NCLEX-RN: Medical–Surgical Nursing

Medical–Surgical Nursing: Endocrine System

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Adrenal Medulla Disorders

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Pheochromocytoma (Hyperfunction)

Focus topic: Medical–Surgical Nursing

Definition: A small tumor in the adrenal medulla of the adrenal gland that secretes large amounts of epinephrine and norepinephrine. Familial autosomal dominant.

Assessment
A. Observe that condition occurs primarily in children and middle-aged women.
B. Assess for hypertension—primary manifestation.
C. Observe for sudden attacks that resemble overstimulation of the sympathetic nervous system.

  • Hypertension (intermittent or persistent).
  • Severe headache.
  • Excessive diaphoresis.
  • Palpitation, tachycardia.
  • Nervousness and hyperactivity.
  • Nausea, vomiting, and anorexia.
  • Dilated pupils.
  • Cold extremities.
  • Tremors.
  • Flushing.
  • Anxiety.
  • Vertigo.
  • Blurred vision.
  • Dyspnea.
  • Cardiac failure or cerebral hemorrhage leading to death if not treated.

D. Assess for increased rate of metabolism and loss of weight.
E. Assess for hyperglycemia.
F. Assess laboratory values.

  • Findings common to hypertension, cardiac disease, and loss of kidney function.
  • Elevated vanillylmandelic acid (VMA) and catecholamine levels in urine.
  • Elevated blood levels of catecholamines.
  • Elevated blood glucose and glycosuria.

G. Presence of tumor may be found on x-rays or identified during surgical exploration.

Implementation
A. Monitor for evidence of hypertensive attacks; keep Regitine (phentolamine) at bedside for hypertensive crisis.
B. Monitor for normal vital signs and absence of glycosuria after alpha-adrenergic-blocking agents (Dibenzyline [phenoxybenzamine]) are given: 1–2 weeks before surgery.
C. Assess daily for glucose and acetone in urine.
D. Provide high-calorie, nutritious diet omitting stimulants.
E. Promote rest and reduce stress.
F. Provide preoperative care for surgical excision of tumor.

  • Give Regitine 1–2 days before surgery to counteract hypertensive effects of epinephrine and norepinephrine.
  • Closely monitor blood pressure (every 15 minutes) during interval of Regitine administration.

G. Provide postoperative care—observe for precipitous shock, hemorrhage, persistent hypertension.
H. Administer drugs if ordered: alpha blocker; Regitine, Dibenzyline, Nitropress (sodium nitroprusside).
I. Surgical removal of the tumor is the treatment of choice.

Medical–Surgical Nursing: Adrenalectomy

Focus topic: Medical–Surgical Nursing

Definition: Surgical removal of an adrenal gland when overproduction of adrenal hormone is evident (Cushing’s syndrome, pheochromocytoma) or in metastatic breast or prostatic cancer.

Assessment
A. Assess test results that indicate whether radiation, drug therapy, or surgery is appropriate to reverse Cushing’s syndrome or restore hormone balance.
B. Surgical intervention requires special management—central venous pressure (CVP), blood pressure (BP), pulse (P).

  • Assess hypertension.
  • Assess degree of edema.
  • Evaluate for signs of diabetes—blood glucose levels.
  • Assess for cardiovascular manifestations.

C. Assess client’s knowledge of disorder and understanding of management.
D. Assess all laboratory reports before surgery.

  • Check for signs of hypernatremia and hypokalemia.
  • Assess for hyperglycemia or glycosuria.

E. Assess dietary intake and fluid intake and output.
F. Assess for complications.

  • Wound infections.
  • Hemorrhage.
  • Peptic ulcers.
  • Pulmonary disorders.

Implementation
A. Preoperative care.

  • Provide general preoperative care.
  • Administer exogenous glucocorticoids.

B. Postoperative care.

  • Monitor vital signs and intake and output.
  • Minimize effects of postural hypotension.
  • Strictly adhere to sterile techniques when changing dressings; assess for infections.
  • Observe for shock, hypoglycemia, hypotension.
  • Maintain IV cortisol replacement (24–48 hours); mineralocorticoids.
  • Monitor for paralytic ileus as this may develop from internal bleeding.
  • Administer IV fluids to maintain blood volume.
  • Monitor ECG changes.
  • Monitor electrolytes.
  • Monitor blood glucose levels.

Medical–Surgical Nursing: Thyroid Gland Disorders

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Cretinism (Thyroid Hypofunction)

Focus topic: Medical–Surgical Nursing

Definition: A condition caused by inadequate secretions from the thyroid gland in the fetus, in utero, or soon after birth caused by congenital hypothyroidism.

Assessment
A. Assess for severe retardation of physical development, resulting in grotesque appearance, sexual retardation.
B. Assess for severe cognitive impairment and apathy.
C. Check for dry skin; coarse, dry, brittle hair.
D. Assess for constipation.
E. Evaluate slow teething.
F. Evaluate poor appetite.
G. Observe for large tongue.

H. Observe for pot belly with umbilical hernia.
I. Evaluate sensitivity to cold.
J. Assess for yellow skin.
K. Assess laboratory values.

  • T4 less than 3 μg/100 mL.
  • Elevated serum cholesterol.
  • Low radioactive iodine uptake.

Implementation
A. Administer desiccated thyroid or Synthroid (levothyroxine).
B. Administer Cytomel (liothyronine); effects more difficult to monitor.

Medical–Surgical Nursing: Hypothyroidism (Myxedema)

Focus topic: Medical–Surgical Nursing

Definition: The decreased synthesis of thyroid hormone in adulthood, resulting in a hypothyroid state—acquired hypothyroidism. Occurs primarily in older age group, five times more frequent in women than in men.

Assessment
A. Assess for slowed rate of body metabolism.

  • Lethargy, apathy, and fatigue.
  • Intolerance to cold, hypothermia.
  • Hypersensitivity to sedatives and barbiturates.
  • Weight gain.
  • Cool, dry, rough skin.
  • Coarse, dry hair; hair loss; brittle nails.
  • Numbness and tingling of fingers.
  • Hoarseness.

B. Assess for personality changes.

  • Forgetfulness and loss of memory.
  • Complacency.
  • Slowed speech.

C. Assess for anorexia, constipation, and fecal impactions.
D. Observe for interstitial edema.

  • Nonpitting edema in the lower extremity.
  • Generalized puffiness.

E. Observe for decreased diaphoresis.
F. Check for reproductive disturbances.

  • Menorrhagia (females).
  • Infertility (females).
  • Decreased libido (males).

G. Assess for cardiac complications.

  • Coronary heart disease.
  • Angina pectoris.
  • Myocardial infarction (MI) and congestive heart failure.
  • Bradycardia
  • Dysrhythmias.

H. Evaluate anemia.
I. Assess laboratory findings.

  • Low serum thyrotoxin concentration.
  • Hyponatremia.
  • Elevated serum cholesterol.

Implementation
A. Allow time for client to complete activities.
B. Provide warm environment: extra blankets, etc.
C. Provide meticulous skin care.
D. Orient client as to date, time, and place.
E. Prevent constipation.
F. If sedatives or narcotics are necessary, give onehalf to one-third normal dosage, as ordered by physician.
G. Monitor thyroid replacement (initial small dosage, increased gradually).
H. Maintain individualized maintenance dosage.

  • Desiccated thyroid.
  • Thyroxine (Synthroid).
  • Triiodothyronine (Cytomel).
  • Natural combinations from animal thyroid.

I. Monitor for overdosage symptoms of thyroid preparations.

  • Myocardial infarction and angina and cardiac failure, particularly in clients with cardiac problems.
  • Restlessness and insomnia.
  • Headache and confusion.

J. Monitor arterial blood gases.
K. Monitor pulse oximetry.
L. Monitor oxygen administration.

Medical–Surgical Nursing: Myxedema Coma

Focus topic: Medical–Surgical Nursing

Definition: A serious condition resulting from persistent low thyroid production.

Assessment
A. Assess for hypoventilation, compromised respiratory function.
B. Observe for hypotension leading to cardiac abnormalities; bradycardia.
C. Evaluate cold sensitivity leading to severe hypothermia.
D. Evaluate mood swings.

Implementation
A. Monitor administration of thyroid hormone IV.
B. Provide total supportive care.
C. Provide psychological support.

  • Body image change.
  • Complete dependency.
  • Mental depression.

D. Closely observe for problems of immobility.

E. Provide low-calorie diet.
F. Provide ventilatory support if needed.
G. Measure vital signs frequently, especially temperature.
H. Monitor fluid intake to prevent dilutional hyponatremia.
I. Avoid use of sedatives and hypnotics.

Medical–Surgical Nursing: Hashimoto’s Thyroiditis

Focus topic: Medical–Surgical Nursing

Definition: An autoimmune disorder in which antibodies that destroy thyroid tissue develop.

Characteristics
A. Functional tissue is replaced with fibrous tissue, and thyroid hormone (TH) level decreases.
B. Decrease in TH levels prompt the gland to enlarge in an effort to compensate, causing goiter.

Assessment and Implementation
See Thyrotoxicosis/Hyperthyroidism/Graves’ Disease below.

Medical–Surgical Nursing: Thyrotoxicosis/Hyperthyroidism/Graves’ Disease

Focus topic: Medical–Surgical Nursing

Definition: A condition that results from the increased synthesis of thyroid hormone. When associated with ocular signs and a diffuse goiter, it is called Graves’ disease. Occurs four times more frequently in women than in men; usually occurs between 20 and 40 years of age.

Medical–Surgical Nursing

Assessment
A. Evaluate laboratory tests.

  • Thyroid antibodies (TAs)—used to determine if thyroid autoimmune disease is causing symptoms. TA is elevated in Graves’ disease.
  • Thyroid suppression test. Radioactive iodine (RAI) and T4 levels are measured. The client then takes TH for 7 to 10 days, after which the tests are repeated. Failure of hormone therapy to suppress RAI and T4 indicates hyperthyroidism.
  • Above-normal test results: protein-bound iodine test (PBI), 131I, and T3, T4.
  • Relatively low serum cholesterol.

B. Assess increased rate of body metabolism.

  • Weight loss despite ravenous appetite and ingestion of large quantities of food.
  • Intolerance to heat.
  • Nervousness, jitters, and fine tremor of hands.
  • Smooth, soft skin and hair.
  • Tachycardia, palpitations, atrial fibrillation, angina, and congestive heart failure.
  • Diarrhea.
  • Diaphoresis.
  • Flushed, moist skin.
  • Muscular weakness.

C. Assess personality changes.

  • Irritability and agitation.
  • Exaggerated emotional reactions.
  • Mood swings—euphoria to depression.
  • Quick motions, including speech.

D. Assess any enlargement of the thyroid gland (goiter).

  • Toxic multinodular goiter is characterized by small, discrete, independently functioning nodules in thyroid gland that secrete TH.
  • May be benign or malignant. Slow to develop. Usually found in women in 60s or 70s.

E. Observe for exophthalmos.

  • Fluid collects around eye sockets, causing eyeballs to protrude (may be unilateral or bilateral).
  • Not always present.
  • Usually does not improve with treatment.

F. Assess for cardiac arrhythmias.
G. Evaluate difficulty focusing eyes.

Implementation
A. Provide adequate rest.

  • Bed rest.
  • Diversionary activities.
  • Sedatives.

B. Provide cool, quiet, stable environment.
C. Maintain high-calorie, high-protein, highcarbohydrate, high-vitamin diet without stimulants—six small meals/day and snacks.

D. Monitor daily weights.
E. Provide emotional support.

  • Be aware that exaggerated emotional responses are a manifestation of hormone imbalance.
  • Be sensitive to needs.
  • Avoid stress-producing situations.

F. Adhere to regular schedule of activities.
G. Provide client education.

  • Protection from infection.
  • Safe self-administration of medications.
  • Importance of adequate rest and diet.
  • Avoidance of stress.

H. When giving iodine solutions in milk or juice, have client drink through a straw to prevent discoloration of the teeth.

Medical–Surgical Nursing: Thyroidectomy

Focus topic: Medical–Surgical Nursing

Definition: Removal of thyroid gland for persistent hyperthyroidism.

Assessment
A. Assess type of surgery to be done: total resection or subtotal resection of the gland.
B. Assess vital signs and weight for baseline data.
C. Assess serum electrolytes for hyperglycemia and glycosuria.
D. Assess level of consciousness.
E. Evaluate for signs of thyroid storm.

Implementation
A. Preoperative care—prevent thyrotoxicosis.

  • Administer antithyroid drugs to deplete iodine and hormones (5–7 days).
  • Administer iodine to decrease vascularity and increase size of follicular cells (5–7 days).
  • Provide routine preoperative teaching.
  • Reassure client.
  • Maintain nutritional status.
  • Monitor for evidence of iodine toxicity.

B. Postoperative care.

  • Check frequently for respiratory distress— keep tracheostomy tray at bedside.
  • Maintain semi-Fowler’s position to avoid strain on suture line.
  • Observe for bleeding.
    a. Vital signs—tachycardia, hypotension.
    b. Pressure on larynx.
    c. Hematoma around wound.
  • Observe for damage to laryngeal nerve.
    a. Respiratory obstruction.
    b. Dysphonia.
    c. High-pitched voice.
    d. Stridor.
    e. Dysphagia.
    f. Restlessness.
  • Observe for signs of hypoparathyroidism (causes an acute attack of tetany).
    a. Positive Chvostek’s sign and Trousseau’s sign.
    b. Convulsions.
    c. Irritability and anxiety.
    d. Stridor, wheezing, and dyspnea.
    e. Photophobia, diplopia.
    f. Muscle and abdominal cramps.

Medical–Surgical Nursing: Thyroid Storm (Thyrotoxic Crisis)

Focus topic: Medical–Surgical Nursing

Definition: An acute, potentially fatal hyperthyroid condition that may occur as a result of surgery, inadequate preparation for surgery, severe infection, or stress.

Characteristics
A. Cause not known; symptoms reflect exaggerated thyrotoxicosis.
B. Infrequent due to premedication of iodine and antithyroid drugs.
C. Can be precipitated by stressors.

  • Infection.
  • Abrupt withdrawal of medication.
  • Metabolic causes.
  • Emotional stress.
  • Pulmonary embolism.
  • Trauma.
  • Surgery.
  • Pregnancy.
  • Vigorous palpation of thyroid.

Assessment
A. Assess for increased temperature (> 101°F, 38.3°C).
B. Assess diaphoresis.
C. Assess for dehydration.
D. Evaluate cardiopulmonary symptoms.

  • Tachycardia (> 120).
  • Arrhythmias.
  • Congestive heart failure.
  • Pulmonary edema.

E. Assess gastrointestinal symptoms.

  • Abdominal pain.
  • Nausea, vomiting, and diarrhea.
  • Jaundice.
  • Weight loss.

F. Assess central nervous system symptoms.

  • Tremors.
  • Severe agitation, restlessness, and irritability.
  • Apathy leading to delirium and coma.
  • Altered mental state.
Medical–Surgical Nursing

Implementation
A. Do not palpate thyroid gland (stimulus increases symptoms).
B. Decrease temperature: acetaminophen, external cold (ice packs, cooling blanket). Salicylates contraindicated— increase free thyroid hormone levels.
C. Protect from infection, especially pneumonia.
D. Monitor vital signs.
E. Maintain fluid and electrolyte balance.

  • Electrolyte shifts cause brittle situation of over- and underhydration.
  • Maintain adequate output.
  • Observe for sodium and potassium imbalance due to vomiting and diarrhea.
  • Observe for signs of overhydration if cardiopulmonary complications are evident.

F. Monitor ECG for arrhythmias if

  • Adrenergic blockers are used.
  • Diuretics are given.
  • Electrolyte imbalance is present.
  • Cardiovascular medication is given.

G. Humidify oxygen.
H. Administer IV glucose diet with glucose and large doses of vitamin B complex.
I. Protect for safety if agitated or comatose.
J. Provide calm, quiet environment.
K. Reassure client and family.

Medical–Surgical Nursing: Parathyroid Gland Disorders

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Hypoparathyroidism

Focus topic: Medical–Surgical Nursing

Definition: A condition caused by acute or chronic deficient hormone production by the parathyroid gland. Usually occurs following thyroidectomy.

Assessment
A. Assess for acute hypocalcemia.

  • Numbness, tingling, and cramping of extremities.
  • Acute, potentially fatal tetany.
    a. Painful muscular spasms.
    b. Seizures.
    c. Irritability.
    d. Positive Chvostek’s sign.
    e. Positive Trousseau’s sign.
    f. Laryngospasm.
    g. Cardiac arrhythmias.

B. Assess for chronic hypocalcemia.

  • Poor development of tooth enamel.
  • Mental retardation.
  • Muscular weakness with numbness and tingling of extremities.
  • Tetany.
  • Loss of hair and coarse, dry skin.
  • Personality changes.
  • Cataracts.
  • Cardiac arrhythmias.
  • Renal stones.

C. Assess laboratory values.

  • Low serum calcium levels.
  • Increased serum phosphorus level.
  • Low urinary calcium and phosphorus output.
  • Increased bone density on x-ray examination.

Implementation
A. Same as for seizures and epilepsy.
B. Administer parenteral parathormone.
C. Frequently check for increasing hoarseness.
D. Observe for irregularities in urine.
E. Force fluids as ordered.
F. Observe for dystonic reactions if on phenothiazines.
G. Maintain environment free of bright lights and noise.
H. Provide psychological support.

  • Altered body image.
  • Emotional instability.
  • Extreme weakness.

I. Provide high-calcium diet.

Medical–Surgical Nursing: Hyperparathyroidism

Focus topic: Medical–Surgical Nursing

Definition: A condition caused by overproduction of the parathyroid hormone by parathyroid gland.

Characteristics
A. Primary hyperparathyroidism—occurs when there is hyperplasia or adenoma in one of the parathyroid glands.
B. Secondary hyperparathyroidism (caused primarily from malabsorption and renal failure) results in chronic hypocalcemia (which stimulates excessive production of PTH).
C. Tertiary hyperparathyroidism (usually the result of long-term secondary hyperparathyroidism) results in hypercalcemia.
D. Treatment focus—decrease elevated serum calcium levels.

  • When cause is malabsorption, there is decreased absorption of calcium from the intestine and a deficiency in vitamin D. Treatment is calcium supplements and vitamin D.
  • When cause is renal failure, phosphate is retained, causing serum calcium levels to decrease and PTH levels to rise. Treatment is aimed at lowering phosphorus level, increasing calcium with oral supplements and vitamin D.
  • If lowering phosphate level (thus, elevating calcium level, which stops chronic stimulation of parathyroid gland) does not work, surgery is performed.

Assessment
A. Assess for bone demineralization with deformities, pain, high susceptibility to fractures.
B. Assess for hypercalcemia.

  • Mild hypercalcemia may not evidence symptoms.
  • Calcium deposits in various body organs: eyes, heart, lungs, and kidneys (stones).
  • Gastric ulcers.
  • Personality changes, depression, apathy, and paranoia.
  • Nausea, vomiting, anorexia, and constipation.
  • Polydipsia and polyuria.
  • Hypertension.
  • Cardiac dysrhythmias.
  • Skeletal pain.
  • Pathologic fractures.

C. Assess laboratory values.

  • Elevated serum calcium level; lowered serum calcium.
  •  Normal to elevated serum phosphorus levels.
  • Elevated urinary calcium and phosphorus levels.
  • Evidence of bone changes on x-ray examinations.
  • Normal to increased alkaline phosphatase.

Implementation
A. Force fluids for hypercalcemia. Include juices to make urine more acidic.
B. Provide normal saline (NS) IV infusion.
C. Observe for electrolyte imbalance with Lasix (furosemide) administration.
D. Measure intake and output.
E. Closely observe urine for stones and gravel.
F. Observe for digitalis toxicity if client is taking digitalis.
G. Prevent accidents and injury through safety measures.
H. Provide surgical care if subtotal surgical resection of parathyroid glands is done.
I. Oral supplements of calcium and vitamin D will be administered with malabsorption, renal failure, or for bone rebuilding processes (several months).
J. Administer calcitonin and corticosteroids if ordered.

Parathyroidectomy
Definition: Removal of one or more of the parathyroid
glands, usually as a result of thyroidectomy.

Assessment
A. Assess for positive Chvostek’s and Trousseau’s signs.
B. Assess for CNS signs of psychomotor or personality disturbances.
C. Evaluate laboratory results for baseline data.

  • Serum potassium, calcium, phosphate, and magnesium.
  • Renal magnesium function tests (renal damage from hyperplasia).

D. Evaluate urine for presence of stones.
E. Assess lung sounds for prevention of pulmonary edema.
F. Assess muscle weakness, ability to walk, and range
of movement for minimizing bone stress.

Implementation
A. Observe for tetany and treat accordingly.
B. Maintain patent airway.

  • Observe for respiratory distress.
  • Keep a tracheostomy tray at the bedside.

C. Provide diet high in calcium, vitamin D, and magnesium salts.
D. Increase fluids to prevent formation of urinary stones—monitor intake and output for low levels of calcium, magnesium, and phosphate.

E. Monitor IV administration of calcium gluconate if given for postoperative emergency.
F. Monitor for postoperative complications.

  • Renal colic.
  • Laryngeal nerve damage.
  • Acute psychosis (look for listlessness).

G. Position client in semi-Fowler’s position and support head and neck to decrease edema.
H. Ambulate client as soon as possible to speed up recalcification of bones.

FURTHER READING/STUDY:

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