Endocrine
9 system
In this chapter, Brush up on key
you’ll review:
✐ components of the
concepts
endocrine system The endocrine system consists of chemical
and their function transmitters called hormones and specialized
✐ tests used to cell clusters called glands.
diagnose endocrine At any time, you can review the major
disorders points of this chapter by consulting the Cheat
sheet on pages 284 to 288.
✐ common endocrine
disorders. Thermostat central
The hypothalamus controls temperature,
respiration, blood pressure, thirst, hunger,
and water balance. Its functions affect the
emotional states. The hypothalamus also pro-
duces hypothalamic-stimulating hormones,
which affect the inhibition and release of
pituitary hormones.
Heavy on the hormones
The pituitary gland is composed of anterior
and posterior lobes. Together these lobes pro-
duce various hormones that affect the body.
The anterior lobe secretes:
• follicle-stimulating hormone, which
stimulates graafian follicle growth and
estrogen secretion in women and sperm mat-
uration in men
• luteinizing hormone, which induces
ovulation and the development of the corpus
luteum in women and stimulates testosterone
secretion in men
• adrenocorticotropic hormone (ACTH),
also called corticotropin, which stimulates
secretion of hormones from the adrenal
cortex
• thyroid-stimulating hormone (TSH),
which regulates the secretory activity of the
thyroid gland
• growth hormone (GH), which is an
insulin antagonist that stimulates the growth
of cells, bones, muscle, and soft tissue.
313419NCLEX-RN_Chap09.indd 283
The posterior lobe secretes:
• vasopressin (antidiuretic hormone, also
called ADH), which helps the body retain water
• oxytocin, which stimulates uterine con-
tractions during labor and milk secretion in
lactating women.
Growth gland
The thyroid gland accelerates growth and
cellular reactions, including basal metabolic
rate (BMR). It’s controlled by the pituitary
gland’s secretion of TSH.
The thyroid gland produces thyrocalci-
tonin, triiodothyronine (T3 ), and thyroxine
(T4 ), which are necessary for growth and
development.
Coping with calcium
The parathyroid gland secretes parathyroid
hormone (parathormone), which regulates
calcium and phosphorus levels and promotes
the resorption of calcium from bones.
Androgen, estrogen, and others
The adrenal glands are composed of the
adrenal cortex and the adrenal medulla.
The adrenal cortex secretes three major
hormones:
• glucocorticoids (cortisol, cortisone, and
corticosterone), which mediate the stress
response, promote sodium and water reten-
tion and potassium secretion, and suppress
ACTH secretion
• mineralocorticoids (aldosterone and
deoxycorticosterone), which promote sodium
and water retention and potassium secretion
• sex hormones (androgens, estrogens,
and progesterone), which develop and main-
tain secondary sex characteristics and libido.
The adrenal medulla secretes two
hormones:
• norepinephrine, which regulates general-
ized vasoconstriction
(Text continues on page 288.)
4/8/2010 3:10:54 PM
 284 Endocrine system

t
t shee
Chea
Endocrine refresher
ACROMEGALY AND GIGANTISM • Weakness and lethargy
Key signs and symptoms • Weight loss
Acromegaly
Key test results
• Enlarged supraorbital ridge
• Blood chemistry analysis reveals decreased
• Thickened ears and nose
hematocrit; decreased hemoglobin, cortisol,
• Paranasal sinus enlargement
glucose, sodium, chloride, and aldosterone
• Thickening of the tongue
levels; and increased blood urea nitrogen and
Gigantism
potassium levels.
• Abrupt excessive growth in all parts of the body
• Fasting blood glucose analysis reveals hypogly-
Key test results cemia.
• Plasma human growth hormone (hGH) levels • Urine chemistry test shows decreased 17-keto-
measured by radioimmunoassay typically are steroids (17-KS) and 17-hydroxycorticosteroids
elevated. However, because hGH secretion (17-OHCS).
is pulsatile, the results of random sampling • Adrenocorticotropic hormone (ACTH)
may be misleading. Insulin-like growth factor-I (Cortrosyn) stimulation test reveals decreased
(somatomedin-C) levels offer a better screening cortisol response.
alternative.
Key treatments
Key treatments • In adrenal crisis, I.V. hydrocortisone given
• Surgery to remove the affecting tumor (trans- promptly along with 3 to 5 L of saline solution
sphenoidal hypophysectomy) • Glucocorticoids: cortisone, hydrocortisone
• Thyroid hormone replacement therapy after • Mineralocorticoid: fludrocortisone
surgery: levothyroxine (Synthroid) • Dextrose, 50%, to treat hypoglycemia
• Corticosteroid: cortisone
Key interventions
• Dopamine agonist: bromocriptine (Parlodel)
• Be prepared to administer I.V. hydrocortisone
• Somatotropic hormone: octreotide (Sandostatin)
and saline solution promptly if the client is in
Only have time Key interventions adrenal crisis.
for a quick review? • Provide emotional support. • Administer I.V. fluids.
Check out the Cheat
• Perform or assist with range-of-motion • Instruct the client to avoid sitting or standing.
sheet.
exercises. • Monitor glucose levels.
• Be aware of inexplicable mood changes. • Weigh the client daily.
Reassure the family that these mood changes
CUSHING’S SYNDROME
result from the disease and can be modified with
Key signs and symptoms
treatment.
• Amenorrhea
• After surgery, monitor vital signs and neuro-
• Hypertension
logic status.
• Mood swings
• Monitor blood glucose levels.
• Muscle wasting
• Monitor intake and output hourly, watching for
• Weight gain, especially truncal obesity, buffalo
large increases.
hump, and moonface
• Encourage the client to ambulate on the first or
second day after surgery. Key test results
• Blood chemistry analysis shows increased
ADDISON’S DISEASE
cortisol, aldosterone, sodium, corticotropin, and
Key signs and symptoms
glucose levels and a decreased potassium level.
• Hypoglycemia
• Dexamethasone suppression test shows no
• Orthostatic hypotension
decrease in 17-OHCS.

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 Brush up on key concepts 285

Endocrine refresher (continued)

CUSHING’S SYNDROME (CONTINUED)
• Magnetic resonance imaging shows pituitary or adrenal Key test results
tumors. • Blood chemistry analysis shows increased glucose, potassium,
• Urine chemistry shows increased 17-OHCS and 17-KS, chloride, ketone, cholesterol, and triglyceride levels; decreased
decreased urine specific gravity, and glycosuria. carbon dioxide level, and pH less than 7.4.
• Fasting blood glucose level is increased (greater than or equal
Key treatments
to 126 mg/dl).
• Hypophysectomy or bilateral adrenalectomy
• Two-hour postprandial blood glucose level shows hyperglyce-
• Adrenal suppressants: metyrapone (Metopirone), ketoconazole
mia (greater than 200 mg/dl).
(Nizoral), etomidate (Amidate)
• Antidiabetic agents: insulin or oral antidiabetic agents, such Key treatments
as chlorpropamide (Diabinese), glyburide (DiaBeta, Micronase), • Antidiabetic agents: insulins and oral agents, such as
glipizide (Glucotrol), rosiglitazone (Avandia) chlorpropamide (Diabinese), glyburide (DiaBeta, Micronase),
glipizide (Glucotrol), rosiglitazone (Avandia), ritagliptin (Januvia),
Key interventions
piaglitazone (Actose), metformin (Glucophage), exenatide (Byetta)
• Perform postoperative care.
• Assess for edema. Key interventions
• Limit water intake. • Assess acid-base and fluid balance.
• Weigh the client daily. • Monitor for signs of hypoglycemia (vagueness, slow cere-
bration, dizziness, weakness, pallor, tachycardia, diaphoresis,
DIABETES INSIPIDUS
seizures, and coma), ketoacidosis (acetone breath, dehydration,
Key signs and symptoms
weak or rapid pulse, Kussmaul’s respirations), and hyperosmolar
• Polydipsia (excessive thirst, consumption of 4 to 40 L/day)
coma (polyuria, thirst, neurologic abnormalities, stupor).
• Polyuria (greater than 5 L/day)
• Treat hypoglycemia; immediately give carbohydrates in the
Key test results form of fruit juice, hard candy, or honey. If the client is uncon-
• Urine chemistry analysis shows urine specific gravity less than scious, administer glucagon or dextrose I.V.
1.004, osmolality 50 to 200 mOsm/kg, decreased urine pH, and • Administer I.V. fluids, insulin and, usually, potassium
decreased sodium and potassium levels. replacement for ketoacidosis or hyperosmolar coma.
• Monitor wound healing.
Key treatments
• Maintain the client’s diet.
• I.V. therapy: hydration (when first diagnosed, intake and output
• Provide meticulous skin and foot care. Clients with diabetes are
must be matched milliliter to milliliter to prevent dehydration),
at increased risk for infection from impaired leukocyte activity.
electrolyte replacement
• Foster independence.
• Antidiuretic hormone replacement: vasopressin
GOITER
Key interventions
Key signs and symptoms
• Assess fluid balance.
• Single or multinodular, firm, irregular enlargement of the
• Monitor and record vital signs, intake and output (urine output
thyroid gland
should be measured every hour when first diagnosed), urine
• Dizziness or syncope with distended head and jugular veins
specific gravity (check every 1 to 2 hours when first diagnosed),
and dyspnea when the client raises his arms above his head
and laboratory studies.
(Pemberton’s sign)
• Administer I.V. fluids.
• Dysphagia
DIABETES MELLITUS • Dyspnea
Key signs and symptoms
Key test results
• Polydipsia
• Laboratory tests reveal high or normal thyroid-stimulating hor-
• Polyphagia
mone (TSH) levels, low serum thyroxine (T4) concentrations, and
• Polyuria
increased iodine 131 uptake.
• Weight loss
• Ultrasound of thyroid reveals nodules.

(continued)

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 286 Endocrine system

Endocrine refresher (continued)

GOITER (CONTINUED)
Key treatments Key treatments
• Subtotal thyroidectomy • Thyroid hormone replacement: levothyroxine (Synthroid),
• Thyroid hormone replacement: levothyroxine (Synthroid) liothyronine (Cytomel)
Key interventions Key interventions
• Measure the client’s neck circumference. Also check for the • Avoid sedation; administer one-half to one-third the normal
development of hard nodules in the gland. dose of sedatives or opiods. Clients taking warfarin (Coumadin)
• Provide preoperative teaching and postoperative care, if sub- with levothyroxine may require lower doses of warfarin.
total thyroidectomy is indicated. • Check for constipation and edema.
• Administer iodine supplements. • Encourage fluid intake.
HYPERTHYROIDISM METABOLIC SYNDROME
Key signs and symptoms Key signs and symptoms
• Atrial fibrillation • Abdominal obesity (waist of greater than 40" in males, 35" in
• Bruit or thrill over thyroid females)
• Diaphoresis • Blood pressure greater than 130/85 mm Hg
• Palpitations • Fasting blood glucose level greater than 100 mg/dl
• Tachycardia
Key test results
Key test results • Most diagnostic procedures are nonspecific, but may show
• Blood chemistry analysis shows increased triiodothyro- hypertension, diabetes, hyperlipidemia, and hyperinsulinemia.
nine (T3), T4, and free thyroxine levels and decreased TSH and
Key treatments
cholesterol levels.
• Lifestyle modifications, focusing on weight reduction and
• Radioactive iodine uptake (RAIU) is increased.
exercise
Key treatments • Medications for weight loss: orlistat (Xenical), sibutramine
• Radiation therapy (Meridia)
• Thyroidectomy • Antilipemics: simvastatin (Zocor), pravastatin (Pravachol)
• Iodine preparations: potassium iodide (SSKI), radioactive • Gastric bypass for appropriate candidates
iodine
Key interventions
Key interventions • Monitor the client’s blood pressure, blood glucose, blood
• Monitor cardiovascular status. cholesterol, and insulin levels.
• Instruct the client to avoid stimulants, such as caffeine- • Encourage lifestyle modifications related to improving diet and
containing drugs and foods. increasing exercise.
• Administer I.V. fluids. • Schedule follow-up appointments with health care profes-
• Provide postoperative nursing care. sionals.
HYPOTHYROIDISM PANCREATIC CANCER
Key signs and symptoms Key signs and symptoms
• Dry, flaky skin and thinning nails • Dull, intermittent epigastric pain (early in disease)
• Fatigue • Continuous pain that radiates to the right upper quadrant or
• Hypothermia dorsolumbar area; may be colicky, dull, or vague and unrelated
• Menstrual disorders to activity or posture
• Mental sluggishness • Anorexia
• Weight gain or anorexia • Rapid, profound weight loss
• Palpable mass in the subumbilical or left hypochondrial region
Key test results
• Blood chemistry analysis shows decreased T3, T4, free thyrox- Key test results
ine, and sodium levels and increased TSH and cholesterol levels. • Percutaneous fine-needle aspiration biopsy of the pancreas
• RAIU is decreased. may detect tumor cells.

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 Brush up on key concepts 287

Endocrine refresher (continued)

PANCREATIC CANCER (CONTINUED) PHEOCHROMOCYTOMA
• Ultrasound or computed tomography scan identifies Key signs and symptoms
pancreatic mass. • Abdominal pain
• Blood studies reveal increased serum bilirubin levels, • Feeling of impending doom
increased serum amylase and lipase levels, prolonged pro- • Headache
thrombin time, elevated alkaline phosphatase (with biliary • Nausea
obstruction) levels, and elevated aspartate aminotransferase • Persistent or paroxysmal hypertension
and alanine aminotransferase levels (when liver cell necrosis • Tachycardia
is present).
Key test results
• Fasting blood glucose studies may indicate hyperglycemia or
• A 24-hour urine specimen shows increased urinary excretion
hypoglycemia.
of total free catecholamine and their metabolites, vanillylman-
Key treatments delic acid, and metanephrine.
• Blood transfusion
Key treatments
• I.V. fluid therapy
• Surgical removal or tumor
• Whipple’s operation or pancreatoduodenectomy (excision of
• Alpha-adrenergic blocker before surgery
the head of the pancreas along with the encircling loop of the
• I.V. fluids, plasma volume expanders, and blood transfusions
duodenum)
postoperatively
• Antineoplastic combinations: fluorouracil, streptozocin
• I.V. phentolamine or nitroprusside (acute hypertensive crisis)
(Zanosar), ifosfamide (Ifex), and doxorubicin; gemcitabine and
erlitinib (Tarceva) Key interventions
• Insulin after pancreatic resection to provide adequate exoge- • Carefully monitor the client’s blood pressure and vital signs.
nous insulin supply • Instruct the client to avoid food high in vanillin (coffee, nuts,
• Opioid analgesics: morphine, meperidine (Demerol), and chocolate) for 2 days before 24-urine test.
codeine, which can lead to biliary tract spasm and increase • Provide a quiet room after surgery to decrease excitement,
common bile duct pressure (used only when other methods which can trigger a hypertensive crisis.
fail) • If autosomal dominant transmission of pheochromocytoma is
• Pancreatic enzyme: pancrelipase (Pancrease) suspected, inform the client’s family of the need for evaluation.
Key interventions THYROID CANCER
• Monitor fluid balance, abdominal girth, metabolic state, and Key signs and symptoms
weight daily. • Dyspnea
• Replace nutrients I.V., orally, or by nasogastric tube. Impose • Enlarged thyroid gland
dietary restrictions, such as a low-sodium or fluid retention diet • Hoarseness
as required. Maintain a 2,500 calorie diet for the client. • Painless, firm, irregular, and enlarged thyroid nodule or mass
• Administer pain medication, antibiotics, and antipyretics, as
Key test results
necessary.
• Blood chemistry analysis shows increased calcitonin,
• Monitor for signs of hypoglycemia or hyperglycemia; adminis-
serotonin, and prostaglandin levels.
ter glucose or an antidiabetic agent as necessary. Monitor blood
• RAIU shows a “cold,” or nonfunctioning, nodule.
glucose levels.
• Thyroid biopsy shows cytology positive for cancer cells.
• Provide emotional support.
Before surgery Key treatments
• Give blood transfusions, vitamin K , antibiotics, and gastric • Radiation therapy
lavage, as necessary. • Radioactive iodine therapy
After surgery • Thyroidectomy (total or subtotal); total thyroidectomy and
• Administer an oral pancreatic enzyme at mealtimes, if radical neck excision
needed.

(continued)

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 288 Endocrine system

Endocrine refresher (continued)

THYROID CANCER (CONTINUED)
Key interventions
• Monitor respiratory status for signs of airway obstruction.
• Assess the client’s ability to swallow.
• Provide postoperative thyroidectomy care.
THYROIDITIS
Key signs and symptoms
• Thyroid enlargement
• Fever
• Pain
• Tenderness and reddened skin over the gland
Key test results
Note: Precise diagnosis depends on the type of thyroiditis.
• In autoimmune thyroiditis, high titers of thyroglobulin and
microsomal antibodies may be present in serum.
• In subacute granulomatous thyroiditis, tests may reveal
elevated erythrocyte sedimentation rate, increased thyroid hor-
mone levels, and decreased thyroidal RAIU.
• In chronic infective and noninfective thyroiditis, varied findings
occur, depending on the underlying infection or other disease.
Key treatments
• Partial thyroidectomy to relieve tracheal or esophageal
compression in Riedel’s thyroiditis
• Thyroid hormone replacement: levothyroxine (Synthroid) for
accompanying hypothyroidism
Key interventions
• Monitor vital signs and examine the client’s neck for unusual
swelling, enlargement, or redness.
• If the neck is swollen, measure and record the circumference
daily.
After thyroidectomy
• Monitor vital signs every 15 to 30 minutes until the client’s
condition stabilizes. Stay alert for signs of tetany secondary to
accidental parathyroid injury during surgery. Keep 10% calcium
gluconate available for I.M. use, if needed.
• Assess dressings frequently for excessive bleeding.
• Monitor for signs of airway obstruction, such as difficulty
talking and increased swallowing; keep tracheotomy equipment
handy.

• epinephrine, which regulates instantane-

Power to the
pancreas! ous stress reaction and increases metabolism,
blood glucose levels, and cardiac output.
Endo and exo
The pancreas is an accessory gland of diges-
tion. In its exocrine function, it secretes
digestive enzymes (amylase, lipase, and
trypsin). Amylase breaks down starches
into smaller carbohydrate molecules. Lipase
breaks down fats into fatty acids and glyc-
erol. Trypsin breaks down proteins. Note that
exocrine glands discharge secretions through
a duct; the pancreas secretes enzymes into
the duodenum through the pancreatic duct.
In its endocrine function, the pancreas
secretes hormones from the islets of Langer-
hans (insulin, glucagon, and somatostatin).
Insulin regulates fat, protein, and carbohy-
drate metabolism and lowers blood glucose
levels by promoting glucose transport into
cells. Glucagon increases blood glucose
levels by promoting hepatic glyconeogenesis.
Somatostatin inhibits the release of insulin,
glucagon, and somatotropin. Note that
endocrine glands discharge secretions into
the blood or lymph.
Keep abreast of
diagnostic tests
Below are the major diagnostic tests for assess-
ing endocrine disorders as well as common
nursing actions associated with each test.
Draw blood and test, part 1
Blood chemistry tests are used to ana-
lyze blood samples for levels of potassium,
sodium, calcium, phosphorus, glucose,
bicarbonate, blood urea nitrogen (BUN),
creatinine, protein, albumin, osmolality,
amylase, lipase, alkaline phosphatase, lac-
tate dehydrogenase, aldosterone, cortisol,
ketones, cholesterol, triglycerides, and
carbon dioxide.
Nursing actions
• Explain the procedure to the client.
• Check the venipuncture site for bleeding.
Draw blood and test, part 2
A hematologic study analyzes a blood
sample for red blood cells (RBCs), white

313419NCLEX-RN_Chap09.indd 288 4/8/2010 3:10:55 PM


blood cells (WBCs), platelets, prothrombin
time, international normalized ratio, partial
thromboplastin time, hemoglobin (Hb) levels,
and hematocrit (HCT).
Nursing actions
• Explain the procedure to the client.
• Note current drug therapy.
• Check the venipuncture site for bleeding.
Fast and test
The fasting blood glucose test measures
plasma glucose levels following a minimum
8-hour fast.
Nursing actions
• Explain the procedure to the client.
• Withhold food and fluids for at least
8 hours before the fasting sample is drawn.
• Withhold insulin until the test is
completed.
Eat carbs and test
In a 2-hour postprandial glucose test, a
blood sample is used to analyze the body’s
insulin response to carbohydrate ingestion.
Nursing actions
• Explain the procedure to the client.
• List any medications that might interfere
with the test.
• Note pregnancy, trauma, or infectious
disease.
• Provide the client with a 100 g carbohy-
drate diet before the test and then ask him to
fast for 2 hours.
• Instruct the client to avoid tobacco, caf-
feine, alcohol, and exercise after the meal.
Carb absorption assessment
The glucose tolerance test (GTT) uses
blood samples and urine specimens to mea-
sure carbohydrate absorption.
Nursing actions
• Explain the procedure to the client.
• List any medications that might interfere
with the test.
• Note pregnancy, trauma, or infectious
disease.
• Provide the client with a high-carbohydrate
diet for 3 days.
313419NCLEX-RN_Chap09.indd 289
Keep abreast of diagnostic tests 289
• Instruct the client to fast for 10 to 16 hours Oui! In the 2-hour
before the test. postprandial test,
• Advise the client not to use tobacco, drink a blood sample is
coffee or alcohol, or exercise strenuously for used to determine
8 hours before or during the test. the body’s insulin
• Withhold any medications that may inter- response to carbs
like me!
fere with testing.
• Draw a fasting blood sample and have the
client provide a urine specimen at the same
time.
• Administer the test dose of oral glucose
and record the time of administration.
• Request laboratory collection of serum
glucose samples and urine specimens at 30,
60, 120, and 180 minutes.
• Refrigerate samples and specimens and
assess the client for hypoglycemia.
Months of blood glucose levels
Glycosylated hemoglobin (HbA1C) testing
uses a blood sample to measure glycosylated
Hb levels. This provides information about
average blood glucose levels during the pre-
ceding 2 to 3 months. This test is used to eval-
uate the long-term effectiveness of diabetes
therapy.
Nursing actions
• Explain the procedure to the client.
• Explain to the client that this test is used
to evaluate diabetes therapy.
• Tell the client that he need not restrict
food or fluids and instruct him to maintain his
prescribed medication and diet regimen.
Checking for cortisol
The ACTH (corticotropin) stimulation
test analyzes blood samples for cortisol aned
measures the ability of the adrenal cortex to
respond to ACTH.
Nursing actions
• Explain the procedure to the client.
• List any medications that might interfere
with the test.
• Know that this test is contraindicated in
pregnant clients.
• Monitor 24-hour I.V. infusion of cortico-
tropin after the baseline serum sample is
drawn.
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 290 Endocrine system
Blood and Blood analysis (with drug)
urine testing The dexamethasone suppression test,
reveal volumes of which involves administration of dexametha-
information on sone, is used to measure the response of the
endocrine disorders. adreanal glands to ACTH.
Nursing actions
• Explain the procedure to the client.
• On the first day, give the client 1 mg of
dexamethasone at 11 p.m.
• On the next day, collect blood samples at
4 p.m. and 11 p.m.
• Monitor the venipuncture site; if a hema-
toma develops, apply warm soaks.
• List any medications that might interfere
with the test.
• Collect urine specimens as ordered for
3 days.
Urine analysis (24-hour collection)
The 24-hour urine test for 17-ketoste-
roids (17-KS) and 17-hydroxycortico-
steroids (17-OHCS) is a quantitative
laboratory analysis of urine collected over
24 hours to determine hormone precursors.
Nursing actions
• Explain the procedure to the client.
• Withhold all medications for 48 hours
before the test.
• Instruct the client to void and note the
time (collection of urine starts with the next
The sella turcica
is located in a voiding).
depression at the • Place the urine container on ice.
base of the skull • Measure each voided urine collection.
and contains the • If done on an outclient basis, instruct
pituitary gland. the client about how to collect the 24-hour
specimen.
• List any medications that might interfere
with the test.
Epinephrine exam
The urine vanillylmandelic acid test is a
quantitative analysis of urine collected over
24 hours to determine the end products of
catecholamine metabolism (epinephrine and
norepinephrine).
Nursing actions
• Explain the procedure to the client.
• List any medications, previous tests, and
medical conditions that might interfere with
the test.
313419NCLEX-RN_Chap09.indd 290
• Restrict foods that contain vanilla, coffee,
tea, citrus fruits, bananas, nuts, and chocolate
for 3 days before test.
• Hold any medications that might interfere
with testing, such as antihypertensives and
aspirin.
• Instruct the client to void and note the
time (collection of urine starts with the next
voiding).
• Place the urine container on ice.
• Measure each voided urine.
Oxygen in, calories used
The BMR test is an indirect, noninvasive
measurement of BMR. The test measures
oxygen consumed by the body during a given
time and evaluates caloric expenditure in a
24-hour period.
Nursing actions
• Explain the procedure to the client.
• List medications taken before the procedure.
• Note environmental and emotional
stressors.
Inspecting the abdomen
Computed tomography (CT) scan allows
visualization of the sella turcica and abdomen.
Nursing actions
• Explain the procedure to the client.
• Note the client’s allergies to iodine, sea-
food, and radiopaque dyes.
• Instruct the client to fast for 4 hours before
the procedure.
• Ensure informed consent has been
obtained per facility policy.
Echo exam
Ultrasonography allows visualization of the
thyroid, pelvis, and abdomen through the use
of reflected sound waves.
Nursing actions
• Explain the procedure to the client.
• Assess whether the client can lie still
during the procedure.
Taking thyroid tissue
A closed percutaneous thyroid biopsy
uses the percutaneous, sterile aspiration of a
small amount of thyroid tissue for histologic
evaluation.
4/8/2010 3:10:56 PM
 Polish up on client care 291

Nursing actions • Remove dentures, jewelry, and other mate-

Before the procedure rials that may interfere with imaging.
• Explain the procedure to the client. After the procedure
• Withhold food and fluids after midnight. • Tell the client he may resume his usual Memory
• Obtain the client’s written, informed medications and diet. jogger
consent. To recall
After the procedure Artery assessment inter-
• Maintain bed rest for 24 hours. Arteriography gives a fluoroscopic examina- ventions for
• Monitor vital signs. tion of the arterial blood supply to the para- Sulkowitch’s test,
• Assess for esophageal or tracheal puncture thyroid, adrenal, and pancreatic glands. remember that
and bleeding or respiratory distress caused
hyper- comes
before hypo-
by hematoma or edema. Nursing actions alphabetically. Then
Before the procedure remember to collect
Thyroid function test • Explain the procedure to the client. a urine specimen
A thyroid uptake, also called radioactive • Check for written, informed consent. before a meal for
iodine uptake or RAIU, measures the • Note the client’s allergies to iodine, sea- hypercalcemia
amount of radioactive iodine taken up by the food, and radiopaque dyes. and after for
hypocalcemia.
thyroid gland in 24 hours. This measurement • Withhold food and fluids after midnight.
gives the physician an indication of thyroid After the procedure
function. • Monitor vital signs.
• Check the insertion site for bleeding and
Nursing actions assess pulses distal to the site.
• Explain the procedure to the client.
• Instruct the client not to ingest iodine-rich Counting calcium
foods for 24 hours before the test. Urine calcium (Sulkowitch’s test) analyzes
• Discontinue all thyroid and cough medica- urine to measure the amount of calcium being
tions 7 to 10 days before the test. excreted.

Radiograph of the ‘roid Nursing actions

A thyroid scan gives visual imaging of radio-
activity distribution in the thyroid gland. The
physician uses these results to assess size,
shape, position, and anatomic function of the
thyroid.
• Explain the procedure to the client.
• If hypercalcemia is indicated, collect a
single urine specimen before a meal.
• If hypocalcemia is indicated, collect a
single urine specimen after a meal.

Nursing actions
Before the procedure
• Explain the procedure to the client.
• If iodine123 (123I) or 131I is to be used, tell
the client to fast after midnight the night
before the test. Fasting isn’t required if an
I.V. injection of isotope technetium (99mTc)
pertechnetate is used.
• Hold any medications that may interfere
with the procedure.
• Instruct the client to stop consuming
iodized salt, iodinated salt substitutes, and
seafood 1 week before the procedure.
• Imaging follows oral administration (123I
or 131I) by 24 hours and I.V. injection (99mTc
pertechnetate) by 20 to 30 minutes.
Polish up on client care
Major endocrine disorders include acromegaly
and gigantism, Addison’s disease, Cushing’s
syndrome, diabetes insipidus, diabetes mellitus,
goiter, hyperthyroidism, hypothyroidism, met-
abolic syndrome, pancreatic cancer, pheochro-
mocytoma, and thyroid cancer.
Acromegaly and gigantism
Acromegaly and gigantism are marked by
hormonal dysfunction and startling skeletal
overgrowth. Both are chronic, progressive

313419NCLEX-RN_Chap09.indd 291 4/8/2010 3:10:57 PM

 292 Endocrine system

It’s a question of diseases that occur when the pituitary gland
timing. Acromegaly produces too much GH, causing excessive
may occur any time growth. Acromegaly develops slowly; gigan-
after adolescence, tism develops abruptly.
when the arms and Acromegaly occurs after epiphyseal
legs have stopped closure, causing bone thickening and
growing. Gigantism
transverse growth and visceromegaly (enlarge-
begins in childhood
or adolescence when ment of the viscera). In other words, acro-
the arms and legs megaly may occur any time after adolescence,
are still growing. when the arms and legs have stopped growing.
Signs of this disorder include swelling and
enlargement of the arms, legs, and face.
Gigantism begins before epiphyseal clo-
sure and causes proportional overgrowth of
all body tissues. In other words, gigantism
begins in childhood or adolescence when the
arms and legs are still growing. That’s why
these clients may attain giant proportions.
DIAGNOSTIC TEST RESULTS
• Plasma hGH levels measured by radio-
immunoassay typically are elevated. How-
ever, because hGH secretion is pulsatile,
the results of random sampling may be
misleading. Insulin-like growth factor-I
(somatomedin-C) levels offer a better screen-
ing alternative.
• Glucose normally suppresses hGH
secretion; therefore, a glucose infusion that
doesn’t suppress the hormone level to below
the accepted normal value of 2 ng/ml, when
combined with characteristic clinical features,
strongly suggests hyperpituitarism.
• Skull X-rays, a CT scan, arteriography, and
magnetic resonance imaging (MRI) deter-
mine the presence and extent of the pituitary
lesion.

CAUSES NURSING DIAGNOSES

• Oversecretion of human growth hormone • Disturbed body image
(hGH) • Chronic pain
• Tumors of the anterior pituitary gland • Impaired physical mobility
(which lead to oversecretion of hGH) • Fatigue
• Activity intolerance
ASSESSMENT FINDINGS • Decreased cardiac output
Acromegaly
• Gradual development TREATMENT
• Enlarged supraorbital ridge • Surgery to remove the affecting tumor
• Head enlargement (transsphenoidal hypophysectomy)
• Thickened ears and nose • Pituitary radiation therapy
• Marked prognathism (projection of the
Think about jaw) that may interfere with chewing Drug therapy
therapeutic
• Laryngeal hypertrophy • Thyroid hormone replacement therapy
communication.
The client needs • Paranasal sinus enlargement after surgery: levothyroxine (Synthroid)
help coping with his • Thickening of the tongue • Corticosteroid: cortisone
body image as well • Oily skin • Dopamine agonist: bromocriptine
as mood changes • Diaphoresis (Parlodel)
brought on by the • Severe headache • Somatotropic hormone: octreotide
disorder. • Bitemporal hemianopia (Sandostatin)
• Loss of visual acuity
• Blindness may occur INTERVENTIONS AND RATIONALES
• Provide emotional support to help the
Gigantism client cope with his body image. Grotesque body
• Abrupt, excessive growth in all parts of the changes characteristic of this disorder can cause
body; height increases as much as 6 (15.2 severe psychological stress.
cm) per year; infants and children up to three • Administer prescribed medications to
times the normal height for their age; adults improve the client’s condition.
taller than 6 8 (203 cm)

313419NCLEX-RN_Chap09.indd 292 4/8/2010 3:10:57 PM


• Perform or assist with range-of-motion
(ROM) exercises to promote maximum joint
mobility.
• Evaluate muscular weakness, especially in
the client with late-stage acromegaly. Check
the strength of his grasp to monitor for disease
progression. If it’s weak, help with tasks such
as cutting food.
• Provide skin care. Avoid using an oily
lotion because the skin is already oily.
• Monitor blood glucose levels to detect early
signs of hyperglycemia. Monitor for signs of
hyperglycemia (fatigue, polyuria, polydipsia)
to avoid treatment delay.
• Be aware of inexplicable mood changes.
Reassure the family that these mood changes
result from the disease and can be modified
with treatment to help the family cope with the
client’s illness.
• Before surgery, reinforce what the sur-
geon has told the client, if possible, and
provide a clear and honest explanation of the
scheduled operation to allay the client’s fears
and anxiety.
• If the client is a child, explain to his
parents that such surgery prevents permanent
soft-tissue deformities but won’t correct bone
changes that have already taken place.
• Arrange for counseling, if necessary, to
help the child and parents cope with permanent
defects.
• After surgery, monitor vital signs and
neurologic status to detect signs of an increase
in intracranial pressure due to intracranial
bleeding or cerebral edema.
• Monitor blood glucose levels. hGH levels
usually fall rapidly after surgery, removing an
insulin antagonist effect in many clients and
possibly precipitating hypoglycemia.
• Monitor intake and output hourly, watch-
ing for large increases. Transient diabetes
insipidus, which sometimes occurs after surgery
for hyperpituitarism, can cause such increases
in urine output.
• If the transsphenoidal approach is used,
a large nasal pack should be kept in place
for several days. Because the client must
breathe through his mouth, provide good
mouth care to prevent breakdown of the oral
mucosa.
313419NCLEX-RN_Chap09.indd 293
Polish up on client care 293
• The surgical site is packed with a piece of A client with
tissue generally taken from a mid-thigh donor acromegaly should
site. Monitor for cerebrospinal fluid (CSF) be periodically
leaks from the packed site. Look for increased screened for colon
external nasal drainage or drainage into the polyps—incidence
nasopharynx. CSF leaks may necessitate of polyps increases
with chronic hGH
additional surgery to repair the leak. These
elevation.
measures detect complications quickly and
avoid treatment delays.
• Encourage the client to ambulate on the
first or second day after surgery to prevent
complications of immobility.
Teaching topics
• Explanation of the disorder and treatment
plan
• Receiving follow-up checkups (there’s a
slight chance that the tumor that caused his
condition could recur)
• Medication use and possible adverse
effects, including continuing hormone
replacement therapy following surgery (warn
against stopping the hormones suddenly)
• Wearing a medical identification bracelet
at all times and bringing his hormone
replacement schedule with him whenever he
returns to the facility
Addison’s disease
Addison’s disease, also known as adrenal In Addison’s
hypofunction, occurs when the adrenal gland disease, the adrenal
fails to secrete sufficient mineralocorticoids, glands don’t secrete
glucocorticoids, and androgens. enough steroid
Addisonian crisis (adrenal crisis) is a hormones.
critical deficiency of mineralocorticoids
and glucocorticoids. It generally occurs
in clients who have chronic adrenal insuf-
ficiency and follows acute stress, sepsis,
trauma, surgery, or omission of steroid
therapy. Addisonian crisis is a medical
emergency that necessitates immediate,
vigorous treatment.
CAUSES
• Autoimmune disease
• Histoplasmosis
• Idiopathic atrophy of adrenal glands
• Metastatic lesions from lung cancer
4/8/2010 3:10:58 PM
 294 Endocrine system
• Pituitary hypofunction
• Surgical removal of adrenal glands
• Trauma
• Tuberculosis
ASSESSMENT FINDINGS
• Anorexia, diarrhea, and nausea
• Bronzed skin pigmentation on nipples,
scars, and buccal mucosa
• Decreased pubic and axillary hair
• Dehydration and thirst
• Depression and personality changes
• Hypotension
• Hypoglycemia
• Orthostatic hypotension
• Weakness and lethargy
• Weight loss
DIAGNOSTIC TEST RESULTS
• Blood chemistry analysis reveals
decreased HCT; decreased Hb, cortisol,
glucose, sodium, chloride, and aldosterone
levels; and increased BUN and potassium
levels.
• BMR is decreased.
• Electrocardiogram demonstrates pro-
longed PR and QT intervals.
• Fasting blood glucose analysis reveals
hypoglycemia.
• Urine chemistry shows decreased 17-KS
and 17-OHCS.
• Abdominal X-ray may show adrenal calcifi-
cation.
• Abdominal CT scan may show adrenal cal-
For adrenal cification, enlargement, or atrophy.
crisis, take • ACTH (Cortrosyn) stimulation test reveals
emergency action— decreased cortisol response.
I.V. hydrocortisone
with 3 to 5 L of
saline solution.
NURSING DIAGNOSES
• Deficient fluid volume
• Imbalanced nutrition: Less than body
requirements
• Risk for infection
TREATMENT
• High-carbohydrate, high-protein, high-
sodium, low-potassium diet in small, fre-
quent feedings before steroid therapy; high-
potassium and low-sodium diet while on
steroid therapy
• In adrenal crisis, I.V. hydrocortisone
administered promptly along with 3 to 5 L of
normal saline solution
313419NCLEX-RN_Chap09.indd 294
Drug therapy
• Antacids: magnesium and aluminum
hydroxide (Maalox), aluminum hydroxide gel
• Glucocorticoids: cortisone, hydrocortisone
• Mineralocorticoid: fludrocortisone
• Vasopressor: norepinephrine (Levophed)
• Dextrose, 50%, to treat hypoglycemia
INTERVENTIONS AND RATIONALES
• Be prepared to administer I.V. hydrocor-
tisone and saline solution promptly if the
client is in adrenal crisis to reverse shock and
hyponatremia.
• Monitor cardiac rhythm during adrenal
crisis or electrolyte imbalance to detect
arrhythmias.
• Assess fluid balance (and increase in fluid
intake in hot weather) to prevent addisonian
crisis, which may be precipitated by salt or fluid
loss in hot weather and during exercise.
• Monitor and record vital signs, intake and
output, urine specific gravity, and laboratory
studies to assess for deficient fluid volume.
• Maintain the client’s diet to promote nutri-
tional balance.
• Administer I.V. fluids to maintain
hydration and prevent addisonian crisis.
• Weigh the client daily to determine nutri-
tional status and detect fluid loss.
• Administer medications, as prescribed, to
maintain or improve the client’s condition.
• Instruct the client to avoid sitting or
standing to avoid orthostatic hypotension.
• Encourage fluid intake to improve fluid
status and prevent addisonian crisis.
• Monitor glucose levels to check response to
glucocorticoids.
• Assist with activities of daily living to con-
serve energy and decrease metabolic demands.
• Maintain a quiet environment to conserve
energy and decrease metabolic demands.
Teaching topics
• Explanation of the disorder and treatment
plan
• Medication use and possible adverse
effects
• Recognizing the signs and symptoms of
adrenal crisis (profound weakness, fatigue,
nausea, vomiting, hypotension, dehydration
and, occasionally, high fever followed by
hypothermia)
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 Polish up on client care 295

• Carrying injectable dexamethasone DIAGNOSTIC TEST RESULTS

• Avoiding over-the-counter drugs unless • Blood chemistry analysis shows increased
approved by the physician cortisol, aldosterone, sodium, corticotropin,
• Avoiding strenuous exercise, particularly and glucose levels and a decreased potassium
in hot weather level.
• CT scan shows pituitary or adrenal
tumors.
Cushing’s syndrome • Dexamethasone suppression test shows The signs of
no decrease in 17-OHCS. Cushing’s syndrome
Cushing’s syndrome, also known as hyper- • GTT shows hyperglycemia. are distinctive.
cortisolism, is characterized by hyperactivity • Hematology shows increased WBC and Let’s see…rapidly
of the adrenal cortex. It results in excessive RBC counts and decreased eosinophil count. developing fatty
secretion of glucocorticoids, particularly cor- • MRI shows pituitary or adrenal tumors. tissue in the face,
neck, and trunk and
tisol. An increase in mineralocorticoids and • Ultrasonography shows pituitary or
purple streaks on
sex hormones may also occur. adrenal tumors. the skin.
• Urine chemistry shows increased
CAUSES 17-OHCS and 17-KS, decreased urine specific
• Adenoma or carcinoma of the adrenal gravity, and glycosuria.
cortex • X-ray shows pituitary or adrenal tumor and
• Adenoma or carcinoma of the pituitary osteoporosis.
gland
• Excessive or prolonged administration of NURSING DIAGNOSES
glucocorticoids or corticotropin • Risk for activity intolerance
• Exogenous secretion of corticotropin by • Disturbed body image
malignant neoplasms in the lungs or gall- • Deficient fluid volume
bladder • Impaired skin integrity
• Hyperplasia of the adrenal glands
• Hypothalamic stimulation of the pituitary TREATMENT
gland • Hypophysectomy or bilateral adrenal-
ectomy
ASSESSMENT FINDINGS • Glucose level monitoring
• Acne • Low-sodium, low-carbohydrate, low-
• Amenorrhea calorie, high-potassium, high-protein diet
• Decreased libido • Radiation therapy
• Ecchymosis • Potassium supplements: potassium
• Edema chloride (K-Lor), potassium gluconate (Kaon)
• Enlarged clitoris
• Fragile skin Drug therapy
• Gynecomastia • Adrenal suppressants: metyrapone (Meto-
• Hirsutism pirone), ketoconazole (Nizoral), etomidate
• Hyperglycemia (Amidate)
• Hypertension • Antidiabetic agents: insulin or oral
• Mood swings antidiabetic agents, such as chlorpropamide
• Muscle wasting (Diabinese), glyburide (DiaBeta, Micro-
• Pain in joints nase), glipizide (Glucotrol), rosiglitazone
• Poor wound healing (Avandia)
• Purple striae on abdomen • Diuretics: furosemide (Lasix), ethacrynic
• Recurrent infections acid (Edecrin)
• Weakness and fatigue
• Weight gain, particularly truncal obesity,
buffalo hump, and moonface

313419NCLEX-RN_Chap09.indd 295 4/8/2010 3:10:59 PM

 296 Endocrine system
INTERVENTIONS AND RATIONALES
• Perform postoperative care to prevent
complications.
• Assess fluid balance to detect fluid deficit or
overload.
• Monitor and record vital signs, intake and
output, urine specific gravity, capillary blood
glucose levels, urine glucose and ketones,
and laboratory studies. Changed parameters
may indicate altered fluid or electrolyte status.
• Assess for edema to detect signs of excess
fluid volume.
• Apply antiembolism stockings to promote
venous return and prevent thromboembolism
formation.
• Maintain the client’s diet to maintain nutri-
tional status.
• Maintain standard precautions to protect
the client from infection.
• Provide meticulous skin care and reposi-
tion the client every 2 hours to prevent skin
breakdown.
• Limit water intake to prevent excess fluid
volume.
• Weigh the client daily to detect fluid reten-
tion.
• Administer medications, as prescribed, to
Because maintain or improve the client’s condition.
diabetes insipidus • Provide emotional support and encourage
commonly affects the client to express his feelings about
fluid balance, changes in body image and sexual function to
monitoring fluid help him cope effectively.
status is a key
• Provide rest periods to prevent fatigue.
element of client
care. • Provide postradiation nursing care to pre-
vent complications.
Teaching topics
• Explanation of the disorder and treatment
plan
• Medication use and possible adverse
effects, including recognizing signs of inad-
equate steroid dosage (fatigue, weakness,
dizziness) and overdosage (severe edema,
weight gain) and avoiding discontinuing ste-
roid dosage
• Recognizing the signs and symptoms of
infection and fluid retention
• Avoiding exposure to people with
infections
• Self-monitoring for infection
313419NCLEX-RN_Chap09.indd 296
• Carrying a medical identification card
and immediately reporting infections, which
necessitate increased steroid dosage
Diabetes insipidus
Diabetes insipidus stems from a deficiency of
ADH (vasopressin) secreted by the posterior
lobe of the pituitary gland. Decreased ADH
reduces the ability of distal and collecting
renal tubules in the kidneys to concentrate
urine, resulting in excessive urination, exces-
sive thirst, and excessive fluid intake.
CAUSES
• Brain surgery
• Head injury
• Idiopathy
• Meningitis
• Trauma to the posterior lobe of the
pituitary gland
• Tumor of the posterior lobe of the pituitary
gland
ASSESSMENT FINDINGS
• Dehydration
• Fatigue
• Headache
• Hypotension
• Muscle weakness and pain
• Polydipsia (excessive thirst, consumption
of 4 to 40 L/day)
• Polyuria (greater than 5 L/day)
• Tachycardia
• Weight loss
DIAGNOSTIC TEST RESULTS
• Blood chemistry shows decreased ADH by
radioimmunoassay and increased potassium,
sodium, and osmolality levels.
• Urine chemistry analysis shows urine
specific gravity less than 1.004, osmolality 50
to 200 mOsm/kg, decreased urine pH, and
decreased sodium and potassium levels.
NURSING DIAGNOSES
• Deficient fluid volume
• Impaired oral mucous membrane
• Risk for imbalanced body temperature
4/8/2010 3:10:59 PM
 Polish up on client care 297

TREATMENT action, and rate of insulin use. There are sev-

• I.V. therapy: hydration (when first diag- eral types of diabetes mellitus.
nosed, intake and output must be matched Type 1 (insulin-dependent diabetes
milliliter to milliliter to prevent dehydration), mellitus) usually develops in childhood.
electrolyte replacement Type 2 (non–insulin-dependent diabetes
• Regular diet with restriction of foods that mellitus) usually develops after age 30;
exert a diuretic effect however, it’s becoming more prevalent in chil-
dren and young adults. Gestational diabetes
Drug therapy mellitus occurs with pregnancy. Secondary
• ADH replacement: vasopressin diabetes is induced by trauma, surgery,
• ADH stimulant: carbamazepine (Tegretol) pancreatic disease, or medications and can be
• Antidiabetic agent: chlorpropamide treated as type 1 or type 2.
(Diabenese) (promotes renal response to
ADH) CAUSES
• Autoimmune disease
INTERVENTIONS AND RATIONALES • Blockage of insulin supply
• Assess fluid balance to avoid dehydration. • Failure of body to produce insulin
• Monitor and record vital signs, intake and • Hyperpituitarism
output (urine output should be measured • Hyperthyroidism
every hour when first diagnosed), urine • Infection
specific gravity (check every 1 to 2 hours
when first diagnosed), and laboratory studies CONTRIBUTING FACTORS
to assess for deficient fluid volume. • Cushing’s syndrome
• Maintain the client’s diet to maintain nutri- • Exposure to chemicals
tional balance. • Genetics
• Encourage fluid intake to keep intake equal • Medications
to output and prevent dehydration. • Pregnancy
• Administer I.V. fluids to replace fluid and • Receptor defect in normally insulin-
electrolyte loss. responsive cells
• Maintain the patency of the indwelling • Obesity
urinary catheter to allow accurate measuring • Stress
of urine output. • Surgery
• Administer medications, as prescribed, to • Trauma In diabetes
enable the client to concentrate urine and pre- mellitus, the body
produces little or
vent dehydration. ASSESSMENT FINDINGS no insulin or resists
• Weigh the client daily to detect fluid loss. • Acetone breath the insulin it does
• Anorexia produce.
Teaching topics • Atrophic muscles
• Explanation of the disorder and treatment • Blurred vision
plan • Dehydration
• Medication use and possible adverse • Fatigue
effects • Flushed, warm, smooth, shiny skin
• Recognizing the signs and symptoms of • Kussmaul’s respirations
dehydration • Mottled extremities
• Increasing fluid intake in hot weather • Multiple infections and boils
• Carrying medications at all times • Pain
• Paresthesia
• Peripheral and visceral neuropathies
Diabetes mellitus • Polydipsia
• Polyphagia
Diabetes mellitus is a chronic disorder result- • Polyuria
ing from a disturbance in the production,

313419NCLEX-RN_Chap09.indd 297 4/8/2010 3:10:59 PM

 298 Endocrine system

• Poor wound healing ensure early intervention and prevent compli-

• Retinopathy cations.
• Sexual dysfunction • Treat hypoglycemia; immediately give
Memory • Weakness carbohydrates in the form of fruit juice, hard
jogger • Weight loss candy, or honey. If the client is unconscious,
To remem- administer glucagon or dextrose I.V. to pre-
ber the DIAGNOSTIC TEST RESULTS vent neurologic complications.
classic signs of • Blood chemistry analysis shows increased • Administer I.V. fluids, insulin and, usually,
diabetes, think of glucose, potassium, chloride, ketone, cho- potassium replacement for ketoacidosis or
the 3 Ps: lesterol, and triglyceride levels; decreased hyperosmolar coma to reduce the risk of poten-
Polydipsia: exces- carbon dioxide level; and pH less than 7.4. tially life-threatening complications.
sive thirst • Fasting blood glucose level is increased • Monitor and record vital signs, intake and
(greater than or equal to 126 mg/dl). output, capillary blood glucose levels, and
Polyphagia: exces-
• HbA1c is increased to 7 or above. laboratory studies to assess fluid and electrolyte
sive hunger
• GTT shows hyperglycemia. balance.
Polyuria: excessive • Two-hour postprandial blood glucose test • Monitor wound healing to assess for infec-
urination. shows hyperglycemia (greater than 200 mg/dl). tion.
• Urine chemistry shows increased glucose • Maintain the client’s diet to prevent compli-
and ketone levels. cations of diabetes, such as hyperglycemia and
hypoglycemia.
NURSING DIAGNOSES • Encourage fluid intake to maintain the
• Imbalanced nutrition: More than body client’s hydration.
requirements • Administer medications as prescribed.
• Risk for deficient fluid volume Diabetic control requires a dynamic balance
• Risk for impaired skin integrity between diet, the antidiabetic agent, and
• Anxiety exercise.
• Encourage the client to express feelings
TREATMENT about his diet, medication regimen, and body
• Dietary modifications image changes to facilitate coping mecha-
• Exercise nisms.
• Pancreas transplantation • Encourage exercise, as tolerated, to pre-
vent long-term complications of diabetes.
Drug therapy • Weigh the client weekly to determine nutri-
Remember, • Antidiabetic agents: insulins and oral tional status.
positive thinking
has a lot of power. agents, such as chlorpropamide (Diabinese), • Provide meticulous skin and foot care.
Repeat to yourself, glyburide (DiaBeta, Micronase), glipiz- Clients with diabetes are at increased risk for
I WILL PASS THE ide (Glucotrol), rosiglitazone (Avandia), infection from impaired leukocyte activity.
EXAM! ritagliptin (Januvia), piaglitazone (Actose), These health care practices minimize the risk of
metformin (Glucophage), exenatide (Byetta) infection and promote early detection of health
• Vitamin and mineral supplements (see problems.
Treating diabetes) • Maintain a warm and quiet environment to
provide rest and reduce metabolic demands.
INTERVENTIONS AND RATIONALES • Foster independence to promote self-esteem.
• Assess acid-base and fluid balance to mon- • Assess the client’s compliance to diet,
itor for signs of hyperglycemia. exercise, and medication regimens to help
• Monitor for signs of hypoglycemia (vague- develop appropriate interventions.
ness, slow cerebration, dizziness, weakness,
pallor, tachycardia, diaphoresis, seizures, and Teaching topics
coma), ketoacidosis (acetone breath, dehy- • Explanation of the disorder and treatment
dration, weak or rapid pulse, Kussmaul’s res- plan
pirations), and hyperosmolar coma (polyuria, • Medication use and possible adverse
thirst, neurologic abnormalities, stupor) to effects

313419NCLEX-RN_Chap09.indd 298 4/8/2010 3:11:00 PM


Management moments
Treating diabetes
Effective treatment for diabetes optimizes
blood glucose levels and decreases compli-
cations. In type 1 diabetes, treatment includes
insulin replacement, meal planning, and
exercise. Current forms of insulin replacement
include single-dose, mixed-dose, split–
mixed-dose, and multiple-dose regimens. The
multiple-dose regimen may use an insulin
pump.
INSULIN ACTION
Insulin may be rapid-acting (Humalog), fast-
acting (Regular), intermediate-acting (NPH),
long-acting (insulin glargine [Lantas]), or a
premixed combination of fast-acting and
intermediate-acting. Insulin may be derived from
pork or human sources. Purified human insulin
is used commonly today.
PERSONALIZED MEAL PLAN
Treatment for both types of diabetes also
requires a meal plan to meet nutritional needs,
• Dietary modifications
• Understanding the importance of routine
follow-up care
• Exercising regularly
• Recognizing the signs and symptoms of
hyperglycemia and hypoglycemia and how to
treat it
• Self-monitoring for infection, skin
breakdown, changes in peripheral circulation,
poor wound healing, and numbness in
extremities
• Adjusting diet and insulin for changes in
work, exercise, trauma, infection, fever, and
stress
• Administering antidiabetic agents and
using the insulin pump
• Monitoring capillary blood glucose levels
• Daily skin and foot care
• Avoiding alcohol and tobacco use
• Adhering to the treatment regimen to pre-
vent complications
• Contacting the American Diabetes
Association and local support groups
313419NCLEX-RN_Chap09.indd 299
Polish up on client care 299
to control blood glucose levels, and to help the
client reach and maintain his ideal body weight.
In type 1 diabetes, the calorie allotment may be
high, depending on the client’s growth stage
and activity level. Weight reduction is a goal for
the obese client with type 2 diabetes.
OTHER TREATMENTS
Exercise is also useful in managing type 2
diabetes because it increases insulin sensitivity,
improves glucose tolerance, and promotes
weight loss. In addition, clients with type 2
diabetes may need oral antidiabetic drugs to
stimulate endogenous insulin production and
increase insulin sensitivity at the cellular level.
THINKING LONG-TERM
Treatment for long-term complications may
include dialysis or kidney transplantation for
renal failure, photocoagulation for retinopathy,
and vascular surgery for large vessel disease.
Pancreas transplantation is also an option.
Goiter
A goiter is an enlargement of the thyroid
gland that isn’t caused by inflammation or
a neoplasm. This condition is commonly
referred to as nontoxic or simple goiter and
classified as endemic or sporadic. With appro-
priate treatment, the prognosis is good for
either type.
Endemic goiter usually results from
inadequate dietary intake of iodine associ-
ated with such factors as iodine-depleted
soil and malnutrition. Endemic goiter affects
females more than males, especially dur-
ing adolescence and pregnancy, when the
demand on the body for thyroid hormone
increases.
Sporadic goiter follows ingestion of
certain drugs or foods. It doesn’t affect
one specific population segment more than
others.
4/8/2010 3:11:00 PM
 300 Endocrine system

As with many CAUSES • Administer iodine supplements to increase

endocrine disorders, • Insufficient thyroid gland production body’s iodine level.
therapeutic care • Depletion of glandular iodine • Provide preoperative teaching and postop-
requires helping the • Ingestion of goitrogenic foods (rutabagas, erative care if subtotal thyroidectomy is indi-
client with goiter cabbage, soybeans, peanuts, peaches, peas, cated. These measures allay the client’s anxiety
cope with a change strawberries, spinach, radishes) and prevent postoperative complications.
in body image.
• Use of goitrogenic drugs (propylthiouracil,
methimazole, iodides, lithium) Teaching topics
• Explanation of the disorder and treatment
ASSESSMENT FINDINGS plan
• Single or multinodular, firm, irregular • Medication use and possible adverse
enlargement of the thyroid gland effects
• Dizziness or syncope with distended head • Understanding the importance of iodized
and jugular veins and dyspnea when the client salt
raises his arms above his head (Pemberton’s • Taking medications
sign) • Recognizing the symptoms of thyrotoxi-
• Dysphagia cosis (increased pulse rate, palpitations, diar-
• Respiratory distress rhea, sweating, tremors, agitation, shortness
• Dyspnea of breath) and how to respond when symp-
toms occur
DIAGNOSTIC TEST RESULTS
• Test to rule out Graves’ disease,
Hashimoto’s thyroiditis, and thyroid Hyperthyroidism
carcinoma.
• Laboratory tests reveal high or normal Hyperthyroidism is the increased synthesis
TSH, low serum T4 concentrations, and of thyroid hormone. It can result from over-
increased iodine 131I uptake. activity (Graves’ disease) or a change in the
• Thyroid scan and uptake identify enlarged thyroid gland (toxic nodular goiter).
thyroid.
• Ultrasound of thyroid reveals nodule. CAUSES
• Autoimmune disease
NURSING DIAGNOSES • Genetic
• Risk for suffocation • Infection
• Risk for injury • Pituitary tumors
• Disturbed body image • Psychological or physiologic stress
• Thyroid adenomas
TREATMENT
• Subtotal thyroidectomy ASSESSMENT FINDINGS
• Anxiety and mood swings
Drug therapy • Atrial fibrillation
• Thyroid hormone replacement: levothy- • Bruit or thrill over thyroid
roxine (Synthroid) • Diaphoresis
• Small doses of iodine (Lugol’s or • Diarrhea
potassium iodide solution) • Dyspnea
• Radioactive iodine • Exophthalmos
• Fine hand tremors
INTERVENTIONS AND RATIONALES • Flushed, smooth skin
• Measure the client’s neck circumference • Heat intolerance
to check for progressive thyroid gland enlarge- • Hyperhidrosis
ment. Also check for the development of hard • Increased hunger
nodules in the gland, which may indicate • Increased systolic blood pressure
carcinoma. • Insomnia

313419NCLEX-RN_Chap09.indd 300 4/8/2010 3:11:01 PM


• Palpitations
• Tachycardia
• Tachypnea
• Weakness
• Weight loss
DIAGNOSTIC TEST RESULTS
• Blood chemistry analysis shows increased
T3, T4, and free thyroxine levels and
decreased TSH and cholesterol levels.
• RAIU is increased.
• Thyroid scan shows nodules.
NURSING DIAGNOSES
• Decreased cardiac output
• Risk for imbalanced body temperature
• Risk for injury
• Imbalanced nutrition: Less than body
requirements
TREATMENT
• High-protein, high-carbohydrate, high-
calorie diet; restricting stimulants such as
caffeine
• Radiation therapy
• Thyroidectomy
Drug therapy
• Adrenergic-blocking agents: propranolol
(Inderal), reserpine (Serpalan)
• Antithyroid agents: methimazole (Tapa-
zole), propylthiouracil
• Cardiac glycoside: digoxin (Lanoxin)
• Glucocorticoids: cortisone, hydrocortisone
• Iodine preparations: potassium iodide
(SSKI), radioactive iodine
• Sedative: lorazepam (Ativan)
• Vitamins: thiamine (vitamin B1 ), ascorbic
acid (vitamin C)
INTERVENTIONS AND RATIONALES
• Monitor cardiovascular status to detect
signs of hyperthyroidism, such as tachycardia,
increased blood pressure, palpitations, and
atrial arrhythmias. Presence of these signs
may require a change in the treatment
regimen.
• Assess fluid balance to determine signs of
deficient fluid volume.
• Monitor and record vital signs, intake and
output, and laboratory studies to detect early
changes and guide treatment.
313419NCLEX-RN_Chap09.indd 301
Polish up on client care 301
• Maintain the client’s diet to promote ade-
quate nutrition.
• Instruct the client to avoid stimulants, such
as caffeine-containing drugs and foods, to
reduce or eliminate arrhythmias.
• Administer I.V. fluids to promote hydration.
• Administer medications as prescribed to
maintain or improve the client’s condition.
• Provide postoperative nursing care to pro-
mote healing and prevent complications.
• Provide rest periods to reduce metabolic
demands.
• Provide a quiet, cool environment to pro-
mote comfort. Hypermetabolism causes intoler-
ance.
• Provide skin and eye care to prevent com-
plications.
• Provide emotional support and encourage
the client to express his feelings about
changes in body image to reduce anxiety and
facilitate coping mechanisms.
• Provide postradiation nursing care to pre-
vent complications associated with treatment.
Teaching topics
• Explanation of the disorder and treatment
plan
• Medication use and possible adverse
effects
• Recognizing the signs and symptoms of
thyroid storm and hypothyroidism
• Avoiding alcohol and tobacco use
• Adhering to activity limitations
• Avoiding exposure to people with infec-
tions
• Self-monitoring for infection
Hypothyroidism
Hypothyroidism, which affects women more
commonly than men, occurs when the thy-
roid gland fails to produce sufficient thyroid
hormone. This deficiency in thyroid hormone
causes an overall decrease in metabolism.
CAUSES
• Hashimoto’s thyroiditis
• Malfunction of pituitary gland
• Overuse of antithyroid drugs
• Thyroidectomy
• Use of radioactive iodine
4/8/2010 3:11:01 PM
 302 Endocrine system

Avoid sedation. ASSESSMENT FINDINGS • Maintain the client’s diet to facilitate

Give clients with • Coarse hair and alopecia nutritional balance.
hypothyroidism • Cold intolerance • Encourage fluid intake to maintain
one-half to one-third • Constipation hydration.
the normal dose of • Decreased diaphoresis • Administer medications, as prescribed, to
sedatives or opioids. • Dry, flaky skin and thinning nails maintain or improve the client’s condition.
• Edema • Encourage the client to express feelings of
• Fatigue depression to promote coping.
• Hypersensitivity to opioids, barbiturates, • Encourage physical activity and mental
and anesthetics stimulation to enhance self-esteem.
• Hypothermia • Provide a warm environment to promote
• Menstrual disorders comfort because the client with hypothyroidism
• Mental sluggishness may be sensitive to cold.
• Thick tongue and swollen lips • Turn the client every 2 hours and provide
• Weight gain or anorexia skin care to prevent skin breakdown.
• Provide frequent rest periods because
DIAGNOSTIC TEST RESULTS clients with hypothyroidism are easily fatigued.
• Blood chemistry analysis shows decreased
T3, T4, and sodium levels and increased TSH Teaching topics
and cholesterol levels. • Explanation of the disorder and treatment
• RAIU is decreased. plan
• Medication use and possible adverse
NURSING DIAGNOSES effects
• Activity intolerance • Exercising regularly
• Disturbed body image • Recognizing the signs and symptoms of
• Decreased cardiac output myxedema coma (progressive stupor, hypo-
• Fatigue ventilation, hypoglycemia, hyponatremia,
hypotension, hypothermia)
TREATMENT • Self-monitoring for constipation
• High-fiber, high-protein, low-calorie diet • Seeking additional protection and limiting
exposure during cold weather
Drug therapy • Avoiding sedatives
• Stool softener: docusate sodium (Colace) • Completing skin care daily
• Thyroid hormone replacement: levothy-
roxine (Synthroid), liothyronine (Cytomel)
Metabolic syndrome
INTERVENTIONS AND RATIONALES
• Avoid sedation: administer one-half to Metabolic syndrome, also called syndrome X
Blood pressure
greater than one-third the normal dose of sedatives or or insulin resistance syndrome, is a cluster
130/85 mm Hg can opioids to prevent complications. Clients of conditions characterized by abdominal
signal metabolic taking warfarin (Coumadin) with levothy- obesity, high blood glucose (type 2 diabetes
syndrome. roxine may require lower doses of warfarin mellitus), insulin resistance, high blood
because levothyroxine enhances the effects of cholesterol and triglycerides, and high blood
warfarin. pressure. More than 22% of people in the
• Assess fluid balance to determine deficient United States meet three or more of these
or excess fluid volume. criteria, raising their risk of heart disease and
• Check for constipation and edema to detect stroke and placing them at high risk for dying
early changes. of myocardial infarction.
• Monitor and record vital signs, intake and Abdominal obesity is a strong predictor of
output, and laboratory studies to determine metabolic syndrome because abdominal fat
fluid status. tends to be more resistant to insulin than fat

313419NCLEX-RN_Chap09.indd 302 4/8/2010 3:11:01 PM


in other areas. This increases the release of
free fatty acid into the portal system, resulting
in decreased high-density lipoprotein (HDL)
and increased low-density lipoprotein (LDL)
and triglyceride levels.
CAUSES
• Unknown, but there may be genetic pre-
disposition
ASSESSMENT FINDINGS
• Abdominal obesity (waist of greater than 40"
(101.6 cm) in males, 35" (89 cm) in females)
• Blood pressure greater than 130/85 mm Hg
• Fasting blood glucose level greater than
100 mg/dl
• Fatigue
DIAGNOSTIC TEST RESULTS
• Most diagnostic procedures are nonspe-
cific, but may show hypertension, diabetes,
hyperlipidemia, and hyperinsulinemia.
NURSING DIAGNOSES
• Fatigue
• Imbalanced nutrition: More than body
requirements
• Risk for injury
• Disturbed body image
• Activity intolerance
TREATMENTS
• Diet high in vegetables, fruits, whole
grains, and fish and low in saturated fat
• Gastric bypass: clients with a body mass
index greater than 40 kg/m2 or 35 kg/m2 if
obesity-related medical conditions present
• Lifestyle modifications, focusing on weight
reduction and exercise
• Reduction of HbA1c level
Drug therapy
• Antilipemics: simvastatin (Zocor),
pravastatin (Pravachol) to decrease LDL
levels and triglycerides and to increase
HDL levels
• Insulin or antidiabetic agents (if the client
has hyperglycemia)
• Medications for weight loss: orlistat
(Xenical), sibutramine (Meridia)
313419NCLEX-RN_Chap09.indd 303
Polish up on client care 303
INTERVENTIONS AND RATIONALES Metabolic
• Monitor the client’s blood pressure, blood syndrome can be
glucose, blood cholesterol, and insulin levels treated by making
to keep within normal limits. sure you add some
• Encourage lifestyle modifications related to exercise into your
improving diet and increasing exercise. Studies routine!
have shown that lifestyle modifications have the
most impact in treating metabolic syndrome.
• Schedule follow-up appointments with
health care professionals to increase client
compliance.
• Use a positive attitude with the client and
promote his active participation to encourage
successful lifestyle changes.
• If the client is scheduled for a gastric
bypass, provide information and emotional
support.
Teaching topics
• Explanation of the disorder and treatment
plan
• Medication regimen and adverse effects
• Dietary changes
• Developing an exercise routine
• Contacting a nutritionist for further dietary
teaching
• Keeping all follow-up appointments
Pancreatic cancer
Pancreatic cancer progresses rapidly and
is deadly. Treatment is rarely successful
because the disease has usually widely
metastasized by the time it’s diagnosed.
Therapeutic care means helping the client When I get
and family come to terms with the end of life. cancer, it usually
results in death. In
Pancreatic tumors are almost always
most clients, the
adenocarcinomas and most arise in the head disease has widely
of the pancreas. Rarer tumors are those of metastasized
the body and tail of the pancreas and islet by the time it’s
cell tumors. The two main tissue types are diagnosed.
cylinder cell and large, fatty, granular cell.
CONTRIBUTING FACTORS
• Tobacco
• Foods high in fat and protein
• Food additives
• Industrial chemicals, such as beta-
naphthalene, benzidine, and urea
4/8/2010 3:11:02 PM
 304 Endocrine system
ASSESSMENT FINDINGS
• Dull, intermittent epigastric pain (early in
disease)
• Continuous pain that radiates to the right
upper quadrant or dorsolumbar area and that
may be colicky, dull, or vague and unrelated
to activity or posture
• Anorexia
• Nausea
• Vomiting
• Diarrhea
• Jaundice
• Rapid, profound weight loss
• Palpable mass in the subumbilical or left
hypochondrial region
DIAGNOSTIC TEST RESULTS
• Percutaneous fine-needle aspiration biopsy
of the pancreas may detect tumor cells.
• Laparotomy with a biopsy allows definitive
diagnosis.
• Ultrasound or CT scan identifies a
pancreatic mass.
• Angiography reveals the vascular supply of
a tumor.
• MRI shows tumor size and location.
• Blood studies reveal increased serum
bilirubin levels, increased serum amylase and
A client with lipase levels, prolonged prothrombin time,
pancreatic cancer elevated alkaline phosphatase levels (with
may experience biliary obstruction), elevated aspartate ami-
hypoglycemia or notransferase and alanine aminotransferase
hyperglycemia. levels (when liver cell necrosis is present).
Administer glucose
or an antidiabetic • Fasting blood glucose studies may indicate
agent as necessary. hyperglycemia or hypoglycemia.
• Plasma insulin immunoassay shows mea-
surable serum insulin in the presence of islet
cell tumors.
• Stool studies may show occult blood if
ulceration in the GI tract or ampulla of Vater
has occurred.
• Tumor markers for pancreatic cancer,
including carcinoembryonic antigen, alpha-
fetoprotein, carbohydrate antigen 19-9,
and serum immunoreactive elastase I, are
elevated.
NURSING DIAGNOSES
• Acute pain
• Chronic pain
313419NCLEX-RN_Chap09.indd 304
• Imbalanced nutrition: Less than body
requirements
• Grieving
• Fear
• Anxiety
TREATMENT
• Blood transfusion
• I.V. fluid therapy
• Total pancreatectomy (surgical removal of
the pancreas)
• Cholecystojejunostomy (surgical anasto-
mosis of the gallbladder and the jejunum)
• Choledochoduodenostomy (surgical
anastomosis of the common bile duct to the
duodenum)
• Choledochojejunostomy (surgical
anastomosis of the common bile duct to the
jejunum)
• Whipple’s operation or pancreatoduo-
denectomy (excision of the head of the
pancreas along with the encircling loop of the
duodenum)
• Gastrojejunostomy (surgical creation of
an anastomosis between the stomach and the
jejunum)
• Radiation therapy
Drug therapy
• Antineoplastic combinations: fluorouracil,
streptozocin (Zanosar), ifosfamide (Ifex),
and doxorubicin; gemcitabine and erlitinib
(Tarceva)
• Antibiotic: cefotetan to prevent infection
and relieve symptoms
• Anticholinergic: propantheline to decrease
GI tract spasm and motility and reduce pain
and secretions
• Histamine2 -receptor antagonists: cimeti-
dine (Tagamet), ranitidine (Zantac), famoti-
dine (Pepcid), nizatidine (Axid)
• Diuretic: furosemide (Lasix) to mobilize
extracellular fluid from ascites
• Insulin after pancreatic resection to pro-
vide adequate exogenous insulin supply
• Opioid analgesics: morphine, meperidine
(Demerol), and codeine, which can lead to
biliary tract spasm and increase common bile
duct pressure (used when other methods fail)
4/8/2010 3:11:02 PM

• Pancreatic enzyme: pancrelipase
(Pancrease)
• Vitamin K: phytonadione
• Stool softener: docusate sodium (Colace)
• Laxative: bisacodyl (Dulcolax)
INTERVENTIONS AND RATIONALES
• Monitor fluid balance, abdominal girth,
metabolic state, and weight daily to determine
fluid volume status.
• Administer an oral pancreatic enzyme at
mealtimes if needed.
• Replace nutrients I.V., orally, or by naso-
gastric tube to combat weight loss. Impose die-
tary restrictions, such as a low-sodium or fluid
retention diet, as required, to combat weight
gain (due to ascites). Maintain a 2,500-calorie
diet for the client to meet increased nutritional
needs.
• Administer laxatives, stool softeners,
and cathartics as required; modify diet; and
increase fluid intake to prevent constipation.
• Administer pain medication, antibiotics,
and antipyretics, as necessary.
• Monitor for signs of hypoglycemia or
hyperglycemia; administer glucose or an
antidiabetic agent as necessary to prevent
complications of hypoglycemia or hyper-
glycemia. Monitor blood glucose levels
to detect early signs of hypoglycemia or
hyperglycemia.
• Provide meticulous skin care to avoid pru-
ritus and necrosis.
• Monitor for signs of upper GI bleeding;
test stools and vomitus for occult blood and
keep a flow sheet of Hb and HCT values to
prevent hemorrhage.
• Apply antiembolism stockings and assist
in ROM exercises to prevent thrombosis. If
thrombosis occurs, elevate the client’s legs to
promote venous return and give an anticoagu-
lant or aspirin, as required, to decrease blood
viscosity and prevent further thrombosis.
• Provide emotional support to help
the family and patient cope with his poor
prognosis.
313419NCLEX-RN_Chap09.indd 305
Polish up on client care 305
Before surgery
• Provide total parenteral nutrition and I.V.
fat emulsions to correct deficiencies and main-
tain positive nitrogen balance.
• Give blood transfusions to combat anemia,
vitamin K to overcome prothrombin deficiency,
antibiotics to prevent postoperative infec-
tion, and gastric lavage to maintain gastric
decompression, as necessary.
• Teach the client about expected postoper-
ative procedures and expected adverse effects
of radiation and chemotherapy to allay anxiety.
After surgery
• Monitor and report complications, such
as fistula, pancreatitis, fluid and electro-
lyte imbalance, infection, hemorrhage, skin
breakdown, nutritional deficiency, hepatic
failure, renal insufficiency, and diabetes, to
ensure early detection and treatment of compli-
cations.
• Treat adverse effects of chemotherapy
symptomatically to promote comfort and pre-
vent complications.
• Administer an oral pancreatic enzyme at
mealtimes, if needed, to aid digestion.
Teaching topics
Don’t forget:
• Explanation of the disorder and treatment If the place where
plan you’re studying
• Medication use and possible adverse isn’t conducive to
effects effective learning,
• Wound care if appropriate find a new place to
• Hospice options and end-of-life issues study.
• Contacting the American Cancer Society
and local support groups
Pheochromocytoma
Pheochromocytoma is a chromaffin-cell
tumor of the adrenal medulla that secretes
an excess of the catecholamines epineph-
rine and norepinephrine, resulting in severe
hypertension, increased metabolism, and
hyperglycemia. This disorder is potentially
4/8/2010 3:11:03 PM
 306 Endocrine system

fatal, but the prognosis is generally good with Drug therapy

Pheochromocytoma
treatment. However, pheochromocytoma- • Alpha-adrenergic blocker: before surgery
episodes can occur
with a change in induced kidney damage is irreversible. • Phenoxybenzamine and propranolol if sur-
body temperature. Symptomatic episodes may recur as gery isn’t possible
Now, where is that seldom as once every 2 months or as often as
campfire…? 25 times per day. Episodes may occur spon- INTERVENTIONS AND RATIONALES
taneously or may follow certain precipitating • Carefully monitor the client’s blood
events, such as postural changes, exercise, pressure and vital signs because transient
laughing, smoking, induction of anesthesia, hypertensive attacks are possible.
urination, or a change in environmental or • Instruct the client to avoid food high in
body temperature. vanillin (coffee, nuts, chocolate) for 2 days
before 24-urine test to avoid interfering with
CAUSES laboratory results.
• Inherited autosomal dominant trait in • Provide a quiet room after surgery to
some clients decrease excitement, which can trigger a hyper-
• Unknown in most clients tensive crisis.
• Monitor the client’s blood glucose levels
ASSESSMENT FINDINGS because he may present with hyperglycemia
• Abdominal pain in addition to pheochromocytoma.
• Diaphoresis • Postoperatively, monitor for abdominal
• Feeling of impending doom distension and bowel sounds to detect return
• Headache of bowel function.
• Nausea • If autosomal dominant transmission of
• Palpitations pheochromocytoma is suspected, inform the
• Persistent or paroxysmal hypertension client’s family of the need for evaluation.
• Tachycardia
• Tremor Teaching topics
• Explanation of the disorder and treatment
DIAGNOSTIC TEST RESULTS plan
• A 24-hour urine specimen shows increased • Medication regimen and adverse effects
urinary excretion of total free catecholamine • Complying with medication regimen
and their metabolites, vanillylmandelic acid, before surgery
and metanephrine. • Surgical treatment plan

NURSING DIAGNOSES
• Fatigue Thyroid cancer
• Risk for injury
• Disturbed body image Thyroid cancer is a malignant, primary tumor
• Activity intolerance of the thyroid. It doesn’t affect thyroid hor-
mone secretion.
TREATMENT
• I.V. fluids, plasma volume expanders, and CAUSES
blood transfusions postoperatively • Chronic overstimulation of the pituitary
• I.V. phentolamine or nitroprusside (acute gland
hypertensive crisis) • Chronic overstimulation of the thymus
• Surgical removal of tumor (treatment of gland
choice) • Neck radiation

313419NCLEX-RN_Chap09.indd 306 4/8/2010 3:11:03 PM


Management moments
Caring for the thyroidectomy client
Keep these crucial points in mind when caring
for the client who has undergone thyroidectomy.
• Keep the client in Fowler’s position to promote
venous return from the head and neck and to
decrease oozing into the incision.
• Watch for signs of respiratory distress
(tracheal collapse, tracheal mucus
accumulation, and laryngeal edema).
• Note that vocal cord paralysis can cause
respiratory obstruction, with sudden stridor and
restlessness.
• Keep a tracheotomy tray at the client’s
bedside for 24 hours after surgery and be
prepared to assist with emergency tracheotomy
if necessary.
ASSESSMENT FINDINGS
• Dysphagia
• Dyspnea
• Enlarged thyroid gland
• Hoarseness
• Painless, firm, irregular, and enlarged thy-
roid nodule or mass
• Palpable cervical lymph nodes
DIAGNOSTIC TEST RESULTS
• Blood chemistry analysis shows increased
calcitonin, serotonin, and prostaglandin
levels.
• RAIU shows a “cold,” or nonfunctioning,
nodule.
• Thyroid biopsy shows cytology positive for
cancer cells.
• Thyroid function test is normal.
NURSING DIAGNOSES
• Anxiety
• Ineffective coping
• Chronic pain
• Ineffective breathing pattern
TREATMENT
• High-protein, high-carbohydrate, high-
calorie diet with supplemental feedings
313419NCLEX-RN_Chap09.indd 307
Polish up on client care 307
• Assess for signs of hemorrhage.
• Assess for hypocalcemia (tingling and
numbness of the extremities, muscle twitch-
ing, cramps, laryngeal spasm, and positive
Chvostek’s and Trousseau’s signs), which may
occur when parathyroid glands are damaged.
• Keep calcium gluconate available for
emergency I.V. administration.
• Be alert for signs of thyroid storm (tachy-
cardia, hyperkinesis, fever, vomiting, and
hypertension).
• Radiation therapy
• Radioactive iodine therapy
• Thyroidectomy (total or subtotal); total
thyroidectomy and radical neck excision
Drug therapy
• Antiemetics: prochlorperazine, ondanse-
tron (Zofran)
• Chemotherapy: chlorambucil (Leukeran),
doxorubicin, vincristine
• Thyroid hormone replacements: levothy-
roxine (Synthroid), liothyronine (Cytomel)
INTERVENTIONS AND RATIONALES
• Monitor respiratory status for signs of
airway obstruction. A tracheotomy set should
be kept at the bedside because swelling may
cause airway obstruction.
• Assess the client’s ability to swallow to
maintain a patent airway.
• Provide postoperative thyroidectomy care
to promote healing and prevent postoperative
complications. (See Caring for the thyroidec-
tomy client.)
• Monitor and record vital signs, intake and
output, and laboratory studies to determine
baseline and detect early changes that may
4/8/2010 3:11:04 PM
 308 Endocrine system
occur with hemorrhage, airway obstruction, or
hypocalcemia.
• Administer medications as prescribed to
maintain or improve the client’s condition.
• Maintain the client’s diet to improve nutri-
tional status.
• Provide emotional support and encourage
the client to express his feelings to facilitate
coping mechanisms.
• Provide postchemotherapy and postradia-
tion nursing care to prevent and treat compli-
cations associated with therapy.
Teaching topics
• Explanation of the disorder and treatment
plan
• Medication use and possible adverse effects
• Recognizing the signs and symptoms of
respiratory distress, infection, myxedema
coma, and difficulty swallowing
• Contacting the American Cancer Society
and local support groups
Thyroiditis
Thyroiditis is inflammation of the thyroid
gland. It may occur in various forms:
After autoimmune thyroiditis (long-term
thyroidectomy, inflammatory disease; also known as
watch for Hashimoto’s thyroiditis), subacute granuloma-
signs of airway tous thyroiditis (self-limiting inflammation),
obstruction, such Riedel’s thyroiditis (rare, invasive fibrotic
as difficulty talking
process), and miscellaneous thyroiditis (acute
and increased
swallowing; keep suppurative, chronic infective, and chronic
tracheotomy noninfective).
equipment handy.
CAUSES
• Antibodies to thyroid antigens
• Bacterial invasion
• Mumps, influenza, coxsackievirus, or ade-
novirus infection
ASSESSMENT FINDINGS
• Thyroid enlargement
• Fever
• Pain
• Tenderness and reddened skin over the
gland
313419NCLEX-RN_Chap09.indd 308
DIAGNOSTIC TEST RESULTS
• Precise diagnosis depends on the type of
thyroiditis:
– autoimmune—high titers of thyroglob-
ulin and microsomal antibodies present in
serum
– subacute granulomatous—elevated
erythrocyte sedimentation rate, increased
thyroid hormone levels, decreased thy-
roidal RAIU
– chronic infective and noninfective—
varied findings, depending on underlying
infection or other disease.
NURSING DIAGNOSES
• Risk for infection
• Acute pain
• Disturbed body image
• Ineffective breathing pattern
TREATMENT
• Partial thyroidectomy to relieve tracheal or
esophageal compression in Riedel’s thyroiditis
Drug therapy
• Thyroid hormone replacement: levothy-
roxine (Synthroid) for accompanying hypo-
thyroidism
• Analgesic and anti-inflammatory agent:
indomethacin (Indocin) for mild subacute
granulomatous thyroiditis
• Beta-adrenergic blocker: propranolol
(Inderal) for transient thyrotoxicosis
INTERVENTIONS AND RATIONALES
• Monitor vital signs and examine the
client’s neck for unusual swelling, enlarge-
ment, or redness to detect disease progression
and signs of airway occlusion.
• Refer the client to speech therapy to eval-
uate swallowing ability to prevent aspiration.
• Measure and record neck circumference
daily to monitor progressive enlargement.
• Monitor for signs of thyrotoxicosis (ner-
vousness, tremor, weakness), which com-
monly occur in subacute thyroiditis to initiate
rapid treatment.
4/8/2010 3:11:04 PM
 Pump up on practice questions 309

After thyroidectomy
• Monitor vital signs every 15 to 30 minutes
until the client’s condition stabilizes. Stay alert
for signs of tetany secondary to accidental
parathyroid injury during surgery. Keep 10%
calcium gluconate available for I.M. use, if
needed. These measures help prevent serious
postoperative complications.
• Assess dressings frequently for excessive
bleeding to detect signs of hemorrhage.
• Monitor for signs of airway obstruction,
such as difficulty talking and increased swal-
lowing; keep tracheotomy equipment handy.
The airway may become obstructed because of
postoperative edema; tracheotomy equipment
should be handy to avoid treatment delay if the
airway becomes obstructed.

Teaching topics Pump up on practice

• Explanation of the disorder and treatment
plan
• Medication use and possible adverse
effects, including understanding the need
for lifelong thyroid hormone replacement
therapy if permanent hypothyroidism occurs
• Watching for and reporting signs of hypo-
thyroidism (lethargy, restlessness, sensitivity
to cold, forgetfulness, dry skin)—especially
if he has Hashimoto’s thyroiditis, which com-
monly causes hypothyroidism
• Recognizing the need to watch for signs
of hyperthyroidism, such as nervousness and
palpitations
questions
1. The nurse is assessing a client with
hypothyroidism and finds the client has a
temperature of 94° F (34.4° C) and exhibits
hypotension and hypoventilation. Based on
these findings, which nursing diagnosis is
most appropriate for this client?
1. Impaired gas exchange
2. Hypothermia
3. Disturbed thought processes
4. Deficient fluid volume
Answer: 1. Hypothermia, hypotension, and
hypoventilation are manifestations of myx-
edema coma, a potentially life-threatening
complication of hypothyroidism. Impaired gas
exchange is the most significant nursing diag-
nosis because a client with myxedema coma
may suffer from hypoventilation, bradypnea,
and respiratory failure caused by respiratory
muscle weakness and coma. Ensuring and
maintaining a patent airway always takes
precedence. Hypothermia occurs in a client in

313419NCLEX-RN_Chap09.indd 309 4/8/2010 3:11:04 PM