP, meningitis, hypopituitarism.
  • Microsurgery—rhinorrhea and meningitis (due to interruption of CSF during surgery). Cerebrospinal fluid (CSF) leak, hypopituitarism.
  • Cryohypophysectomy—probe hits other vital structures.

Medical–Surgical Nursing: Dwarfism (Anterior Pituitary Hypofunction)

Focus topic: Medical–Surgical Nursing

Definition: Dwarfism is the hyposecretion of growth hormone by the anterior pituitary. Growth is symmetrical but decreased.

Assessment
A. Assess for retarded physical growth.
B. Evaluate premature body-aging processes.

C. Assess for pale, dry, smooth skin.
D. Check poor development of secondary sex characteristics and external genitalia.
E. Evaluate slow intellectual development.

Implementation
A. Administer human growth hormone (HGH) injections if the imbalance is diagnosed and treated in early stage.
B. Monitor for complications.

Medical–Surgical Nursing: Diabetes Insipidus (Posterior Pituitary Hypofunction)

Focus topic: Medical–Surgical Nursing

Definition: An antidiuretic hormone (ADH) deficiency, usually seen in young adults, resulting from damage or tumors in the posterior lobe of the pituitary gland. May develop following brain surgery, head injury, infection of the central nervous system (CNS).

Characteristics
A. Neurogenic diabetes—can result from a disruption of the hypothalamus and pituitary gland (e.g., head trauma or cranial surgery) or can be idiopathic.
B. Nephrogenic—disorder that occurs when renal tubules are not sensitive to ADH. May be familial or the result of renal failure.

Assessment
A. Assess for severe polyuria (as much as 24 L/day) and polydipsia.
B. Evaluate fatigue and muscle pain.
C. Assess for dehydration. ↓ Skin turgor and dry mucous membranes, tachycardia.
D. Assess weight loss, muscle weakness, headache.
E. Evaluate for inability to concentrate urine.
F. Monitor laboratory values.

  • Urine specific gravity. Low urinary specific gravity (< 1.006 or less).
  • Serum sodium.
  • Serum vasopressin.

G. Assess for postural hypotension that may result in collapse if not rehydrated.

Implementation
A. Maintain adequate fluids.
B. Measure intake and output and weight.
C. Stress importance of Medic-Alert band.
D. Avoid liquids or foods with diuretic-type action.
E. Provide comfort measures if client is on radiation therapy.
F. Provide preoperative and postoperative care for hypophysectomy.
G. Administer Pitressin tannate (vasopressin tannate) intramuscular (IM) or nasal spray if ordered (often given for temporary DI after head trauma or surgery).
H. Monitor diet: low sodium, low protein with diuretics.
I. Administer benzthiazide diuretics for mild cases.
J. Administer Diabinese (chlorpropamide) to potentiate vasopressin or act as antidiuretic.
K. Administer Atromid-S (clofibrate) for antidiuretic effect.
L. Monitor administration of nonsteroidal antiinflammatory agents (NSAIDs) to increase urinary concentration.
M. Give supportive care for irradiation of tumor.

Medical–Surgical Nursing: Adrenal Cortex Disorders

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Addison’s Disease (Adrenocortical Insufficiency)

Focus topic: Medical–Surgical Nursing

Definition: The hypofunction of the adrenal cortex of the adrenal gland, resulting in a deficiency of the steroid hormones. It often has a slow and insidious onset, and is eventually fatal if left untreated.

Assessment
A. Assess for normal dietary intake.
B. Assess for lassitude, lethargy, fatigue, and muscular weakness.
C. Check out any gastrointestinal (GI) disturbances, nausea, diarrhea, and anorexia.
D. Assess for hypotension.
E. Evaluate increased pigmentation of the skin of nipples, buccal mucosa, and scars. This condition occurs in 15% of clients.
F. Evaluate emotional disturbances, depression.
G. Assess for weight loss, emaciation.
H. Assess laboratory values and diagnostic tests.

  • Elevated potassium; decreased sodium; elevated blood urea nitrogen (BUN) levels due to decreased glomerular filtration rate.
  • Low blood glucose.
  • Lack of normal rise in urinary output of 17-ketosteroids and 17-hydroxycorticosteroids following intravenous (IV) administration of ACTH over 8 hours.
  • Lack of normal rise in blood level of plasma cortisol following IM injection of ACTH.
  • Serum cortisol levels—decreased.
  • ACTH stimulation test—cortisol levels rise with pituitary deficiency but do not rise in primary adrenal insufficiency.
  • Computed tomography (CT) of head—identify intracranial problems impinging on the pituitary gland.
  • Electrocardiogram (ECG)—look for characteristic changes associated with hyperkalemia (peaked T waves, widening QRS complex, and an increased PR interval).

Implementation
A. Monitor daily weight and record accurate intake and output—restoration of fluid and electrolyte balance priority.
B. Take vital signs qid (more often if client unstable).
C. Check for inadequate or overdosage of hormones.

  • Cortisone and Cortef (hydrocortisone).
    a. Sodium and water retention.
    b. Potassium depletion or hyperkalemia (may disappear with cortisol therapy).
    c. Drug-induced Cushing’s syndrome.
    d. Gastric irritation (give medication with meal or antacid).
    e. Mood swings.
    f. Local abscess at injection site when given intramuscularly (IM) (inject deeply into gluteal muscle).
    g. Addisonian crisis, which might be produced by sudden withdrawal of medication.
  • Florinef (fludrocortisone acetate)—the same side effects as cortisone and hydrocortisone, particularly sodium retention and potassium depletion.

D. Protect from exposure to infection.
E. High-protein, high-carbohydrate diet in small, frequent feedings.
F. Provide emotional support; assist client to avoid stress.
G. Provide client education.

  • Safe self-administration of replacement hormones. Lifelong replacement therapy with synthetic corticosteroid drugs is necessary.
  • Avoidance of over-the-counter drugs.
  • Care to avoid infections; report promptly to physician if infections appear.
  • Medic-Alert band.
  • Regular exercise; avoid strenuous activity, particularly in hot weather.
  • Importance of continuous medical supervision.
  • Avoidance of stress.
  • Avoidance of exposure to cold.

Medical–Surgical Nursing: Addisonian Crisis

Focus topic: Medical–Surgical Nursing

Definition: A life-threatening condition caused by acute adrenal insufficiency that may be precipitated by infection, trauma, stress, surgery, or diaphoresis with excessive salt loss. Death may occur from shock, vascular collapse, or hyperkalemia.

Assessment
A. Assess for severe headache and abdominal, leg, and lower back pain.
B. Assess for extreme, generalized muscular weakness.
C. Assess for manifestations of shock.

  • Hypotension.
  • Rapid, weak pulse.
  • Pallor.
  • Rapid respiratory rate.
  • Extreme weakness.

D. Assess for irritability and confusion.

Implementation
A. Administer parenteral fluids for restoration of electrolyte balance.
B. Administer adrenocorticosteroids; do not vary dosage or time from that ordered.
C. Continually monitor vital signs and intake and output until crisis passes.
D. Protect client from infection.
E. Keep client immobile and as quiet as possible; avoid unnecessary nursing procedures.
F. Monitor neurological status, noting confusion and irritability.

Medical–Surgical Nursing: Cushing’s Syndrome (Adrenocortical Hyperfunction)

Focus topic: Medical–Surgical Nursing

Definition: Clinical condition resulting from the combined metabolic effects of persistently elevated blood levels of glucocorticoids.

Characteristics
A. Etiology.

  • Overactivity of adrenal cortex.
  • Benign or malignant tumor of adrenal gland.

B. Cause may be iatrogenic—drug therapy for other conditions.

Assessment
A. Assess for abnormal adipose tissue distribution.

  • Moon face.
  • Buffalo hump.
  • Obese trunk with thin extremities.

B. Assess skin—color and texture.

  • Florid facies.
  • Red striae of skin stretched with fat tissue.
  • Fragile skin, easily bruised.

C. Assess for osteoporosis—susceptible to fractures, renal stones.
D. Assess for hyperglycemia—may eventually develop diabetes mellitus.
E. Evaluate mood swings—euphoria to depression.
F. Assess for high susceptibility to infections; diminished immune response to infections once they occur.
G. Evaluate lassitude and muscular weakness.
H. Assess for masculine characteristics in females.
I. Assess for thin extremities.
J. Assess for hypertension.

K. Evaluate electrolyte imbalance.

  • Potassium depletion.
  • Sodium and water retention.
  • Metabolic alkalosis.

L. Assess laboratory values.

  • Elevated blood glucose and glycosuria.
  • Elevated white blood count (WBC) with depressed eosinophils and lymphocytes.
  • Elevated plasma cortisone levels.
  • Elevated 17-hydroxycorticosteroids in urine.

Implementation
A. Protect from infections.
B. Protect from accidents or falls.
C. Provide meticulous skin care, avoiding harsh soaps.
D. Provide low-calorie, high-protein, high-potassium diet.
E. Provide emotional support.

  • Allow for venting of client’s feelings.
  • Avoid reactions to client’s appearance.
  • Anticipate the needs of the client.
  • Explain that changes in body appearance and emotional lability should improve with treatment.

F. Measure intake and output and daily weights; test blood glucose.
G. Follow specific nursing measures postadrenalectomy or hypophsectomy.
H. Provide comfort measures during radiation therapy, cobalt irradiation of the pituitary or implants.
I. Provide postsurgery care for adrenalectomy, unilateral or bilateral.

  • Bilateral—lifetime replacement of steroids.
  • Unilateral—temporary steroid replacement (6–12 months).

J. Monitor drug therapy.

  • Cytadren (aminoglutethimide)—inhibits cholesterol synthesis.
  • Metopirone (metyrapone)—inhibits adrenal cortex steroid synthesis.
  • Lysodren (mitotane)—usually for inoperable, cancerous tumors.
  • Cyproheptadine—serotonin antagonist that inhibits ACTH.

K. Provide client teaching.

  • Importance of continuous medical supervision.
  • Safe self-administration of replacement hormones.
  • Side effects of medications.
  • Avoidance of infections and stress.
  • Need for adequate nutrition and rest.

Medical–Surgical Nursing: Primary Aldosteronism

Focus topic: Medical–Surgical Nursing

Definition: A disorder due to the hypersecretion of aldosterone from the adrenal cortex of the adrenal gland. It is usually caused by tumors. Females are at greater risk.

Assessment
A. Assess for hypokalemia.

  • Weakness of muscles.
  • Excessive urine output (polyuria); excessive thirst (polydipsia).
  • Metabolic alkalosis.

B. Assess for hypertension, postural hypotension, headache.
C. Assess for positive Chvostek’s sign (muscle twitching when area over facial nerves is tapped).
D. Assess laboratory values.

  • Lowered potassium level.
  • Elevated serum sodium level.
  • Increased urinary output of aldosterone.
  • Metabolic alkalosis.

Implementation
A. Provide quiet environment.
B. Measure intake and output and daily weights.
C. Check muscular strength and presence of Chvostek’s sign.
D. Measure blood pressure in supine and standing positions.
E. Monitor administration of potassium salts and spironolactone.

FURTHER READING/STUDY:

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