NCLEX: Caring for the Client with Disorders of the Endocrine System

Terms you’ll need to understand:
Acromegaly
Chvostek’s sign
Corticosteroids
Cretinism
Cushing’s syndrome
Dwarfism
Endocrine
Exophthalmoses
Glucocorticoids
Goiter
Grave’s disease
Hashimoto’s disease
Hormones
Myxedema
Syndrome of inappropriate antidiuretic hormone (SIADH)
Thyroid-stimulating hormone (TSH)
Thyroid storm
Transpenoidal hypophysectomy
Trousseau’s sign

Pituitary Disorders
The pituitary gland is responsible for secreting a number of hormones that regulate many bodily processes, including growth, reproduction, and metabolic activity.
Hormones secreted by the anterior lobe are
- Growth hormone—Regulates cell division and protein synthesis
- Adrenocorticotropic hormone—Regulates functions of the adrenal cortex
- Thyrotrophic hormone—Regulates functional activity of the thyroid
- Gonadotrophic hormones—Stimulate development of ovarian follicles in females and spermatogenesis in males

Tumors of the Pituitary
Tumors of the pituitary tend to be benign, but due to their location they can be fatal. Depending on the area of the tumor, several problems can arise.
Elevations in prolactin inhibit the secretion of gonadal steroids and gonadotropins in men and women, resulting in galactorrhea, amenorrhea, and infertility. Overproduction of growth hormone results in gigantism or acromegaly. If the disorder is noted prior to puberty, a diagnosis of gigantism is made. If the disorder occurs in the adult, it is known as acromegaly. Because growth hormone is an insulin antagonist, hyperglycemia can also occur.
Symptoms associated with pituitary tumors include
- Diminished vision due to pressure on the optic chiasm
- Headache and a feeling of 'fullness' in the head
- Amenorrhea
- Sterility
- Increased growth plates
- Skeletal thickness
- Hypertrophy of the skin
- Enlargement of the visceral organs, such as the heart and liver

Management of the client with a pituitary tumor involves
- Surgery using a transphenoidal approach
- Radiation
- Chemotherapy
- Parlodel, Dostinex
A client with transspenoidal surgery has no incision. The tumor is located by passing an instrument through the nose and the sphenoid sinuses to locate the tumor and remove it. The clients return from surgery with nose packings. Assessment of the airway is the nurse’s priority.

Thyroid Disorders
The thyroid is located below the larynx and anterior to the trachea. The thyroid gland produces two iodine-dependent hormones (thyroxin and thyroid stimulating hormone) that regulate the metabolic processes controlling the rate of growth, oxygen consumption, contractility of the heart, and calcium absorption.

Hypothyroidism
Hypothyroidism is causes by a deficiency of thyroid hormone. In the adult this is called myxedema, and in the infant it is called cretinism.
Signs and symptoms of hypothyroidism in the adult are as follows:
- Fatigue and lethargy
- Decreased body temperature
- Decreased pulse rate
- Decreased blood pressure
- Weight gain
- Edema of hands and feet
- Hair loss
- Thickening of the skin

Signs and Symptoms of Hypothyroidism in the Infant
As mentioned previously, hypothyroidism in an infant is called cretinism. The following list gives you the signs and symptoms of cretinism:
- Decreased respirations
- Changes in skin color (jaundice or cyanosis)
- Poor feeding
- Hoarse cry
- Mental retardation in those not detected or improperly treated

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

Managing Hypothyroidism
Management of the client with hypothyroidism includes the replacement of thyroid hormone, usually in the form of synthetic thyroid hormone
(Synthroid). The client’s history should include other drugs the client is taking. Prior to administering thyroid medications, the pulse rate should be evaluated. If the pulse rate is above 100 in the adult or above 120 in the infant, the physician should be notified. The client requires a warm environment and high fiber diet to prevent constipation.

Hyperthyroidism
Hyperthyroidism, or Graves’ disease, results from an increased production of thyroid hormone. The most common cause of hyperthyroidism is hyperplasia of the thyroid, commonly referred to as a goiter. Signs and symptoms of hyperthyroidism include
- Increased heart rate and pulse pressure
- Tremors, or nervousness
- Moist skin and sweating
- Increased activity
- Insomnia
- Atrial fibrillation
- Increased appetite and weight loss
- Exopthalmos

A thyroid storm is an abrupt onset of the symptoms of hyperthyroid. These symptoms result from inadequate treatment, trauma, infection, surgery, embolus, diabetic acidosis, emotional upset, or toxemia of pregnancy. This collection of symptoms represent a medical emergency that requires immediate intervention.

Diagnosis of hyperthyroidism involves the evaluation of T3 and T4 levels and a thyroid scan with or without contrast media. These thyroid function studies tell the physician if the client has an adequate amount of circulating thyroid hormone. A thyroid scan can clarify the presence of an enlargement of tumor of the thyroid gland.
Management of the client with hyperthyroidism includes
- The use of antithyroid drugs (prophythiouracil or tapazole)
- Radioactive iodine, which can be used to test and to destroy portions of the gland
- Surgical removal of a portion of the gland

Prior to thyroid surgery, the client is given Lugol’s solution—an iodine preparation—to decrease the vascularity of the gland. Post-operatively the client should be carefully assessed for the following:
- Edema and swelling of the airway (the surgical incision is located at the base of the neck anterior to the trachea)
- Bleeding (check for bleeding behind the neck)
- Tetany, nervousness, and irritability (complications resulting from dam- age to the parathyroid)
Since the thyroid is located anterior to the trachea any surgery in this area may result in swelling of the trachea. For this reason it is imperitive that the nurses be prepared for laryngeal swelling and occlusion of the airway. The nurse should keep a tracheostomy set at the bedside and call the doctor if the client has changes in his voice or signs of laryngeal stridor. The nurse should instruct the client to keep the head and neck as straight as possible and to support the neck when getting out of bed.

Parathyroid Disorders
The parathyroid glands are four small glands located on the thyroid gland.
The primary function of the parathyroid glands is the regulation of calcium and phosphorus metabolism. Diagnosis of parathyroid disorders is based on an evaluation of serum calcium and serum phosphorus levels and 24-hour urine levels of calcium and phosphorus. Radioimmunoassay exams are used to check serum parathormone. Potential disorders of these glands include hypoparathyroidism and hyperparathyroidism.

Hypoparathyroidism
Hypoparathyroidism is an inadequate production of parathormone. This hormone is responsible for the regulation of calcium and phosphorus levels in the blood. Calcium and phosphorus levels must be maintained within normal limits in order to have adequate nerve function. Bone density is also maintained by the parathormone. Signs and symptoms of hypoparathyroidism include the following:
- Decreased blood calcium
- Increased blood phosphorus
- Neuromuscular hyperexcitability
- Carpopedal spasms
- Urinary frequency
- Mood changes (depression)
- Dry, scaly skin and thin hair
- Cataracts
- Changes in teeth (cavities)
- Seizures
- Changes in EKG (prolonged QT intervals and inverted T waves)

Management of the client with hypoparathyroidism involves the administration of IV calcium gluconate and long-term use of calcium salts. Vitamin D supplements can be given to increase the absorption of calcium preparations as well as calcium in the diet.

Hyperparathyroidism
Hyperparathyroidism is the direct opposite of hypoparathyroidism. In this disorder, you find an overproduction of parathormone. Signs and symptoms of hyperparathyroidism include
- Decreased blood phosphorus
- Increased blood calcium
- Muscle weakness
- Osteoporosis
- Bone pain and pathological fractures
- Increased urinary output and renal calculi
- Nausea and vomiting
- Changes in EKG (shortened QT interval and signs of heart block. Heart block involves an alteration in the conduction system of the heart. In third and fourth degree heart block there is an alteration in the heart’s ability to transmit electrical impulses from the sinus node located in the right atria to the ventricle. This interference in the conduction system may cause a prolonged p-r interval and possibly deletion of atrial contractions.

Managing a client with hyperparathyroidism is accomplished by the removal of the parathyroid. Pre-operative management involves the reduction of calcium levels. Post-operative management includes
- Assessment of the client for respiratory distress
- Maintaining suction, oxygen, and a tracheostomy set at bedside
- Checking for bleeding (1–5 cc’s is normal)
- Checking the serum calcium level and serum phosphorus
- Checking Trousseau’s sign, which is carpopedal spasms (noted when the blood pressure cuff is inflated on the arm) or checking the Chvostek’s sign (noted when the facial nerve is tapped with the nurse’s index finger and twitching of the facial muscles is observed)
Here’s a way to remember that the facial nerve is cranial nerve 7: Place your hand on the cheek bone and move your finger out toward the ear and down the jaw line.
You will note that you have formed the number seven.

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

Adrenal Gland Disorders
Adrenal gland disorders result from insufficient production of cortisol or overproduction of cortisol. Two adrenal gland disorders include adrenocortical insufficiency (Addison’s disease) and adrenocortical hypersecretion (Cushing’s disease).

Adrenocortical Insuffiency (Addison’s Disease)
Addison’s disease can occur as a result of long-term use of steroids or the rapid cessation of corticosteroids. It may also be caused by sepsis, surgical stress, or hemorrhage of the adrenal glands (Waterhouse-Friderichsen Syndrome).

Signs and symptoms associated with Addison’s disease include
- Weakness
- Bronze-like pigmentation of the skin
- Decreased glucose levels
- Decreased blood pressure
- Anorexia
- Sparse axillary hair
- Urinary frequency
- Depression
- Addisonian Crises (The symptoms of Addisonian Crises are severe hypotension, cyanosis, and shock. This constitutes an emergency situation. The nurse should call the doctor immediately to obtain orders for medications to treat shock.)
Diagnosis of Addison’s disease involves an evaluation of serum sodium and chloride levels. Evaluation of ketosteroid and 17-hydroxycorticoids is also done. Adrenal function is evaluated by administering adrenocorticoid stimulating hormone (ACTH) and checking for changes in cortisol levels.
Management of the client with Addison’s disease includes the use of intravenous cortisone and plasma expanders to achieve and maintain the blood pressure. Once stable, the client can be given intramuscular cortisol in the form of dexamethasone (Decadron) or orally in the form of prednisolone
(Prednisone). The client with Addison’s disease requires life-long maintenance with cortisone. The client should be instructed to take the medication exactly as prescribed and to avoid sudden cessation of the drug.

Adrenocortical Hypersecretion (Cushing’s Disease)
Cushing’s disease can result from prolonged administration of cortisone or due to hypersecretion of the adrenal cortex. Signs and symptoms associated with Cushing’s disease include
- Pendulous abdomen
- Buffalo hump
- Moon faces
- Hirsutism (facial hair)
- Ruddy complexion (dark red)
- Increased BP
- Hyperglycemia
- Osteoporosis
- Decreased serum potassium and decreased serum chloride
- Increased 17-hydroxycorticoids
- Decreased eosinophils and decreased lymphocytes

Management of the client with Cushing’s disease is accomplished by removing part of the adrenal gland or by decreasing the dosage of steroid medication the client is receiving.

Diabetes Mellitus
Diabetes mellitus is a chronic disorder of carbohydrate metabolism, marked by hyperglycemia and glycosuria resulting in the inadequate production or use of insulin. Diabetes mellitus is believed to be multifactoral in nature (genetic, autoimmune, or insulin resistance). Signs and symptoms associated with it include
- Weight loss—Insulin is required for carbohydrates to be converted into useable glucose; a lack of insulin results in a lack of glucose with cellular starvation.
- Ketonuria—The breakdown of fats leads to the production of ketones that causes characteristic fruity breath.
- Polyphagia—Cellular starvation causes the diabetic to increase food consumption.
- Polyuria—The kidneys attempt to regulate pH by increasing urinary output of ketones and glucose.
- Polydipsia—The loss of large amounts of fluid leads to metabolic acido- sis and dehydration. To compensate for the fluid loss, the client drinks large amounts of water.
- Delayed wound healing—Increased blood sugar contributes to poor wound healing.
- Elevated blood glucose—Normal is 70–110 mg/dl.
Uncorrected or improperly managed diabetes mellitus leads to coma and death.

Diagnosis of diabetes mellitus is made by checking blood glucose levels.
There are several diagnostic test that can be performed to determine the presence and extent of diabetes. The following are diagnostic test done for determining if the client has diabetes.
- Glucose tolerance test.
- Fasting blood glucose levels.
- Two-hour post-prandial.
- Dextrostix.
- Hemoglobin A-1C or glycosylated hemoglobin (the normal range is 4%–6%). This test indicates compliance with the client’s diet and medication regimen for the past 90–120 days.
- Urine checks for glucose (ketouria occurs if blood glucose levels exceed 240 mg/dl).

Management of the client with diabetes mellitus includes the following:
- Diet—The diet should contain a proper balance of carbohydrates, fats, and proteins.
- Exercise—The client should follow a regular exercise program. He should not exercise if his blood glucose is above 240 mg/dl. He should wait until his blood glucose level returns to normal.
- Medications—Oral antidiabetic agents or insulin.
Because regular insulin peaks in 90–120 minutes and NPH insulin peaks in 8–12 hours, the nurse should instruct the client to draw up the regular insulin (clear) and then draw up the NPH insulin. This prevents contaminating the regular insulin with the NPH insulin.

Because Lantus insulin is released slowly over an extended time, it should not be mixed in the same syringe with any other insulin. This would cause a client to experience a hypoglycemic reaction.

It is very important that the nurse be aware of the signs of hyperglycemia to teach the client and family. Signs and symptoms of hyperglycemia are
- Headache
- Nausea/vomiting
- Coma
- Flushed, dry skin
- Glucose and acetone in urine

The following statements are a couple of helpful hints for dealing with diabetes mellitus clients:
- Hot and dry; blood sugar high—This means that, if the diabetic’s skin is hot and he is dehydrated, his blood glucose level is likely high.
- Cold and clammy; need some candy—This means that, if the diabetic’s skin is cold and clammy, his blood glucose level is low and he needs a glucose source.

Signs and symptoms of hypoglycemia are
- Headache
- Irritability
- Disorientation
- Nausea/vomiting
- Diaphoresis
- Pallor
- Weakness
- Convulsions
- Coma
- Death
If the client fails to eat her regular bedtime snack, she might experience Somogyi effect. This abrupt drop in the client’s blood glucose level during the night is followed by a false elevation. The treatment of Somogyi effect is to teach the client to eat a bedtime snack consisting of a protein source, such as peanut butter and a glass of milk.

Management of hypoglycemia includes giving glucose. Glucagon is an injectable form of glucose given in emergency. Cake icing, orange juice, or a similar carbohydrate can be administered. The best bedtime snack is milk and a protein source, such as peanut butter and crackers.

Diagnostic Tests for Review
The following are diagnostic test you should review. These test require the collection of a blood sample to determine the glucose level:
- Glucose tolerance test—The glucose tolerance test is the most diag- nostic test for determining whether the client has diabetes. A highcarbohydrate diet is eaten prior to the exam. The client is told to remain
NPO after midnight the day of the test and to come to the clinic for a blood sample to be collected. After a fasting blood sample is obtained, the client is told to drink a liquid containing 75 gm of glucose. A sample of blood is then collected 1 hour after the glucose is administered. Some physicians also obtain blood samples at 2 hours or more.
- Fasting blood glucose—A fasting blood glucose is an excellent method of determining an accurate estimate of the glucose level. It is obtained by asking the client to refrain from eating after midnight and coming to the clinic for a blood sample.
- Dextrostix—A glucose test that requires a sample of blood be collected, usually prior to meals.
- Hgb A-1C or glycosylated hemoglobin—A blood test done to deter- mine the client’s compliance to his diet and medication regimen. It is obtained by a collection of a blood sample.


Pharmacology Categories for Review
Several drug categories are used in the care of the client with disorders of the endocrine system. The following list highlights the drug categories you should be familiar with:
- Antidiabetics
- Calcium supplements
- Glucocorticoids
- Insulin
- Mineralcorticoids
- Plasma expanders
- Synthetic thyroid hormone