EndocrineThyroid, Pituitary, Adrenal

Nursing Care of the Adult I

Glands of the Endocrine System and the Human Body

• Hypothalamus• Anterior pituitary (hormones regulate growth,

metabolism & sexual development)• Posterior pituitary: (Hormones secrete vasopressin –

antidiuretic)• Adrenal cortex• Adrenal medulla• Thyroid• Pancreatice islet cells• Kidney• Ovaries• Testes

• Hypothalamus• Anterior pituitary (hormones regulate growth,

metabolism & sexual development)• Posterior pituitary: (Hormones secrete vasopressin –

antidiuretic)• Adrenal cortex• Adrenal medulla• Thyroid• Pancreatice islet cells• Kidney• Ovaries• Testes

Endocrine System

Hormones of the Endocrine Systems

• Ant. Pituitary: TSH, ACTH, FSH, PRL, GH, MSH

• Post. Pituitary: ADH, Oxytocin

• Thyroid: T₃, T₄, Calcitonin

• Adrenal Gland: Cortisol, aldosterone

• Pancreas: Insulin, glucagon, somatostatin

• Hypothalamus: CRH, TRH, GnRH, GHIH, MIH

Pituitary GlandWho is really in charge?

• Where is it located?• What is its main

function?• Is it really in charge?

Anterior Pituitary Gland• Controls the following hormones: • growth hormone (GH,

somatotropin), • thyrotropin (thyroid-stimulating

hormone [TSH],• corticotropin (adrenocorticotropic

hormone [ACTH], • follicle-stimulating hormone

[FSH], • luteinizing hormone [LH],• melanocyte-stimulating hormone

[MSH] and • prolactin [PRL]

Hypopituitarism

• Etiology• Clinical signs/symptoms• Complications• Nursing interventions• Nursing rationales

Hypopituitarism• Selective hypopituitarism: Disorder of pituitary gland

when only one hormone is affected.

• Panhypopitutarism: decreased production of all of the anterior pituitary hormones.

• Etiology------

• tumors [benign or malignant], malnutrition, rapid loss of body fat [anorexia nervosa], shock/hypotension, head trauma, infection, radiation, surgery of the head/brain, AIDS, Sheehan’s syndrome (resulting from postpartum hemorrhage).

Hypopituitarism: Complications

• Amenorrhea

• Hypothyroidism

• Hypotension

• Infertility

• Failure to develop during puberty

• Osteoporosis

• Short stature.• (http:www.freemed.com/hypopituitarism/complications.htm)

HypopituitarismClinical Manifestations - Anterior

Growth Hormone (GH) ---- • decreased bone density, pathologic fractures,

decreased muscle strength, increased serum cholesterol levels

Gonadotropins -- • Female: amenorrhea, anovulation, low estrogen levels,

breast atrophy, loss of bone density, decreased axillary and pubic hair, decreased libido.

• Male: decreased facial hair, decreased ejaculate volume, reduced muscle mass, loss of bone density, decreased body hair, decreased libido, impotence

HypopituitarismClinical Manifestations - Anterior

Thyroid Stimulating Hormone (TSH) ----- • decreased thyroid hormone levels, weight gain,

intolerance to cold, scalp alopecia, hirsutism, menstrual abnormalities, decreased libido, slowed cognition, lethargy

Adrenocorticotropic hormone (ACTH) --- • decreased serum cortisol levels, pale, sallow

complexion, malaise & lethargy, anorexia, postural hypotension, headache, hypoglycemia, hyponatremia, decreased axillary & pubic hair in women

Care of the patient with Hypopituitarism

• Assess for physical appearance changes (males - facial & hair loss, females: amenorrhea

• Assess for neurological changes/presentation

• Check lab values: Triiodothyroidine (T3) & Thyroxine (T4)

Medications

• Male: steroid replacement therapy with androgens (testosterone) [IM or patch]. Monitor for adverse side effects.

• Female: hormone replacement [estrogen & progesterone] therapy

Posterior Pituitary GlandHypofunction Diabetes Insipidus (DI)

• A water metabolism problem caused by deficiency of ADH (vasopressin) secreted by posterior lobe of pituitary gland

• Caused by brain surgery, head injury, meningitis.

Pathophysiology• Different types: nephrogenic DI, primary DI, drug related DI

Clinical manifestations• Hypotension, decreased pulse pressure, tachycardia, weak

peripheral pulses, hemoconcentration: elevated h/h & BUN• Increased urine o/p, dilute, low specific gravity• Poor skin tugor, dry mucous membranes• Increased sensation of thirst, irritability, decreased cognition,

hyperthermia, lethargy that leads to coma, ataxia.

Caring for the patient with DI• Medical management is the focus:– Desmopressin (DDAVP)– Vasopressin– Chlorpropamide

• Administration of medication & patient teaching most important aspect– Monitor for s/s dehydration– I&O’s– Fluids– Daily weights– Monitor s/s water intoxification

Hyperpituitarism

• Etiology• Clinical

signs/symptoms• Complications• Nursing

interventions• Nursing rationales

Hyperpituitarism

• Hormone over-secretion• Etiology--- tumors [pituitary adenoma /

hyperplasia (tissue growth] or genetics: multiple endocrine neoplasia genet, type I (Melmed & Kleinberg, 2008).

• Complications• Acromegaly• Cushing's disease

Clinical Manifestations

Prolactin Oversecretion

• Hypogonadism (loss of secondary sexual characteristics)

• Decreased gonadotropin levels

• Galactorrhea• Increased body fat• Increased serum

prolactin levels

Acromegaly (see next slide)• Folding of scalp skin• Thickened lips, coarse

facial features, increasing hand size, protrusion of the lower jaw

• Deepening of the voice, enlarged hands/feet, joint enlargement and pain, kyphosis and backache, barrel shaped chest

• Excessive sweating, airway narrowing, sleep apnea, enlarged heart, lungs & liver

Acromegaly

Clinical Manifestations

Thyrotropin Hormone (TSH)• Elevated plasma TSH levels

• Elevated plasma thyroid hormone levels

• Weight loss

• Tachycardia, Dysrhythmias

• Heat intolerance

• Increased GI motility

• Fine tremors

Gonadotropins (LH, FSH)

• Men: elevated LH & FSH levels

• Hypogonadism or hypergonadism

• Women: Normal LH & FSH levels

Nursing Diagnosisand Disorders of the “Pit” Gland

• Disturbed body image r/t illness/treatment

• Sexual dysfunction r/t loss of libido, infertility impotence

• Acute/chronic pain r/t compression of tumor

• Anxiety r/t threat or change in health status

• Disturbed sensory perception r/t altered sensory reception, transmission or integration

Surgical ManagementTranssphenoidal Hypophysectomy

• Pre-operative care:• Explain procedure.• Nasal packing/mouth breathing.

• Post-operative care:• Do not bend forward, brush teeth,

cough, sneeze, or blow nose. • Muscle graft from thigh• Check neuro status: mentation, vision, LOC, decreased

strength, check for transient diabetes insipidous, CSF leakage (halo sign), infection or IICP. Keep HOB.

• Check dressing, Keep HOB elevated, check for infection• Pt to avoid coughing early after surgery.

Syndrome of InappropriateAntidiuretic Hormones (SIADH)

• Schwartz-Bartter syndrome: A condition characterized by overproduction or oversecretion of ADH (ADH dysfunction).

• There is an abnormal production or sustained secretion of ADH resulting in fluid retention, serum hypoosmolarity, hyponatremia, hypochloremia, concentrated urine with normal intravascular volume and normal renal function.

• Thought to be the most common cause of hyponatremia in older adults.

• Schwartz-Bartter syndrome: A condition characterized by overproduction or oversecretion of ADH (ADH dysfunction).

• There is an abnormal production or sustained secretion of ADH resulting in fluid retention, serum hypoosmolarity, hyponatremia, hypochloremia, concentrated urine with normal intravascular volume and normal renal function.

• Thought to be the most common cause of hyponatremia in older adults.

SIADH Risk Factors• Small cell carcinoma• Pancreatic cancer• Lymphoid cancer• Head injury• Brain tumors• Infection (encephalitis, meningitis)• Drug therapy: carbamazepine, chlorpropamide, opioids, oxytocin,

thiazide diuretics, general anesthesia agents, tricyclic antidepressants, antineoplastic agents

• Hypothyroidism• Lung infection: pneumonia, TB, lung abscess• COPD• Positive pressure mechanical ventilation

• Small cell carcinoma• Pancreatic cancer• Lymphoid cancer• Head injury• Brain tumors• Infection (encephalitis, meningitis)• Drug therapy: carbamazepine, chlorpropamide, opioids, oxytocin,

thiazide diuretics, general anesthesia agents, tricyclic antidepressants, antineoplastic agents

• Hypothyroidism• Lung infection: pneumonia, TB, lung abscess• COPD• Positive pressure mechanical ventilation

SIADH Clinical Manifestations

• Thirst• Dyspnea on exertion• Fatigue• Dull sensorium• As hyponatremia worsens---- abdominal cramps,

NV, muscle cramping, decreased neurological function, seizures

• Decreased urinary o/p• Increased body weight

• Thirst• Dyspnea on exertion• Fatigue• Dull sensorium• As hyponatremia worsens---- abdominal cramps,

NV, muscle cramping, decreased neurological function, seizures

• Decreased urinary o/p• Increased body weight

Caring for the patient with SIADH

Nursing Diagnosis• Fluid volume excess r/t

abnormal production & secretion of ADH

• Thirst r/t fluid restriction

• Risk for injury r/t possible altered mental status 2 ⁰hyponatremia

Nursing Management• Restore fluid balance– Restrict fluids 800-1000

mL/day– Positioning– Medications: Lasix

• Protect from injury– Side rails– Ambulation assistance– Close to nurses station– Institute seizure

precautions– Frequent T & P

Thyroid Gland

• Understanding the pathophysiology of the function of this gland is critical to understanding the abnormalities..

Thyroid Gland• Hormonal maintenance:– T ₃ (triiodothyronine) & T₄ (thyroxine)– TCT (thyrocalcitonin)

• Role/functions of thyroid hormones:– Control of metabolic rate of cells– Promotion of sufficient pituitary secretion of GH &

gonadotropins– Regulates protein, carbs, & fat metabolism– Exerts chronotropic & inotropic cardiac effects

• Increases RBC production• Affects respiratory rate & drive– Increase bone formation & decrease bone resorption of

calcium– Act as insulin antagonists

• Hormonal maintenance:– T ₃ (triiodothyronine) & T₄ (thyroxine)– TCT (thyrocalcitonin)

• Role/functions of thyroid hormones:– Control of metabolic rate of cells– Promotion of sufficient pituitary secretion of GH &

gonadotropins– Regulates protein, carbs, & fat metabolism– Exerts chronotropic & inotropic cardiac effects

• Increases RBC production• Affects respiratory rate & drive– Increase bone formation & decrease bone resorption of

calcium– Act as insulin antagonists

Hyperthyroidism

• Etiology• Clinical signs/symptoms• Nursing interventions• Nursing rationales• Patient education

Hyperthyroidism

• Excessive thyroid hormone secretion from the thyroid gland (T3 and T4 hormones).

• Causing the levels of thyroid hormone in the blood to be too high.

• Characterized by an increased rate of body metabolism.

• Other names: thyrotoxicosis,

• Common Cause: Graves’ disease

• Excessive thyroid hormone secretion from the thyroid gland (T3 and T4 hormones).

• Causing the levels of thyroid hormone in the blood to be too high.

• Characterized by an increased rate of body metabolism.

• Other names: thyrotoxicosis,

• Common Cause: Graves’ disease

Risk Factors for Hyperthyroidism

• Autoimmune response

• Third/fourth decade of life

• Women > men

• Emotional trauma, infection, increased stress

• Overdose of medications used to treat hypothyroidism

• Use of certain weight-loss products

• Autoimmune response

• Third/fourth decade of life

• Women > men

• Emotional trauma, infection, increased stress

• Overdose of medications used to treat hypothyroidism

• Use of certain weight-loss products

Clinical ManifestationsHyperthyroidism

• Nervousness, mood swings

• Palpitations• Heat intolerance• Dyspnea• Muscle weakness,

tremors, hyperkinesia• Goiter• Abnormal menstruation• Frequent bowel

movements

• Nervousness, mood swings

• Palpitations• Heat intolerance• Dyspnea• Muscle weakness,

tremors, hyperkinesia• Goiter• Abnormal menstruation• Frequent bowel

movements

• Exophthalmos• Warm, moist velvety

skin• Increased sweating,

melanin pigmentation• Weight loss• VS: increased systolic

blood pressure, widened pulse pressure, tachycardia

• Exophthalmos• Warm, moist velvety

skin• Increased sweating,

melanin pigmentation• Weight loss• VS: increased systolic

blood pressure, widened pulse pressure, tachycardia

Care of the patient with hyperthyroidism

• Protect from stress.– Private room, restrict visitors, quiet environment

• Promote physical & emotional equilibrium– Quiet, cool– Eye care: protective wear, eye drops– Diet: high in calories, weigh daily, avoid stimulants

• Prevent complications:• Give meds as ordered:

– propylthiouracil (to block thyroid synthesis), – methimazole [Tapazole] (to inhibit thyroid hormone

synthesis, Iodine preparation, Propranolol for tachycardia, tremors & anxiety.

• Protect from stress.– Private room, restrict visitors, quiet environment

• Promote physical & emotional equilibrium– Quiet, cool– Eye care: protective wear, eye drops– Diet: high in calories, weigh daily, avoid stimulants

• Prevent complications:• Give meds as ordered:

– propylthiouracil (to block thyroid synthesis), – methimazole [Tapazole] (to inhibit thyroid hormone

synthesis, Iodine preparation, Propranolol for tachycardia, tremors & anxiety.

Hyperthyroidism & Nursing Diagnosis

• Altered nutrition, less than body requirements r/t elevated BMR

• Risk for injury r/t exophthalmos & tremors

• Activity intolerance r/t fatigue from over-activity

• Anxiety r/t tachycardia

• Sleep pattern disturbance r/t excessive amounts of circulating thyroid hormone.

• Treatment of Hyperstyroidism: Radiation and thyroidectomy.

• Altered nutrition, less than body requirements r/t elevated BMR

• Risk for injury r/t exophthalmos & tremors

• Activity intolerance r/t fatigue from over-activity

• Anxiety r/t tachycardia

• Sleep pattern disturbance r/t excessive amounts of circulating thyroid hormone.

• Treatment of Hyperstyroidism: Radiation and thyroidectomy.

Radioactive Iodine Therapy

• ₁₃₁I is a radioactive isotope of iodine to decrease thyroid activity

• Its dissolved in water and ingested orally• If large doses, patient requires hospitalization• Minimal precautions for usual dose:

• Sleep alone for several nights• Flush toilet several times after use• Monitor for signs of hypothyroidism

• ₁₃₁I is a radioactive isotope of iodine to decrease thyroid activity

• Its dissolved in water and ingested orally• If large doses, patient requires hospitalization• Minimal precautions for usual dose:

• Sleep alone for several nights• Flush toilet several times after use• Monitor for signs of hypothyroidism

Grave’s Disease

Complications: Thyroid Storm• Uncontrolled hyperthyroidism• Untreated: death 2 CHF⁰• Etiology: severe sudden stress---------– Infection– Surgery beginning of labor– Taking inadequate amounts of antithyroid

medications before thyroidectomy• Clinical Manifestations: • apprehension, restlessness, elevated temperature (106 F), ⁰

hypotension, extreme tachycardia, respiratory distress, pulmonary edema, weakness & delirium

• Treatment (medications): propythiouracil or methimazole, IV sodium iodine, propranolol, ASA, steroids, diuretics, digitalis

• Uncontrolled hyperthyroidism• Untreated: death 2 CHF⁰• Etiology: severe sudden stress---------– Infection– Surgery beginning of labor– Taking inadequate amounts of antithyroid

medications before thyroidectomy• Clinical Manifestations: • apprehension, restlessness, elevated temperature (106 F), ⁰

hypotension, extreme tachycardia, respiratory distress, pulmonary edema, weakness & delirium

• Treatment (medications): propythiouracil or methimazole, IV sodium iodine, propranolol, ASA, steroids, diuretics, digitalis

Complications: Hashimoto’s Disease

• Hashimoto's disease (also known as chronic lymphocytic thyroiditis), is a disorder that affects your thyroid gland.

• The body’s immune system attacks the thyroid gland. The resulting inflammation often leads to an underactive thyroid gland (hypothyroidism).

• Hashimoto's disease is the most common cause of hypothyroidism in the United States.

• It primarily affects middle-aged women, but also can occur in men and women of any age and in

Complications: Myxedema coma

• Myxedema coma, a life-threatening complication of hypothyroidism, characterized by swelling of the hands, face and feet, periorbital tissues.

• The disease may lead to coma and death.• Results from persistently low thyroid production• Coma can be precipitated by acute illness, rapid

withdrawal of thyroid medication, anesthesia and surgery, hypothermia and the use of sedatives and opiods analgesics.

• Symptoms include fatigue, mental impairment, cold intolerance, headaches.

Surgical Management - Thyroidectomy

• Partial removal of thyroid gland (for hyperthyroidism) or

• Total removal (for malignancy of thyroid)

• Indicated when there is unsuccessful medical treatment of hyperthyroidism

• Preop Teaching:

• Importance of supporting the neck while coughing or moving.

• Hoarseness of voice may be present for a few days due to endotracheal tube placement.

• Partial removal of thyroid gland (for hyperthyroidism) or

• Total removal (for malignancy of thyroid)

• Indicated when there is unsuccessful medical treatment of hyperthyroidism

• Preop Teaching:

• Importance of supporting the neck while coughing or moving.

• Hoarseness of voice may be present for a few days due to endotracheal tube placement.

Thyroidectomy: Post-op care:

• Promote physical & emotional equilibrium.– Positioning (Fowler’s position to promote venous return

head & neck), Immobilization/support of head• Prevent complications: – Chvostek’s sign: Face twitches on one side of mouth, nose,

& cheek when tapped just below & in front of the ear (facial nerve). Trousseau’s sign: Hand & fingers go into spasm in palmar flexion when BP cuff is inflated to above pt’s systolic BP & left for 1-4 minutes.

– Assess for respiratory distress & vocal cords paralysis (sudden stridor and restlessness).

– Monitor for elevated temperature.– Check dressing for hemorrhage

• Minimize talking/check & minimize laryngeal nerve damage– Keep close to nurses station.

• Promote physical & emotional equilibrium.– Positioning (Fowler’s position to promote venous return

head & neck), Immobilization/support of head• Prevent complications: – Chvostek’s sign: Face twitches on one side of mouth, nose,

& cheek when tapped just below & in front of the ear (facial nerve). Trousseau’s sign: Hand & fingers go into spasm in palmar flexion when BP cuff is inflated to above pt’s systolic BP & left for 1-4 minutes.

– Assess for respiratory distress & vocal cords paralysis (sudden stridor and restlessness).

– Monitor for elevated temperature.– Check dressing for hemorrhage

• Minimize talking/check & minimize laryngeal nerve damage– Keep close to nurses station.

Hypothyroidism

• Etiology• Clinical signs/symptoms• Nursing interventions• Nursing rationales• Patient education

Hypothyroidism (Myxedema)

• Occurs when thyroid gland fails to produce sufficient thyroid hormone.

• Deficiency of circulating thyroid hormone

• Often a final consequence of Hashimoto’s thyrioditis and Graves’ disease.

• Affects women more than men.

• Often causes an overall decrease in metabolism.

• Complications: Myxedema coma, miscarriage. Infertility, Wt gain, Alopecia, bradycardia

• Occurs when thyroid gland fails to produce sufficient thyroid hormone.

• Deficiency of circulating thyroid hormone

• Often a final consequence of Hashimoto’s thyrioditis and Graves’ disease.

• Affects women more than men.

• Often causes an overall decrease in metabolism.

• Complications: Myxedema coma, miscarriage. Infertility, Wt gain, Alopecia, bradycardia

HypothyroidismRisk Factors

• Total thyroidectomy

• Inadequate replacement therapy

• Genetics

• Hypophyseal failure

• Dietary iodine deficiencies

• Irradiation of thyroid gland

• Over-treatment of hyperthyroidism

• Total thyroidectomy

• Inadequate replacement therapy

• Genetics

• Hypophyseal failure

• Dietary iodine deficiencies

• Irradiation of thyroid gland

• Over-treatment of hyperthyroidism

Clinical ManifestationsHypothyroidism

• Weakness, fatigue, lethargy.

• Headache, slowed memory

• Psychotic beh.avior• Loss of interest in

sexual activity• Menstrual disturbances,

depression• Depressed BMR

• Weakness, fatigue, lethargy.

• Headache, slowed memory

• Psychotic beh.avior• Loss of interest in

sexual activity• Menstrual disturbances,

depression• Depressed BMR

• Cardiomegaly, bradycardia, hypotension, anemia

• Dry skin, brittle nails, coarse hair, hair loss

• Slowed speech, hoarseness, thickened tongue

• Weight gain, edema, periorbital puffiness

• Cardiomegaly, bradycardia, hypotension, anemia

• Dry skin, brittle nails, coarse hair, hair loss

• Slowed speech, hoarseness, thickened tongue

• Weight gain, edema, periorbital puffiness

Hypothyroidism: Diagnostic Test Results

• Blood chemistry analysis shows:

• decreased Triiodothyroidine (T3) and Thyroxine (T4), free thyroxine & sodium levels

• Increased Thyroid Stimulating Hormone (TSH) and cholesterol levels.

Care of the patient with hypothyroidism

• Provide for comfort and safety

–Monitor for infection (vital signs)

– Prevent heat loss

• High fiber diet, high protein, low-calorie diet.

• Encourage fluid intake to maintain hydration

• Administer thyroid medications:

– levothyroxine Synthroid] or

– liothyronine [Cytomel]

– (Thyroid hormone replacements)

• Provide for comfort and safety

–Monitor for infection (vital signs)

– Prevent heat loss

• High fiber diet, high protein, low-calorie diet.

• Encourage fluid intake to maintain hydration

• Administer thyroid medications:

– levothyroxine Synthroid] or

– liothyronine [Cytomel]

– (Thyroid hormone replacements)

Nursing Diagnosis & Hypothyroidism

• Risk for injury r/t hypersensitivity to drugs

• Activity intolerance r/t fatigue

• Constipation r/t decreased peristalsis

• Risk for impaired skin integrity r/t dry skin & edema

• Social isolation r/t lethargy

• Hypothermia r/t cold intolerance

• Risk for injury r/t hypersensitivity to drugs

• Activity intolerance r/t fatigue

• Constipation r/t decreased peristalsis

• Risk for impaired skin integrity r/t dry skin & edema

• Social isolation r/t lethargy

• Hypothermia r/t cold intolerance

Thyroid – Diagnostic Test

• Ultrasound• Biopsy• CT/MRI

Adrenal Glands

• One on each kidney

• Mineralcorticoids = help control the body’s NA+ & K+

• Glucocorticoids, androgens & estrogens = main cortisol --- carbohydrate, protein & fat metabolism, emotional stability, immune function

Left Adrenal Gland

Addison’s Disease

• Etiology• Clinical signs/symptoms• Complications• Nursing interventions• Nursing rationales

Addison’s DiseaseAdrenal Hypofunction

• Chronic primary adrenocorticortropic hormone (ACTH) insufficiency.

• Primary cause: atrophy of the adrenal gland.

• Deficiencies Galore In Addison’s

• Deficiency in mineralocorticoid

secretion: Aldosterone

• Deficiency in glucocorticoid

secretion: Cortisol

• Deficiency in androgen hormone

• Chronic primary adrenocorticortropic hormone (ACTH) insufficiency.

• Primary cause: atrophy of the adrenal gland.

• Deficiencies Galore In Addison’s

• Deficiency in mineralocorticoid

secretion: Aldosterone

• Deficiency in glucocorticoid

secretion: Cortisol

• Deficiency in androgen hormone

Risk Factors in Addison’s

• Autoimmune process• Infection• Malignancy• Vascular obstruction• Bleeding• Environmental hazards• Congenital defects• Bilateral adrenalectomy• Pheochromocytoma

• Autoimmune process• Infection• Malignancy• Vascular obstruction• Bleeding• Environmental hazards• Congenital defects• Bilateral adrenalectomy• Pheochromocytoma

Clinical ManifestationsAddison’s Disease

• Muscle weakness, fatigue, lethargy

• Dizziness, fainting• Nausea, food

idiosyncrasies, anorexia• Abdominal pain, cramps• Weight loss, salt

craving

• Muscle weakness, fatigue, lethargy

• Dizziness, fainting• Nausea, food

idiosyncrasies, anorexia• Abdominal pain, cramps• Weight loss, salt

craving

• VS: hypotension, widened pulse pressure, pulse increased & irregular, temperature is low

• Hyponatremia, hyperkalemia, hypercalcemia

• Vomiting, diarrhea• Tremors• Poor skin turgor,

excessive pigmentation [bronze tone]

• VS: hypotension, widened pulse pressure, pulse increased & irregular, temperature is low

• Hyponatremia, hyperkalemia, hypercalcemia

• Vomiting, diarrhea• Tremors• Poor skin turgor,

excessive pigmentation [bronze tone]

Caring for the patient with Addison’s

• Decrease stress– Quiet non-demanding environment

• Promote adequate nutrition– Diet, fluids

• Medication regimen– Life-long exogenous replacement therapy: glucocorticoids:

prednisone, hydrocortisone or mineralocortocoids: fludrocortisone [Florinef]

• Prevent complications: Addisonian Crisis– Bed rest & avoid stimuli– High doses of steroids– IV to treat shock– I&O, VS q15 mins

• Decrease stress– Quiet non-demanding environment

• Promote adequate nutrition– Diet, fluids

• Medication regimen– Life-long exogenous replacement therapy: glucocorticoids:

prednisone, hydrocortisone or mineralocortocoids: fludrocortisone [Florinef]

• Prevent complications: Addisonian Crisis– Bed rest & avoid stimuli– High doses of steroids– IV to treat shock– I&O, VS q15 mins

Addisonian Crisis

• (Adrenal Crisis)

• A very serious condition that can lead to death quickly if untreated.

• A critical deficiency of mineralo-corticoids and gluco-corticoids, follows:

• Severe hypotension

• Shock

• Coma

• Vasomotor collapse r/t strenuous activity

• Omission of prescribed medications

• (Adrenal Crisis)

• A very serious condition that can lead to death quickly if untreated.

• A critical deficiency of mineralo-corticoids and gluco-corticoids, follows:

• Severe hypotension

• Shock

• Coma

• Vasomotor collapse r/t strenuous activity

• Omission of prescribed medications

Emergency Intervention for Addisonian Crisis

• Hormone replacement: rapid infusion NS & hydrocortisone sodium succinate,in addition give hydrocortisone IM concomitantly

• Hyperkalemia management: insulin IV with D5W, give Kayexalate, give loop diuretics, avoid K+ sparing meds, monitor I&O’s, VS, EKG

• Hypoglycemia management: administer IV glucose (glucagon), monitor BS levels carefully

• Hormone replacement: rapid infusion NS & hydrocortisone sodium succinate,in addition give hydrocortisone IM concomitantly

• Hyperkalemia management: insulin IV with D5W, give Kayexalate, give loop diuretics, avoid K+ sparing meds, monitor I&O’s, VS, EKG

• Hypoglycemia management: administer IV glucose (glucagon), monitor BS levels carefully

Nursing Diagnosis & Addison’s Disease

• Fluid volume deficit r/t decreased sodium level

• Altered renal tissue perfusion r/t hypotension

• Decreased cardiac o/p r/t aldosterone deficiency

• Risk for infection r/t cortisol deficiency

• Activity intolerance r/t muscle weakness & fatigue

• Altered nutrition, less than body requirements r/t nausea, anorexia & vomiting

• Fluid volume deficit r/t decreased sodium level

• Altered renal tissue perfusion r/t hypotension

• Decreased cardiac o/p r/t aldosterone deficiency

• Risk for infection r/t cortisol deficiency

• Activity intolerance r/t muscle weakness & fatigue

• Altered nutrition, less than body requirements r/t nausea, anorexia & vomiting

Diagnostic Test for Adrenal Function

• Eight hour Intravenous ACTH test• Administration of 25 U of ACTH in 500 mL/NS over

8 hours.• Collect 24 hr urine before & after drug administration• Measuring of 17-ketosteroids & 17-

hydroxycorticosteroids• Addison’s Disease: urinary o/p of steroids does not

increase after drug administration• Cushing’s Disease: there is an increase in urinary o/p

of steroids tenfold

• Eight hour Intravenous ACTH test• Administration of 25 U of ACTH in 500 mL/NS over

8 hours.• Collect 24 hr urine before & after drug administration• Measuring of 17-ketosteroids & 17-

hydroxycorticosteroids• Addison’s Disease: urinary o/p of steroids does not

increase after drug administration• Cushing’s Disease: there is an increase in urinary o/p

of steroids tenfold

Cushing’s Syndrome

• Etiology• Clinical signs/symptoms• Complications• Nursing interventions• Nursing rationales

• Diagnostic Testing• Plasma cortisol levels, Na

levels, Serum K+ levels, BUN, Corticotropin levels,

• Urinalysis

Cushing’s DiseaseAdrenal Hyperfunction

• This is the overactivity of the adrenal glands leading to prolonged elevated plasma concentration of adrenal steroids.

• Risk Factors for Cushing’s Disease.• Adrenal hyperplasia

• Excessive hypothalamic stimulation

• Tumors: adrenal glands, hypophyseal, pituitary, bronchogenic, gallbladder

• Excessive steroid therapy

• This is the overactivity of the adrenal glands leading to prolonged elevated plasma concentration of adrenal steroids.

• Risk Factors for Cushing’s Disease.• Adrenal hyperplasia

• Excessive hypothalamic stimulation

• Tumors: adrenal glands, hypophyseal, pituitary, bronchogenic, gallbladder

• Excessive steroid therapy

Symptoms of Cushing’s Disease

• Nursing Diagnoses

• Body image disturbance r/t changes in physical appearance

• Activity intolerance r/t backache & weakness

• Risk for injury r/t infection & bleeding

• Knowledge deficit r/t management of disease

• Pain r/t headache

• Nursing Diagnoses

• Body image disturbance r/t changes in physical appearance

• Activity intolerance r/t backache & weakness

• Risk for injury r/t infection & bleeding

• Knowledge deficit r/t management of disease

• Pain r/t headache

• Clinical Manifestations• Headache, backache• Weakness, decreased

work capacity• Mood swings• Hypertension, wt gain,

pitting edema, buffalo hump, moon face, hirsutism on face, arms & legs, hyperpigmentation, menstrual changes, impotence

• Clinical Manifestations• Headache, backache• Weakness, decreased

work capacity• Mood swings• Hypertension, wt gain,

pitting edema, buffalo hump, moon face, hirsutism on face, arms & legs, hyperpigmentation, menstrual changes, impotence

Caring for the patient with Cushing’s

Promote comfort• Assist with prep for diagnostic tests• Explain procedures• Protect from trauma• Prepare for surgery: adrenalectomy [next slide]

Prevent complications• Maintain fluid balance• Check for glucose metabolism (Monitor glucose level)• Prevent/manage hypertension• Prevent infection: URI, UTI• Observe behaviors: mood swings.• Give prescribed meds (potassium supplements).

Promote comfort• Assist with prep for diagnostic tests• Explain procedures• Protect from trauma• Prepare for surgery: adrenalectomy [next slide]

Prevent complications• Maintain fluid balance• Check for glucose metabolism (Monitor glucose level)• Prevent/manage hypertension• Prevent infection: URI, UTI• Observe behaviors: mood swings.• Give prescribed meds (potassium supplements).

Adrenalectomy

• This is the surgical removal of the adrenal glands due to tumors or uncontrolled overactivity of the adrenal glands. May also be done to control metastatic breast or prostate cancer.

• Prepare patient for surgery:• Pre-operative care:• Give steroids• Stop hypertensive medications• Give sedation.

• This is the surgical removal of the adrenal glands due to tumors or uncontrolled overactivity of the adrenal glands. May also be done to control metastatic breast or prostate cancer.

• Prepare patient for surgery:• Pre-operative care:• Give steroids• Stop hypertensive medications• Give sedation.

Adrenalectomy

• Post-operative care:

• Monitor VS• Monitor for adrenal crisis: pulse that is rapid, weak,

thready, elevated temperature, severe weakness & hypotension, headache, convulsions, com

• Auscultate lungs/bowel sounds• IV hydration• Maintain NPO status• Reposition q2hr, mouth care, ambulation when

ordered, teds

• Post-operative care:

• Monitor VS• Monitor for adrenal crisis: pulse that is rapid, weak,

thready, elevated temperature, severe weakness & hypotension, headache, convulsions, com

• Auscultate lungs/bowel sounds• IV hydration• Maintain NPO status• Reposition q2hr, mouth care, ambulation when

ordered, teds

Phenochromocytoma

• A catecholamin-producing tumor that arises in adrenal medulla.

• Tumors can occur as single lesion, or can be bilateral.• Tumors are usually benign.• Cause is unknown, may be inherited.• CM: severe headache, palpitations, profuse

diaphoresis, flushing appearance, sense of impending doom, pain in chest or abdomen, n&v.

• Treatment: antidepressants, antihypertensives, surgical removal of one or both adrenal glands.

Question

1. During treatment of a client in Addison’s crisis, it is most appropriate for the nurse to administer I.V.

a. Insulin.

b. Normal saline solution.

c. Dextrose 5% in half NS solution

d. Dextrose 5% in water