ENDOCRINE SYSTEM

STRUCTURE AND FUNCTION OF THE

ENDOCRINE AND METABOLIC
SYSTEMS

A. Hormones: are chemicals substances

secreted by endocrine glands directly into
the blood stream to act on specific target
cells. Hormones regulate growth and
development, fluid and electrolyte balance,
reproduction, adaptation to stress, and
metabolism.
1. Types of hormones
a. Protein or peptide hormones- act on
cell membranes by binding to receptors.
Examples include insulin, vasopressin,
growth hormone (GH), and
adrenocorticotropic hormone (ACTH)

b. Amine hormones or amino acids-act

on cell membranes. Examples include
derivatives, epinephrine, and
norepinephrine.
 c. Steroids- act intracellularly to modify
protein synthesis. Examples include
cortisol, estrogen, and testosterone.

2. Hormone regulation. Hormone secretion

is regulated through feedback
mechanisms (i.e. for increased levels of a
specific hormone, its cations or
metabolites inhibit secretion; decreased
levels stimulate secretion).
B. Pituitary gland. Located at the inferior
aspect of the brain within the sella turcica
(i.e. small recess in the sphenoid bone),
the pituitary gland consists of anterior and
posterior lobes.

1. The anterior lobe synthesizes and

releases hormones. Release of these
hormones is regulated by the
hypothalamus, which secretes releasing
and inhibiting hormones.
 a. GH
 b. Prolactin
 c. Thyroid stimulating hormone
 d. ACTH
 e. Follicle stimulating hormone
 f. Luteinizing hormone
2. The posterior lobe stores and releases
hromones synthesized in the
hypothalamus.
a. Oxytocin
b. ADH
C. Thyroid gland. A butterfly-shaped gland
located in the neck behind the trachea, the
thyroid produces three hormones.
1. Thyroxine (T4) and triiodothyronine (T3)
regulate cellular metabolic activity T3 is
produced predominantly from peripheral
conversion of T4. Secretion of T4 and T3
is under the control of TSH.

2. Thyrocalcitonin is secreted in response

to high blood calcium levels. It lowers
blood calcium levels by inhibting bone
resorption.
D. Parathyroid glands
1. These small glands, usually four,
surround the posterior thyroid gland, they
are often difficult to locate and may be
removed accidentally during thyroid or
other neck surgery.

2. In response to a low blood calcium

level, the parathyroids produce
parathromone, which raises blood calcium
levels by increasing calcium resorption
from kidneys, intestines, and bones.
E. Adrenal glands. Located at the upper
poles of both kidneys, the adrenals contain
two distinct types of endocrine tissue.
1. The adrenal medulla in the center of
the gland, reacts to autonomic nervous
system signals to release catecholamines.
a. Epinephrine-which accounts for
approximately 90% of adrenal medulla
secretions, prepares the body for the fight-
or-flight response by converting glycogen,
stored in the liver, to glucose and
increasing cardiac output.
 b. Norepinephrine produces
effects similar to epinephrine and
produces extensive vasoconstriction.

2. The adrenal cortex, the outer portion of

the gland, is stimulated by ACTH to
produce corticosteroids.
a. Minelacorticoids (primarily
aldosterone), which are released in
response to angiotensin II and
ACTH,increase sodium reabsorption and
potassium loss primarily through the renal
tubules.
 b. Glucocorticoids (primarily cortisol),
which are released in response to ACTH,
increase blood glucose by stimulating
gluconeogensis and lipolysis and
decrease protein synthesis, suppress the
inflammatory response, and promote
sodium retention and potassium loss.

c. Adrenal sex hormones (i.e.

androgens and estrogen) govern
development of certain secondary sex
characteristics. Secretion of adrenal
androgens is controlled by ACTH.
F. Pancreas. A slender elongated organ
lying horizontally in the posterior abdomen
behind the stomach, the pancreas
functions as an exocrine and an endocrine
gland.
1. Exocrine functions involve secretion
of pancreatic digestive enzymes by
specialized cells.
2. Endocrine functions are controlled by
the alpha, beta, delta cells of the islets of
Langerhans.
G. Gonads
1. The gonads consist of the ovaries
and testes.
2. Although the gonads exert some
systemic metabolic effects, their primary
function is reproduction.
ENDOCRINE SYSTEM
DIABETES MELLITUS
I. Definition
a. Metabolic disorder characterized by
hyperglycemia resulting from lack of
insulin, lack of insulin effect, or both.
b. Four general classifications as
recognized:
1. Pre-diabetes (fasting blood glucose
> 100 mg/dl and < 126 mg/dl or
postprandial blood glucose > 140mg/dl
and 200 < 200 mg/dl)
 2. Type 1 (absolute insulin
insufficiency)
3. Type 2 (insulin resistance with
varying degrees of insulin secretory
defects)
4. Gestational (develops during
pregnancy)
II. Underlying pathophysiology
a. Type 1
1. A triggering event, possibly a viral
infection, causes production of
autoantibodies against beta cells of the
pancreas
2. Resultant destruction of beta cells
leads to a decline in and an ultimate lack
of insulin
3. Insulin deficiency leads to
hyperglycemia, enhanced lipolysis
(decomposition of fat),and protein
metabolism
 4. These characteristics occur when
more than 90 % of beta cells have been
destroyed.

b. Type 2
1. Impaired insulin secretion,
inappropriate hepatic glucose production,
or peripheral insulin receptor insensitivity
leads to hyperglycemia.
c. Gestational
1.Occurs when a woman not previously
diagnosed with diabetes shows glucose
intolerance during pregnancy
2. This intolerance may occur if
placental hormones counteract insulin,
causing insulin resistance
III. Causes
A. Type 1
1. Autoimmune process triggered by viral
or environmental factors
2. Idiopathic (no evidence of autoimmune
process)
B. Type 2
1. Beta cell exhaustion due to lifestyle
choices or hereditary factors
2. Risk factors
a. Obesity
b. Family history
c. Pregnancy ending in birth of neonate
weighing more than 9 lb.
d. Hypertension
e. Age
IV. Pathophysiologic changes
a. Polyuria and polydipsia
b. Polyphagia
c. Weight loss
d. Headaches, fatigue, lethargy, reduced energy
level
e. Muscle cramps, irritability, and emotional
lability due to electrolyte imbalance
f. Numbness and tingling due to neural tissue
damage
g. Abdominal discomfort
h. Nausea, diarrhea, or constipation
i. Slow-healing skin infections or wounds, itching
of skin, and recurrent monilial infections of the
vagina or anus due to hyperglycemia
V. Complications
a. Microvascular disease, including retinopathy,
nephropathy, and neuropathy
b. Dyslipidemia
c. Macrovascular disease, including coronary,
peripheral, and cerebral artery disease.
d. Diabetic ketoacidosis (DKA)
e. Hyperosmolar hyperglycemic nonketotic
syndrome
f. Excessive weight gain
g. Skin ulcerations
h. Amputation
i. Chronic renal failure
VI. Diagnostic test findings
a. Blood testing reveals fasting plasma
glucose level of 126 mg/dl or more on at
least two occasions; random blood
glucose level of 200 mg/dl or more; 2-hour
blood glucose test results of 200 mg/dl or
more (2 hours after ingesting 75 g of oral
dextrose); and increased glycosylated
hemoglobin (HbA1c), reflecting glycemic
control during the previous 2 to 3 months.
b. Ophthalmologic examination may show
diabetic retinopathy
c. Urinalysis reveals elevated acetone and
glucose
VII. Treatment
a. Careful monitoring of blood glucose and
HbA1c levels
b. Regular exercise
c. Type 1
1. Insulin replacement
2. Pancreas transplantation (requires
chronic immunosuppression)
d. Type 2
1. Oral antidiabetic drugs
e. Gestational
1.Medical nutrition therapy
2. Injectable insulin if glucose level isn’t
achieved with diet alone
3. Postpartum counseling to address
the high risk of gestational diabetes in
subsequent pregnancies and type 2
diabetes later in life.
VIII. Nursing considerations
1. Stress the importance of complying with
prescribed treatment program (diet,
exercise, blood glucose monitoring
recognition and treatment of
hypoglycemia and hyperglycemia)
2. Teach the patient and his family about
possible adverse effects of medications
3. Watch for complications, especially
hypoglycemia (dizziness, weakness,
pallor, tachycardia, diaphoresis, seizures
and coma)
4. Stay alert for signs of ketoacidosis (acetone
breath, dehydration, weak and rapid pulse,
Kussmaul’s respirations) and Hyperosmolar
coma (polyuria, thirst, neurologic
abnormalities, stupor); these hyperglycemic
crises require I.V. fluids and regular insulin.
5. Teach the patient and his family how to
recognize hypoglycemia and ketoacidosis, how
to respond, and when to seek medical
attention.
6. Monitor diabetes control by obtaining blood
glucose, HbA1c level, annd blood pressure
measurements regularly.
7. Watch for diabetic effects on the
cardiovascular system and the peripheral
and autonomic nervous system
a. Meticulously treat all injuries, cuts,
and blisters
b. Monitor for signs and symptoms of
cellulitis (skin reddening and edema,
possible blistering or ulceration)
c. Stay alert for signs of UTI and renal
disease
8. Urge the patient to get regular
ophthalmologic examinations to detect
diabetic retinopathy.
9. Assess the patient for signs of diabetic
neuropathy (changes in sensation or in
motor strength or agility in an extremity)
a. Stress the need for personal safety
precautions.
b. Minimize complications by
maintaining strict blood glucose control
Disorders of the Anterior
Pituitary
Pituitary gland. Located at the inferior
aspect of the brain within the sella turcica
(i.e. small recess in the sphenoid bone),
the pituitary gland consists of anterior and
posterior lobes.
The anterior lobe synthesizes and
releases hormones. Release of these
hormones is regulated by the
hypothalamus, which secretes releasing
and inhibiting hormones.
A. GH
B. Prolactin
C. Thyroid stimulating hormone
D. ACTH
E. Follicle stimulating hormone
F. Luteinizing hormone
2. The posterior lobe stores and releases
hromones synthesized in the
hypothalamus.
a. Oxytocin
b. ADH
Disorders of the Anterior Pituitary
A. Hypopituitarism
1. Definition - underactivity of the front
(anterior) pituitary gland
a. classifications of pituitary tumors
i. functioning: hormone present
in insufficient quantities
ii. non-functioning: hormone
absent
iii. if in childhood - decreased
growth hormone results in
dwarfism
2. Etiology - most common cause:
neoplasms, usually benign as a pituitary
adenoma
3. Findings - result from hormone
deficiency (hypogonadism)
a. hypogonadism, female:
i. amenorrhea
ii. infertility
iii. decreased libido
iv. breast and uterine atrophy
v. loss of axillary and pubic hair
vi. vaginal dryness
b. hypogonadism, male
i. decreased libido
ii. impotence
iii. small, soft testicles
iv. loss of axillary and pubic hair
c. hypothyroidism (because pituitary
regulates thyroid glands by thyroid
stimulating hormone (TSH))
d. hypoadrenalism (because pituitary
regulates adrenal glands by ACTH
production)
e. may see signs of increased intracranial
pressure (ICP)
f. SIADH - fluid overload and dilutional
hyponatremia related to increased ADH
levels
 Management
a. expected outcome: hormone deficiency
corrected
b. hormone replacement therapy
i. corticosteroid therapy
ii. thyroid hormone replacement
iii. sex hormone replacement
c. surgical removal of tumor
Diagnostics
a. history and physical exam
b. neuro-ophthalmological exam
c. x-rays of pituitary fossa
d. radioimmunoassays of anterior pituitary
hormones
e. computerized tomogram (CT) scan
• Nursing interventions
a. provide for
i. care of the client with increased
ICP

CARE OF THE CLIENT WITH

INCREASED INTRACRANIAL
PRESSURE

1. Monitor neuro vital signs as ordered

2. Maintain fluid restriction as ordered
3. Raise head of bed at 30-45 degrees
4. Prevent any activities that increase ICP
such as straining at stool, coughing,
vomiting, any restrictive clothing around
neck, neck rotation, flexion, extension,
anxiety
5. Observe for herniation syndrome
6. Monitor intracranial pressure
7. Administer oxygen as ordered
8. Seizure precautions
ii. care of the client undergoing surgery
b. monitor for desired effects of
administered medications as ordered
c. provide emotional support with referral
to support groups
d. teach client
i. medications desired effects and side
effects
ii. need for lifelong hormone replacement
therapy and regular checks of serum
levels
B. Hyperpituitarism
1. Definition - anterior pituitary secretes too
much growth hormone and/or ACTH
2. Etiology
a. usually caused by benign
neoplasm
b. growth hormone overproduction
i. acromegaly - if growth plates
closed
ii. giantism - if growth plates open
c. ACTH overproduction leads
adrenal gland to overproduce cortisone:
Cushing's disease
 3. Findings
 a. may see signs of increased ICP
 b. acromegaly: excess longitudinal bone
growth, increase in density and size of organs
and soft tissue
 c. prognathism
 d. coarse facial features
 e. prominent forehead and orbital ridge
 f. large, broad, spade-like hands
 g. arthritis, kyphosis
 h. prominent tongue
 i. change in ring or shoe size drastically over
short period of time
Diagnostics
a.history and physical exam
b.computerized tomogram (CT) scan
c.plasma hormone levels: increased growth
hormone, ACTH
Management
a.expected outcome: remove tumor and
restore hormonal balance
b.surgical removal of tumor
c.irradiation of gland
d.pharmacologic: growth hormone
suppressant: bromocriptine (parlodel)
e.physical changes of acromegaly are
irreversible
Nursing interventions
a. provide
i. care of the client with increased ICP
ii. care of the client undergoing surgery
iii. care of the client undergoing radiation
therapy
iv. emotional support
b. assess for signs of diabetes insipidus,
since removal of a pituitary tumor may
injure the posterior pituitary glands and
decrease antidiuretic hormone (ADH)
secretions - drastic fluid loss
c. teach client that treatment usually
produces hypopituitarism so lifelong
hormone replacement therapy with regular
check-ups are required
Disorders of the
Posterior Pituitary
Disorders of the Posterior Pituitary
A. Diabetes insipidus
1. Posterior pituitary gland makes too little
antidiuretic hormone (ADH). Body loses
too much water in the urine; plasma
osmolality and sodium levels increase.
 Diabetes Insipidus (DI)
Etiology
Excessive output of dilute urine
 Nephrogenic DI
Inherited defect: renal tubules do not respond to ADH,
resulting in inadequate water reabsorption
Neurogenic DI
A defect in either the production or secretion of ADH
Dipsogenic DI
A disorder of thirst stimulation
When patient ingests water, serum osmolality
decreases, which causes reduced vasopressin
secretion
3. Findings
a. excessive thirst (polydipsia)
b. polyuria: as much as 20 liters
per day with specific gravity
below 1.006
c. nocturia
d. signs of dehydration
e. constipation
4. Diagnostics
a. water deprivation tests: inability to
concentrate urine; also
differentiates between primary DI
and nephrogenic DI
b. osmotic stimulation
c. administration of vasopressin
(pitressin) or desmopressin
acetate (stimate)
d. computerized tomogram (CT)
scan
Management
A. expected outcomes: to correct
underlying cause and restore hormonal
balance
B. pharmacotherapy
A. desmopressin acetate (stimate)
B. vasopressin (pitressin) -
antidiuretic hormone
C. lypressin (diapid)
D. chloropropamide (chloronase)
C. IV fluid replacement therapy
D. surgical removal of tumor
Nursing interventions
A. monitor for findings of dehydration;
measure urine; specific gravity
B. administer medications as ordered
C. monitor fluids and give IV fluids as
ordered
D. measure intake and output
E. weigh client daily
F. care of the client with increased ICP
G. care of the client undergoing surgery
H. teach client
A. to record intake and output
B. about medications and side
effects
C. to check urine specific gravity
D. the need to wear disease
identification jewelry
B. Syndrome of Inappropriate Antidiuretic
Hormone (SIADH)- oversecretion of
ADH, results in excessive water
conservation
Etiology
1. Central nervous system disorders
2. Stimulation due to hypoxia or decreased
left atrial filling pressure
3. Pharmacologic agents
4. Overuse of vasopressin therapy
5. Ectopic ADH production asociated with
some disorders
6. Nausea or opioid use, which can
stimulate ADH secretion
Pathophysiology
When ADH is elevated despite normal
or low serum osmolality, kidneys retain
excessive water
Plasma volume expands, causing the
blood pressure to rise. Body sodium is
diluted (hyponatremia), and water
intoxication develops
 Signs and symptoms
1. Decreased urine output
2. Weight gain
3. Altered mental status (e.g. headache,
confusion, lethargy, seizures, and coma
in severe hyponatremia)
4. Delayed deep tendon reflexes
 Laboratory and diagnostic study findings
1. Plasma osmolality and serum sodium
levels are decreased.
2. Urinalysis detects elevated urine sodium
and osmolality.
3. Serum ADH level is elevated.
 Nursing care
1. Administer prescribed medications,
which may include furosemide (Lasix) to
prevent concentration of urine; isotonic
urine is exreted, achieving a change in
water balance diuretics. Drugs that
render the kidneys less sensitive to ADH
may be prescribed; demeclocycline is
preferred, but lithium may be prescribed.
2. Restrict fluid intake as indicated.
3. Regularly assess mental status.
 DISORDERS OF THE THYROID GLAND
I. Hypothyroidism
1. Definition - an underactive thyroid
resulting in a lessened secretion of thyroid
hormone
a. deficiency of thyroid hormones
causing decreased metabolic rate
i. affects more women
ii. age group: 30 to 50 years of
age
b. classifications
i. cretinism: hypothyroidism in
children; leads to mental
retardation
ii. hypothyroidism without
myxedema: mild thyroid failure
iii. hypothyroidism with
myxedema: severe thyroid failure;
usually seen in older adults
iv. myxedema coma
• most severe type of
hypothyroidism
• precipitated by stress
• findings include:
o hypothermia
o bradycardia
o hypoventilation
o altered LOC leading to
coma
• potentially life threatening
condition
Etiology
a. thyroid surgery - may cause hypothyroid
state after surgery depending on extent of
thyroid removal
b. treatment for hyperthyroid condition
c. overdosage of thyroid medications
d. deficiency in dietary iodine
 Findings
a. cognitive impairment
b. constipation, fatigue, depression
c. intolerance to cold
d. coarse, dry skin; periorbital edema;
thick, brittle nails
e. bradycardia; increased diastolic pressure
f. menstrual changes - increased menstrual
flow
g. loss of the outer one-third of eyebrows
h. weight gain
i. fluid retention
 Diagnostic test findings
a. Radioimmunoassay shows low T3 and T4
levels
b. Blood testing reveals increased TSH level
when hypothyroidism is caused by thyroid
disorder and decreased TSH when the cause is
hypothalamic or pituitary disorder
c. Thyroid panel differentiates between primary
hypothyroidism (thyroid gland hypofunction),
secondary hypothyroidism (pituitary
hyposecretion of TSH), tertiary hypothyroidism
(hypothalamic hyposecretion of TRH)
d. Blood testing reveals elevated serum
cholesterol, alkaline phosphatase, and
triglyceride levels and low serum sodium
level.
e. Arterial blood gas (ABG) analysis
shows decreased pH and increased partial
pressure of carbon dioxide (indicating
respiratory acidosis)
 Management
a. expected outcomes: to restore
hormonal balance and prevent
complications
b. administer synthetic thyroid
hormone: levothyroxine sodium
(levothroid)
c. myxedema coma:
i. IV fluids as ordered
ii. correct hypothermia
iii. give synthetic thyroid hormone
 Nursing interventions
 a. give medications as ordered
 b. watch client for signs of myxedema
 c. provide restful environment
 d. teach client
i. how to conserve energy
ii. how to avoid stress
iii. about the medications and side effects -
synthyroid is to be taken in the morning on
an empty stomach at least one hour before
any other medications or vitamins or
ingestion of milk
iv. the importance of lifelong therapy
e. protect client from cold
B. Hyperthyroidism (Graves' disease,
thyrotoxicosois)
Definition - overactive thyroid over
secretes hormones, and causes increased
basal metabolic rate or hyperactivity of
thyroid as a primary disease state
Etiology - considered autoimmune
response
women affected more than men
age group: 30 to 50 years
3. Findings
a. hyperphagia, weight loss, diarrhea
b. heat intolerance
c. exophthalmos
d. tachycardia
e. Palpitations
f. increased systolic BP
g. difficulty concentrating
h. irritability
i. hyperactivity
j. thin, brittle hair, pliable nails:
plummer's nails
k. diaphoresis
l. insomnia
m. reduced tolerance for stress
 Diagnostics
1. history and physical exam: palpable
thyroid enlargement: (goiter)
2. elevated serum T3 and T4 levels
3. elevated radioactive iodine uptake
4. presence of thyroid autoantibodies
5. decreased TSH (thyroid-stimulating
hormone; comes from pituitary) levels
 Complication: thyrotoxic crisis (thyroid storm)
1. rare but potentially fatal
2. breakdown of body's tolerance to
chronic hormone excess
3. state of extreme hypermetabolism
4. precipitating factors: stress, infection,
pregnancy
5. findings include:
1. systolic hypertension
2. hyperthermia
3. angina
4. infarction or heart failure
5. extreme anxiety
6. even psychosis
 Management
a. expected outcomes: to reduce the
excess hormone secretion and to prevent
complications
b. pharmacologic
i. sodium131I
ii. antithyroid agents: propylthiouracil
(PTU)
iii. beta-adrenergic blocking agents:
propranolol (inderol)
iv. iodides: useful adjunct to decrease
vascularity of thyroid pre-surgical removal
 c. surgical: thyroidectomy: partial or
total removal of thyroid gland
d. diet high in calories, protein,
carbohydrates
Nursing interventions
a.monitor vital signs, especially blood
pressure and heart rate
b.provide quiet, restful, cool environment
c.monitor diet therapy
d.provide extra fluids
e.provide emotional support
f. administer medications as ordered
g. teach client
i. about medications and side
effects
ii. stress avoidance measures
iii. energy conservation measures
h. care of the client undergoing surgery
i. assess for laryngeal nerve damage
post-surgery
j. assess for excessive swallowing or
pooling of blood behind neck indicating
hemorrhage
 Disorders of the Parathyroid Gland
A. Hypoparathyroidism
 1. Definition - parathyroid produces too
little parathormone; results in
hypocalcemia
 2. Etiology unknown
 a. possibly an autoimmune disorder
 b.most often results from surgical removal of
parathyroid glands
3. Findings (mild to severe order)
a. neuromuscular
i. irritability
ii. personality changes
iii. muscular weakness or cramping
iv. numbness of fingers
v. tetany
vi. carpopedal spasms
vii. laryngospasms
viii. seizures
b. dry, scaly skin
c. hair loss
d. abdominal cramping

Diagnostics
1. Parathyroid hormone (PTH)
2. Serum calcium, total
3. Serum calcium, ionized
4. Serum phosphate
a. history and physical exam
b. positive Chvostek's sign (facial muscle
twitching when cheek is stroked)
c. positive Trousseau's sign (carpopedal
spasm as inflated BP cuff is released)
d. decreased serum calcium
e. increased serum phosphate
Management
a.expected outcomes: to restore hormonal
balance and prevent complications
b.calcium replacement therapy: ideal serum
calcium level 8.6mg/dl
c.vitamin D preparations facilitate uptake of
calcium
d.calcium-rich diet
Nursing interventions
a.monitor carefully for signs of tetany
b.place airway, suction and tracheotomy tray
at bedside
c.institute seizure precautions
d.administer medications as ordered
e.calcium gluconate kept at bedside
f. teach client
i. about medications and side
effects
ii. signs of vitamin D toxicity
iii. to consume more calcium and get
vitamin D from sun exposure to
skin
iv. to reduce phosphorus intake:
minimize intake of fish, eggs,
cheese and cereals
B. Hyperparathyroidism
1. Definition - parathyroid secretes
too much parathormone; results in
increased serum calcium
(hypercalcemia)
2. Etiology
a. benign growth in parathyroid
b. secondarily as result of
kidney disease or
osteomalacia
c. incidence increases
dramatically in both sexes
after age 50
3. Findings
a. many clients are asymptomatic
b. gastrointestinal: constipation, nausea,
vomiting, anorexia
c. skeletal: bone pain, demineralization,
pathological fractures
d. irritability
e. muscle weakness and fatigue
Diagnostics
a. history and physical exam
b. elevated serum calcium
c. decreased serum phosphate level
d. x-rays reveal bone demineralization
PHARMACOLOGIC INTERVENTIONS
FOR HYPERPARATHYROIDISM
1. Hydration with 0.9% normal saline
solution
2. Diuretics
3. Plicamycin
4. Didronel
5. Glucocorticoids
6. Phosphate as antihypercalcemic agent
7. Calcitonin
8. Estrogen
9. Etidronate disodium
10.Phosphate-binding antacid
11.Calcium supplement
12.Vitamin D
a. expected outcomes: to restore
hormonal balance and prevent
complications
b. surgery: removal of parathyroid glands
- parathyroidectomy
Nursing interventions
a.care of the client undergoing surgery
b.after surgery observe for signs of
hypocalcemia
c.after surgery, teach client to consume diet
rich in calcium
d.After parathyroidectomy
1. Check frequently for respiratory
distress and keep a tracheotomy tray at
the bedside; watch for postoperative
complications, such as laryngeal edema
or, rarely, hemorrhage
2. Monitor intake and output
3. Check for swelling at the postoperative
site; place the patient in semi-Fowler’s
position, and support his head and neck
with sandbags to decrease edema, which
may cause pressure on the trachea.
4. Watch for signs of mild tetany such as
complaints of tingling in the hands and
around the mouth; these symptoms should
subside quickly but may be prodromal
signs of tetany, so keep calcium gluconate
or calcium chloride I.V. available for
emergency administration.
Disorders of the Adrenal
Gland
Disorders of the Adrenal Gland
A. Addison's disease
1. Definition
a. adrenal cortex secretes too little
adrenocorticotropic hormone
(ACTH)
b. decreases secretion of other
adrenal products:
mineralocorticoid, glucocorticoids,
and sex hormones
c. relatively rare
2. Etiology - autoimmune adrenalitis
3. Findings
a. acute adrenal insufficiency
(Addisonian crisis)
i. severe headache or back pain
ii. severe generalized muscle
weakness
iii. diarrhea or constipation
iv. confusion
v. lethargy
vi. severe hypotension
vii. circulatory collapse
b. adrenal insufficiency
i. vague complaints or findings
ii. fatigue
iii. muscle weakness
iv. vague abdominal complaints:
anorexia, nausea, vomiting
v. personality changes
vi. skin pigmentation darkens
Diagnostics
a. history and physical exam
b. ACTH stimulation test: low cortisol level
c. low blood levels of sodium and glucose
and high levels of potassium
d. 24-hour urine collection: decreased
levels of free cortisol
Management
Pharmacologic Interventions for Adrenal
Insufficiency
1. Glucocorticoids
2. Betamethasone (CELESTONE)
3. Cortisone (CORTONE)
4. Dexamethasone (DECADRON)
5. Hydrocortisone
6. Methylprednisone (MEDROL)
7. Prednisolone (DELTA-CORTEF)
8. Prednisone (DELTASONE tablets,
liquid)
9. Mineralocorticoids
10.Desoxycorticosterone (DOCA
PERCORTEN)
11.Fludrocortisone (FLORINEF)
 a. expected outcome: to return to hormonal
balance
 b. Addisonian crisis
i. emergency management of circulatory
collapse
ii. intravenous hydrocortisone
 c. chronic insufficiency
i. glucocorticoid replacement therapy:
hydrocortisone (cortef)
ii. mineralocorticoid replacement therapy:
fludrocortisone acetate (florinef acetate)
iii. diet high in protein, carbohydrates, and
sodium
Nursing interventions during
hospitalization
a. administer medications as ordered
b. manipulate the environment to reduce
stressors
c. preserve the client's energy by
assisting with ADL as indicated
d. monitor diet therapy
e. measure intake and output and
observe for signs of hyponatremia,
hyperkalemia, and hypoglycemia.
A. Cushing's syndrome
1. Definition: adrenal gland secretes too
much cortisol
2. Etiology
a. average age of onset 20 to 40
years of age
b. affects women more often than
men
c. primary syndrome caused by
tumor of adrenal cortex
d. secondary syndrome caused by an
ACTH-producing tumor of pituitary
e. long term steroid therapy
3. Findings
a. personality changes
b. hypertension
c. metabolic alkalosis
d. weight gain, buffalo hump, truncal
obesity
e. change in libido
f. moon face
g. muscle weakness
h. virilization in women, amenorrhea, or
menstrual irregularities
i. osteoporosis
j. acne or hyperpigmentation
Diagnostics
a. history and physical exam
b. blood tests show
i. increased levels of cortisol,
ii. increased sodium and glucose,
iii. decreased potassium
c. 24-hour urine collection:
i. elevated free cortisol
ii. elevated 17-ketosteroids
iii. elevated 17-hydroxycorticosterone
Management
a. expected outcome: to restore hormonal
balance
b. surgery for adrenal or pituitary tumor
c. irradiation therapy
d. pharmacologic
e. adrenal enzyme inhibitors that block
enzymes needed for cortisol synthesis
i. aminogluthemide
ii. metyrapone
iii. mitotane
f. potassium supplements
g. high protein diet with sodium restriction
Nursing interventions
a. administer medications as ordered
b. monitor diet therapy
c. monitor for signs of hypokalemia,
hypernatremia
d. teach client
 CARE OF CLIENT ON STEROID THERAPY
 Teach client to:
 1. Never discontinue medications abruptly-
could precipitate acute crisis.
 2. Take medication with breakfast -
corresponds to biorhythms and reduces gastric
irritation.
 3. Take higher dose in AM and lower doses in
PM.
 4. Always take medication with a meal or a
snack.
 5. Carry extra medication on self during travel.
 6. Adjust medications during periods of acute or
chronic stress such as pregnancy or infections;
contact health care provider.
 7. Wear medical identification jewelry or carry
medical card .
 8. Avoid other people with infections or
shopping malls, grocery stores, etc in times
when the flu or colds are most evident.
 i. the need for lifelong treatment
 ii. about medications and side effects
 iii. the need for medical alert jewelry
 iv. body changes may reverse but may take
months to years
 e. surgical treatment may cause adrenal or
pituitary insufficiency
Pheochromocytoma
1. Definition
Adrenal medulla secretes too much
epinephrine and norepinephrine (called
the catecholamines). Causes excessive
stimulation of the sympathetic nervous
system
2. Etiology
a. generally benign tumor of the
adrenal medulla
b. curable, but fatal if untreated
3. Findings
a. severe stress response
b. panic metabolic state
c. hypertensive crisis
d. headache, usually severe
e. orthostatic hypotension
f. tachycardia
g. pallor or flushing
h. diaphoresis
i. palpitations
j. anxiety, high and sustained
k. hyperglycemia
l. dysrhythmias
 Diagnostics
a. increased BMR
b. computerized tomogram (CT) scan
c. 24-hour urine collection: increased
urinary catecholamines
 Management
 a. expected outcomes: to remove the tumor
and correct the imbalance
 b. surgical removal of the tumor: scheduled
only after client has been normotensive for at
least one week
 c. antihypertensive agents as needed preop
 d. alpha-adrenergic blocking agent and beta
adrenergic blocking agent (beta blockers):
phentolamine (regitine), nitroprusside
(nitropress), propranolol (inderal)
 e. tyrosine inhibitors: alphamethylparatyrosine
decreases circulating catecholamines
 f. antidysrhythmic agents as needed preop
Nursing interventions
a. monitor vital signs, especially blood
pressure
b. administer medications as ordered
c. provide care of the client undergoing
surgery
d. if bilateral adrenalectomy performed,
lifelong steroid therapy required
e. teach client
i. about medications and side
effects
ii. need for lifelong follow up
1. The nurse recognizes that lowered
blood glucose stimulates the release of
which hormone from the pancreas?
A. Glycogen
B. Glucagon
C. Cortisol
D. Glucocorticoid
2. In evaluating a patient with suspected
diabetes mellitus (DM), which of the
following clinical manifestations is seen in
type I and not type II DM?
A. Hyperglycemia
B. Polydipsia
C. Polyuria
D. Weight loss
3. In monitoring a patient response to
insulin therapy, the nurse correlates which
clinical manifestations to hypoglycemia?
A. Diaphoresis and hunger
B. Increased urine output and thirst
C. Dry, flushed skin and confusion
D. Hyperventilation and tachycardia
4. The nurse correlates which clinical
manifestations with the diagnosis of
hyperthyroidism?
A. Fatigue, weight gain, cold intolerance
B. Decreased pulse rate, slurred speech,
anorexia
C. Abdominal pain, constipation, heat
intolerance
D. Nervousness, weight loss, tachycardia
5. The nurse monitors for which of the
following as indicative of effective
treatment of hyperthyroidism?
A. Elevated body temperature
B. Weight loss
C. Decreasing heart rate
D. Increasing blood glucose
6. The nurse monitors for which of the
following as indicative of effective
treatment of hypothyroidism?
A. Decreased sweating
B. Weight gain
C. Decreasing heart rate
D. Increasing energy level
7. Which finding in the client receiving
treatment for hypoparathyroidism indicates
the need for further evaluation?
A. Increasing serum calcium
B. Muscle weakness
C. Circumoral numbness
D. Constipation
8. A client receiving propylthiouracil should
be instructed to stop the medication
immediately and call the health care
provider if which sign occurs?
 A. Diarrhea
 B. Palpitations
 C. Fever
 D. Weight gain
9. In assessing parathyroid function, the
nurse monitors which laboratory value?

A. Calcium
B. Magnesium
C. Sodium
D. Potassium
10. Which statement about analgesic
therapy for a client with hypothyroidism
would be appropriate to use as a basis for
developing the client’s plan?
 A. Increase dosage will be needed
because the client is overweight.
 B. Analgesics are not needed because
the client already is lethargic.
 C. Decreased dosages are needed
because of prolonged drug degradation
rates.
 D. Increased dosages will be needed
because of the hypermetabolic state.
11. Which client behavior would support
the nursing diagnosis deficient knowledge
for the client with insulin-dependent
diabetes mellitus?
 A. Recent weight gain of 15lb
 B. Failure to monitor blood glucose
level
 C. Skipping insulin doses when feeling
ill
 D. Crying whenever diabetes is
mentioned
12. Which outcome represents the best
indicator of good overall diabetes control?
 A. The client reports urine glucose
levels indicating no glucosuria.
 B. The client displays a glycosylated
hemoglobin level within normal range.
 C. The client reports urine ketone
levels reflecting no ketonuria
 D. The client records home glucose
test results daily.
13. The results of blood glucose
monitoring for a client with diabetes who
takes regular and NPH insulin in the
morning and evening reveals that the
client is hyperglycemic before breakfast.
Which dose of insulin would the nurse
expect to be increased?
 A. Morning dose of regular insulin
 B. Evening dose of NPH insulin
 C. Morning dose of NPH insulin
 D. Evening dose of regular insulin
14. Signs of thyroid storm include all of the
following except:
 A. Bradycardia
 B. Delirium
 C. Dyspnea and chest pain
 D. Hyperpyrexia
15. A patient is diagnosed with type 1
diabetes. The nurse knows that all of the
are probable clinical characteristics
except:
 A. Ketosis-prone
 B. Little or endogenous insulin
 C. Obesity at diagnosis
 D. Younger than 30 years of age.
16. The most sensitive test for diabetes
mellitus is the:
 A. Fasting plasma glucose
 B. Glycosylated hemoglobin
 C. Oral glucose tolerance test
 D. Urine glucose
17. The nurse is asked to assess a patient
for glucosuria. The nurse would secure a
specimen of:
 A. Blood
 B. Sputum
 C. Stool
 D. Urine
18. The nurse should expect that insulin
therapy will be temporarily substituted for
oral antidiabetic therapy if the diabetic:
 A. develops an infection with fever
 B. Suffers trauma
 C. Undergoes major surgery
 D. Develops any of the above condition
ENDS