ENDOCRINE DISORDERS

Assessing a Patient With Endocrine Disorders

 

Endocrine Disorders

 

Focus Topic: Endocrine Disorders

Review the endocrine system in your anatomy and physiology book. Obtain a health history from the patient, assessing for any chronic or new symptoms. There are many complex disorders that involve the endocrine system. I will go over each disorder and highlight the most frequently tested information.

Endocrine Diagnostics

Labs: Amylase, lipase, thyroxine (T4), triiodothyronine (T3), thyroid-stimulating hormone (TSH), Hgb A1C, BUN/Cr, serum glucose, fasting glucose, growth hormone, and various urine tests. Normal values are as follows:

  • Urine specific gravity: 1.003 to 1.030
  • Blood glucose: 70 to 110 mg/dL
  • Hgb A1C: 4% to 6%
  • Lipase: 10 to 160 U/L
  • Amylase serum: 40 to 140 U/L
  • T4: 5 to 12 mcg/dL
  • TSH: 0.4 to 4.2 mIU/L

CT scan or ultrasound of the thyroid and adrenal glands may be done.

Endocrine Disorders: Disorders of the Pituitary: Diabetes Insipidus (DI) and Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

Focus Topic: Endocrine Disorders

Definition: Diabetes insipidus is a decrease in the level of antidiuretic hormone (ADH) with a resulting increase in urine osmolarity. Kidney function is impaired owing to the lack of ADH, leading to excessive water loss and concentraton of urine. SIADH is the continuous release of or increase in ADH. Head injury, trauma, and stroke can all cause alterations in ADH levels.

Signs and Symptoms: 3Ps—polydipsia (excessive thirst), polyuria (frequent urination), and polyphagia (frequent hunger). Other symptoms include decreased urine specific gravity, hypernatremia, weight loss, nausea, decreased BP, muscle pain, and fatigue. Signs and symptoms of SIADH are low urine output, fatigue, increased urine specific gravity, weight loss, hyponatremia, and edema.

Diagnostics: ADH levels, urine specific gravity, urine osmolarity, electrolytes, and clinical symptoms.

Complications: Worsening of symptoms, seizure with SIADH, and shock.

Drug Therapy: DI is treated with ADH replacement medications such as desmopressin (DDAVP) by the intranasal route and vasopressin (Pitressin) as first-line treatment. Treatment for SIADH is a diuretic such as furosemide (Lasix); sodium may be administered; declomycin (Demeclocycline) or lithium carbonate (Lithobid) is used to block ADH production and increase urine production.

Nursing Care: Assess patient vital signs, intake, and output. Daily weights are important to assess for urinary retention.

Strict intake and output must be recorded. Monitor labs. Fluid restriction may be needed for patients with SIADH. Assess mental status for any changes.

Endocrine Disorders: Adrenal Disorders: Cushing’s Syndrome and Addison’s Disease

Focus Topic: Endocrine Disorders

Cushing’s Syndrome

Definition: This condition is caused by an increase in adrenal hormones such as adrenocorticotropic hormone (ACTH), glucocorticoids, and cortisol. It can be caused by pituitary tumor or steroid use.

Signs and Symptoms: Weight gain, moon face, dry skin, buffalo hump, hypokalemia, increased glucose levels, purple striae, hypertension, muscle wasting, poor healing, truncal obesity, osteoporosis, and bruising.

Diagnostics: Lab work such as cortisol, ACTH levels, glucose, and electrolytes. CT and MRI of the pituitary gland.

Complications: Hypertension, CHF, and worsening of symptoms.

Drug Therapy: Potassium may be administered. Corticosteroids may be ordered to help relieve symptoms.

Nursing Care: Treat the underlying cause. Surgical removal of the tumor or adrenalectomy may be necessary. Monitor hormone levels and electrolytes. Monitor blood glucose and ACTH levels. Administer steroids as ordered. Steroids also increase glucose levels; it is important to monitor and treat as ordered. Monitor for any complications.

Addison’s Disease

Definition: This is an autoimmune disorder caused by a decrease in mineralocorticoids (which control Na and K levels) and glucocorticoids. It can occur after an adrenalectomy.

Signs and Symptoms: Fatigue, weakness, weight loss, hypotension, hyperkalemia, hyponatremia, nausea, vomiting, and diarrhea.

Diagnostics: Labs such as glucose levels, cortisol levels, ACTH, electrolytes, and presentation of symptoms. ACTH stimulation tests.

Complications: Addison’s crisis may occur and can lead to death if left untreated. It can be caused by high levels of stress or high levels of steroids. Signs and symptoms are hypotension, increased heart rate, peak T waves, decreased sodium, increased potassium, dehydration, and cyanosis. Shock can occur if left untreated. It is treated with glucocorticoids such as hydrocortisone sodium succinate (Solu-Cortef) to replace hormones; calcium with vitamin D to increase calcium levels; and intravenous fluids. Monitor glucose and BP levels closely.

Drug Therapy: Corticosteroids therapy such as hydrocortisone, sodium, fluids, and dextrose. Here is a little trick: “Addison’s” means to add steroids for treatment.

Nursing Care: Monitor vital signs (especially BP), glucose levels, and signs of Addison’s disease. Evaluate for edema and urinary retention. Check daily weight. Maintain a low-stress environment. Minimize the risk of infection. Patients must be placed on a high-protein, low-potassium diet. Patients are placed on bed rest to conserve energy.

Endocrine Disorders: Hypothyroidism and Hyperthyroidism

Focus Topic: Endocrine Disorders

Hypothyroidism

Definition: This is a condition in which there is a decrease in thyroid hormones T3 and T4 and an increase in TSH levels.

Signs and Symptoms: Fatigue, weakness, slowed speech, weight gain, dry skin, brittle nails, cold intolerance, constipation, bradycardia, decreased activity, myxedema (swelling of face/eyes). Cardiac changes may be present, and a goiter (growth on the thyroid) can cause hypothyroidism.

Diagnostics: Thyroid levels, glucose levels, and a CT scan of the thyroid to assess for a goiter.

Complications: Hypothyroidism can lead to myxedema coma, characterized by a decrease in heart rate, low sodium, and low blood sugar. Patients may present with respiratory difficulty. This is a medical emergency, and the physician must be notified immediately. Administration of fluids, corticosteroids, levothyroxine (Synthroid), and glucose can decrease the severity of complications. Monitor vital signs and labs. Don’t forget your ABCs!

Drug Therapy: Thyroid replacement such as levothyroxine (Synthroid).

Nursing Care: The focus of care is proper administration of medication and patient education. Monitor thyroid levels. Monitor electrolytes. Keep the patient’s environment stress-free and warm. Supply the patient with extra blankets to help with intolerance to cold. Teach patients the signs and symptoms of hyperthyroidism and myxedema coma.

Hyperthyroidism (Graves’ Disease)

Definition: This is an autoimmune disorder that causes an increase in T3 and T4 thyroid hormones. A decrease in iodine and TSH is seen. It is typically caused by a goiter.

Signs and Symptoms: Hypertension, increased heart rate, weight loss, heat intolerance, exophthalmos (protruding eyeballs), hair loss, tremors, and cardiac arrhythmias.

Diagnostics: Increased T3 and T4 levels. Decrease in TSH levels. Obtain iodine levels.

Complications: Thyroid storm or thyrotoxic crisis can occur. Signs and symptoms are severely increased, and include hyperpyrexia, nausea, vomiting, diarrhea, and increased heart rate and blood pressure. Cardiac arrhythmias are seen on the EKG. Treatment includes administering oxygen, treating arrhythmias, administering antithyroid medications, iodine, beta-blockers, acetaminophen (Tylenol), and steroids. A thyroidectomy may be needed.

Surgical Measures: A thyroidectomy may be needed to treat hyperthyroidism. Preoperative and postoperative teachings are needed. Monitor for complications such as thyroid storm and hypothyroidism. After surgery, it is important to keep a trach kit at the bedside, because respiratory complications can occur. Assess labs such as electrolytes, glucose, and calcium levels. A thyroidectomy can cause low calcium levels. Assess for Chvostek’s and Trousseau’s signs.

Drug Therapy: The purpose of drug therapy is to maintain thyroid levels at a therapeutic level. Antithyroid medications include methimazole (Tapazole) or Lugol’s solution. Lugol’s solution can stain teeth and should be given orally with a straw. To control heart rate, beta-adrenergic blockers such as atenolol (Tenormin) are used.

Nursing Care: Graves’ disease is treated with medications and patient education on monitoring for complications. Monitor vital signs and electrolytes. Maintain a high-protein diet to treat weight loss. Maintain a cool environment. The patient may be placed on a cardiac monitor to assess for cardiac arrhythmias. Continue to monitor thyroid levels. Assess and treat complications if they arise. Monitor and maintain airway if respiratory distress occurs.

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Endocrine Disorders: Hyperparathyroidism and Hypoparathyroidism

Focus Topic: Endocrine Disorders

Hyperparathyroidism

Definition: This is caused by increased secretion of parathyroid hormone (PTH) from the parathyroid gland. The parathyroid gland controls calcium and phosphorus levels. When there is an increase in PTH levels, calcium is increased and phosphorus is decreased. Hyperparathyroidism can be caused by a tumor on the parathyroid gland.

Signs and Symptoms: Hypercalcemia, hypophosphatemia, increase in blood pressure, muscle pain, constipation, cardiac dysrhythmias, broken bones, kidney stones, nausea, vomiting, and irritability.

Diagnostics: Increased PTH levels, decreased phosphorus, increased calcium, CT scan, bone density, and x-rays.

Complications: Bone damage and kidney damage.

Drug Therapy: Administer medications such as cinacalet (Sensipar) to increase calcium in the blood. Administer loop diuretics to excrete calcium levels. Biophosphonates are also used to treat osteoporosis and prevent the loss of calcium from the bones.

Surgical Measures: A parathyroidectomy may be needed. Preoperative and postoperative teaching is needed. IV calcium is given to prevent postoperative hypocalcemia. Assess for respiratory distress, incision, and drainage from the surgical site, and notify the physician of any complications.

Nursing Care: Administer medications as ordered. Monitor calcium intake. Administer intravenous fluids. Fall risk precautions should be in place due to an increased risk of bone fractures. Assistive devices are used to promote a steady gait. Cardiac monitoring may be ordered. Monitor vital signs. Assess for kidney stones.

Hypoparathyroidism

Definition: In this condition, there is a decrease in PTH levels, an increase in phosphorus, and a decrease in calcium levels. Hypoparathyroidism can be caused by parathyroidectomy, which is the surgical removal of the parathyroid gland.

Signs and Symptoms: Hypocalcemia, hyperphosphatemia, tetany, positive Chvostek’s and Trousseau’s signs, cardiac dysrhythmias, hair loss, abdominal cramping, nausea, vomiting, and laryngospasms. Chvostek’s sign is present when the facial nerve is stimulated and eye twitching occurs. Trousseau’s sign is present when a blood pressure cuff is applied to the arm and spasms occur in the upper extremity. Laryngospasms can be fatal and cause respiratory failure.

Diagnostics: Parathyroid levels, x-ray of the glands, electrolytes, calcium, and phosphorus levels.

Complications: Respiratory distress and seizures.

Drug Therapy: Administration of IV calcium, calcium supplements, and vitamin D.

Nursing Care: Administer medications as ordered. Monitor calcium and phosphorus levels. Maintain seizure precautions. Keep a trach kit at the patient’s bedside in case respiratory distress occurs. Maintain an open airway, and assess for signs of respiratory distress.

Endocrine Disorders: Diabetes Mellitus (DM)

Focus Topic: Endocrine Disorders

Definition: This is a pancreatic disorder caused by decreased or inadequate insulin production. The beta cells in the islets of Langerhans secrete insulin, which is used to control glucose levels in the body. There are two types of diabetes mellitus: Type 1 and type 2. In type 1, also known as insulin-dependent diabetes mellitus, beta cells of the pancreas do not produce enough of the hormone insulin. Type 1 is usually diagnosed in childhood. It is important to assess and avoid ketoacidosis in patients with type 1 DM. In type 2, known as non– insulin- dependent diabetes mellitus, the body develops resistance to insulin production. Type 2 is most commonly seen in adults, and often occurs as a result of lifestyle factors (e.g., obesity).

Signs and Symptoms: The 3Ps are the first signs of DM: polydipsia, polyuria, and polyphagia. Patients with type 1 have symptoms of 3Ps, fatigue, weight loss, and blurred vision, and symptoms occur rapidly. Those with type 2 have symptoms of 3Ps, weight gain, fatigue, increase in infections, and blurred vision, and can be asymptomatic. Type 2 can be asymptomatic for years and develop over a long period of time.

Diagnostics: Serum glucose levels (normal range is 60 to 100 mg/dL, fasting blood glucose, Hgb A1C (4% to 6%), BUN/Cr, and urine tests (looking for ketones).

Complications: Among the many complications of DM, are those listed below:

  • Diabetic Ketoacidosis (DKA): This occurs in DM type 1, when the body responds to its inability to use glucose for fuel by breaking down proteins into ketones that accumulate in the bloodstream. Symptoms include glucose levels of 300 to 800 mg/dL, metabolic acidosis, ketones in the urine, fruity breath, weakness, alteration in K levels, and dehydration. DKA needs to be treated immediately, with an insulin drip, and fluids are needed.
  • Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHS): This occurs in patients with DM type 2. It causes severe dehydration with a marked increase in glucose levels (glucose levels of above 600 mg/dL). Symptoms are extreme thirst, weakness, confusion, loss of vision, and fever. Treatment includes insulin and intravenous fluids.
  • Hypoglycemia: This occurs when the blood sugar levels go below 70 mg/dL. It can occur as a side effect of insulin. Symptoms are dizziness, visual changes, mental status changes, sweating, tachycardia, nervousness, numbness, syncope, and fatigue. Treatment is to increase blood glucose levels. Orange juice (6 ounces) and graham crackers can be given, then blood glucose level should be rechecked in 15 minutes. If blood glucose remains low, intravenous D5 must be administered to increase glucose levels. Continue to assess blood glucose.
  • Diabetic Nephropathy: This is progressive damage to the kidneys as a result of end-stage renal disease caused by uncontrolled DM.
  • Diabetic Neuropathy: Neuropathy in DM occurs when there is a lack of blood supply to the nerves, and causes pain, numbness, and tingling in the feet and fingertips. Patients with DM should be referred to a podiatrist. Due to the lack of feeling in their feet, patients are at risk for infections and wounds. Diabetic ulcers often occur from wounds or infection in the feet.

Drug Therapy:

Oral hypoglycemic medications:

  • Sulfonylureas such as glimepiride (Amaryl) or glipizide (Glucotrol).
  • Biguanides such as metformin (Glucophage).
  • Alpha-glucosidase inhibitors such as acarbose (Precose) or miglitol (Glyset).
  • Thiazolidinedione such as pioglitazone (Actos) or rosiglitazone (Avandia).
  • Meglitinides such as nateglinide (Starlix) or repaglinide (Prandin).
  • Dipeptidyl peptidase-4 such as stigliptin (Januvia).

Insulin:

  • Rapid-acting insulin has an onset of 15 minutes, peaks in 60 to 90 minutes, and lasts 3 to 4 hours. Types are lispro (Humalog) and aspart.
  • Short-acting insulin has an onset of 30 minutes to 1 hour, peaks in 2 to 3 hours, and lasts 3 to 6 hours. Regular insulin is short-acting insulin.
  • Intermediate insulin has an onset of 2 to 4 hours, peaks in 4 to 10 hours, and lasts for 10 to 16 hours. One type of intermediate insulin is NPH. It can be mixed with regular insulin.
  • Long-acting insulin has an onset of 1 to 2 hours, no peak, and lasts for 24 hours. Types are glargine (Lantus) and detemir (Levemir).

Insulin is discussed in more detail in Chapter 5. Rapid-acting and short-acting insulin is administered at mealtimes and bedtime with glucose levels checked before administration. An insulin sliding scale is used to determine how much insulin is to be given based on the patient’s glucose level. Insulin must be refrigerated and the expiration date (expires in 30 days from opening) checked before administering. Insulin is given subcutaneously and sites should be rotated at each injection. Always wash hands and use an alcohol wipe to clean the skin before injecting. If the patient is hypoglycemic or blood glucose is below 70 mg/dL, insulin should be held, and orange juice or D5 should be given. When mixing NPH and regular insulin, remember to always mix the clear insulin first, which is regular insulin, and then the NPH, which is cloudy. Clear before cloudy.

Nursing Care: DM can often be treated with diet, exercise, and medications. Patient education is needed to provide information about the disease and promote a healthy lifestyle, as well as to avoid complications that could arise if DM is left untreated. The importance of an exercise regimen and weight control is emphasized. A diabetic diet includes an intake of 1,800 to 2,000 daily calories and excludes food with sugars to maintain healthy glucose levels. Blood glucose levels should always be checked before insulin administration, with the use of a sliding scale. Always monitor for signs of hypoglycemia. Patients with diabetes are also susceptible to infections and wounds. A podiatrist should be seen monthly. Other medications such as beta-adrenergic blockers, including metoprolol (Lopressor) and atenolol (Tenormin), can mask symptoms of hypoglycemia, and corticosteroids can increase blood glucose levels.

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