Chapter 79:
Endocrine Disorders
Danielle Watson, MBA, MSN, RN
The Endocrine System
• Endocrine system
– Regulates nearly all body processes
• Endocrine glands
– Groups of cells that produce chemical substances
called hormones
• Endocrine disorders
– Caused by overproduction or underproduction of
specific hormones
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Major Endocrine Glands
• Anterior pituitary
• Posterior pituitary
• Thyroid
• Parathyroids
• Adrenal medulla
• Adrenal cortex
• Pancreatic islets
• Testes
• Ovaries
• Page 1383- The Major Endocrine Glands and Their
Hormones- GET FAMILIAR WITH THIS, THIS IS NORMAL,
then learn abnormal
• Page 1384- Tests of Thyroid function
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Location of the Endocrine Glands in the
Female and Male Body
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Diagnostic Tests
• Disorders of the endocrine system related to either the
excess or deficiency of a hormone.
• Many tests are blood, urine, or saliva.
• Stimulation tests involve giving hormone to stimulate the
target gland to determine if the gland is capable of normal
hormone production.
• Suppression testing involves giving a medication to evaluate
the body’s ability to suppress excessive hormone
production.
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Diagnostic Tests
• Water deprivation test deprives the client of fluids and
measures the kidney’s ability to concentrate urine in light
of an increased plasma osmolality and a low blood ADH
level. It requires a controlled setting with careful
observation of the client.
Helpful to identify causes of polyuria including diabetes
insipidus.
NPO after midnight or at the start of the test. Fluids can be
withheld for 8-12 hours. WEIGHT MEASURED HOURLY.
Monitor for postural hypotension resulting from
dehydration. Measure the clients osmolality every hour, if
greater than 280 a dose of ADH (vasopressin) given subQ.
Post procedure assist with rehydration.
Review Chapter 68 in ATI- Endocrine Diagnostic Procedures
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Pituitary Gland Disorders
• AKA the “master gland” due to it’s regulation of many bodily
functions. Located at the base of the skull underneath the
hypothalamus.
Divided into two lobes
• Disorders of the anterior lobe ( 6 hormones: TSH, ACTH, LH,
FSH, Prolactin, GH)
– Gigantism and acromegaly
• Disorders of the posterior lobe (2 hormones: Antidiuretic
hormone ADH, Oxytocin)
– Syndrome of inappropriate antidiuretic hormone
(SIADH)
– Diabetes insipidus
– Pituitary neoplasms
– Hypophysectomy
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Acromegaly
Characterized by an overproduction of the growth
hormone. INCREASES size of body parts but not height.
Manifestations: overgrowth of skin, bones of forehead, jaw,
feet, hands, and enlargement of organs (LIVER-HEART)
Expected Findings: severe headaches, thick lips, muscle
weakness, enlarged hands/feet, hyperglycemia, sweating,
hypertension
Lab Tests: Growth hormone suppression test glucose
administered and growth hormone level measured.
EXPECTED is for GH to be suppressed, however, with
Acromegaly will only show slight decrease or no decreased
at all.
Diagnostic procedures: Xray, CT Scan, MRI
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Acromegaly Continued
Nursing Care: Emotional support, medication regimen enforcement.
Medications: Dopamine agonists ( bromocriptine, cabergoline) inhibit the
release of GH
Somatostatin analogs (octreotide, lanreotide) inhibit GH release.
Growth hormone receptor blocker (pegvisomant) prevents GH receptor
activity and blocks production of insulin-like growth factor
Therapeutic Procedures: Hypophysectomy (removal of pituitary gland
Right: Coarse facial features typical of acromegaly. Left: Patient’s face several
years before she developed the pituitary tumor.
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Diabetes Insipidus
• Results from a deficiency of ADH
• Expected Findings: POLYURIA ( excessive urination 520L/day of DILUTE URINE); POLYDIPSIA ( excessive thirst
consumption of 2-20 L/day)
Tachycardia, hypotension, loss of skin turgor, dry mucous
membranes, weak pulses, decreased cognition, constipation, weight
loss, weakness, nocturia. THIRSTY
Lab Tests: DILUTE Decreased
Decreased urine specific gravity below 1.006, urine osmolality,
decreased urine pH, decreased urine sodium, decreased
potassium,
Blood Testing: CONCENTRATED
Increased blood osmolality(greater than 300); increased sodium,
potassium
Diagnostic procedures: water deprivation test (ADH stimulation test)
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Diabetes Insipidus
Nsg Care: Monitor vitals, I&O, lab work, daily weight, LIMIT
CAFEINE due to diuretic effects, high fiber diet due to
constipation, monitor for signs and symptoms of
dehydration, restrict fluids as ordered to prevent
overhydration, MONITOR fluid and electrolytes
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Syndrome of Inappropriate Antidiuretic
Hormone
SIADH excessive release of ADH AKA vasopressin
leads to HYPONATREMIA.
Expected Findings: headache, weakness, anorexia, weight
gain (WITHOUT EDEMA), confusion, lethargy, seizures,
coma, death leads to personality changes aggression.
Lab Tests: Urine CONCENTRATED increased sodium,
specific gravity,
Blood Tests: DILUTE decreased blood sodium, blood
osmolarity ( LESS THAN 270)
Nsg Care: oral fluid restriction (500-1000ml/day) to
prevent further hemodilution; STRICT I&O; vitals, safety
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Question
Is the following statement true or false?
Diabetes insipidus is a disease that results from
overproduction of the antidiuretic hormone.
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Answer
False
Diabetes insipidus is a disease that results from
underproduction of antidiuretic hormone (ADH or
vasopressin).
Primary nephrogenic insipidus is caused by kidney
dysfunction due to a deficiency in ADH or to a lesion in
the midbrain.
Secondary central diabetes insipidus results from a
tumor in the gland itself or pressure in the pituitary area
from head trauma, infection, or other tumors.
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Thyroid Gland Disorders
• Hyperthyroidism
– Overproduction of T4, increase in metabolic rate
– Graves disease or exophthalmic or toxic diffuse
goiter
• Hypothyroidism
– Deficiency of T4, decrease in metabolic rate
– Congenital hypothyroidism, myxedema
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Hyperthyroidism
- FAST
Expected Findings: Nervousness, irritability, change in mental status, frequent
mood changes, weakness, heat intolerance, weight change (LOSS), insomnia,
increased appetite, diarrhea, tremors, tachycardia, EXOPHTHALMOS (Grave’s
Disease) Page 560 ATI; Page 1388 in Roshdahl.
Lab Tests: TSH, t4, t3 elevated
*TSH is decreased in the presence of Grave’s disease
Diagnostic Procedures: ultrasound assess
Thyroid scan size and function of gland; radioactive isotope administered orally
6-24 hours before the exam.
Nsg Care: Assist with ADL’s as needed to promote rest, Monitor I&O; provide eye
protection, administer medications as ordered
Medications: Thionamides: methimazole, prophylthiouracil inhibit the
production of thyroid hormone. Take at the same time everyday; monitor CBC
Beta adrenergic blockers: OLOL’s given to treat tachycardia/palpitations.
Monitor HR
Iodine solutions inhibits the release of thyroid hormone
Therapeutic procedures: radioactive iodine therapy
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Hyperthyroidism
Thyroidectomy: surgical removal of all or part of the thyroid
gland pg.562
Semi Fowlers position (reduces swelling); Support the airway,
assist with deep breathing, monitor for bleeding Pooling; keep
trach supplies at bedside, pain management, monitor for
infection, monitor for HYPOCALCEMIA and tetany muscle
spasms (Chvostek’s and Trousseau’s signs) {Page 1378 in
Roshdahl }
Monitor for thyroid crisis sudden surge of large amounts of
hormones into the blood stream. MEDICAL EMERGENCY! NSG:
assist with transport to ICU, MAINTAIN AIRWAY, decrease
temperature.
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Hypothyroidism
--SLOW!
Inadequate amount of circulating thyroid hormones (t3 and t4). Can
decline slowly or rapidly (myxedema)
Manifestations can mimic the aging process- often undiagnosed in older
adult clients.
Expected Findings: Fatigue, lethargy, intolerance to cold, constipation,
thick and brittle finger nails, dry skin, weight gain without an
increase in caloric intake, bradycardia, hypotension, swelling of
the face, hands, feet, hoarseness of the voice, decreased libido,
abnormal menstrual periods
Lab Tests: TSH (pg 567 , t3, t4 decreased
Diagnostic Procedures: Thyroid scan Assess
Nsg Care: Treat symptoms (ex: increased fiber r/t constipation;
lotion r/t dry skin ETC), medication management, continuous
assessment and monitoring; keep client WARM
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Hypothyroidism
Medications: Review Chapter 35 in ATI Pharmacology
Levothyroxine: Most common administered. Synthetic hormone
replacement. FIBER LAXATIVES & CALCIUM/IRON AFFECTS
ABSORPTION. TSH must be monitored for therapeutic effect.
Take on empty stomach! Do not stop abruptly. Lifelong
treatment. Take once daily first thing in the morning to prevent
insomnia. Tremors, nervousness, and insomnia may indicate the
dose is too high.
Complication: Myxedema Coma life threatening from
hypothyroidism being untreated or a stressor affects the disease
process (surgery, trauma, medications etc)
Manifestations: Respiratory failure, hypotension, bradycardia,
hypoglycemia, hyponatremia, coma
Nursing Actions: I&O monitoring weights, keep client warm,
treat symptoms, monitor for infection
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Question
Is the following statement true or false?
A nurse should ensure that following a thyroidectomy, an
endotracheal tube is available in the client’s room.
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Answer
True
The nurse should ensure that an endotracheal tube is
available in the client’s room, both preoperatively and
postoperatively, because swelling may obstruct the
airway, causing respiratory distress.
In this event, an endotracheal tube is inserted, and the
client is taken to the operating room for tracheostomy.
Internal hemorrhage and edema following
thyroidectomy are postoperative threats.
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Parathyroid Gland Disorders
• Hyperparathyroidism
– Excess of PTH that causes blood calcium
levels to rise, resulting in calcium depletion
in bones (osteomalacia); monitor safety
falls higher risk of fracture
• Hypoparathyroidism
– Deficiency of PTH from lowered production of
the hormone
– Consequent reduction in the amount of
calcium available to the body and an
accumulation of phosphorus in the blood
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Adrenal Gland Disorders
• Cushing syndrome over secretion
 Hypokalemia, hypernatremia, hyperglycemia
• Addison disease insufficiency
 Destruction or degeneration of the adrenal
cortex
 Addisonian crisis
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Cushing’s Disease/Syndrome
Cushing’s Disease endogenous causes of increased cortisol:
adrenal hyperplasia, carcinomas
Cushing’s Syndrome exogenous causes of increased cortisol:
use of glucocorticoids for organ transplant, chemotherapy,
asthma, allergies.
Expected Findings: weakness, fatigue, sleep disturbances,
depression, decreased libido, evidence of decreased immune
function, THIN SKIN, bruising or petechiae, purple striations,
hypertension, tachycardia, hypokalemia, Changes in fat
distribution MOON FACE, fat collection on the back, buffalo
hump; weight gain, hypertension, hyperpigmentation
Lab Tests: Elevated blood cortisol levels, increased glucose and
sodium; DECREASED POTASSIUM/CALCIUM.
Diagnostic Procedures: x-ray, MRI, CT scans to identify lesions of
the pituitary gland, lung, GI tract, pancreas.
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Cushing’s Disease Nursing Care
• Monitor I&O; daily weight
• Monitor for hypervolemia (EDEMA, SOB, DISTENDED NECK VEINS,
HTN, tachycardia)
• Safety, infection prevention, skin care
• Education r/t lifelong medication therapy
• Increase vitamin D and calcium; LOW SODIUM intake high
Potassium; low calorie
Medications: Ketoconazole: take w food, monitor liver enzymes,
Mitotane: reduces size of tumor; monitor renal and orthostatic
hypotension
Hydrocortisone: replacement therapy; often used with
ketoconazole; monitor K and glucose; DAILY WEIGHT
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Cushing’s Disease Continued
Therapeutic Procedures: Chemotherapy; hypophysectomy
(surgical removal of the pituitary gland); Adrenalectomy
(surgical removal of the adrenal gland);
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Addison’s Disease
Adrenal insufficiency
Expected Findings: weight loss, cravings for salt, hyperpigmentation of
the skin and mucous membranes, weakness, fatigue, severe
hypotension,tachycardia, dehydration, HYPONATREMIA, hyperkalemia,
hypoglycemia, hypercalcemia
Lab Tests: blood electrolytes, increased BUN/creatinine
Diagnostic Procedures: EKG-> detect cardiac abnormalites
Nsg Care: preventing shock, monitoring electrolytes (especially K+);
safety
Medications: glucocorticoids are used are adrenocorticoid replacement
and anti-inflammatory
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Question
Is the following statement true or false?
When caring for a client with Addison disease, the nurse
should increase the client’s water intake.
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Answer
False
Because this client is dehydrated, fluid replacement is
key, but because sodium loss results from previous
hormone imbalance, sodium also must be replaced in the
diet. Increased sodium will aid in fluid retention without
excess fluid intake. Water intake is thus restricted as
excess water overloads the system.
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Pancreatic Endocrine Disorders
Diabetes Mellitus
• Diabetes Mellitus is a metabolic disorder resulting from either an
inadequate production of insulin (TYPE 1) or an inability of the body’s
cells to respond to insulin that is present (TYPE 2)
• Type 1: autoimmune dysfunction involving the destruction of beta
cells which produce insulin in the pancreas.
• Type 2: progressive condition due to increasing ability of cells to
respond to insulin and decreased production of insulin by the beta
cells. Linked to obesity, lifestyle, heredity.
• Diabetic ketoacidosis (DKA) is an acute and lifethreatening condition
characterized by uncontrolled hyperglycemia (greater than 250),
metabolic acidosis, and an accumulation of ketones in the blood and
urine.
• Hyperglycemic hyperosmolar state (HHS) is an acute life threatening
condition characterized by profound hyperglycemia (greater than
600)
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Type 1 and Type 2 Diabetes Mellitus
Age of onset
Classic
symptoms
Hereditary
factors
Weight
Ketoacidosis
Usual
treatment
TYPE 1
TYPE 2
Under 30 years
Nearly always
present
Occasionally
present
Normal or
underweight
Susceptible
Over 30 years
Usually not present
Usually present
Usually overweight
Not susceptible
Insulin, meal plan, Meal plan, exercise,
exercise
oral medications, or
insulin
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Diabetes Mellitus
• Diabetes screening/Client Education: exercise and good nutrition are
necessary for preventing uncontrolled diabetes.
Expected Findings: 3 P’s
POLYURIA: excessive urine production
POLYDIPSIA: excessive thirst due to dehydration
POLYPHAGIA: excessive hunger and eating
Kussmaul respirations: increased respiratory rate and depth in attempt
to excrete carbon dioxide and acid due to metabolic acidosis
Recurrent infections yeast
Other: FRUITY breath, headache, nausea, vomiting abdominal pain,
fatigue, weakness, vision changes, slow wound healing, decreased LOC,
seizures
LAB TESTS: two findings on separate days of at least one of the
following: Manifestations of DM plus causal blood glucose greater than
200; fasting blood sugar greater than 126 (8 hour fast); 2 hour glucose
greater than 200 with oral glucose tolerance test; HBA1C greater than
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6.5%
Diabetes
• Fasting blood glucose nothing to eat or drink other than
water for 8 hours prior to test
• Oral glucose tolerance test fasting glucose (10-12 hour)
taken then glucose given and sugars are taken 1 and 2 hours
post administration. Should be less than 110, 180 at 1 hour
and 140 at 2 hour.
• HbA1C Expected reference range is 5.5-7% best indicator
of the average blood glucose level for the past 120 days.
EVALUATES TREATMENT EFFECTIVENESS AND COMPLIANCE.
• Self monitored blood glucose blood sugar collection via a
glucometer. Check the machine using control solution
provided, store strips in the closed container in a dry location,
infection prevention, keep record of readings. Use side of
finger as the testing site. Do not use ball of finger or dominant
hand or thumbs. Page 1399; Testing for blood glucose level
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Diabetes
• Medications: Review Pharmacology Review Module Chapter 34: DM
Insulin:
1.
Rapid acting insulin: Insulin Lispro, Insulin aspartRAPID ONSET
(10-30 mins) RIGHT BEFORE MEALS ie: when the meal arrives
2.
Short acting insulin: Regular insulin Administer 30-60 mins before
meals; used to treat diabetic ketoacidosis
3.
Intermediate-acting insulin: NPH insulinnot administered before
meals. Given between meals and at night. Peaks 4-14 hours post
admin
4.
Long Acting Insulin: Insulin glargine, insulin determir once or
twice daily at the same time everyday. No peak
5.
Ultra long acting insulin: U-300 insulin glargine duration longer
than 24 hours.
Nsg actions: monitor for signs of hypoglycemia, education regarding
administering and observe self demonstration, rotate injection sites,
inject at 90 degree angle (45 if client is thin); eat at regular intervals,
avoid alcohol, exercise, diet etc
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Diabetes
• When mixing a rapid or short acting insulin with a longer
acting insulin, draw up the shorter acting insulin into the
syringe first THEN the longer acting insulin. This reduces
the risk of introducing longer acting insulin into the
shorter acting vial.
• Oral antidiabetics: Page 490 ATI
1. Metformin take with meal
2. Glipizide stimulates pancreas to release insulin
3. Prandin
4. Acarbose
5. Sitagliptin
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Diabetes
Hypoglycemia Vs Hyperglycemia
ATI Page 587 75.2
Roshdahl Page 1403 79.5
• Hypoglycemia ( glucose to
• Hyperglycemia (insulin to
Cool clammy skin
Hot dry/moist skin
Confusion, nervousness
Fruity breath(acetone)
DKA
raise BS)
Sweating(diaphoresis)
Palpitations/ Shaky
Blurred vision
Tachycardia
Headache
reduce BS)
3 P’s
Rapid respirations
Diminished reflexes
Nausea/vomiting
Dizziness
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Diabetes
• Nursing Care: Monitor blood sugar, education regarding self
administering insulin.
• Education regarding foot care podiatrist should cut nails cut
straight across inspect feet DAILY, wash daily with warm water.
Test water with wrist or thermometer. Do not soak feet. Dry
thoroughly especially between toes. NO over the counter treatment
for toes, closed toe shoes, clean cotton socks. Page 1393 Image
Page 1409 Educating the client: Foot Care and Diabetes Mellitus
Pg 589 ATI
• Monitor blood sugar closely when ill- every 4 hours when sick or
every 2 hours when illness is severe. Extra insulin maybe
required.
• Monitor eyes due to risk of diabetic retinopathy. Yearly exams.
• Monitor safety due to diabetic neuropathy decreased sensory
resulting in numbness or pain
• Diabetic neuropathy damage to the kidneys from prolonged
elevated blood sugar. Monitor kidney function, I&O, BP
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 *Priority is to maintain
stable
blood
levels!
Injection Sites for Insulin
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Insulin Reminders
• Insulin injected into the abdomen is most rapidly
absorbed– then arms, thighs, and buttocks.
• Unopened vials of insulin should be stored in the
refrigerator.
• Roll vials in hands before drawing to ensure that it is
evenly suspended
• Page 587 in ATI for images.
• Page 591 Diabetic ketoacidosis vs. Hyperglycemic
hypermolar state
• Rosdahl Page 1399- Review of Insulins
• ATI Pharmacology book- Chapter 34
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Medications
1. Review ALL insulins. {Regular, Glargine, NPH, Detemir,
Lispro, Lantus etc.}
2. Glipizide
3. Metformin
4. Levothyroxine
5. Methimazole
6. Prophylthiouracil
7. Prandin
8. Propanolol
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End of Presentation
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