NCLEX: Care of the Client with Endocrine Disorders

Focus topic: Care of the Client with Endocrine Disorders

The endocrine system comprises glands distributed throughout the body and is responsible for secretion and regulation of hormones. The endocrine system is made up of the following glands:

  • Pituitary gland
  • Adrenal glands
  • Thyroid gland
  • Pancreas
  • Parathyroid glands
  • Ovaries, testes
Care of the Client with Endocrine Disorders

Endocrine System

Problems with the endocrine system occur when there is too little production or excess production of hormones. The onset of endocrine disorders can appear suddenly and be life-threatening, or can appear gradually.

Care of the Client with Endocrine Disorders: Pituitary Gland

Focus topic: Care of the Client with Endocrine Disorders

The pituitary gland is located in the center of the skull at the base of the brain in an area called the sella turcica. The anterior lobe, or adenohypophysis, secretes hormones that stimulate the thyroid gland, adrenal cortex, and the gonads. Growth hormone and prolactin are produced by the anterior pituitary gland. The posterior pituitary produces vasopressin or antidiuretic hormone and oxytocin.

The neurohypophysis, the posterior portion of the pituitary gland, stores hormones produced by the hypothalamus. The hypothalamus shares a circulatory system with the anterior pituitary gland. This system of nerve fibers connects the hypothalamus to the posterior pituitary and controls how the central nervous system and endocrine system regulate homeostasis of the body. Other functions of the pituitary gland include development of the gonads, regulation of heart rate and rhythm, and assisting other glands in the endocrine system to secrete their hormones.

The diagnosis of pituitary disorders is done by evaluating various hormone levels. Computer tomography (CT) scans, x-rays, and magnetic resonance imaging (MRI) can also identify tumors. Alterations in pituitary function are often reflected as a decrease in pituitary hormone or an increase in pituitary hormone. The sections that follow discuss these problems in greater detail.

Care of the Client with Endocrine Disorders: Hypopituitarism

Focus topic: Care of the Client with Endocrine Disorders

Hypopituitarism is a disorder in which there is a deficiency of one or more of the hormones produced in the anterior pituitary. Deficiencies in thyroid-stimulating hormone (TSH) and adrenocorticotropic hormone (ACTH) often result in hypotension and can be life-threatening. Other problems that occur when there is a lack of pituitary function are failure to develop secondary sex characteristics associated with a lack of gonadotropins, luteinizing hormone (LH), and follicle-stimulating hormone (FSH).

A lack of these hormones is not life-threatening but can alter body image and prevent the client from being able to reproduce. Management of hypopituitarism consists of early diagnosis and treatment with hormone supplementation.

Care of the Client with Endocrine Disorders: Hyperpituitarism

Focus topic: Care of the Client with Endocrine Disorders

Hyperpituitarism is a state that occurs with anterior pituitary tumors or hyperplasia of the pituitary gland. Tumors are the most common reason for hyperpituitarism. Women with prolactinomas usually experience anovulation, irregular menses, reduction in sex drive, and lactation. Other signs and symptoms of pituitary tumors include headache, visual disturbances, and altered levels of consciousness. Gigantism (increased levels of growth hormone in the child) or acromegaly (increased levels of growth hormone in the adult) can also result from hyperpituitarism.

Management depends on the type and location of the tumor. Many clients respond well to medical management with bromocriptine mesylate (Parlodel) or cabergoline (Dostinex). These drugs should be given with food to decrease gastrointestinal disturbance. Pregnant clients should not be prescribed Parlodel.

Surgical removal of the tumor can be accomplished by a transsphenoidal approach. This type of surgery is performed by passing an instrument through the sphenoid sinus. Clients return from surgery with nose packing in place. Postoperatively the client should be taught to avoid coughing, sneezing, nose blowing, and bending. Soft toothbrushes should be used for several weeks following surgery. Any discharge from the nose should be checked for glucose because cerebrospinal leakage can occur.

Care of the Client with Endocrine Disorders

Transsphenoidal surgery for the removal of pituitary tumors

X-ray therapy is sometimes used to shrink the tumor. Radiotherapy, a stereotactic radiation, is generally preferred over external beam radiation because a higher dose of radiation can be delivered to the tumor with less radiation to normal brain structures. Damage to pituitary structures of the brain can occur with this treatment, so the client must be assessed for signs of altered neurological function or brain infections such as meningitis.

 Care of the Client with Endocrine Disorders: Disorders of the Posterior Pituitary Gland

Focus topic: Care of the Client with Endocrine Disorders

Two disorders of the posterior pituitary gland are diabetes insipidus and syndrome of inappropriate antidiuretic hormone (SIADH). These problems can be caused by a deficiency or excess of the hormone vasopressin (antidiuretic hormone).

Care of the Client with Endocrine Disorders: Diabetes Insipidus

Focus topic: Care of the Client with Endocrine Disorders

Diabetes insipidus is a result of either a decrease in antidiuretic hormone synthesis or an inability of the kidneys to respond to ADH. The lack of antidiuretic hormone will result in dehydration with resulting hypotension. The nurse should assess the client’s urine for specific gravity. The normal specific gravity is 1.010–1.030. A client with diabetes insipidus will have a specific gravity of less than 1.010.

The diagnosis of diabetes insipidus is confirmed by a 24-hour urine screening for osmolality and a hypertonic saline test. This test is done by administering a normal water load to the client followed by an infusion of hypertonic saline and measuring the urinary output hourly. This test detects ADH release.

A decrease in urinary output is a sign of ADH release. Treatment includes chlorpropamide (Diabinese) or clofibrate (Atromid-S) to increase the action of ADH, or if a severe deficiency in ADH exists, the client can be prescribed ADH in the form of vasopressin either nasally or parenterally. The client should be taught to alternate from one nostril to the other because this medication is irritating to the nasal passages.

Care of the Client with Endocrine Disorders: Syndrome of Inappropriate Antidiuretic Hormone

Focus topic: Care of the Client with Endocrine Disorders

Syndrome of inappropriate antidiuretic hormone (SIADH) is a disorder of the posterior pituitary gland where vasopressin (ADH) is secreted even when plasma osmolality is normal or low. SIADH, or Schwartz-Barter syndrome, occurs when ADH is secreted in the presence of a low plasma osmolality. This alteration results in increased levels of anti-diuretic hormone. High levels of ADH results in excretion of sodium.

The incidence is unknown but might be related to cancers, viral and bacterial pneumonia, lung abscesses, tuberculosis, chronic obstructive pulmonary disease, mycoses, positive pressure ventilators, pneumothorax, brain tumors, head trauma, certain medications, and infectious diseases. Signs and symptoms include nausea, vomiting, muscle twitching, changes in level of consciousness, and low sodium levels with increased urine sodium.

The treatment for SIADH includes fluid restrictions because fluid further dilutes the serum sodium levels, gradual replacement of sodium, and administration of demeclocycline (Declomycin) and intravenous hypertonic sodium.

 Care of the Client with Endocrine Disorders: Thyroid Disorders

Focus topic: Care of the Client with Endocrine Disorders

The thyroid is located below the larynx and anterior to the trachea. The thyroid gland produces two iodine-dependent hormones: thyroxine (T4) and triiodothyronine (T3). A third hormone known as thyrocalcitonin (calcitonin) is produced by the C cells of the thyroid gland in response to calcium levels.

The C cell makes calcitonin that helps to regulate calcium levels in the blood. These hormones play a role in regulating the metabolic processes controlling the rate of growth, oxygen consumption, contractility of the heart, and calcium absorption.

Care of the Client with Endocrine Disorders: Hypothyroidism

Focus topic: Care of the Client with Endocrine Disorders

Hypothyroidism occurs when thyroid hormone production is inadequate. The thyroid gland often enlarges to compensate for a lack of thyroid hormone, resulting in a goiter. Another cause for development of a goiter is a lack of iodine in the diet. Other causes of primary hypothyroidism include genetic defects that prevent the metabolism of iodine. In the infant, this is known as cretinism. Other causes include eating a diet high in goitrogens, such as turnips, cabbage, spinach, and radishes, or taking the medications lithium, phenylbutazone, and para-aminosalicylic acid. Secondary hypothyroidism, known as myxedema, is the result of a lack of pituitary production of thyroid-stimulating hormone.

Care of the Client with Endocrine Disorders

Thyroid and parathyroid glands.

Signs and symptoms of hypothyroidism in the adult are as follows:

  • Fatigue and lethargy
  • Decreased body temperature
  • Decreased pulse rate
  • Decreased blood pressure
  • Weight gain
  • Edema of hands and feet
  • Hair loss
  • Thickening of the skin

In severe cases, myxedema coma can occur. Symptoms of myxedema include coma, hypotension, hypothermia, respiratory failure, hyponatremia, and hypoglycemia. Myxedema coma can be brought on by withdrawal of thyroid medication, anesthesia, use of sedatives, narcotics, surgery, or hypothermia.

Care of the Client with Endocrine Disorders: Signs and Symptoms of Hypothyroidism in the Infant

Focus topic: Care of the Client with Endocrine Disorders

As mentioned earlier, hypothyroidism in an infant is called cretinism. The following list gives you the signs and symptoms of cretinism:

  • Decreased respirations
  • Changes in skin color (jaundice or cyanosis)
  • Poor feeding
  • Hoarse cry
  • Mental retardation in those not detected or improperly treated

Diagnostic studies for cretinism include evaluation of T3 and T4 levels using test doses of thyroid-stimulating hormone

Care of the Client with Endocrine Disorders: Managing Hypothyroidism

Focus topic: Care of the Client with Endocrine Disorders

Management of the client with hypothyroidism includes the replacement of thyroid hormone, usually in the form of synthetic thyroid hormone levothyroxine sodium (Synthroid). Clients should be instructed to take Synthroid in the morning one hour prior to meals with water only because food can alter absorption. Soy products should be limited because soy can also alter absorption.

The client’s history should include other drugs the client is taking. Prior to administering thyroid medications, the pulse rate should be evaluated. If the pulse rate is above 100 in the adult or 120 in the infant, the physician should be notified. The client requires a warm environment due to alteration in metabolic rate affecting temperature.

Another problem associated with a slower metabolic rate is constipation. A high-fiber diet is recommended to prevent constipation. Treatment of myxedema coma includes treatment of hypotension, glucose regulation, and administration of corticosteroids.

Care of the Client with Endocrine Disorders: Hyperthyroidism

Focus topic: Care of the Client with Endocrine Disorders

Hyperthyroidism or thyrotoxicosis is caused by excessive thyroid hormone. Because the thyroid gland is responsible for metabolism, the client with hyperthyroidism often experiences increased heart rate, increased stoke volume, weight loss, and nervousness. The cause of hyperthyroidism is multifactorial. Some of these causes are autoimmune stimu- lation such as Graves’ disease, hypersecretion of thyroid-stimulating hormone (TSH), thyroiditis, or neoplasms of the thyroid gland.

Graves’ disease results from an increased production of thyroid hormone. The most common cause of hyperthyroidism is hyperplasia of the thyroid, commonly referred to as a toxic diffuse goiter.

Signs and symptoms of hyperthyroidism include

  • Increased heart rate and pulse pressure
  • Tremors or nervousness
  • Moist skin and sweating
  • Increased activity
  • Insomnia
  • Atrial fibrillation
  • Increased appetite and weight loss
  • Exophthalamus

A thyroid storm is an abrupt onset of symptoms of hyperthyroidism due to Graves’ disease, inadequate treatment of hyperthyroidism, trauma, infection, surgery, pulmonary embolus, diabetic acidosis, emotional upset, or toxemia of pregnancy. Fever, tachycardia, hypertension, tremors, agitation, anxiety, and gastrointestinal upset occur. The treatment for a thyroid storm includes maintenance of a patent airway and medication to treat hypertensive crises.

Propylthiouracil (PTU) and methimazole (Tapazole) are two antithyroid drugs used to treat thyroid storm. These drugs work by blocking the synthesis and secretion of thyroid hormone. Soluble solution of potassium iodine (SSKI) or Lugol’s solution can be given to stop the release of thyroid hormone already in the gland. This drug can also be given prior to thyroid surgery to prevent a thyroid storm.

The client should be taught to take the medication with a fruit juice high in ascorbic acid, such as orange or tomato juice, to increase the absorption of the medication and mask the taste. Taking the medication through a straw can also increase the palatability of the medication. Propranolol (Inderal) or other beta-blocking agents can be given to slow the heart rate and decrease the blood pressure. If fever is present, the client can be treated with a nonaspirin medication such as acetaminophen (Tylenol) or ibuprofen.

Diagnosis of hyperthyroidism involves the evaluation of T3 and T4 levels and a thyroid scan with or without contrast media. These thyroid function studies tell the physician whether the client has an adequate amount of circulating thyroid hormone. A thyroid scan can clarify the presence of an enlargement of tumor of the thyroid gland.

Management of the client with hyperthyroidism includes

  • The use of antithyroid drugs (propylthiouracil or Tapazole)
  • Radioactive iodine, which can be used to test and destroy portions of the gland
  • Surgical removal of a portion of the gland

Prior to thyroid surgery, the client is given Lugol’s solution (SSKI)—an iodine preparation—to decrease the vascularity of the gland. Postoperatively, the client should be carefully assessed for the following:

  • Edema and swelling of the airway (the surgical incision is located at the base of the neck anterior to the trachea).
  • Bleeding (check for bleeding behind the neck).
  • Tetany, nervousness, and irritability (complications resulting from damage to the parathyroid). Calcium gluconate should be kept available to treat hypocalcemia.

Because the thyroid gland is located anterior to the trachea, any surgery in this area might result in swelling of the trachea. For that reason, it is imperative that the nurse be prepared for laryngeal swelling and occlusion of the airway. The nurse should keep a tracheostomy set at the bedside and call the doctor if the client has changes in her voice or signs of laryngeal stridor. The nurse should instruct the client to keep her head and neck as straight as possible.

Vital signs should be monitored, and the client should be evaluated for signs of hypoparathyroidism. Those signs include tingling around the mouth. The nurse should check for hypocalcemia by checking Chvostek’s sign. This is elicited when cranial nerves 7 and 5 are stimulated and result in facial grimacing when the cheek is tapped with the examiner’s finger. Trousseau’s sign is also an indication of hypocalcemia and is elicited by placing a blood pressure cuff on the arm and watching for carpopedal spasms.

 Care of the Client with Endocrine Disorders: Parathyroid Disorders

Focus topic: Care of the Client with Endocrine Disorders

The parathyroid glands are four small glands located on the thyroid gland. The primary function of the parathyroid glands is the regulation of calcium and phosphorus metabolism. Diagnosis of parathyroid disorders is based on an evaluation of serum calcium and serum phosphorus levels and 24-hour urine levels of calcium and phosphorus. The normal serum calcium level is approximately 8.5–10.5 mg/dl; the normal phosphorus level is about 2.5–4.5 mEq/L. Radioimmunoassay exams are used to check serum parathormone. Potential disorders of these glands include hypoparathyroidism and hyperparathyroidism.

Care of the Client with Endocrine Disorders: Hypoparathyroidism

Focus topic: Care of the Client with Endocrine Disorders

Hypoparathyroidism is an inadequate production of parathormone and is most often related to the removal of the parathyroid glands during thyroid surgery. Parathyroid hormone (PTH) is responsible for the regulation of calcium and phosphorus levels in the blood. Calcium and phosphorus levels must be maintained within normal limits to have adequate nerve function. Bone density is also maintained by parathormone. Signs and symptoms of hypoparathyroidism include the following:

  • Decreased blood calcium
  • Increased blood phosphorus
  • Neuromuscular hyperexcitability
  • Carpopedal spasms (Trousseau’s sign)
  • Positive Chvostek’s sign
  • Urinary frequency
  • Mood changes (depression)
  • Dry, scaly skin and thin hair
  • Cataracts
  • Changes in teeth (cavities)
  • Seizures
  • Changes in EKG (prolonged Q-T intervals and inverted T waves)
Care of the Client with Endocrine Disorders

Management of the client with hypoparathyroidism involves the administration of IV calcium gluconate and long-term use of calcium salts. If calcium gluconate is administered intravenously, the rate should be monitored carefully because rapid administration can result in cardiac arrhythmias. Phosphate binders such as calcium acetate (Phoslo) can be used to bind with phosphates. This will result in a rise in the calcium level. Vitamin D supplements can be given to increase the absorption of calcium preparations as well as calcium in the diet.

Care of the Client with Endocrine Disorders: Hyperparathyroidism

Focus topic: Care of the Client with Endocrine Disorders

Hyperparathyroidism is the direct opposite of hypoparathyroidism. In this disorder, you find an overproduction of parathormone. Signs and symptoms of hyperparathyroidism include

  • Decreased blood phosphorus.
  • Increased blood calcium.
  • Muscle weakness.
  • Osteoporosis.
  • Bone pain and pathological fractures.
  • Increased urinary output and renal calculi.
  • Nausea and vomiting.
  • Changes in EKG (shortened Q-T interval and signs of heart block). Heart block involves an alteration in the conduction system of the heart. In third- and fourth- degree heart block, there is an alteration in the heart’s ability to transmit electrical impulses from the sinus node located in the right atria to the ventricle. This interference in the conduction system can cause a prolonged P-R interval and possibly deletion of atrial contractions.

Managing a client with hyperparathyroidism is accomplished by the removal of the parathyroid. Preoperative management involves the reduction of calcium levels. Postoperative management includes

  • Assessment of the client for respiratory distress
  • Maintaining suction, oxygen, and a tracheostomy set at bedside
  • Checking for bleeding (1–5ml is normal)
  • Checking the serum calcium and serum phosphorus levels

To prevent the need for lifelong treatment with calcium, the client might have a parathyroid transplant—implantation of one or more parathyroid glands to another part of the body. If this is not possible, a total parathyroidectomy might be performed. If this is the situation, or if inadequate production of parathormone is found, the client will require lifelong supplementation with calcium and vitamin D.

FURTHER READING/STUDY:

Resources:

Leave a Reply

Your email address will not be published. Required fields are marked *