NCLEX: Endocrine disorders

Endocrine disorders: Treatments

Focus topic: Endocrine disorders

Here is practical information about treatments for patients with endocrine disorders. You’ll play a crucial role in preparing these patients for treatment, monitoring them during and after treatment, and teaching various aspects of self-care.

Endocrine disorders: Drug therapy

Focus topic: Endocrine disorders

Commonly used drugs to treat endocrine disorders include:
• corticosteroids for inflammation and adrenal insufficiency
• antidiabetics to lower blood glucose levels for type 1 and type 2 diabetes mellitus and diabetic ketoacidosis
• glucagon for hypoglycemia
• drugs that affect calcium levels for Paget’s disease and hypocalcemia
• pituitary hormones for some forms of diabetes insipidus and pituitary growth hormone deficiency
• thyroid hormone antagonists for hyperthyroidism
• thyroid hormone for hypothyroidism.

Endocrine disorders: Nonsurgical treatments

Focus topic: Endocrine disorders

Nonsurgical treatments for endocrine disorders include meal planning for diabetes and radioactive iodine (131I) administration.

Diabetic meal planning
Diabetes specialists regard meal planning as the cornerstone of diabetes care because it directly controls the body’s major glucose source. Your patient’s food intake can be carefully controlled to prevent widely fluctuating blood glucose levels. If he’s taking insulin or sulfonylureas, he’ll have to adhere to his meal plan even more carefully to avoid hypoglycemia.

Endocrine disorders: In balance

Focus topic: Endocrine disorders

Your patient’s nutritional requirements include a well-balanced diet containing all the necessary nutrients. However, to avoid wide blood glucose variations, he needs to closely regulate his protein, fat and, especially, carbohydrate intake. Currently, the American Dietetic Association and the American Diabetes Association recommend an individual nutritional assessment to determine appropriate medical nutrition therapy. Carbohydrate and protein composition will vary, depending on therapeutic goals, and fat should be less than 30% of total calories. The relatively low fat content may also help reduce the risk of cardiovascular disease.

Patient preparation
If your patient requires a meal plan, take the following steps:
• Explain to the patient that his meal plan will help control his blood glucose levels.
• Take a thorough dietary history, keeping in mind that difficulty with the diabetic meal plan may result from unnecessarily limiting the patient’s food preferences and habits. Considering not only what he eats but also when he eats will help you and the patient to set up appropriate meal and snack times.
• Determine what your patient knows about diabetic meal planning. If he will be using the exchange system, explain that he needs to keep track of all the foods he eats and categorize them according to food exchanges. Mention that no foods can be exempted — even so-called dietetic foods.

Endocrine disorders: Concentrating on sweets

Focus topic: Endocrine disorders

• Make sure you discuss concentrated sweets (foods high in simple sugars) with the patient. Old-fashioned diabetic diets forbid such foods as ice cream, cookies, candies, and pastries. Studies that categorize foods according to their glycemic index (the blood glucose level after ingestion) show that complete restriction may not be necessary. Baked potatoes, for instance, have a higher glycemic index than ice cream. Findings such as these challenge researchers to investigate diabetic meal plans more closely. However, encourage your patient to remain cautious about concentrated sweets, particularly if weight loss is a goal. He still may need to avoid them unless his diabetes is well controlled.
• Arrange for a dietitian to teach your patient how to plan his meals. The dietitian may recommend the food exchange system. This method, based on the carbohydrate, fat, and protein content of six basic food groups, allows greater flexibility in meal planning. Exchange groups include milk products, vegetables, fruits, breads, meats, and fats.

Monitoring and aftercare
If your patient has newly diagnosed diabetes with extremely high blood glucose levels, he may require hospitalization while his blood glucose levels are monitored and insulin therapy is initiated.
During his stay, take the following steps:
• Monitor for signs of hypoglycemia, such as nervousness, diaphoresis, tremors, dizziness, fatigue, faintness and, possibly, seizures or coma.

• Also watch for signs of hyperglycemia, such as polyuria, polydipsia, and dehydration.
• Finally, be on guard for signs of ketoacidosis, such as a fruity breath odor, dehydration, weak and rapid pulse, and Kussmaul’s respirations. Be sure to monitor urine ketones if his blood glucose levels are over 400 mg/dl.

Home care instructions
Teach the patient how to adjust his meal plan when he engages in extra activity or exercise. If he eats many meals in restaurants, have the dietitian show him how to select a meal that fits his plan. If appropriate, tell him how to obtain nutrient composition lists from fast-food restaurants.
For an overweight patient, implement weight-reduction measures as ordered, and explain the reduced-calorie meal plan. Suggest a support group, such as Weight Watchers and Over-eaters Anonymous, if necessary.

131I administration
A form of radiation therapy, the administration of 131I treats hyperthyroidism, particularly Graves’ disease, and is an adjunctive treatment of thyroid cancer. It shrinks functioning thyroid tissue, decreasing circulating thyroid hormone levels and destroying malignant cells.

Endocrine disorders: The incredible shrinking thyroid

Focus topic: Endocrine disorders

After oral ingestion, 131I is rapidly absorbed and concentrated in the thyroid as if it were normal iodine, resulting in acute radiation thyroiditis and gradual thyroid atrophy. 131I causes symptoms to subside after about 3 weeks and exerts its full effect only after 3 to 6 months.

Patient preparation
Take the following steps before 131I administration:
• Explain the procedure to the patient and check his history for allergies to iodine.
• Unless contraindicated, instruct the patient to stop thyroid hormone antagonists 4 to 7 days before 131I administration because these drugs reduce the sensitivity of thyroid cells to radiation.
• Tell the patient to fast overnight because food may delay 131I absorption.
• Make sure the patient isn’t taking lithium carbonate, which may interact with 131I to cause hypothyroidism.

Patient preparation
Before adrenalectomy, take these steps:
• Expect to give oral or I.V. potassium supplements to correct low serum potassium levels. Monitor for muscle twitching and a positive Chvostek’s sign (indications of alkalosis).
• Keep the patient on a low-sodium, high-potassium diet as ordered to help correct hypernatremia.
• Give aldosterone antagonists as ordered for blood pressure control.
• Explain to the patient that surgery may cure his hypertension if it results from an adenoma.

Endocrine disorders: A soothing setting

Focus topic: Endocrine disorders

• Give the patient with adrenal hyperfunction emotional support and a controlled environment to offset his emotional lability. If ordered, give a sedative to help him rest.
• Expect to administer medications to control his hypertension, edema, diabetes, and cardiovascular signs and symptoms as well as his increased tendency to develop infections.
• As ordered, give glucocorticoids the morning of surgery to help prevent acute adrenal insufficiency during surgery.

Monitoring and aftercare
After adrenalectomy, take these steps:
• Monitor the patient’s vital signs carefully, observing for indications of shock from hemorrhage.
• Keep in mind that postoperative hypertension is common because handling the adrenal glands stimulates catecholamine release.
• Watch for weakness, nausea, and vomiting, which may signal hyponatremia.
• Use sterile technique when changing dressings to minimize the risk of infection.
• Administer analgesics for pain, and give replacement steroids as ordered.

Endocrine disorders: Crisis control

Focus topic: Endocrine disorders

• Remember, glucocorticoids from the adrenal cortex are essential to life and must be replaced to prevent adrenal crisis until the hypothalamic, pituitary, and adrenal axis resumes functioning.
• If the patient had primary hyperaldosteronism, he’ll have had preoperative renin suppression with resulting postoperative hypoaldosteronism. Monitor his serum potassium levels carefully; he may develop hyperkalemia if he’s receiving spironolactone (Aldactone), a potassium-sparing diuretic for control of postoperative hypertension. Fludrocortisone may be indicated.

Home care instructions
Before discharge, take these steps:
• Explain the importance of taking prescribed medications as directed. If the patient had a unilateral adrenalectomy, explain that he may be able to taper his medications in a few months, when his remaining gland resumes function and his pituitary resumes secreting corticotropin.
• Make sure the patient understands that sudden withdrawal of steroids can precipitate adrenal crisis and that he needs continued medical follow-up to adjust his steroid dosage appropriately during stress or illness.

Endocrine disorders: Sign language

Focus topic: Endocrine disorders

• Describe the signs of adrenal insufficiency, and make sure the patient understands how this can progress to adrenal crisis if  not treated. Explain that he should consult his practitioner if he develops such adverse reactions as weight gain, acne, headaches, fatigue, and increased urinary frequency, which can indicate steroid  overdose. Advise him to take his steroids with meals or antacids to minimize gastric irritation.
• If the patient had adrenal hyperfunction, explain that he’ll see a reversal of the physical characteristics of his disease over the next few months. However, caution him that his improved physical appearance doesn’t mean he can stop his medications.
• Advise the patient to wear medical identification jewelry to ensure adequate medical care in an emergency.

Hypophysectomy
Micro-surgical techniques have dramatically reversed the high mortality previously associated with removal of pituitary and sella turcica tumors. Transsphenoidal hypophysectomy is now the treatment of choice for pituitary tumors, which can cause acromegaly, gigantism, and Cushing’s disease. The surgery also serves as a palliative measure for patients with metastatic breast or prostate cancer to relieve pain and reduce the hormonal secretions that spur neoplastic growth.

Home care instructions
Before discharge, take these steps:
• Explain the importance of taking prescribed medications as directed. If the patient had a unilateral adrenalectomy, explain that he may be able to taper his medications in a few months, when his remaining gland resumes function and his pituitary resumes secreting corticotropin.
• Make sure the patient understands that sudden withdrawal of steroids can precipitate adrenal crisis and that he needs continued medical follow-up to adjust his steroid dosage appropriately during stress or illness.

Endocrine disorders: Sign language

Focus topic: Endocrine disorders

• Describe the signs of adrenal insufficiency, and make sure the patient understands how this can progress to adrenal crisis if not treated. Explain that he should consult his practitioner if he develops such adverse reactions as weight gain, acne, headaches, fatigue, and increased urinary frequency, which can indicate steroid overdose. Advise him to take his steroids with meals or antacids to minimize gastric irritation.
• If the patient had adrenal hyperfunction, explain that he’ll see a reversal of the physical characteristics of his disease over the next few months. However, caution him that his improved physical appearance doesn’t mean he can stop his medications.
• Advise the patient to wear medical identification jewelry to ensure adequate medical care in an emergency.

Hypophysectomy
Microsurgical techniques have dramatically reversed the high mortality previously associated with removal of pituitary and sella turcica tumors. Transsphenoidal hypophysectomy is now the treatment of choice for pituitary tumors, which can cause acromegaly, gigantism, and Cushing’s disease. The surgery also serves as a palliative measure for patients with metastatic breast or prostate cancer to relieve pain and reduce the hormonal secretions that spur neoplastic growth.

Endocrine disorders: Risky business

Focus topic: Endocrine disorders

Hypophysectomy may be performed subfrontally (approaching the sella turcica through the cranium) or transsphenoidally (entering from the inner aspect of the upper lip through the sphenoid sinus). The subfrontal approach carries a high risk of mortality or complications, such as loss of smell and taste and permanent, severe diabetes insipidus. As a result, this approach is used only rarely — in cases where a tumor causes marked subfrontal or subtemporal extension and with optic chiasm involvement.

Endocrine disorders

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Patient preparation
Before hypophysectomy, take these steps:
• Tell the patient that he’ll receive a general anesthetic and may go to the intensive care unit (ICU) postoperatively for up to 48 hours for careful monitoring.
• Explain that he’ll have a nasal catheter and packing in place for at least 1 day after surgery as well as an indwelling urinary cath eter.
• Arrange for appropriate tests and examinations as ordered. For example, if the patient has acromegaly, he’ll need a thorough cardiac evaluation because he may have incipient myocardial ischemia. If he has Cushing’s disease, he’ll need blood pressure and serum potassium level checks.
• Arrange for a visual field test to serve as a baseline for the patient.
• Review the patient’s preoperative medication regimen if appropriate. If he has hypothyroidism, he may need hormone replacement therapy (HRT). Many patients receive I.V. hydrocortisone (Solu-Cortef) preoperatively and postoperatively.

Monitoring and aftercare
After hypophysectomy, take these steps:
• Keep the patient on bed rest for 24 hours after surgery and then encourage ambulation.
• Keep the head of his bed elevated to avoid placing tension or pressure on the suture line.
• Tell him not to sneeze, cough, blow his nose, or bend over for several days to avoid disturbing the suture line.
• Give mild analgesics as ordered for headache caused by cerebrospinal fluid loss during surgery or for paranasal pain. Paranasal pain typically subsides when the catheters and packing are removed — usually 24 to 72 hours after surgery.
• Anticipate that the patient may develop transient diabetes insipidus, usually 24 to 48 hours after surgery. Be alert for increased thirst and increased urine volume with a low specific gravity.
• If diabetes insipidus occurs, replace fluids and administer aqueous or sublingual desmopressin acetate (DDAVP), as ordered. With these measures, diabetes insipidus usually resolves within 72 hours.
• Arrange for visual field testing as soon as possible and compare the results to the patient’s baseline because new vis ion defects can indicate hemorrhage.
• Collect a serum sample to measure pituitary hormone levels and evaluate the need for hormone replacement.

Home care instructions
Before discharge, take these steps:
• Instruct the patient to report signs of diabetes insipidus immediately. Explain that he may need to limit fluid intake or take prescribed medications.
• Tell the patient with hyperprolactinemia that she’ll need follow-up visits for several years because relapse is possible. Explain that she may be placed on bromocriptine (Parlodel), which inhibits secretion of prolactin, if relapse occurs.
• Advise the patient to brush teeth gently using a fingertip soft brush and to avoid suture line disruption. Tell the patient that using a mouthwash is acceptable.
• Explain to the patient that she may need HRT as a result of decreased pituitary secretion of tropic hormones. If cortisol or thyroid hormone replacement becomes necessary, teach the patient to recognize the signs of excessive or insufficient dosage.
• Advise the patient to wear medical identification jewelry.

Thyroidectomy
Thyroidectomy (removal of all or part of the thyroid gland) is performed to treat hyperthyroidism, respiratory obstruction from goiter, and thyroid cancer. Subtotal thyroidectomy, which reduces secretion of thyroid hormone, is used to correct hyperthyroidism when drug therapy fails or radiation therapy is contraindicated. It may also effectively treat diffuse goiter. After surgery, the remaining thyroid tissue usually supplies enough thyroid hormone for normal function, although hypothyroidism may occur later.

Patient preparation
Before thyroidectomy, take these steps:
• Explain to the patient that thyroidectomy will remove diseased thyroid tissue or, if necessary, the entire gland.
• Tell him that he’ll have an incision in his neck and a drain and dressing in place after surgery and that he may experience some hoarseness and a sore throat from intubation and anesthesia. Reassure him that he’ll receive analgesics to relieve his discomfort.
• Make sure that the patient has followed his preoperative drug regimen, which will render the gland euthyroid (having a normally functioning thyroid gland) to prevent thyrotoxicosis during surgery. He probably will have received either propylthiouracil or methimazole (Tapazole), usually starting 4 to 6 weeks before surgery.
• Expect him to receive iodine for 10 to 14 days before surgery to reduce the gland’s vascularity and thus prevent excess bleeding. He may also take propranolol (Inderal) to reduce excess sympathetic effects. Notify the practitioner immediately if the patient hasn’t followed his medication regimen.
• If necessary, arrange for an electrocardiogram (ECG) to evaluate cardiac status.

Monitoring and aftercare
After thyroidectomy, take these steps:
• Watch for signs of respiratory distress. Tracheal collapse, mucus accumulation in the trachea, laryngeal edema, and vocal cord paralysis can all cause respiratory obstruction with sudden stridor and restlessness. Keep a tracheostomy tray at the patient’s bedside for 24 hours after surgery, and be prepared to assist with emergency tracheotomy if necessary.
• Be alert for indications of thyroid storm (a sudden and dangerous increase of the signs of thyrotoxicosis), a rare but serious complication. In thyroid storm, pulse and respirations rise to dangerous levels and temperature increases rapidly.
• Keep the patient in high semi-Fowler’s position to promote venous return from the head and neck and to decrease oozing into the incision.

• Check for laryngeal nerve damage by asking the patient to speak as soon as he wakes from anesthesia.
• Assess for signs of hemorrhage, which may cause shock, tracheal compression, and respiratory distress. Check the patient’s dressing and palpate the back of his neck, where drainage tends to flow. Expect about 50 ml of drainage in the first 24 hours; if you find no drainage, check for drain kinking or the need to reestablish suction. Expect only scant drainage after 24 hours.

A pain in the neck

Focus topic: Endocrine disorders

• As ordered, administer an analgesic to relieve a sore neck or throat. Reassure the patient that his discomfort should resolve within a few days.
• Assess for hypocalcemia, which may occur when bones depleted of calcium from hyperthyroidism begin to heal, rapidly taking up calcium from the blood, or if the parathyroid glands are injured or destroyed. Test for positive Chvostek’s and Trousseau’s signs, indicators of neuromuscular irritability from hypocalcemia. Keep calcium gluconate available for emergency I.V. administration.

Home care instructions
Before discharge, take these steps:
• If the patient has had a subtotal or total thyroidectomy, or if the parathyroid glands are injured or destroyed, explain the importance of regularly taking his prescribed thyroid hormone replacement. Teach him to recognize and report signs of hypo thyroidism and hyperthyroidism.
• If parathyroid damage occurred during surgery, explain to the patient that he may need to take calcium supplements. Teach him to recognize the warning signs of hypocalcemia.
• Tell the patient to keep the incision site clean and dry.
• Arrange follow-up appointments as necessary, and explain to the patient that the practitioner needs to check the incision and serum thyroid hormone levels.

Fashion tips

Focus topic: Endocrine disorders

• Help the patient cope with concerns about appearance. Suggest loosely buttoned collars, high-necked blouses and shirts, jewelry, or scarves, which can hide the incision until it heals. The practitioner may recommend a mild body lotion to soften the healing scar and improve its appearance.

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