Medical-Surgical Nursing -- Endocrine System

Review of the Anatomy and Physiology of the endocrine glands

Review of the Common Laboratory procedures
Review of the Common endocrine disorders
Review of Diabetes Mellitus

The ANATOMY of the Endocrine System

The Hypothalamus
This part of the DIENCEPHALON is located below the thalamus and is connected to the pituitary gland
by a stalk
The PHYSIOLOGY of the Endocrine System: Hypothalamus
Secretes RELEASING HORMONES for the pituitary gland
Secretes OXYTOCIN that is stored in the Posterior pituitary gland
Secretes Anti-Diuretic Hormone or VASOPRESSIN that is stored also in the posterior pituitary gland
The ANATOMY of the Endocrine System
The Pituitary Gland
Is a gland located below the hypothalamus at the base of the brain
The optic chiasm passes over this structure
Is divided into two parts- the anterior or adenohypophysis and the posterior or the neurohypophysis
The PHYSIOLOGY of the Endocrine System: Anterior Pituitary
Secretes the following hormones:
1. Growth hormone
2. Prolactin
3. Gonadotrophins- LH and FSH
4. Stimulating hormones and trophic hormones
• ACTH TSH MSH

The PHYSIOLOGY of the Endocrine System: Posterior Pituitary

Stores and releases
1. OXYTOCIN
2. ADH/Vasopressin
The ANATOMY of the Endocrine System
The THYROID gland
Located in the anterior neck lateral to the trachea
Contains two lobes connected by the isthmus
Microscopically composed of thyroid follicles where the hormones are produced and stored
The PHYSIOLOGY of the Endocrine System: Thyroid
Produces the thyroid hormones by the thyroid follicles:
1. Tri-iodothyronine or T3
2. Tetra-iodothyronine or thyroxine or T4

The Parafolloicular cells secrete CALCITONIN

The PARAthyroid glands

Located at the back of the thyroid glands
Four in number
The PHYSIOLOGY of the Endocrine System: Parathyroid gland
Secretes PARATHYROID hormone (PTH) that controls calcium and phosphorus levels
PTH is stimulated by a DECREASED Calcium level
The ANATOMY of the Endocrine System -- The Adrenal Glands

Located above the kidneys

Composed of two parts- the outer Adrenal Cortex and the inner Adrenal medulla
Secretes three types of STERIOD hormones
1. Glucocorticoids-
Glucocorticoids- like Cortisol, cortisone and corticosterone
2. Mineralocorticoids-
Mineralocorticoids- like Aldosterone
3. Sex hormones- like estrogen and testosterone
Essentially a part of the SYMPATHETIC autonomic system
Secretes Adrenergic Hormones:
1. Epinephrine
2. Nor-epinephrine

The ANATOMY of the Endocrine System-- The Pancreas

This retroperitoneal organ has both endocrine and exocrine functions
The endocrine function resides in the ISLETS of Langerhans
The islets have three types of cells- alpha, beta and delta cells
The ALPHA cells secrete GLUCAGON
The BETA cells secrete INSULIN
The DELTA cells secrete SOMATOSTATIN

The ANATOMY of the Endocrine System

The GONADS- Ovaries
These two almond-shaped glands are found in the pelvic cavity attached to the uterus by the ovarian
ligament
The GONADS- Testes
These two oval-shaped glands are found in the scrotum

The PHYSIOLOGY of the Endocrine System: Gonads

The Ovaries contains Granulosa and Theca cells which secrete ESTROGEN and Progesterone
The testes contains Leydig cells that secrete Testosterone

DISORDERS OF THE ENDOCRINE GLAND

Disorders are generally grouped into:
1. HYPER- when the gland secretes excessive hormones
2. HYPO- when the gland does not secrete enough hormones
Hyper and Hypo can be classified as PRIMARY when the Gland itself is the problem or SECONDARY
when the pituitary or the hypothalamus is causing the problem

DISORDERS OF the PITUITARY GLAND

HYPOPITUITARISM
Hyposecretion of the anterior pituitary gland
CAUSES: Congenital, Post-partal necrosis, infection and tumor
PATHOPHYSIOLOGY:
Depends on the major hormone/s depleted

Hypopituitarism:
Hypopituitarism: ASSESSMENT Findings
1. Retarded physical growth due to decreased GH
GH dwarfism
2. Low intellectual development
3. poor development of secondary sexual characterisitcs
NURSING INTERVENTIONS
1. provide emotional support to the family
2. encourage client and family to express feelings
3. administer prescribed hormonal replacement therapy

HYPERPITUITARISM
The hypersecretion of the gland
ACROMEGALY
CAUSES: tumor, congenital disorder

PATHOPHYSIOLOGY
Depends on the hormone/s that is/are increased

ASSESSMENT FINDINGS for Hyperpituitarism

1. Increased growth
growth Gigantism or Acromegaly 3. Visual disturbances
2. large and thick hands and feet 4. Hypertension,
Hypertension, hyperglycemia
5. Organomegaly

NURSING INTERVENTIONS
1. provide emotional support to clients and family
2. provide frequent skin care
3. prepare patient for surgery- removal of pituitary gland

NURSING INTERVENTIONS
Post-operative care
1. Monitor VS,
VS, LOC and neurologic status
2. Place patient on Semi-Fowler’s
3. Monitor for Increased ICP,
ICP, bleeding, CSF leakage
4. instruct patient to AVOID sneezing, coughing and nose-blowing
5. Monitor development of DI- measure I and O
6. Administer prescribed medications- antibiotics, analgesics and steroids

DISORDERS OF the PITUITARY GLAND: Posterior gland

DIABETES INSIPIDUS
A hyposecretion of ADH
CAUSES: Conditions that increase ICP, Surgical removal of post pit. tumor
PATHOPHYSIOLOGY
Decreased ADH
ADH failure of tubular reabsorption of water
water increased urine volume

ASSESSMENT findings
1. Polyuria of more than 4 liters of urine/day 4. Muscle pain and weakness
2. Polydipsia 5. Postural hypotension and tachycardia
3. Signs of Dehydration

DIAGNOSTIC TEST
1. Urinary Specific gravity
gravity very low, 1.006 or less
2. Serum Sodium levels
levels high

NURSING INTERVENTIONS
1.Monitor VS,
VS, neurologic status and cardiovascular status
2. Monitor Intake and Output
3. Monitor urine specific gravity
4. Provide adequate fluids
5. Administer Chlorpropamide or Clofibrate as prescribed to increase the action of ADH if decreased
6. Administer VASOPRESIN. Desmopressin or Lypressin are given intranasal.
intranasal. Pitressin is given IM

SIADH
Hypersecretion of ADH abnormally
CAUSES: tumor, paraneoplastic syndromes

PATHOPHYSIOLOGY
Increased ADH
ADH water reabsorption
reabsorption water intoxication, hypervolemia

DIAGNOSTIC TEST for SIADH

1. urine specific gravity is increased
2. Hyponatremia
3. CBC shows hemodilution

ASSESSMENT findings
1. Signs of Hypervolemia
2. Mental status changes
3. Abnormal weight gain
4. hypertension
5. Anorexia, Nausea and Vomiting
6. HYPOnatremia

NURSING INTERVENTIONS
1. Monitor VS and neurologic status
2. provide safe environment
3. Restrict fluid intake (less than 500cc/day)
4. Monitor I and O and daily weight
5. Administer Diuretics and IVF carefully
6. Administer prescribed Demeclocycline to inhibit action of ADH in the kidney

DISORDERS OF the ADRENAL GLAND

Hyposecretion: ADDISON’S Disease
Decreased secretion of adrenal cortex hormones, especially glucocorticoids and mineralocorticoids
CAUSE: tumor, idopathic

PATHOPHYSIOLOGY
Decreased Glucocorticoids
Glucocorticoids decreased resistance to stress, hypoglycemia
Decreased mineralocorticoids
mineralocorticoids decreased retention of sodium and water

ASSESSMENT Findings for Addison’s disease

1. Weight loss 5. hyperkalemia
2. GI disturbances 6. hypoglycemia
3. Muscle weakness, lethargy and fatigue 7. dehydration and hypovolemia
4. Hyponatremia 8. Increased skin pigmentation

NURSING INTERVENTIONS
1. Monitor VS especially BP 3. Monitor blood glucose level and K
2. Monitor weight and I and O 4. Administer hormonal agents as prescribed
5. Observe for ADDISONIAN crisis
6. Educate the client regarding lifelong treatment, avoidance of strenuous activities, stress and seeking
prompt consult during illness
7. Provide a high-protein
high-protein,, high carbohydrate and increased sodium intake

ADDISONIAN crisis
A life-threatening disorders caused by acute severe adrenal insufficiency
CAUSES: Severe stress, infection, trauma or surgery
PATHOPHYSIOLOGY
Overwhelming stimuli
stimuli mobilize body defense
defense decreased stress hormones
hormones inadequate coping

ASSESSMENT Findings for Addisonian Crisis

1. Severe headache 4. Severe hypotension
2. Severe pain 5. Signs of Shock
3. Generalized weakness

NURSING INTERVENTIONS:
1. Administer IV glucocorticoids,
glucocorticoids, usually hydrocortisone
2. Monitor VS frequently
3. Monitor I and O, neurological status, electrolyte imbalances and blood glucose
4. Administer IVF
5. Maintain bed rest
6. Administer prescribed antibiotics

Hypersecretion: CUSHING’S DISEASE

A condition resulting from the hypersecretion of glucocorticoids from the adrenal cortex
CAUSES: Pituitary tumor, adrenal tumor, abuse of steroids
PATHOPHYSIOLOGY
Increased Glucocorticoids
Glucocorticoids exaggerated effects of the hormone

ASSESSMENT FINDINGS for Cushing

1. generalized muscle weakness and wasting 7. Hirsutism and acne
2. truncal obesity 8. Hypertension
3. moon-face 9. hyperglycemia
4. buffalo hump 10. Osteoporosis
5. easy bruisability 11. Amenorrhea
6. Reddish-purplish striae on the abdomen and thighs

DIAGNOSTIC TEST
1. Serum cortisol level
2. Serum glucose and electrolytes

NURSING INTERVENTIONS
1. Monitor I and O , weight and VS
2. Monitor laboratory values- glucose, Na, K and Ca
3. Provide meticulous skin care
4. Administer prescribed medications like aminogluthetimide to inhibit adrenal hyperfunctioning
5. Prepare client for surgical management- pituitary surgery and adrenalectomy
6. protect patient from infection
7. Improve body image
8. Provide a LOW carbohydrate,
carbohydrate, LOW sodium and HIGH protein diet

DISORDERS OF the ADRENAL GLAND

Hypersecretion: CONN’S DISEASE
Hypersecretion of Aldosterone from the adrenal cortex
CAUSES: pituitary tumor, adrenal tumor
PATHOPHYSIOLOGY
Increased Aldosterone
Aldosterone exaggerated effects

ASSESSMENT findings in CONN’S disease

1. Symptoms of HYPOkalemia 4. Headache, N/V
2. hypertension 5. Visual changes
3. hypernatremia 6. Muscles weakness, fatigue and nocturia

DIAGNOSTIC TEST
1. Urine gravity- low 3. Serum Potassium- low
2. Serum Sodium- high 4. Increased urinary Aldosterone

NURSING INTERVENTIONS
1. Monitor VS, I and O and urine sp gravity
2. Monitor serum K and Na
3. Provide Potassium rich foods and supplements
4. Administer prescribed diuretic- Spironolactone
5. Maintain sodium-restricted diet
6. Prepare patient for possible surgical interventions

Hypersecretion: Pheochromocytoma
Increased secretion of epinephrine and nor-epinephrine by the adrenal medulla
CAUSE: tumor

PATHOPHYSIOLOGY
Increased Adrenergic hormones
hormones exaggerated sympathetic effects

ASSESSMENT Findings in Pheochromocytoma

1. Hypertension 5. Profuse sweating and Flushing
2. Severe headache 6. Weight loss, tremors
3. Palpitations 7. Hyperglycemia and glycosuria
4. Tachycardia

NURSING INTERVENTIONS
1. Monitor VS especially BP
2. Monitor for HYPERTENSIVE crisis
3. Avoid stimulation that can cause increased BP
4. Administer Anti-hypertensive agents like alpha-adrenergic blockers- Phenoxybenzamine
5. Prepare Phentolamine for hypertensive crisis
6. Monitor blood glucose and urine glucose
7. promote adequate rest and sleep periods
8. provide HIGH calorie foods and Vitamins/mineral supplements
9. Prepare patient for possible surgery
 DISORDERS OF the THYROID GLAND
HYPOsecretion: HYPOTHYROIDISM
A hypothyroid state characterized by decreased secretions of T3 and T4
CAUSES: Hypofunctioning tumor, IDG, Pituitary tumor, Ablation therapy, Surgical removal of thyroid

PATHOPHYSIOLOGY
Decreased T3 and T4
T4 decreased basal metabolism

ASSESSMENT findings for Hypothyroidism

1. Lethargy and fatigue
2. Weakness and paresthesia
3. COLD intolerance
4. Weight gain
5. Bradycardia, constipation
6. Dry hair and skin, loss of body hair
7. Generalized puffiness and edema around the eyes and face
8. Forgetfulness and memory loss
9. Slowness of movement
10. Menstrual irregularities and cardiac irregularities

NURSING INTERVENTIONS
1. Monitor VS especially HR
2. Administer hormone replacement: usually Levothyroxin( Synthroid)-should
Synthroid)-should be taken on an empty
stomach
3. Instruct patient to eat LOW calorie,
calorie, LOW cholesterol and LOW fat diet
4. Manage constipation appropriately
5. Provide a WARM environment
6. Avoid sedatives and narcotics because of increased sensitivity to these medications
7. Instruct patient to report chest pain promptly

HYPERfunctioning: HYPERTHYROIDISM
Called GRAVE’S DISEASE
A hyperthyroid state characterized by increased circulating T3 and T4
CAUSES: Auto-immune disorder, toxic goiter, tumor
PATHOPHYSIOLOGY
Increased hormone activity
activity increased Basal Metabolism

ASSESSMENT Findings for Hyperthyroidism

1. Weight loss but increased appetite 6. Diarrhea
2. HEAT intolerance 7. Warm skin
3. Hypertension 8. Diaphoresis
4. Tachycardia and palpitations 9. Smooth and soft skin
5. Exopthalmos 10. Fine tremors and nervousness
11. Shortness of breath,
breath, Irritability, mood swings, personality changes and agitation

NURSING INTERVENTIONS
1. Provide adequate rest periods
2. Administer anti-thyroid medications that block hormone synthesis- Methimazole and PTU
3. Provide a HIGH-calorie diet
4. Manage diarrhea
5. provide a cool and quiet environment
6. Avoid giving stimulants
Provide eye care
7. Administer PROPRANOLOL for tachycardia
8. Administer IODIONE preparation- Lugol’s solution and SSKI to inhibit the release of T3 and T4
9. Prepare clients for Radioactive iodine therapy
10. Prepare patient for thyroidectomy
11. Manage thyroid storm appropriately

Thyroid storm
An acute LIFE-threatening condition characterized by excessive thyroid hormone
CAUSE: Manipulation of the thyroid during surgery causing the release of excessive hormones in the
blood

ASSESSMENT Findings for Thyroid Storm

1. HIGH fever
2. Tachycardia,
Tachycardia, Tachypnea
3. Systolic HYPERtension
4. Delirium and coma
5. Severe vomiting and diarrhea
6. Restlessness, Agitation, confusion and Seizures

NURSING INTERVENTIONS
1. Maintain PATENT airway and adequate ventilation
2. Administer anti-thyroid medications such as Lugol’s solution, Propranolol, and Glucocorticoids
3. Monitor VS
4. Monitor Cardiac rhythms
5. Administer PARACETAMOL ( not Aspirin) for FEVER
6. Manage Seizures as required. Provide a quiet environment

THYROIDECTOMY
Removal of the thyroid gland

PRE-OPERATIVE CARE - Thyroidectomy

1. Obtain VS and weight
2. Assess for Electrolyte levels, glucose levels and T3/T4 levels
3. Provide pre-operative teaching like coughing and deep breathing, early ambulation and support of the
neck when moving
4. Administer prescribed medications

POST-OPERATIVE CARE - Thyroidectomy

1. Position patient: Semi-Fowler’s
2. Monitor for respiratory distress- apparatus at bedside- tracheostomy set, O2 tank and suction machine!
3. Check for edema and bleeding by noting the dressing anteriorly and at the back of the neck
4. LIMIT client talking
5. Assess for HOARSENESS
6. Monitor for Laryngeal Nerve damage – Respiratory distress, Dysphonia, voice changes, Dysphagia and
restlessness
7. Monitor for signs of HYPOCALCEMIA and tetany due to trauma of the parathyroid
8. Prepare Calcium gluconate
9. Monitor for thyroid storm

DISORDERS OF the PARATHYROID GLAND

Hypofunctioning: HYPOPARATHYROIDISM
Hyposecretion of parathyroid hormone
CAUSES: tumor, removal of the gland during thyroid surgery
PATHOPHYSIOLOGY
Decreased PTH
PTH deranged calcium metabolism

ASSESSMENT Findings for HypoParaThyroidism

1. Signs of HYPOCALCEMIA 5. Bronchospasms, laryngospasms, dysphagia
2. Numbness and tingling sensation on the face 6. Cardiac dysrhythmias
3. Muscle cramps 7. Hypotension
4. (+) Trosseau’s and Chvostek’s signs 8. Anxiety, irritability ands depression

NURSING INTERVENTIONS
1. Monitor VS and signs of HYPOcalcemia 5. Provide a HIGH-calcium and LOW phosphate
2. Initiate seizure precautions and management diet
3. Place a tracheostomy set. O2 tank and suction 6. Advise client to eat Vitamin D rich foods
at the bedside 7. Administer Phosphate binding drugs
4. Prepare CALCIUM gluconate

Hyperfunctioning: HYPERPARATHYROIDISM
Hypersecretion of the gland
CAUSE: Tumor

PATHOPHYSIOLOGY
Increase PTH
PTH increased CALCIUM levels in the body

ASSESSMENT Findings for Hyperparathyroidism

1. Fatigue and muscle weakness/pain 5. Constipation
2. Skeletal pain and tenderness 6. Hypertension
3. Fractures 7. Cardiac Dysrhythmias
4. Anorexia/N/V epigastric pain 8. Renal Stones

NURSING INTERVENTIONS
1. Monitor VS, Cardiac rhythm,
rhythm, I and O 5. Administer NORMAL saline
2. Monitor for signs of renal stones,
stones, skeletal 6. Administer calcium chelators
fractures. Strain all urine. 7. Administer CALCITONIN
3. Provide adequate fluids- force fluids 8. Prepare the patient for surgery
4. Administer prescribed Furosemide to lower
calcium levels
Endocrine Medications
Antidiuretic hormones
Enhance reabsorption of water in the kidneys
Used in DI
1. Desmopressin and Lypressin intranasally
2. Pitressin IM
SIDE-effects
Flushing and headache
 Water intoxication

Thyroid Medications
Thyroid hormones
Levothyroxine (Synthroid), Liothyroxine (Cytomel)
Replace hormonal deficit in the treatment of HYPOTHYROIDSM
Side-effects
1. N/V
2. Signs of increased metabolism
Nursing responsibility
1. Monitor weight, VS
2. Instruct client to take daily medication the same time each morning WITHOUT FOOD
3. Advise to report palpitation, tachycardia, chest pain
4. Instruct to avoid foods that inhibit thyroid secretions like cabbage, spinach and radishes

ANTI-THYROID medications
Inhibit the synthesis of thyroid hormones
1. Methimazole 3. Iodine solution- SSKI and Lugol’s solution
2. PTU

Side-effects
N/V
Diarrhea
AGRANULOCYTOSIS

Nursing responsibilities
1. Monitor VS, T3 and T4, weight
2. The medications WITH MEALS to avoid gastric upset
3. Instruct to report SORE THROAT or unexplained FEVER
4. Monitor for signs of hypothyroidism. Instruct not to stop abrupt medication

STEROIDS
Replaces the steroids in the body
Cortisol, cortisone, betamethasone, hydrocortisone
Side-effects
HYPErglycemia
Increased susceptibility to infection
Hypokalemia
Edema
If high doses- osteoporosis, growth retardation, peptic ulcer, hypertension, cataract, mood changes,
hirsutism, fragile skin
Nursing responsibilities
1. Monitor VS, electrolytes, glucose 4. Handle patient gently
2. Monitor weight edema and I/O 5. Instruct to take meds WITH MEALS
3. Protect patient from infection

Board Examination Questions

Ms. Angie Lu is admitted in the hospital because of easy fatigability for the past few months. After a
series of examination, a diagnosis of hyperthyroidism was confirmed

1. An assessment was made, the LEAST symptom that she would experience is:
A. Fine tremor of the hands C. Palpitation
B. Hyperactivity D. Drowsiness
Questionable question
2.Anti-thyroid drug was prescribed. Which of the following is an anti-thyroid drug?
A. Cytomel C. Synthroid
B. Tapazole D. Tagamet

3. The nursing responsibility is to assess her for the symptoms of thyrotoxicosis. Which of these is not a
symptom of thyrotoxicosis?
thyrotoxicosis?
A. Anorexia C. Shortness of breath
B. increased appetite D. Diarrhea

4. The following are the diagnostic examinations for thyroid function that measures the amount of oxygen
consumed by the body during a given time:
A. Thyrotropin-releasing hormone C. Radio-iodine uptake and excretion test
B. T3 resin uptake D. Basal metabolic rate

Board Examination Question

Mrs. Josie Lee has lost 12 pounds in two months although she has increased appetite. A diagnosis of
hyperthyroidism has been confirmed

1. The following are the symptoms of hyperthyroidism.

hyperthyroidism. During your PE, which of these would you NOT
expect?
A. Pulse rate of 120 bpm C. Dyspnea
B. Respiration of 34 bpm D. Cyanosis

2. If Mrs. Lee does not receive treatment for her illness, which of the following symptoms would indicate
a serious complication?
A. Bradycardia C. Increased BP
B. tachycardia D. Sudden weight loss

3. Which of the following should be your main concern for her while the symptoms are pronounced?
A. Protect her from exposure to heat C. Encourage her to be friendly with other patient
B. Keep her environment always cool D. Provide diversional stimulating activities

Bopep is suffering from toxic hyperthyroidism

1. You help to ensure that the BMR will be done under the standard procedure by telling him that the test
will involve?
A. Obstructing his vision C. Obstructing his hearing
B. Restraining the upper and lower extremities D. Occluding the nostrils with clamp

2. The physician orders Lugol’s solution to:

A. Decrease the vascularity and size of the thyroid C. Increase the vascularity of the thyroid
B. Decrease the size of the thyroid only D. Increase the size of the thyroid

3. In the administration of the Lugol’s solution, the precautionary measure the nurse should take is:
A. Administer it with glass only C. Administer it with milk
B. Dilute with juice and administer with straw D. Follow it with milk of magnesia

4. Which of these is the toxic effect of Lugol’s solution?

A. Anorexia B. Ringing of the ear
C. Nystagmus D. Excessive salivation