Medical Surgical Nursing Hypothalamus (taga-utos)

by: RJLP
➢ Produces regulatory hormones
• Corticotropin releasing hormones (CRH)
Endocrine System o Stimulates adrenocorticotropic hormones
Feedback System • Thyrotropin releasing hormones (TRH)
➢ Positive Feedback o Stimulates thyroid stimulating hormones
o Increases the change or output • Gonadotropin releasing hormones (GnRH)
➢ Negative Feedback o Stimulates FSH and LH
o Decreases the change or output • Growth hormone releasing hormone (GHRH)
o Stimulates growth hormones
Hypothalamus • Growth hormone inhibiting hormone (GHIH)
o Hypothalamus is not a gland, part of the brain o Negative feedback loop of GH
o It stimulates the pituitary to release hormones • Prolactin inhibiting hormone (PIH)
o Inhibits milk production
• Melanocyte inhibiting hormone (MIH)
o Inhibits melanin (skin pigmentation)

Hypothalamic-Hypophysial Portal System

➢ Allows the hormones from the hypothalamus to travel to the anterior
pituitary gland
➢ Posterior pituitary (neurohypophysis) gland came directly into the brain
o Hormone releases by the PPG came from the hypothalamus
➢ Anterior pituitary gland (adenohypophysis) came from the throat during
fetal development Pituitary Gland (gagalaw)
o Hormone releases by APG came from itself si hypothalamus lang • Located at the base of the brain in the sphenoid bone
nag- • Anterior pituitary gland (APG) – adenohypophysis
• Posterior pituitary gland (PPG) – neurohypophysis
• Secretes tropic hormone which stimulate other glands
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 Hormones Target Tissue Actions • Deficiencies of ACTH and TSH are the most life threatening
• Deficiency of the gonadotropins changes sexual functions in men and
TSH Thyroid • Synthesis and release of
thyroid hormone women
ACTH Adrenal cortex • Synthesis and release of o Amenorrhea
corticoids and adrenocortical o Dyspareunia
growth o Infertility
LH Ovary /testes • Ovulation and progesterone o Decreased libido
secretion o Hair loss
• Testosterone secretions o Dry skin
FSH Ovary/testes • Estrogen secretion and follicle • Growth hormone deficiency
maturation o Stimulates liver to produce somatomedins
• Spermatogenesis o Changes tissue growth patterns indirectly
Prolactin (PRL) Mammary gland • Breast milk production o May lead to pediatric growth retardation
GH/somatotropin Bone and soft tissue • Growth through lipolysis, o May cause osteoporosis and an increased risk of fractures
protein anabolism and insulin • Pituitary function may be impaired by severe malnutrition or rapid loss of
antagonism body fat
Melanocyte Melanocytes • Pigmentation • May be caused by shock, severe hypotension, head trauma, radiation, AIDS,
stimulating brain tumors or infection, postpartum hemorrhage
hormone (MSH)

Management
Anterior Pituitary Gland (Hypopituitarism) Hormone replacement therapy
• Testosterone
o Increased male sexual characteristics
o Acne
o Prostate enlargement
o Gynecomastia
• Estrogen and Progesterone
o It increases hypercoagability of the blood watch out for Thrombosis

Anterior Pituitary Gland (Hyperpituitarism)

• Hormone over secretion that occurs with pituitary tumors or tissue hyperplasia
• Most commonly secretes GH, PRL, ACTH
• Most caused by a pituitary adenoma
o Eventually causes headaches, increased ICP, and visual changes
• Excessive PRL
o Galactorrhea, amenorrhea, infertility
• Excessive GH
• Deficiency of one or more APG hormones o Acromegaly
o Metabolic and sexual dysfunction o Hyperglycemia – GH antagonizes insulin
o Panhypopituitarism – decreased production of all the APG hormones
(lahat mababa)

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Management Types of DI:
• Nonsurgical • Central DI – characterized by a deficiency of the posterior pituitary gland
o Dopamine agonists (bromocriptine, cabergoline, pergolide) to release ADH
dopamine inhibits the release of GH and PRL o Increased urine output can cause dehydration which increases
o BROMOCRIPTINE – causes orthostatic hypotension, gastric Hematocrit
irritation, nausea, headaches, abd cramps, constipation • Nephrogenic DI – characterized by the terminal distal convoluted tubule
o Somatostatin analogs and collecting duct resistance to ADH
▪ Ocreotide inhibits GH release • Dipsogenic DI - characterized by excessive thirst due to a low osmotic
▪ Pegvisomant blocks GH receptor activity threshold
o Radiation therapy • Gestational DI, characterized by increased concentration of placental
• Surgical vasopressinase during pregnancy
o Transsphenoidal hypophysectomy – removal of the pituitary gland
▪ WOF CSF leak (HALO SIGN) Signs and Symptoms:
• Dehydration
• Polyuria
• Intense thirst
• Decreased urine specific gravity

Management:
▪ Avoid any activity that increases ICP ➢ Drug Therapy
• Lifelong desmopressin (IV or IM)
Posterior Pituitary Gland o Monitor for fluid retention
➢ Accurate fluid intake and output monitoring
Hormones Target Tissue Actions ➢ Weighing daily with the same scale at the same time with the same clothing

Anti-Diuretic Kidney • Promotes water

Hormone (ADH) reabsorption
Oxytocin Uterus and • Stimulates uterine
mammary gland contractions and ejection
of the breast milk

PPG (Diabetes Insipidus or DI)

• D-aming I-hi
• Caused by ADH deficiency or inability of the kidneys to respond to ADH
• Results in excretion of large volumes of dilute urine and dehydration
• Intense thirst
• Primary or secondary or nephrogenic

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 Assessment and Management of Patients with Endocrine Disorders • Syndrome of inappropriate antidiuretic hormone (SIADH): excessive secretion of
GLOSSARY antidiuretic hormone from the pituitary gland despite low serum osmolality level
• Acromegaly: progressive enlargement of peripheral body parts resulting from • Thyroidectomy: surgical removal of all or part of the thyroid gland
excessive secretion of growth hormone • Thyroiditis: inflammation of the thyroid gland; may lead to chronic
• Addison’s disease: chronic adrenocortical insufficiency due to inadequate hypothyroidism or may resolve spontaneously
adrenal cortex function • Thyroid-stimulating hormone (TSH): released from the pituitary gland; causes
• Addisonian crisis: acute adrenocortical insufficiency; characterized by stimulation of the thyroid, resulting in release of T3 and T4
hypotension, cyanosis, fever, nausea/vomiting, and signs of shock • Thyroid storm: life-threatening condition of the thyroid due to untreated
• Adrenalectomy: surgical removal of one or both adrenal glands hyperthyroidism
• Adrenocorticotropic hormone (ACTH): hormone secreted by the anterior • Thyrotoxicosis: condition produced by excessive endogenous or exogenous
pituitary, essential for growth and development thyroid hormone
• Androgens: male sex hormones basal metabolic rate: chemical reactions • Thyroxine (T4): thyroid hormone; active iodine compound formed and stored in
occurring when the body is at rest the thyroid; deiodinated in peripheral tissues to form triiodothyronine;
• Calcitonin: hormone secreted by the thyroid gland; participates in calcium maintains body metabolism in a steady state
regulation • Triiodothyronine (T3): thyroid hormone; formed and stored in the thyroid;
• Chvostek sign: spasm of the facial muscles produced by sharply tapping over the released in smaller quantities, biologically more active, and with faster onset of
facial nerve in front of the parotid gland and anterior to the ear; suggestive of action than T4; widespread effect on cellular metabolism
latent tetany in patients with hypocalcemia • Trousseau sign: carpopedal spasm induced when blood flow to the arm is
• Corticosteroids: hormones produced by the adrenal cortex or their synthetic occluded using a blood pressure cuff or tourniquet, causing ischemia to the distal
equivalents nerves; suggestive sign for latent tetany in hypocalcemia
• Cushing’s syndrome: group of symptoms produced by an oversecretion of • Vasopressin: antidiuretic hormone secreted by the posterior pituitary
adrenocorticotropic hormone; characterized by truncal obesity, “moon face,”
acne, abdominal striae, and hypertension
• Diabetes insipidus: condition in which abnormally large volumes of dilute urine
are excreted as a result of deficient production of vasopressin
• Euthyroid: state of normal thyroid hormone production
• Exophthalmos: abnormal protrusion of one or both eyeballs
• Glucocorticoids: steroid hormones secreted by the adrenal cortex in response to
adrenocorticotropic hormone; produce a rise of liver glycogen and blood glucose
• Goiter: enlargement of the thyroid gland
• Grave’s disease: a form of hyperthyroidism; characterized by a diffuse goiter and
exophthalmos
• Hormones: chemical transmitter substances produced in one organ or part of the
body and carried by the bloodstream to other cells or organs on which they have
a specific regulatory effect
• Mineralocorticoids: steroid hormones secreted by the adrenal cortex
• Myxedema: severe hypothyroidism; can be with or without coma
• Negative feedback: regulating mechanism in which an increase or decrease in the
level of a substance decreases or increases the function of the organ producing
the substance
• Pheochromocytoma: adrenal medulla tumor

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Anatomic and Physiologic Overview Function and Regulation of Hormones
➢ The endocrine system involves the release of chemical transmitter substances • The endocrine glands are composed of secretory cells arranged in minute
known as HORMONES clusters known as acini
o Chemical signaling molecules secreted by endocrine glands into the • A rich blood supply provides a vehicle for the hormones produced by the
extracellular fluids to exert an effect elsewhere in the body endocrine glands to enter the bloodstream rapidly
o Hormones travel in blood or lymph throughout the body • To prevent accumulation, these hormones must be inactivated
o BIOLOGICAL SPECIFICITY: Hormones Interact with specific receptors of continuously by a negative feedback system so that when the hormone
specific cells of specific organs. concentration increases, further production of that hormone is inhibited
➢ Endocrine Glands are Ductless and secrete by Exocytosis into the Extracellular • Conversely, when the hormone concentration decreases, the rate of
Fluid →Diffuses into Blood production of that hormone increases
• These substances regulate and integrate body functions by acting on local
or distant target sites. Classification and Action of Hormones
• Hormones are generally produced by the endocrine glands but may also be ➢ Hormones are classified into four categories according to their structure:
produced by specialized tissues such as those found in the gastrointestinal
(GI) system, the kidney, and white blood cells

Glands of the Endocrine System

➢ The endocrine system is composed of the pituitary gland, thyroid gland,
parathyroid glands, adrenal glands, pancreatic islets, ovaries, and testes
• Most hormones secreted from endocrine glands are released directly into
the bloodstream.
➢ However, exocrine glands, such as sweat glands, secrete their products
through ducts onto epithelial surfaces or into the GI tract.

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1. Amines and amino acids Long or Short-Range Signalling?
• (e.g., epinephrine, norepinephrine, and thyroid hormones); • Endocrine: Some signals are “broadcasted” throughout the entire
2. Peptides, polypeptides, proteins, and glycoproteins body via bloodstream. → Hormones (produced by endocrine cells)
• (e.g., thyrotropin-releasing hormone [TRH], follicle-stimulating [TV]
hormone [FSH], and growth hormone [GH]); • Autocrine: Signals that affect only cells of the same cell type as the
3. Steroids emitting cell. [doctor conference]
• (e.g., corticosteroids, which are hormones produced by the adrenal cortex • Paracrine: Signals (aka local mediators) that act on cells in the
or their synthetic equivalents); vicinity of the emitting cell but on different cell types than the
4. Fatty acid derivatives emitting cell. [Lecture]
• (e.g., eicosanoid, retinoids)

Synthesis of Chemical Messengers:

➢ Steroidogenesis:
o All steroid hormones are derived from Cholesterol

➢ There are 5 Families of Steroids, each with their main physiological

member:
o Progestogens (Progesterone)
o Androgens (Testosterone)
o Mineralocorticoids (Aldosterone)
o Glucocorticoids (Cortisol)
o Oestrogens (Oestrogen)

Reactive Properties of Chemical Messengers:

• Biological Specificity: Certain Chemical Messengers will only fit into certain
receptors
• Affinity: The degree to which a chemical is attracted towards a receptor
• Efficacy: The degree of effectiveness of the binding of the messenger to the
receptor Regulation of Hormone Release:
• ‘Agonists’: Chemical Messengers with High Affinity & High Efficacy ➢ Humoral: Where the concentration of a solute in the blood (Eg: High
• ‘Antagonists’: Chemical Messengers with High Affinity but Low Efficacy Glucose/Low Calcium) is detected by a specific gland, stimulating
o Note: There are no Endogenous Receptor-Antagonists, Only Exogenous hormone release (Eg: Insulin/ParathyroidHormone)
(Drugs) ➢ Neural: Where the Nervous System Directly stimulates hormone release.
• Hormone Binding Proteins: Proteins that inactivate hormones by binding Eg: Sympathetic NS Activated → Stimulates Adrenal Medulla → Secretes
to them, limiting Bioactivity Catecholamines.
• Epitope: An Immunologically active binding site on a protein to which an ➢ Hormonal: Where one hormone stimulates the release of another
antibody can attach hormone from a different cell.
o Eg: The Hypothalamus secretes hormones → Stimulate Ant. Pituitary
→ Secrete Hormones.
o Eg: The Ant. Pituitary secretes Hormones → Stimulate other organs to
secrete hormones.

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 Additional Diagnostic Studies
Health History • Stimulation tests - are used to confirm hypofunction of an endocrine
• Patients should be asked if they have experienced changes in the following organ. The tests determine how an endocrine gland responds to the
areas: energy level, tolerance to heat or cold, weight, thirst, frequency of administration of stimulating hormones that are normally produced or
urination, bowel function, body proportions, muscle mass, fat and fluid released by the hypothalamus or pituitary gland
distribution, secondary sexual characteristics (e.g., loss or growth of hair), o If the endocrine gland responds to this stimulation, the specific
menstrual cycle, memory, concentration, sleep patterns, mood, vision, joint disorder may be in the hypothalamus or pituitary. Failure of the
pain, and sexual dysfunction endocrine gland to respond to this stimulation helps identify the
problem as being in the endocrine gland itself
Physical Assessment ➢ Suppression tests - are used to detect hyperfunction of an endocrine organ.
• physical examination should include vital signs; head-to-toe inspection; They determine if the organ is not responding to the negative feedback
and palpation of skin, hair, and thyroid mechanisms that normally control secretion of hormones from the
• Findings should be compared with previous findings, if available. Physical, hypothalamus or pituitary gland.
psychological, and behavioral changes should be noted. o Suppression tests measure the effect of a given exogenous dose of the
• Examples of changes in physical characteristics on examination may hormone on the endogenous secretion of the hormone or on the
include appearance of facial hair in women, “moon face,” “buffalo secretion of stimulation hormones from the hypothalamus or pituitary
hump,” exophthalmos (abnormal protrusion of one or both eyeballs), gland.
vision changes, edema, thinning of the skin, obesity of the trunk, thinness ➢ Imaging studies include radioactive scanning, magnetic resonance imaging
of the extremities, increased size of the feet and hands, edema, and hypo- (MRI), computed tomography (CT), ultrasonography, positron emission
or hyperreflexia. tomography (PET), and dual-energy x-ray absorptiometry (DXA)
• The patient may also exhibit changes in mood and behavior such as
nervousness, lethargy, and fatigue THE PITUITARY GLAND
➢ The pituitary gland, or hypophysis, is commonly referred to as the master
Blood Tests gland because of the influence it has on secretion of hormones by other
• determine the levels of circulating hormones, the presence of endocrine glands
autoantibodies, and the effect of a specific hormone on other substances
(e.g., the effect of insulin on blood glucose levels).
• The serum levels of a specific hormone may provide information to
determine the presence of hypo- or hyperfunction of the endocrine
system and the site of dysfunction.
o An example of a specific hormone that is amenable to analyzing by
blood testing is thyroid hormone (i.e., T3 and T4;)
• Radioimmunoassay tests are frequently used to detect antigen levels
which give additional information about hormone levels and levels of
other substances

Urine Tests
• Urine tests are used to measure the amount of hormones or the end
products of hormones excreted by the kidneys.
• For example, urinary levels of free catecholamines (norepinephrine,
epinephrine, and dopamine) may be measured in patients with
suspected pheochromocytoma, a tumor of the adrenal medulla

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 o Secretion of GH is increased by deep sleep, stress, exercise, fasting,
malnutrition, hypoglycemia, trauma, hypovolemic shock, and sepsis,
and is decreased in the presence of obesity, depression, and
hypothyroidism

Posterior Pituitary
➢ The important hormones secreted by the posterior lobe of the pituitary gland
are vasopressin, also referred to as antidiuretic hormone (ADH), and
oxytocin
➢ These hormones are synthesized in the hypothalamus and travel from the
hypothalamus to the posterior pituitary gland for storage
➢ Vasopressin - controls the excretion of water by the kidney; its secretion is
stimulated by an increase in the osmolality of the blood or by a decrease in
blood pressure
➢ Oxytocin - secretion is stimulated during pregnancy and at childbirth.
Oxytocin also facilitates milk ejection during lactation and increases the force
of uterine contractions during labor and delivery

Pathophysiology
➢ Abnormalities of pituitary function are caused by over- or undersecretion
Anterior Pituitary of any of the hormones produced or released by the gland
➢ The major hormones of the anterior pituitary gland are FSH, luteinizing ➢ anterior and posterior portions of the gland may occur independently.
hormone (LH), prolactin (PRL), adrenocorticotropic hormone (ACTH), Hypopituitarism, or hypofunction of the pituitary gland, can result from
thyroid-stimulating hormone (TSH), and GH (also referred to as disease of the pituitary gland itself or disease of the hypothalamus; the
somatotropin) outcome is essentially the same
➢ Arises from an upward out-pouching of the Oral-Ectoderm from the roof ➢ Hypopituitarism can result from radiation therapy to the head and neck
of the oral cavity called Rathke’s Pouch. This pouch pinches off from the area. The total destruction of the pituitary gland by trauma, tumor, or
oral cavity and is later separated by the vascular lesion removes all stimuli that are normally received by the
➢ sphenoid bone. thyroid, the gonads, and the adrenal glands
➢ The secretion of these major hormones is controlled by releasing factors ➢ This leads to extreme weight loss, emaciation, atrophy of all endocrine
secreted by the hypothalamus glands and organs, hair loss, impotence, amenorrhea, hypometabolism,
➢ These releasing factors reach the anterior pituitary by way of the bloodstream and hypoglycemia. Coma and death occur if the missing hormones are not
in a special circulation called the pituitary portal blood system. replaced
➢ Other hormones include melanocyte stimulating hormone and beta-
lipotropin; the function of lipotropin is poorly understood Anterior Pituitary
➢ GH, the most abundant anterior pituitary hormone, regulates growth in ➢ Over secretion (hypersecretion) of the anterior pituitary gland most
children and energy and metabolism in adults. commonly involves ACTH or GH and results in Cushing’s syndrome (group
o GH increases protein synthesis in many tissues, increases the of symptoms produced by an over secretion of ACTH) or acromegaly,
breakdown of fatty acids in adipose tissue, and increases blood respectively
glucose levels

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 o Acromegaly, a disorder caused by an excess of GH in adults, results in ➢ Basophilic tumors give rise to Cushing’s syndrome with features largely
enlargement of peripheral body parts and soft tissue, after the fusion attributable to hyperadrenalism, including masculinization and amenorrhea
of the epiphyseal plates has occurred in females, truncal obesity, hypertension, osteoporosis, and polycythemia
o Although rare, over secretion of GH in children before the fusion of ➢ Chromophobic tumors
epiphyseal growth plates result in pituitary gigantism; a person may • produce no hormones but destroy the rest of the pituitary gland, causing
grow to be 7 or even 8 feet tall hypopituitarism
o Conversely, insufficient secretion of GH during childhood can result • People with this disease often have obesity, are somnolent, and exhibit
in generalized limited growth and pituitary dwarfism fine, scanty hair; dry, soft skin; a pasty complexion; and small bones.
o Under secretion (hyposecretion) commonly involves all of the • They also experience headaches, loss of libido, and visual defects
anterior pituitary hormones and is termed panhypopituitarism. In progressing to blindness.
this condition, the thyroid gland, the adrenal cortex, and the gonads • Other signs and symptoms include polyuria, polyphagia, a lowering of the
atrophy (shrink) because of loss of the tropic-stimulating hormones. basal metabolic rate (chemical reactions occurring when the body is at
rest), and a subnormal body temperature
Posterior Pituitary
➢ The most common disorder related to posterior lobe dysfunction is ASSESSMENT AND DIAGNOSTIC FINDINGS
diabetes insipidus (DI), a condition in which abnormally large volumes of • Careful history and physical examination, including assessment of visual
dilute urine are excreted as a result of deficient production of vasopressin acuity and visual fields
➢ DI may occur following surgical treatment of a brain tumor, secondary to • CT and MRI scans are used to diagnose the presence and extent of pituitary
nonsurgical brain tumors, traumatic brain injury, infections of the tumors
nervous system, post hypophysectomy (removal of the pituitary), failure • Serum levels of pituitary hormones
of renal tubules to respond to ADH, and the use of specific medications

MEDICAL MANAGEMENT
Pituitary Tumors • Hypophysectomy, or surgical removal of the pituitary gland through a
➢ Almost all pituitary tumors are benign and are slow growing, may be primary transsphenoidal approach
or secondary and functional or nonfunctional
• Stereotactic radiation therapy, which requires the use of a neurosurgery-
Types of pituitary tumors: type stereotactic frame, may be used to deliver external-beam radiation
a. Eosinophilic Cells therapy precisely to the pituitary tumor with minimal effect on normal
b. Basophilic Cells tissue
c. Chromophobic Cells (I.E., Cells With No Affinity For Either Eosinophilic Or • Other treatments include conventional radiation therapy, bromocriptine,
Basophilic Stains and octreotide.
o Octreotide and lanreotide may also be used preoperatively to improve
Clinical Manifestations the patient’s clinical condition and to shrink the tumor
➢ Eosinophilic tumors that develop early in life result in gigantism
o yet so weak and lethargic that they can hardly stand
• If the disorder begins during adult life result in acromegaly
• severe headaches and visual disturbances because the tumors exert
pressure on the optic nerves
• Decalcification of the skeleton, muscular weakness, and endocrine
disturbances, similar to those occurring in patients with hyperthyroidism,
also are associated with this type of tumor

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SURGICAL MANAGEMENT

➢ Hypophysectomy is the treatment of choice in patients with Cushing’s

disease resulting from excessive production of ACTH by a pituitary tumor
o may also be performed on occasion as a palliative measure to relieve ➢ DI is characterized as
bone pain secondary to metastasis of malignant lesions of the breast • Central
and prostate o Characterized by a deficiency of the posterior pituitary gland to
➢ Surgical removal by transfrontal, subcranial, or oronasal transsphenoidal release ADH
approaches; irradiation; and cryosurgery • Nephrogenic
➢ The transsphenoidal approach and the nursing management of a patient o Characterized by the terminal distal convoluted tubule and
undergoing cranial surgery collecting duct resistance to ADH
o Maintain nasal packing in place and reinforce as needed. o Nephrogenic DI etiologic factors include kidney injury, medications
o Instruct patient to avoid blowing the nose. Provide oral care according such as lithium, hypokalemia, and hypercalcemia
to institutional procedure. • Dipsogenic
o Keep head of bed elevated to promote venous drainage and drainage o Characterized by excessive thirst due to a low osmotic threshold
from the surgical site o Dipsogenic DI is caused by a defect in the hypothalamus and may
be the result of damage to the pituitary gland from a head injury,
surgery, infection, inflammatory process, or a tumor
• Gestational
Diabetes Insipidus (Daming Ihi) o characterized by increased concentration of placental
vasopressinase during pregnancy
➢ is a rare disorder that occurs due to injury to the hypothalamus or pituitary
gland with a deficiency of ADH (vasopressin) that results in excretion of large
➢ Primary etiology for central DI is head trauma but other causes include:
volumes of dilute urine and extreme thirst
• Surgery
➢ ADH exerts its effects on the distal convoluted tubule and collecting duct of
• Infection
the nephron by upregulating aquaporin-2 channels (AQP2) on the cellular
• Inflammation
apical membrane surface.
• brain tumors
• cerebral vascular disease; it also may be idiopathic

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DI must be differentiated from diabetes, which may also cause polydipsia and excessive Pharmacologic Therapy
urination • Desmopressin, a synthetic vasopressin without the vascular effects of
Clinical Manifestations natural ADH, is the drug of choice for central DI.
• An enormous daily output (greater than 250 mL per hour) o The drug may be given orally or intranasally
o normal urine output 30 ml and above per hour o Vasopressin causes vasoconstriction; therefore, it must be used
• very dilute urine with a specific gravity of 1.001 to 1.005 occurs cautiously in patients with coronary artery disease
o normal urine specific gravity is: 1.010 to 1.030 • Chlorpropamide and thiazide diuretics are also used in mild forms of the
• Urine contains no abnormal substances such as glucose or albumin disease because they potentiate the action of vasopressin but are used with
o urine contains no abnormal substances such as glucose or albumin caution due to the risk for hypoglycemia
• In adults, the onset of DI may be insidious or abrupt • If the DI is renal in origin, the previously described treatments are
• Disease cannot be controlled by limiting fluid intake, because the high- ineffective
volume loss of urine continues even without fluid replacement o Thiazide diuretics, mild salt depletion, and prostaglandin inhibitors
• Restricting fluids cause the patient to experience an insatiable craving for (e.g., indomethacin and aspirin) are used to treat the nephrogenic
fluid and to develop hypernatremia and severe dehydration form of DI
Assessment and Diagnostic Findings
➢ Fluid deprivation test Nursing Management
o is carried out by withholding fluids for 8 to 12 hours or until 3% to • Ongoing physical assessment and patient education are the pillars of
5% of the body weight is lost skilled nursing management of the patient with a diagnosis of DI
o Plasma and urine osmolality studies are performed at the • Initially, the nurse reviews the patient history and physical assessment
beginning and end of the test and monitors for clinical manifestations of dehydration
o The test is terminated if tachycardia, excessive weight loss, or • Severe dehydration can lead to decreased cardiac output and, therefore,
hypotension develops decreased perfusion of the vital organs, specifically the brain and kidneys
➢ Inability to increase the specific gravity and osmolality of the urine is • Ongoing monitoring of vital signs as well as intake and output (I&O) is
characteristic of DI essential
➢ Patient continues to excrete large volumes of urine with low specific • The nurse is responsible to educate the patient, family, and other
gravity and experiences weight loss, increasing serum osmolality, and caregivers about follow-up care, prevention of complications, and
elevated serum sodium levels emergency measures
➢ Other diagnostic procedures include: • The nurse is responsible to educate the patient, family, and other
• concurrent measurements of plasma levels of ADH caregivers about follow-up care, prevention of complications, and
• plasma and urine osmolality emergency measures
• trial of desmopressin therapy • The patient should be advised to wear a medical identification bracelet and
• intravenous (IV) infusion of hypertonic saline solution carry required medication and information about DI at all times.
• If the diagnosis is confirmed and the cause (e.g., head injury) is not
obvious, the patient is carefully assessed for tumors that may be
causing the disorder
Medical Management
• Objectives of therapy are to replace ADH (which is usually a long-term Syndrome of Inappropriate Antidiuretic Hormone Secretion
therapeutic program) ➢ results from a failure of the negative feedback system that regulates the
• Ensure adequate fluid replacement release and inhibition of ADH
• Identify and correct the underlying intracranial pathology ➢ Patients with SIADH cannot excrete a dilute urine, retain fluids, and develop a
• Nephrogenic causes require different management approaches sodium deficiency known as dilutional hyponatremia

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➢ SIADH is often of nonendocrine origin; for instance, the syndrome may occur ➢ Thyroxine and triiodothyronine are needed by all body cells for metabolism
in patients with bronchogenic carcinoma in which malignant lung cells
synthesize and release ADH
o SIADH has also occurred in patients with severe pneumonia,
pneumothorax, and other disorders of the lungs, as well as malignant
tumors that affect other organs
➢ Disorders of the central nervous system, such
➢ as head injury, brain surgery or tumor, and infection, are thought to produce
SIADH by direct stimulation of the pituitary gland
➢ Some medications (e.g., vincristine, phenothiazines, tricyclic
antidepressants, thiazide diuretics) and nicotine have been implicated in
SIADH; they either directly stimulate the pituitary gland or increase the
sensitivity of renal tubules to circulating ADH.

Medical Management
• SIADH is generally self-limiting and treatment is focused on eliminating
the underlying cause, if possible, and restricting fluid intake
• Because retained water is excreted slowly through the kidneys, the • Thyroid Hormone Thyroid hormone is comprised of T4 and T3 , two
extracellular fluid volume contracts and the serum sodium concentration separate hormones produced by the thyroid gland.
gradually increases toward normal o Both are amino acids that contain iodine molecules bound to the
• Diuretic agents such as furosemide may be used along with fluid amino acid structure; T4 contains four iodine atoms in each molecule,
restriction and T3 contains three.
• In severe hyponatremia sometimes a hypertonic NaCl (3%) may be o These hormones are synthesized and stored bound to proteins in the
prescribed and administered IV cells of the thyroid gland until needed for release into the
bloodstream.
Nursing Management • Three thyroid-binding hormones:
Close monitoring of fluid I&O, daily weight, urine and blood chemistries, 1. Thyroxine-binding globulin (TBG)
• Neurologic status is indicated for the patient at risk for SIADH • This is like a strong, secure truck that carries most of the thyroid
• Supportive measures and explanations of procedures and treatments hormone, especially T4, to different parts of your body
assist the patient in managing this disorder • carries the majority of T3
2. Transthyretin (formerly known as thyroid-binding prealbumin)
• This protein is like a smaller delivery vehicle that carries T4 and
THE THYROID GLAND
also helps move vitamin A around.
➢ The thyroid gland—the largest endocrine gland—is a butterfly-shaped organ
3. Albumin—bind and transport T3 and T4
located in the lower neck, anterior to the trachea
• This is the most common transport protein in your blood. It
➢ It consists of two lateral lobes connected by an isthmus
doesn't hold onto thyroid hormones as tightly but helps
o The gland is about 5 cm long and 3 cm wide and weighs about 30 g
distribute them where needed.
➢ The blood flow to the thyroid is very high (about 5 mL/min per gram of
thyroid tissue), approximately five times the blood flow to the liver Thyroid-binding hormones - Think of these proteins as "transport vehicles" for
➢ The thyroid gland produces three hormones: thyroid hormones in your blood
a. thyroxine (T4) • Thyroid hormones—T3 and T4—help control how fast your body uses energy
b. triiodothyronine (T3) and regulates many important functions, like metabolism, heart rate, and
c. calcitonin body temperature.

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• Since hormones can't just float freely in your bloodstream, they need these Shows the hypothalamic–pituitary– thyroid axis, which regulates thyroid
special carrier proteins to help them travel to where they're needed hormone production

Synthesis of Thyroid Hormone

• Iodine is essential to the thyroid gland for synthesis of its hormones
o The major use of iodine in the body is by the thyroid, and the major
derangement in iodine deficiency is alteration of thyroid function
o Iodide is ingested in the diet and absorbed into the blood in the GI tract
o The thyroid gland is extremely efficient at taking up iodide from the
blood and concentrating it within the cells, where iodide ions are
converted to iodine molecules, which react with tyrosine (an amino
acid) to form the thyroid hormones
Regulation of Thyroid Hormone
• the secretion of T3 and T4 by the thyroid gland is controlled by TSH (also
called thyrotropin) from the anterior pituitary gland
o TSH controls the rate of thyroid hormone release through a negative
feedback mechanism
o In turn, the level of thyroid hormone in the blood determines the
release of TSH Mechanism of Action of Thyroid Hormone:
o If the thyroid hormone concentration in the blood decreases, the 1. Thyroxine (T4) reaches target cell
release of TSH increases, which causes increased output of T3 and T4 2. Binding Protein releases Thyroxine (T4)
o The term euthyroid refers to thyroid hormone production that is 3. Thyroxine (T4) diffuses into cytosol → Converts to T3
normal 4. T3 (The most active form) enters Nucleus → Binds to Nuclear Receptor on
• TRH, secreted by the hypothalamus, exerts a modulating influence on the DNA → Alters Gene Transcription.
release of TSH from the pituitary 5. Activating Different Genes → leads to Change in Cell’s Protein/Enzyme
profile → Change in Activity.

Cellular Changes:
• ↑Carbohydrate/Fat Metabolism
• ↑Glucose Uptake
• ↑Protein Synthesis + Catabolism
• ↑Mitochondrial Activity & Number
• ↑Na/K-ATPase Activity

Bodily Changes:
• CVS: ↑O2 Consumption → ↑Cardiac Output, HR & Respiration
• Environmental factors, such as a decrease in temperature, may lead to • GIT:
increased secretion of TRH, resulting in elevated secretion of thyroid o ↑Food Intake (↑Glucose Absorption from GIT)
hormones. o ↑Secretion of Digestive Juices
• Most of the hormone secreted by the thyroid is T4, but it’s considered the o ↑GIT Motility
"inactive" form. Once T4 reaches tissues, like the liver and kidneys, it’s
converted into T3, the more active form that directly affects metabolism. Metabolism:

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 • ↑Metabolism (Basal Metabolic Rate) • T4, a relatively weak hormone, maintains body metabolism in a steady
• ↑Insulin Secretion state
• ↑Lipolysis → Higher [FFA] in Plasma • T3 is about five times as potent as T4 and has a more rapid metabolic action
• ↑Body Temp → Sweating • T3 is about five times as potent as T4 and has a more rapid metabolic action
• ↑Vitamin Requirements due to ↑Quantities of Enzymes (Of which vitamins • These hormones accelerate metabolic processes by increasing the level of
are a vital component specific enzymes that contribute to oxygen consumption and altering the
responsiveness of tissues to other hormones
➢ Bone: ↑Bone Turnover & ↑Resorption • The thyroid hormones influence cell replication, are important in brain
➢ Muscle: ↑Speed of Muscle Contraction & ↑Speed of Relaxation development, and are necessary for normal growth
➢ Sympathetic NS: ↑Catecholamine Sensitivity of Heart, Muscle, Fat & • Thyroid hormones affect virtually every major organ system and tissue
Lymphocytes function, including the basal metabolic rate, tissue thermogenesis, serum
cholesterol levels, and vascular resistance
Note: Because Thyroid Hormones act by Gene Activation, they are said to have a
Long ‘Latent Calcitonin
• Period’, during which they seem to have no discernible effect. • Calcitonin, or thyrocalcitonin, is another important hormone secreted by
Thyroxine: 2-3 Days the thyroid gland
Triiodothyronine: 6-12 Hours • The hormone is secreted in response to high plasma levels of calcium, and
it reduces the plasma level of calcium by increasing its deposition in bone

Pathophysiolog y
• Congenital hypothyroidism, which occurs when there is inadequate
secretion of thyroid hormone during fetal and neonatal development,
results in intellectual disability and stunted physical growth because of
general depression of metabolic activity
• In adults, hypothyroidism manifests as lethargy, slow mentation, weight
gain, constipation, cold intolerance, and generalized slowing of body
functions
• Hyperthyroidism (over-secretion of thyroid hormones) is manifested by a
greatly increased metabolic rate
o result from the increased response to circulating catecholamines
(epinephrine and norepinephrine)
• Over secretion of thyroid hormones is usually associated with an enlarged
thyroid gland known as a goiter
• Goiter also commonly occurs with iodine deficiency. In this latter condition,
lack of iodine results in low levels of circulating thyroid hormones, which
causes increased release of TSH;
o the elevated TSH causes overproduction of thyroglobulin (a precursor
of T3 and T4) and hypertrophy of the thyroid gland
Function of Thyroid Hormone
• The main function of thyroid hormone is to control cellular metabolic Assessment Physical Examination
activity • The thyroid gland is inspected and palpated routinely in all patients.
Inspection begins with identification of landmarks

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 o lower neck region between the sternocleidomastoid muscles is • The most widely used tests are serum immunoassay for TSH and free T4.
inspected for swelling or asymmetry Free T4 levels correlate with metabolic status; they are elevated in
o The patient is instructed to extend the neck slightly and swallow hyperthyroidism and decreased in hypothyroidism
o Thyroid tissue rises normally with swallowing • Ultrasound, CT, and MRI may be used to clarify or confirm the results of
o The thyroid is then palpated for size, shape, consistency, symmetry, other diagnostic studies
and the presence of tenderness
• The health care provider may examine the thyroid from an anterior or a Thyroid Tests
posterior position. In the posterior position, both hands encircle the ➢ Serum Thyroid-Stimulating Hormone
patient’s neck • Measurement of the serum TSH concentration is the primary screening
• The thumbs rest on the nape of the neck, while the index and middle test of thyroid function
fingers palpate for the thyroid isthmus and the anterior surfaces of the • The ability to detect minute changes in serum TSH makes it possible to
lateral lobes. When palpable, the isthmus is perceived as firm and of a distinguish subclinical thyroid disease from euthyroid states in patients
rubber-band consistency. with low or high normal values
• The left lobe is examined by positioning the patient so that the neck flexes • Measurement of TSH is also used for monitoring thyroid hormone
slightly forward and to the left replacement therapy and for differentiating between disorders of the
• The thyroid cartilage is then displaced to the left with the fingers of the thyroid gland itself and disorders of the pituitary or hypothalamus.
right hand. This maneuver displaces the left lobe deep into the
sternocleidomastoid muscle, where it can be more easily palpated.
• The left lobe is then palpated by placing the left thumb deep into the ➢ Serum Free T4
posterior area of the sternocleidomastoid muscle, while the index and • is a direct measurement of free (unbound) thyroxine, the only
middle fingers exert opposite pressure in the anterior portion of the metabolically active fraction of T4
muscle. • The range of free T4 in serum is normally 0.7 to 2.0 ng/dL (10 to 26
• Having the patient swallow during the maneuver may assist the examiner pmol/L)
to locate the thyroid as it ascends in the neck. The procedure is reversed to • When measured by the dialysis method, free T4 is not affected by
examine the right lobe. variations in protein binding and is the procedure of choice for
• The isthmus is the only portion of the thyroid that is normally palpable. If monitoring the changes in T4 secretion during treatment for
a patient has a very thin neck, two thin, smooth, nontender lobes may also hyperthyroidism
be palpable.
• If palpation discloses an enlarged thyroid gland, both lobes are ➢ Serum T3 and T4
auscultated using the diaphragm of the stethoscope. • Measurement of total T3 or T4 includes protein-bound and free hormone
o Auscultation identifies the localized audible vibration of a bruit. This levels that occur in response to TSH secretion. T4 is 70% bound to TBG;
is indicative of increased blood flow through the thyroid gland T3 is bound less firmly
associated with hyperthyroidism and necessitates referral to a • Serious systemic illnesses, medications (e.g., oral contraceptives,
primary provider corticosteroids, carbamazepine, salicylates), and protein wasting as a
o Other abnormal findings that require referral for further evaluation result of nephrosis or the use of androgens may interfere with accurate
may include a soft texture (Graves disease), firmness (Hashimoto test results
thyroiditis or malignancy), and tenderness (thyroiditis) • Normal range for T4 is 5.4 to 11.5 µg/dL (57 to 148 nmol/L).
• Although serum T3 and T4 levels generally increase or decrease together,
Diagnostic Evaluation the T3 level appears to be a more accurate indicator of hyperthyroidism or
• Assessment measures in addition to palpation and auscultation include severity of the disorder, as T4 levels are often within normal range. The
thyroid function tests, such as laboratory measurement of thyroid normal range for serum T3 is 260 to 480 pg/dL
hormones, thyroid scanning, biopsy, and ultrasonography

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➢ T3 Resin Uptake Test affected by the patient’s intake of iodide or thyroid hormone, a careful
• is an indirect measure of unsaturated TBG preliminary clinical history is essential in evaluating results.
• Its purpose is to determine the amount of thyroid hormone bound to TBG • Normal values vary from one geographic region to another and with the
and the number of available binding sites. intake of iodine.
o This provides an index of the amount of thyroid hormone already • Patients with hyperthyroidism exhibit a high uptake of the 123I (in some
present in the circulation patients, as high as 90%), whereas patients with hypothyroidism exhibit
• Normally, TBG is not fully saturated with thyroid hormone, and additional a very low uptake.
binding sites are available to combine with radioiodine-labeled T3 added
to the blood specimen ➢ Fine-Needle Aspiration Biopsy
• normal T3 uptake value is 25% to 35% (relative uptake fraction, 0.25 to • use of a small-gauge needle to sample the thyroid tissue for biopsy is a
0.35), which indicates that about one third of the available sites of TBG are safe and accurate method of detecting malignancy and is often the initial
occupied by thyroid hormone test for evaluation of thyroid masses.
• If the number of free or unoccupied binding sites is low, as in • Results are reported as benign, malignant, suspicious, or
hyperthyroidism, the T3 uptake is greater than 35% (0.35). If the number nondiagnostic/insufficient. Within the malignancy category, masses are
of available sites is high, as occurs in hypothyroidism, the test result is reported as a follicular neoplasm or a follicular lesion
less than 25% (0.25).

• T3 uptake is useful in evaluating thyroid hormone levels in patients who ➢ Thyroid Scan, Radioscan, or Scintiscan
have received diagnostic or therapeutic doses of iodine. The test results • In a thyroid scan, a scintillation detector or gamma camera moves back
may be altered by the use of estrogens, androgens, salicylates, phenytoin, and forth across the area to be studied in a series of parallel tracks, and a
anticoagulants, or corticosteroids visual image is made of the distribution of radioactivity in the area being
scanned. The most commonly used isotopes of iodine are
➢ Thyroid Antibodies • Scans are helpful in determining the location, size, shape, and anatomic
• Autoimmune thyroid diseases include both hypo- and hyperthyroid function of the thyroid gland, particularly when thyroid tissue is
conditions. Results of testing by immunoassay techniques for antithyroid substernal or large
antibodies are positive in chronic autoimmune thyroid disease (90%), • Identifying areas of increased function (“hot” areas) or decreased
Hashimoto thyroiditis (100%), Graves disease (80%), and other organ- function (“cold” areas) can assist in diagnosis. Although most areas of
specific autoimmune diseases, such as systemic lupus erythematosus decreased function do not represent malignancies, lack of function
(SLE) and rheumatoid arthritis increases the likelihood of malignancy, particularly if only one
• Antithyroid antibody titers are normally present in 5% to 10% of the nonfunctioning area is present
population and increase with age • Scanning of the entire body, to obtain the total body profile, may be
carried out in a search for a functioning thyroid metastasis (i.e., a lesion
that produces thyroid hormones)
➢ Radioactive Iodine Uptake
• radioactive iodine uptake test measures the rate of iodine uptake by the ➢ Serum Thyroglobulin
thyroid gland. The patient is given a tracer dose of iodine or another • Thyroglobulin (Tg) can be measured reliably in the serum by
radionuclide, and a count is made over the thyroid gland with a radioimmunoassay
scintillation counter, which detects and counts the gamma rays released • Clinically, it is used to detect persistence or recurrence of thyroid
from the breakdown of in the thyroid. carcinoma
• radioactive iodine uptake test is a simple test with reliable results. The
test measures the proportion of the given dose that is present in the
thyroid gland at a specific time after its administration. Since the test is

16
Nursing Implications ➢ If thyroid deficiency is present at birth, it is referred to as neonatal
• thyroid tests involve the use of iodine, determining if the patient has any hypothyroidism.
allergies to iodine or is taking medications that contain iodine is essential. ➢ In such instances, the mother may also have thyroid deficiency.
o the relationship between having an allergy to shellfish and having an ➢ The term myxedema refers to the accumulation of mucopolysaccharides in
allergy to iodine is a long-held belief; however, an allergy to shellfish subcutaneous and other interstitial tissues.
is due to specific proteins in the shellfish and not iodine ➢ Although myxedema occurs in long-standing hypothyroidism, the term is used
• Patients should be asked if they have had a reaction to iodine previously and appropriately only to describe the extreme symptoms of severe hypothyroidism
to shellfish so that the radiologist can determine what precautions need to
Causes of Hypothyroidism
be taken
• Autoimmune disease (Hashimoto thyroiditis, post-Graves disease)
• Patients should be asked about obvious sources of iodine containing
medications such as contrast agents and those used to treat thyroid • Atrophy of thyroid gland with aging
disorders such as radioactive iodine • Infiltrative diseases of the thyroid (amyloidosis, scleroderma, lymphoma)
• They should also be asked whether they eat kelp or seaweed. Numerous • Iodine deficiency, iodine excess, and iodine compounds Medications (e.g.,
medications may also affect test results because they affect the thyroid. Lithium)
o Amiodarone, aspirin, cimetidine, diazepam, estrogens, furosemide • Radioactive iodine
glucocorticoids, heparin, lithium , phenytoin and other • Therapy for hyperthyroidism
anticonvulsants propranolol • Thyroidectomy
• Radiation to head and neck in treatment for head and neck cancers,
lymphoma

Hypothyroidism
Clinical Manifestations
➢ results from suboptimal levels of thyroid hormone
• Complaints of fatigue
➢ Thyroid deficiency can affect all body functions and can range from mild,
• Lethargy that may interfere with activities of daily living, weight gain
subclinical forms to myxedema an advanced life-threatening form
without an increased intake of calories
➢ most common cause of hypothyroidism in adults is autoimmune thyroiditis
• Cold intolerance
(Hashimoto disease), in which the immune system attacks the thyroid gland
• Dry skin,
➢ commonly occurs in patients with previous hyperthyroidism that has been
• In some patients, a deepening of the voice.
treated with radioiodine or antithyroid medications or thyroidectomy

Testing of thyroid function is recommended for all patients who receive radiation therapy to Other clinical manifestations are related to gender, age, and duration of the
the neck decrease in thyroid function
➢ More than 95% of patients with hypothyroidism have primary or thyroidal • These include cardiovascular related manifestations such as bradycardia
hypothyroidism, which refers to dysfunction of the thyroid gland itself. and changes in electrical conduction of the heart which will be noted on
➢ If the cause of the thyroid dysfunction is failure of the pituitary gland, the the electrocardiogram
hypothalamus, or both, the hypothyroidism is known as central • In women, changes in the menstrual cycle will be noted
hypothyroidism. • Severe hypothyroidism results in a subnormal body temperature and
➢ If the cause is entirely a pituitary disorder, it may be referred to as pituitary or pulse rate
secondary hypothyroidism. • Patient usually begins to gain weight even without an increase in food
➢ If the cause is a disorder of the hypothalamus resulting in inadequate secretion intake, although they may be cachectic
of TSH due to decreased stimulation of TRH, it is referred to as hypothalamic or • Skin becomes thickened because of an accumulation of
tertiary hypothyroidism. mucopolysaccharides in the subcutaneous tissues
• hair thins and falls out, and the face becomes expressionless and
masklike
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 • patient often complains of being cold even in a warm environment. • In myxedema coma, the patient may initially show signs of:
o Depression
▪ patient’s respiratory drive is depressed, resulting in alveolar
hypoventilation, progressive carbon dioxide retention, narcosis, and
coma
o Diminished cognitive status
o Lethargy
▪ Increasing lethargy may progress to stupor
o Somnolence

• Patients with myxedema coma can also exhibit hyponatremia,

hypoglycemia, hypoventilation, hypotension, bradycardia, and
hypothermia
o these symptoms, along with cardiovascular collapse and shock,
require aggressive and intensive supportive and hemodynamic
therapy if the patient is to survive
Medical Management
• objectives in the management of hypothyroidism are to restore a normal
metabolic state by replacing the missing hormone, as well as prevention
of disease progression and complications
• Severe hypothyroidism is associated with an elevated serum cholesterol level, Pharmacologic Therapy
atherosclerosis, coronary artery disease, and poor left ventricular function • Synthetic levothyroxine is the drug of choice for the treatment of
o patient with advanced hypothyroidism is hypothermic and abnormally hypothyroidism
sensitive to sedative, opioid, and anesthetic agents, which must be given • General range is 75 to 150 mcg per day and treatment is generally started
with extreme caution. at the lower dose and titrated slowly until desired levels of TSH achieved
o Patients with unrecognized hypothyroidism who are undergoing surgery • Older adult patients generally require a lower dose; normal TSH levels are
are at increased risk for intraoperative hypotension, postoperative heart often achieved with 50 mcg per day
failure, and altered mental status. Some patients on thyroid hormone replacement may complain of continued clinical
• Myxedema coma is a rare life-threatening condition and a decompensated manifestations despite normal TSH levels
state of severe hypothyroidism in which the patient is hypothermic and
unconscious
o This condition may develop with undiagnosed hypothyroidism and may Prevention of Cardiac Dysfunction
be precipitated by infection or other systemic disease or by use of • patient who has had hypothyroidism for a long period usually has
sedatives or opioid analgesic agents associated
o Patients may also experience myxedema coma if they forget to take their o elevated serum cholesterol
thyroid replacement medication o atherosclerosis
o The condition occurs most often among older women in the winter o coronary artery disease
months and appears to be precipitated by cold. However, the disorder can • As long as metabolism is subnormal and the tissues (including the
affect any age group myocardium) require relatively little oxygen, a reduction in blood supply is
tolerated without overt symptoms of coronary artery disease
• When thyroid hormone is given, the oxygen demand increases, but oxygen
delivery cannot be increased unless, or until, the atherosclerosis improves

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 o occurrence of angina and acute coronary syndrome is the signal that • The latter should be avoided to prevent increased oxygen demands and
the oxygen needs of the myocardium exceed its blood supply hypotension
o angina or arrhythmias can occur when thyroid replacement is initiated
because thyroid hormones enhance the cardiovascular effects of Educating Patients About Self-Care
catecholamines. • The patient and family require education and support to manage this
NOTE!!! complex disorder at home.
• If angina or arrhythmias occur, thyroid hormone administration must be • Oral and written instructions should be provided regarding the following:
discontinued immediately • The importance of life-long therapy and the need to take thyroid
• Later, when it can be resumed safely, it should be prescribed cautiously at medication everyday
a lower dosage and with close monitoring by the primary provider and the • Desired actions and side effects of medications
nurse. • Correct medication administration (“Take first thing in the morning with
a full glass of water on an empty stomach.”)
Prevention of Medication Interactions • Importance of continuing to take the medications as prescribed even after
• Oral thyroid hormones interact with many other medications. They symptoms improve
increase the effect of warfarin and the cardiovascular effects of • When to seek medical attention Importance of nutrition and diet to
adrenergic agents (bronchodilators and vasopressors) promote weight loss and normal bowel patterns Importance of periodic
• the dosage of insulin and oral hypoglycemic medications used to treat follow-up testing
diabetes may require adjustment • The patient and family should be educated that the symptoms observed
• Caution is also needed in patients who are concomitantly taking estrogen, during the course of the disorder will disappear with effective treatment
which may necessitate an increased dosage of the oral thyroid hormone
• Absorption may be affected by any supplement or food that contains
calcium, iron, magnesium or zinc Continuing and Transitional Care
• Even in small IV doses, hypnotic and sedative agents may induce profound • If indicated, a referral is made for home, community-based or transitional
somnolence, lasting far longer than anticipated and leading to narcosis care
(stupor like condition) • nurse monitors the patient’s recovery and ability to cope with changes,
• they are likely to cause respiratory depression, which can easily be fatal and assesses the patient’s physical and cognitive status and the patient’s
because of decreased respiratory reserve and alveolar hypoventilation and family’s understanding of previous education
• dose of these medications should be one half or one third of that typically • nurse documents and reports to the patient’s primary provider subtle
prescribed for patients of similar age and weight with normal thyroid signs and symptoms that may indicate either inadequate or excessive
function thyroid hormone

Supportive Therapy
• Severe hypothyroidism and myxedema coma require prompt, aggressive Hyperthyroidism
management to maintain vital functions ➢ a common endocrine disorder, is a form of thyrotoxicosis resulting from an
• Arterial blood gases may be measured to determine carbon dioxide excessive synthesis and secretion of endogenous or exogenous thyroid
retention and to guide the use of assisted ventilation to combat hormones by the thyroid
hypoventilation ➢ most common causes are Graves disease, toxic multinodular goiter, and
• Oxygen saturation levels should be monitored using pulse oximetry. toxic adenoma.
• Fluids are given cautiously because of the danger of water intoxication. ➢ Other causes include thyroiditis (inflammation of the thyroid gland) and
• Passive rewarming with a blanket is recommended versus active excessive ingestion of thyroid hormone
rewarming such as application of external heat (e.g., heating pads).

19
 • Graves disease - is an autoimmune disorder that results from an excessive • Myocardial hypertrophy and heart failure may occur if the hyperthyroidism is
output of thyroid hormones caused by abnormal stimulation of the thyroid severe and untreated.
gland by circulating immunoglobulins • Symptoms of hyperthyroidism may occur with the release of excessive
o This disease affects women eight times more frequently than men, amounts of thyroid hormone as a result of inflammation after irradiation of the
with onset usually between the second and fourth decades. The thyroid or destruction of thyroid tissue by tumor. Such symptoms may also
disorder may appear after an emotional shock, stress, or an infection, occur with excessive administration of thyroid hormone for the treatment of
but the exact significance of these relationships is not understood hypothyroidism.

Clinical Manifestations
• Clinical manifestations are related to the increase in metabolic rate and Assessment and Diagnostic Findings
increased oxygen consumption • The thyroid gland is enlarged to some extent. It is soft and may pulsate; a
• The patient may appear anxious, seem restless and irritable, and exhibit thrill often can be palpated, and a bruit is heard over the thyroid arteries
fine tremors of the hands • These are signs of greatly increased blood flow through the thyroid gland.
• The patient will be tachycardic and complain of palpitations. • In advanced cases, the diagnosis is made on the basis of the symptoms, a
• Heat intolerance will be noted with increased perspiration. decrease in serum TSH, increased free T4, and an increase in radioactive
Additional clinical manifestations include an increase in appetite, diarrhea, iodine uptake.
weight loss, and thin skin.
• Patients with Graves disease may present with exophthalmos and may Medical Management
exhibit reduced blinking and lid retraction. Treatment may not reverse • treatment of hyperthyroidism depends on the underlying cause and often
ocular manifestations consists of a combination of therapies, including antithyroid agents,
• Women experience changes in menstruation including oligomenorrhea radioactive iodine, and surgery.

• Treatment of hyperthyroidism is directed toward reducing thyroid

hyperactivity to relieve symptoms and preventing complications
• use of radioactive iodine is the most common form of treatment for
Graves disease.
• Beta-adrenergic blocking agents (e.g., propranolol, atenolol, metoprolol)
are used as adjunctive therapy for symptomatic relief, particularly in
transient thyroiditis
• three treatments (radioactive iodine therapy, antithyroid medications [e.g.,
thionamides], and surgery) share the same complications: relapse or
recurrent hyperthyroidism and permanent hypothyroidism
• Patients with Graves disease may sustain remission for up to 12 to 18
months but often experience recurrence within 12 months of treatment

Pharmacologic Therapy
• Two forms of pharmacotherapy are available for treating hyperthyroidism
and controlling excessive thyroid activity:
• Cardiac effects may include sinus tachycardia or arrhythmias, decreased
o the use of irradiation by administration of the radioisotope for
cardiac output, increased pulse pressure, and palpitations; these changes may
destructive effects on the thyroid gland
be related to increased sensitivity to catecholamines or to changes in
neurotransmitter turnover.
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 o antithyroid medications that interfere with the synthesis of thyroid o A major advantage of treatment with radioactive iodine is that it
hormones and other agents that control manifestations of avoids many of the side effects associated with antithyroid
hyperthyroidism medications.
o However, some patients may elect to be treated with antithyroid
Radioactive Iodine Therapy medications rather than radioactive iodine for a variety of reasons,
• used to treat toxic adenomas, toxic multinodular goiter, and most including fear of radiation
varieties of thyrotoxicosis and is considered the treatment of choice
because a single dose is effective in treating 80% to 90% of cases
• Radioactive iodine is contraindicated during pregnancy because it crosses ➢ Thyroid Storm (Thyrotoxic Crisis, Thyrotoxicosis) Thyroid storm (thyrotoxic
the placenta. Women of childbearing age should be given a pregnancy test crisis)
48 hours before administration of radioactive iodine • is a form of severe hyperthyroidism, usually of abrupt onset. Untreated, it
• They should also be instructed to not conceive for at least 6 months is almost always fatal, but with proper treatment the mortality rate is
following treatment. In addition, breast-feeding for up to 6 weeks prior to reduced substantially
radioactive iodine treatment is contraindicated • The patient with thyroid storm or crisis is critically ill and requires astute
• The goal of radioactive iodine therapy is to eliminate the hyperthyroid observation and aggressive and supportive nursing care during and after
state with the administration of sufficient radiation in a single dose the acute stage of illness.
• Almost all of the iodine that enters is retained in the body becomes
concentrated in the thyroid gland. Therefore, the radioactive isotope of Clinical Manifestations
iodine is concentrated in the thyroid gland, where it destroys thyroid cells ➢ Thyroid storm is characterized by:
without jeopardizing other radiosensitive tissues. • Hyperpyrexia (high fever), >38.5°C (>101.3°F)
• The use of an ablative dose of radioactive iodine initially causes an acute • Extreme tachycardia (>130 bpm)
release of thyroid hormone from the thyroid gland and may cause • Exaggerated symptoms of hyperthyroidism with disturbances of a major
increased symptoms. system—for example, gastrointestinal (weight loss, diarrhea, abdominal
• The patient is observed for signs of thyroid storm pain) or cardiovascular (edema, chest pain, dyspnea, palpitations)
o a life-threatening condition manifested by cardiac arrhythmias, fever, • Altered neurologic or mental state, which frequently appears as delirium
and neurologic impairment which may lead to heart failure, psychosis, somnolence, or coma
circulatory collapse and dangerous elevation of body temperature, all
related to the increase in metabolism Life-threatening thyroid storm is usually precipitated by stress, such as injury, infection,
o Beta-blockers are used to control these symptoms. Thyroid hormone thyroid and non-thyroid surgery, tooth extraction, insulin reaction, diabetic ketoacidosis,
replacement is started 4 to 18 weeks after the antithyroid medications pregnancy, digitalis intoxication, abrupt withdrawal of antithyroid medications, extreme
have been stopped based on the results of thyroid function tests emotional stress, or vigorous palpation of the thyroid.
• Medications have been stopped based on the results of thyroid function
tests. TSH measurements can be misleading in the early months following
Management
treatment with radioactive iodine.
• A hypothermia mattress or blanket, ice packs, a cool environment,
o Therefore, serum free T4 is the principal test measured at 3 to 6
hydrocortisone, and acetaminophen.
weeks following administration of radioactive iodine and then every 1
• Salicylates (e.g., aspirin) are not used because they displace thyroid
to 2 months until normal thyroid function is established.
hormone from binding proteins and worsen the hypermetabolism.
o If TSH and free T4 are both persistently low, the total T3 then must be
• Humidified oxygen is given to improve tissue oxygenation and meet the
measured to differentiate between persistent hyperthyroidism (T3
high metabolic demands.
elevated) or transient hypothyroidism (T3 normal or low).
• Arterial blood gas levels or pulse oximetry may be used to monitor
o Once a normal thyroid state has been established, TSH should be
measured every 6 to 12 months for life respiratory status. IV fluids containing dextrose are given to replace liver

21
 glycogen stores that have been decreased in the patient who is • Propylthiouracil is recommended during the first trimester of pregnancy
hyperthyroid. rather than methimazole due to the teratogenic effects of methimazole.
• Propylthiouracil or methimazole is given to impede formation of thyroid • Due to risk of hepatotoxicity, propylthiouracil should be discontinued
hormone and block conversion of T4 to T3, the more active form of thyroid after the first trimester and the patient should be switched to
hormone. methimazole for the remainder of the pregnancy and when breast-feeding
• Hydrocortisone is prescribed to treat shock or adrenal insufficiency.
• Iodine is given to decrease output of T4 from the thyroid gland. For Agent Action Nursing Considerations
cardiac problems such as atrial fibrillation, arrhythmias, and heart failure, Propylthiouracil Blocks synthesis of Monitor cardiac parameters.
sympatholytic agents may be given. hormones (conversion Observe for conversion to
• Propranolol, combined with digitalis, has been effective in reducing severe of T4 to T3) hypothyroidism. Must be given
cardiac symptoms. by mouth. Watch for rash,
• T3, triiodothyronine; T4, thyroxine. nausea, vomiting,
agranulocytosis, SLE
o Patients who receive radioactive iodine should be informed that they
Methimazole Inhibits synthesis of More toxic than
can contaminate their household and other people through saliva,
thyroid hormone propylthiouracil. Watch for
urine, or radiation emitting from their body.
rash and other symptoms as for
o They should avoid sexual contact, sleeping in the same bed with other propylthiouracil.
people, having close contact with children and pregnant women, and Sodium iodide Suppresses release of Given 1 h after propylthiouracil
sharing utensils and cups. thyroid hormone or methimazole. Watch for
edema, hemorrhage,
Antithyroid Medications gastrointestinal upset.
• objective of pharmacotherapy is to inhibit one or more stages in thyroid Potassium Suppresses release of Discontinue for rash. Watch for
hormone synthesis or hormone release iodide. thyroid hormone signs of toxic iodinism
• Antithyroid agents block the utilization of iodine by interfering with the Saturated Suppresses release of Mix with juice or milk. Given by
iodination of tyrosine and the coupling of iodotyrosines in the synthesis of solution of thyroid hormone straw to prevent staining of
thyroid hormones potassium teeth.
• The most commonly used antithyroid drugs in the United States are iodide (SSKI)
methimazole or propylthiouracil Beta-blocker Beta-blocker (e.g., Monitor cardiac status. Hold
(e.g., propranolol) Beta- for bradycardia or decreased
• The medications are used until the patient is euthyroid (i.e., neither
propranolol) adrenergic blocking cardiac output. Use with
hyperthyroid nor hypothyroid). These medications block extrathyroidal
Beta- agent caution in patients with heart
conversion of T4 to T3 adrenergic failure
• therapeutic dose is determined on the basis of clinical criteria, including blocking agent
changes in pulse rate, pulse pressure, body weight, size of the goiter, and
results of laboratory studies • Discontinuation of antithyroid medications before therapy is complete
• patient should be instructed to take the medication in the morning on an usually results in relapse within 6 months. It is important that the possibility
empty stomach 30 minutes before eating to avoid decrease in absorption of relapse be discussed so that a treatment strategy will be in place if relapse
associated with some foods such as walnuts, soybean flour, cottonseed occurs.
meal, and dietary fiber
• it may take several weeks until symptom relief occur Adjunctive Therapy
• Toxic complications of antithyroid medications are relatively uncommon; • Potassium iodide (SSKI) may be used in combination with antithyroid
nevertheless, the importance of periodic follow-up is emphasized, agents or beta-adrenergic blockers to prepare the patient with
because medication sensitization, fever, rash, urticaria, or even hyperthyroidism for surgery
agranulocytosis and thrombocytopenia

22
 • The drugs reduce the effects of hyperthyroidism quickly and help to ▪ Some are symmetric and diffuse; others are nodular. Some are accompanied
prevent the onset of thyroid storm. The usual dosage for SSKI is 5 drops by hyperthyroidism, in which case they are described as toxic; others are
every 6 hours. associated with a euthyroid state and are referred to as nontoxic goiters.
• The usual dose of propylthiouracil is 200 mg every 6 hours and the usual
dose of propranolol is 60 to 80 mg orally every 6 hours to prevent Endemic (Iodine-Deficient) Goiter
tachycardia. ▪ most common type of goiter that occurs when iodine intake is deficient is the
• The patient will need to continue to take the propylthiouracil and any simple or colloid goiter and caused by an iodine deficiency, simple goiter may
cardiac medication until the free T4 and T3 levels are near normal be caused by an intake of large quantities of goitrogenic substances in
patients with unusually susceptible glands
Surgical Management ▪ These substances include excessive amounts of iodine.
• Surgery to remove thyroid tissue is reserved for special circumstances, for ▪ Lithium prescribed for the treatment of bipolar disorder has also been found
example, in pregnant women who are allergic to antithyroid medications, to also have antithyroid actions
in patients with large goiters, or in patients who are unable to take ▪ Simple goiter is a compensatory hypertrophy of the thyroid gland, caused by
antithyroid agents stimulation by the pituitary gland
• Surgery for treatment of hyperthyroidism is performed soon after the o Its production increases if there is subnormal thyroid activity, as when
thyroid function has returned to normal (4 to 6 weeks) insufficient iodine is available for production of the thyroid hormone
• surgical removal of about five sixths of the thyroid tissue (subtotal ▪ Goiters usually cause no symptoms, except for the swelling in the neck, which
thyroidectomy) reliably results in a prolonged remission in most patients may result in tracheal compression when excessive swelling is present
with exophthalmic goiter. o Many goiters of this type recede after the iodine imbalance is corrected
• Its use today is reserved for patients with obstructive symptoms, some o Supplementary iodine, such as SSKI, is prescribed to suppress the
pregnant women, and for patients with a need for rapid normalization of pituitary’s thyroid-stimulating activity
thyroid function. Before surgery, an antithyroid medication is given until o When surgery is indicated, the risk of postoperative complications is
signs of hyperthyroidism have disappeared. minimized by ensuring a preoperative euthyroid state through treatment
• A beta-adrenergic blocking agent (e.g., propranolol) may be used to with antithyroid medications and iodide to reduce the size and vascularity
reduce the heart rate and other signs and symptoms of hyperthyroidism. of the goiter. The introduction of iodized salt has been the single most
• Medications that may prolong clotting (e.g., aspirin) are stopped several effective means of preventing goiter in at-risk populations
weeks before surgery to reduce the risk of postoperative bleeding.
• Patients receiving iodine medication must be monitored for evidence of Nodular Goiter
iodine toxicity, which requires immediate withdrawal of the medication.
▪ Some thyroid glands are nodular because of areas of hyperplasia
• Symptoms of toxicity include mucosa membranes stained brown, burning
(overgrowth).
pain in the mouth and esophagus, laryngeal edema, and shock
▪ No symptoms may arise as a result of this condition, but not uncommonly
these nodules slowly increase in size, with some descending into the thorax,
where they cause local pressure symptoms
Thyroid Tumors ▪ Some nodules become malignant, and some are associated with a
▪ Tumors of the thyroid gland are classified on the basis of being benign or hyperthyroid state. Therefore, the patient with many thyroid nodules may
malignant, the presence or absence of associated thyrotoxicosis, and the eventually require surgery
diffuse or irregular quality of the glandular enlargement.
▪ If the enlargement is sufficient to cause a visible swelling in the neck, the Thyroid Cancer
tumor is referred to as a goiter
▪ Cancer of the thyroid is less prevalent than other forms of cancer; however,
▪ All grades of goiter are encountered, from those that are barely visible to
the incidence has tripled in the last 30 and accounts for 90% of endocrine
those producing disfigurement.
malignancies.

23
 ▪ it has the fastest-growing cancer rate among both men and women, women o modified neck dissection or more extensive radical neck dissection is
are three times more likely to develop this cancer than men performed if there is lymph node involvement
▪ thyroid cancer is more likely to develop in patients that are younger than 50 o efforts are made to spare parathyroid tissue to reduce the risk of
years postoperative hypocalcemia and tetany
o after surgery, ablation procedures are carried out with radioactive
Lifestyle Factors and the Risk of Thyroid Cancer iodine to eradicate residual microscopic disease
• alcohol consumption o radioactive iodine is also used for thyroid cancers with metastasis
• smoking habits • after surgery, thyroid hormone is given to lower the levels of TSH to a
• lower physical activity levels euthyroid state
• higher stress, • if the remaining thyroid tissue is inadequate to produce sufficient thyroid
• unhealthy eating habits (consumption of more instant food products and hormone, thyroxine is required permanently
fewer vegetables) • Several routes are available for administering radiation to the thyroid or
➢ External radiation of the head, neck, or chest in infancy and childhood tissues of the neck, including oral administration of radioactive iodine
increases the risk of thyroid carcinoma and external administration of radiation therapy
➢ The incidence of thyroid cancer appears to increase 5 to 40 years after • radioactive iodine for DTC is the most successful targeted therapy in
irradiation oncology
Assessment and Diagnostic Findings o Short-term side effects of radioactive iodine treatment may include
• Lesions that are single, hard, and fixed on palpation or associated with neck soreness, nausea, and upset stomach; tender and swollen salivary
cervical lymphadenopathy suggest malignancy glands; dry mouth; changes in taste; and, rarely, pain
• Thyroid function tests may be helpful in evaluating thyroid nodules and o patient who receives external sources of radiation therapy is at risk for
masses; however, results are rarely conclusive mucositis, dryness of the mouth, dysphagia, redness of the skin,
anorexia, and fatigue
• An ultrasound-guided fine needle biopsy of the thyroid gland is the
o Chemotherapy is infrequently used to treat thyroid cancer
standard diagnostic procedure for evaluating thyroid nodules
• It is performed as an outpatient procedure to make a diagnosis of thyroid
• Patients whose thyroid cancer is detected early, who are younger than 50
cancer, to differentiate cancerous thyroid nodules from noncancerous
years, and who are appropriately treated have a good prognosis
nodules, and to stage the cancer if detected
o papillary cancer—the most common and least aggressive tumor—have
• The procedure is safe and usually requires only a local anesthetic agent
the best prognosis of all thyroid cancers
Additional diagnostic studies include ultrasound, MRI, CT, thyroid scans, o long-term survival is also common in follicular cancer, which is a more
radioactive iodine uptake studies, and thyroid suppression tests aggressive form of thyroid cancer
o later follow-up includes clinical assessment for recurrence of nodules or
masses in the neck and signs of hoarseness, dysphagia, or dyspnea
Medical Management • First year evaluation includes clinical examination, TSH and free thyroxine,
• medical management depends on the classification of cell type found on and measurement of serum thyroglobulin within 6 months following the
biopsy initial treatment, and a routine neck ultrasound with the first 6 to 12 months
• three common groups include: following initial treatment
o well-differentiated thyroid cancer (DTC) • Tests used to confirm sites of metastasis if there is clinical evidence of
o papillary thyroid carcinoma (PTC) recurrence include radioiodine imaging, CT, MRI, skeletal x-rays, and
o follicular thyroid carcinoma (FTC) skeletal radionucleotide imaging.
• treatment of choice for localized thyroid carcinoma is surgical removal • Fluorodeoxyglucose (FDG) PET is useful to establish prognosis if there is
o total or near-total thyroidectomy is performed if evidence of distant metastases

24
• Free T4, TSH, and serum calcium and phosphorus levels are monitored to • When patient is in a recumbent position, the nurse observes the sides and
determine whether the thyroid hormone supplementation is adequate and to the back of the neck as well as the anterior dressing for bleeding
note whether calcium balance is maintained • tracheostomy set is kept at the bedside at all times, and the surgeon is
summoned at the first indication of respiratory distress. If the respiratory
Nursing Management distress is caused by hematoma, surgical evacuation is required
• Important preoperative goals are to prepare the patient for surgery and • intensity of pain is assessed, and analgesic agents are given as prescribed
reduce anxiety for pain.
• patient’s home life has become tense because of their restlessness, • the nurse should anticipate apprehension in the patient and should inform
irritability, and nervousness secondary to hyperthyroidism. Efforts are the patient that oxygen will assist breathing. When moving and turning
necessary to protect the patient from tension and stress to avoid the patient, the nurse carefully supports the patient’s head and avoids
precipitating thyroid storm tension on the sutures.
• suggestions are made to limit stressful situations. Quiet and relaxing • most comfortable position is the semi-Fowler position, with the head
activities are encouraged elevated and supported by pillows
• IV fluids are given during the immediate postoperative period. Water may
Providing Preoperative Care be given by mouth as soon as nausea subsides and bowel sounds are
• nurse educates the patient about importance of diet with high present.
carbohydrates and proteins it is necessary because of the increased • Usually, there is a little difficulty in swallowing; initially, cold fluids and
metabolic activity and rapid depletion of glycogen reserves. ice may be taken better than other fluids. Often, patients prefer a soft diet
• supplementary vitamins, particularly thiamine and ascorbic acid, may be to a liquid diet in the immediate postoperative period.
prescribed. The patient is reminded to avoid tea, coffee, cola, and other • patient is advised to talk as little as possible to reduce edema to the vocal
stimulants cords; however, when the patient does speak, any voice changes are noted,
• nurse also informs the patient about the purpose of preoperative tests, if indicating possible injury to the recurrent laryngeal nerve, which lies just
they are to be performed, and explains what preoperative preparations to behind the thyroid next to the trachea.
expect
• help to reduce the patient’s anxiety about the surgery. In addition, special • overbed table is provided for access to frequently used items so that the
efforts are made to ensure a good night’s rest before surgery. patient avoids turning their head
• Preoperative education includes demonstrating to the patient how to • the table can also be used to support a humidifier when vapor-mist
support the neck with the hands after surgery to prevent stress on the inhalations are prescribed for the relief of excessive mucous accumulatio
incision.
o This involves raising the elbows and placing the hands behind the neck An essential assessment following a thyroidectomy is of voice changes. Difficulty in speaking
to provide support and reduce strain and tension on the neck muscles (the act of moving air to vibrate vocal cords) may indicate increasing edema, damage to
and the surgical incision laryngeal nerve, or hemorrhage and should be reported immediately.

Providing Postoperative Care • patient is encouraged to be out of bed as soon as possible and to eat foods
• priorities are to observe for any difficulty in breathing due to edema of the that are easily swallowed, high-calorie diet may be prescribed to promote
glottis, hematoma formation, or injury to the recurrent laryngeal nerve weight gain.
which requires the insertion of an airway, and to monitor the pulse and • The incision may be closed using absorbable sutures, nonabsorbable
blood pressure for any indication of internal bleeding sutures, and adhesive strips. Absorbable sutures dissolve within the body.
• alert for complaints of a sensation of pressure or fullness at the incision If nonabsorbable sutures are used, the timeline for removal may vary;
site which may indicate subcutaneous hemorrhage and hematoma however, these types of sutures are usually removed 5 to 7 days following
formation and should be reported surgery.

25
 • Adhesives will peel off spontaneously. The patient is usually discharged
from the hospital on the day of surgery or soon afterward if the
postoperative course is uncomplicated Pathophysiology
• Excess parathormone can result in markedly increased levels of serum
Monitoring and Managing Potential Complications calcium, which is a potentially life-threatening situation
• Hemorrhage, hematoma formation, edema of the glottis, and injury to the • When the product of serum calcium and serum phosphorus (calcium ×
laryngeal nerve are complications reviewed previously in this chapter. phosphorus) rises, calcium phosphate may precipitate in various organs of
• Occasionally in thyroid surgery, the parathyroid glands are injured or the body (e.g., the kidneys) and cause tissue calcification
removed, producing a disturbance in calcium metabolism
• As the blood calcium level falls, hyperirritability of the nerves occurs, with Hyperparathyroidism
spasms of the hands and feet and muscle twitching ▪ is caused by overproduction of parathormone by the parathyroid glands
• This group of symptoms is termed tetany, and the nurse must and is characterized by bone decalcification and the development of renal
immediately report its appearance because laryngospasm, although rare, calculi (kidney stones) containing calcium.
may occur and obstruct the airway. Tetany of this type is usually treated ▪ Primary hyperparathyroidism
with IV calcium gluconate. This calcium abnormality is usually temporary o Over production of PTH regardless of the calcium level in the
after thyroidectomy unless all parathyroid tissues were removed blood
o occurs two to four times more often in women than in men and is most
THE PARATHYROID GLANDS common in people between 60 and 70 years of age
▪ Secondary hyperparathyroidism
▪ The parathyroid glands (normally four) are situated in the neck and embedded
o The parathyroid gland is normal but it makes excess PTH in response to
in the posterior aspect of the thyroid gland
chronic hypocalcemia due to another cause (CKD)
▪ Parathormone (parathyroid hormone)—the protein hormone produced by the
o with manifestations similar to those of primary hyperparathyroidism,
parathyroid glands—regulates calcium and phosphorus metabolism.
occurs in patients who have chronic kidney failure and the so-called
▪ Increased secretion of parathormone results in increased calcium absorption
renal rickets as a result of phosphorus retention, increased stimulation
from the kidney, intestine, and bones, which raises the serum calcium level
of the parathyroid glands, and increased parathormone secretion
▪ Some actions of this hormone are increased by the presence of vitamin D.
Clinical Manifestations
▪ Parathormone also tends to lower the blood phosphorus level.
▪ patient may have no symptoms or may experience signs and symptoms
▪ The serum level of ionized calcium regulates the output of parathormone.
resulting from involvement of several body systems
Increased serum calcium results in decreased parathormone secretion, creating
▪ Apathy, fatigue, muscle weakness, nausea, vomiting, constipation,
a negative feedback system
hypertension, and cardiac arrhythmias may occur

26
Assessment and Diagnostic Findings • Because of the risk of hypercalcemic crisis the patient is instructed to
• Primary hyperparathyroidism is diagnosed by persistent elevation of avoid dehydration and to seek immediate health care if conditions that
serum calcium and an elevated concentration of parathormone commonly produce dehydration (e.g., vomiting, diarrhea) occur
• Radioimmunoassays for parathormone are sensitive and differentiate
primary hyperparathyroidism from other causes of hypercalcemia in more ➢ Mobility
than 80% of patients with elevated serum calcium levels • encourage the patient to be mobile, patient with limited mobility is
• Bone changes may be detected on x-ray or bone scans in advanced disease. encouraged to walk.
The double-antibody parathyroid hormone test is used to distinguish • Bones subjected to the normal stress of walking give up less calcium
between primary hyperparathyroidism and malignancy as a cause of • Bed rest increases calcium excretion and the risk of renal calculi.
hypercalcemia. • Oral phosphates lower the serum calcium level in some patients; long-
• Ultrasound, MRI, thallium scan, and fine-needle biopsy have been used term use is not recommended because of the risk of ectopic calcium (a
to evaluate the function of the parathyroid glands and to localize pathologic deposition of calcium salts in tissues or bone growth in soft
parathyroid cysts, adenomas, or hyperplasia tissues) phosphate deposition in soft tissues.

Medical Management ➢ Diet and Medications

➢ Surgical Management • avoid a diet with restricted or excess calcium
• recommended treatment for primary hyperparathyroidism is • If the patient has a coexisting peptic ulcer, prescribed antacids and
parathyroidectomy (surgical removal of abnormal parathyroid tissue) protein feedings are necessary.
• For asymptomatic patients who have only mildly elevated serum calcium o Because anorexia is common, efforts are made to improve the
concentrations and normal kidney function, surgery may be delayed and appetite.
the patient monitored closely for worsening of hypercalcemia, bone • Prune juice, stool softeners, and physical activity, along with increased
deterioration, renal impairment, or the development of kidney stones fluid intake, help offset constipation, which is common postoperatively
• Surgery is recommended for patients who are asymptomatic and who
meet one or more of the following criteria: Nursing Management
o younger than 50 years • patient undergoing parathyroidectomy is essentially the same as that of a
o unable or unlikely to participate in follow-up care patient undergoing thyroidectomy. However, the previously described
o serum calcium level more than 1 mg/dl (0.25 mmol/l) above normal precautions about airway patency, dehydration, immobility, and diet are
reference range particularly important in the patient who is awaiting or recovering from
o GFR less than 60 ml/min parathyroidectomy
o urinary calcium level greater than 400 mg per day (10 mmol per day) • closely monitors the patient to detect symptoms of tetany (which may be
o bone density at hip, lumbar spine, or distal radius with t score less an early postoperative complication)
than–2.5 or previous fracture at any site • Most patients quickly regain function of the remaining parathyroid tissue
o nephrolithiasis or nephrocalcinosis and experience only mild, transient postoperative hypocalcemia
• In patients with significant bone disease or bone changes, a more
➢ Hydration Therapy prolonged period of hypocalcemia should be anticipated
• Patients with hyperparathyroidism are at risk for renal calculi. Therefore,
a daily fluid intake of 2000 mL or more to prevent calculus formation Complications: HYPERCALCEMIC CRISIS!!!
• Patient is instructed to report other manifestations of renal calculi, such • Acute hypercalcemic crisis can occur with extreme elevation of serum
as abdominal pain and hematuria. calcium levels.
• Thiazide diuretics are avoided, because they decrease the renal excretion • Serum calcium levels greater than 13 mg/dL (3.25 mmol/L) result in
of calcium and further elevate serum calcium levels. neurologic, cardiovascular, and kidney symptoms that can be life-
threatening

27
 • Rapid rehydration with large volumes of IV isotonic saline fluids to Clinical Manifestations
maintain urine output of 100 to 150 mL per hour is combined with • irritability of the neuromuscular system and contributes to the chief
administration of calcitonin symptom of hypoparathyroidism—tetany
o Calcitonin promotes renal excretion of excess calcium and reduces o Tetany is general muscle hypertonia, with tremor and spasmodic or
bone resorption uncoordinated contractions occurring with or without efforts to make
• The saline infusion should be stopped and a loop diuretic may be needed if voluntary movements
the patient develops EDEMA • Symptoms of latent tetany are:
• patient should be monitored carefully for fluid overload o Numbness
• Loop diuretics are not recommended as initial therapy in the absence of o Tingling
heart failure and kidney insufficiency o cramps in the extremities, and the
• Bisphosphonates are added to promote a sustained decrease in serum o patient complains of stiffness in the hands and feet.
calcium levels by promoting calcium deposition in bone and reducing the • In overt tetany, the signs include:
GI absorption of calcium o Bronchospasm
• Cytotoxic agents (e.g., mithramycin), calcitonin, and dialysis may be used o laryngeal spasm
in emergency situations to decrease serum calcium levels quickly o carpopedal spasm (flexion of the elbows and wrists and extension of
• combination of calcitonin and corticosteroids is given in emergencies to the carpophalangeal joints and dorsiflexion of the feet)
reduce the serum calcium level by increasing calcium deposition in bone o dysphagia,
• reduce the serum calcium level by increasing calcium deposition in bone. o photophobia
Other agents that may be given to decrease serum calcium levels include o cardiac arrhythmias
bisphosphonates (e.g., etidronate, pamidronate) o seizures.
• Other symptoms include anxiety, irritability, depression, and even delirium.
The patient in acute hypercalcemic crisis requires close monitoring for life-threatening ECG changes and hypotension also may occur.
complications (e.g., airway obstruction) and prompt treatment to reduce serum calcium
levels. Assessment and Diagnostic Findings
▪ A positive Chvostek sign or a positive Trousseau sign suggests latent
tetany
Hypoparathyroidism ▪ Trousseau sign is positive when carpopedal spasm is induced by occluding
▪ is caused by abnormal parathyroid development, destruction of the the blood flow to the arm for 3 minutes with a blood pressure cuff
parathyroid glands (surgical removal or autoimmune response), and vitamin
D deficiency
▪ most common cause is the near-total removal of the thyroid gland. The result
is inadequate secretion of parathormone
▪ Deficiency of parathormone results in hyperphosphatemia (increased blood
phosphate levels) and hypocalcemia (decreased blood calcium levels)
▪ In the absence of parathormone, there is decreased intestinal absorption of
dietary calcium and decreased resorption of calcium from bone and through
the renal tubules. Decreased renal excretion of phosphate causes
hypophosphaturia, and low serum calcium levels result in hypocalciuria

28
Medical Management THE ADRENAL GLANDS
▪ goal of therapy is to increase the serum calcium level to 9 to 10 mg/dL (2.2 ▪ Each person has two adrenal glands, one attached to the upper portion of each
to 2.5 mmol/L) and to eliminate the symptoms of hypoparathyroidism and kidney.
hypocalcemia ▪ Each adrenal gland is, in reality, two endocrine glands with separate,
▪ Treatment may include combinations of calcium, magnesium, and independent functions.
ergocalciferol or calcitriol, the latter being preferred. ▪ The adrenal medulla at the center of the gland secretes catecholamines, and
▪ A thiazide diuretic (e.g., hydrochlorothiazide) may be given to help the outer portion of the gland, the adrenal cortex, secretes steroid hormones
decrease urinary calcium excretion ▪ The secretion of hormones from the adrenal cortex is regulated by the
▪ Recombinant parathyroid hormone has been approved for the treatment hypothalamic–pituitary–adrenal axis.
of osteoporosis but not for hypoparathyroidism at this time o The hypothalamus secretes corticotropin-releasing hormone (CRH), which
▪ When hypocalcemia and tetany occur after a thyroidectomy, the stimulates the pituitary gland to secrete ACTH, which in turn stimulates
immediate treatment is administration of IV calcium gluconate, If this the adrenal cortex to secrete glucocorticoid hormone (cortisol).
does not decrease neuromuscular irritability and seizure activity ▪ Increased levels of the adrenal hormone then inhibit the production or
immediately, sedative agents such as PENTOBARBITAL may be given. secretion of CRH and ACTH. This system is an example of a negative feedback
▪ If the patient develops respiratory distress, a tracheostomy or mechanical mechanism.
ventilation may become necessary, along with medications that cause
bronchodilation in order to provide respiratory support
▪ Diet high in calcium and low in phosphorus is prescribed. Although milk,
milk products, and egg yolk are high in calcium, they are restricted
because they also contain high levels of phosphorus.
▪ Spinach also is avoided because it contains oxalate, which would form
insoluble calcium substances
▪ Oral tablets of calcium salts, such as calcium gluconate, may be used to
supplement the diet.
▪ Aluminum hydroxide gel or aluminum carbonate also is given after meals
to bind phosphate and promote its excretion through the GI tract.

Nursing Management
Adrenal Medulla
▪ Care of postoperative patients who have undergone thyroidectomy,
➢ Adrenal medulla functions as part of the autonomic nervous system
parathyroidectomy, or radical neck dissection is directed toward detecting
▪ The adrenal medulla functions as part of the autonomic nervous system.
early signs of hypocalcemia and anticipating signs of tetany, seizures, and
Stimulation of preganglionic sympathetic nerve fibers, which travel
respiratory difficulties.
directly to the cells of the adrenal medulla, causes release of the
▪ Calcium gluconate should be available for emergency IV administration. If
catecholamine hormones epinephrine and norepinephrine.
the patient requiring administration of calcium gluconate has a cardiac
▪ major effects of epinephrine release are to prepare to meet a challenge
disorder, is subject to arrhythmias, or is receiving digitalis, the calcium
(fight-or-flight response)
gluconate is given slowly and cautiously
▪ Secretion of epinephrine causes decreased blood flow to tissues that are
▪ Calcium and digitalis increase systolic contraction and also potentiate
not needed in emergency situations, such as the GI tract, and increased
each other; this can produce potentially fatal arrhythmias. Consequently,
blood flow to tissues that are important for effective fight or flight, such as
the cardiac patient requires continuous cardiac monitoring and careful
cardiac and skeletal muscle.
assessment.
▪ Catecholamines also induce the release of free fatty acids, increase the
▪ Ensuring a diet high in calcium and vitamin D, low in phosphorous.
basal metabolic rate, and elevate the blood glucose level
▪ Alternating activity and rest periods.

29
 Adrenal Cortex ➢ Adrenal Sex Hormones (Androgens)
▪ A functioning adrenal cortex is necessary for life; adrenocortical • third major type of steroid hormones produced by the adrenal cortex,
secretions make it possible for the body to adapt to stress of all kinds. exert effects similar to those of male sex hormones
▪ The three types of steroid hormones produced by the adrenal cortex are: • adrenal gland may also secrete small amounts of some estrogens, or
o glucocorticoids, mainly cortisol (Zona Fasciculata) female sex hormones
o mineralocorticoids, mainly aldosterone (Zona Glomerulosa) • ACTH controls the secretion of adrenal androgens.
o sex hormones, mainly androgens (Zona Reticularis) • When secreted in normal amounts, the adrenal androgens have little
▪ Without the adrenal cortex, severe stress would cause peripheral effect, but when secreted in excess, they produce masculinization in
circulatory failure, circulatory shock, and prostration. women, feminization in men, or premature sexual development in
▪ Survival in the absence of a functioning adrenal cortex is possible only children. This is called the adrenogenital syndrome
with nutritional, electrolyte, and fluid replacement and appropriate
replacement with exogenous adrenocortical hormones
Pheochromocytoma
➢ Glucocorticoids ▪ is a rare tumor of the adrenal medulla that secretes catecholamines and
• so named because they have an important influence on glucose causes hypertension, tachycardia, sweating, and headaches
metabolism: Increased cortisol secretion results in elevated blood glucose ▪ is a rare tumor that is usually benign and originates from the chromaffin cells
levels (stores catecholamine) of the adrenal medulla
• Corticosteroids are the classification of drugs that include glucocorticoids ▪ Pheochromocytoma may occur at any age, but its peak incidence is between
• These drugs are given to inhibit the inflammatory response to tissue 40 and 50 years of age and affects men and women equally
injury and to suppress allergic manifestations. ▪ Pheochromocytoma may occur in the familial form as part of multiple
• Their side effects include the development of diabetes, osteoporosis, and endocrine neoplasia type 2; therefore, it should be considered a possibility in
peptic ulcer; increased protein breakdown resulting in muscle wasting and patients who have medullary thyroid carcinoma and parathyroid hyperplasia
poor wound healing; and redistribution of body fat. or tumor
• When large doses of exogenous glucocorticoids are given, the release of
ACTH and endogenous glucocorticoids are inhibited. This can cause the Clinical Manifestations
adrenal cortex to atrophy. If exogenous glucocorticoid administration is ▪ severity of symptoms of functioning tumors of the adrenal medulla
discontinued suddenly, adrenal insufficiency results because of the depend on the relative proportions of epinephrine and norepinephrine
inability of the atrophied cortex to respond adequately secretion.
▪ TYPICAL TRIAD OF SYMPTOMS is headache, diaphoresis, and
➢ Mineralocorticoids palpitations in the patient with hypertension.
• exert their major effects on electrolyte metabolism ▪ Other symptoms may include tremor, headache, flushing, and anxiety
• ACTH only minimally influences aldosterone secretion. It is primarily ▪ Hyperglycemia may result from conversion of liver and muscle glycogen
secreted in response to the presence of angiotensin II in the bloodstream to glucose due to epinephrine secretion; insulin may be required to
• The resultant increased aldosterone levels promote sodium reabsorption maintain normal blood glucose levels
by the kidney and the GI tract, which tends to restore blood pressure to ▪ Clinical picture in the paroxysmal form of pheochromocytoma is usually
normal. characterized by acute, unpredictable attacks lasting seconds or several
• The release of aldosterone is also increased by hyperkalemia. Aldosterone hours. Symptoms usually begin abruptly and subside slowly
is the main hormone for the long-term regulation of sodium balance o During these attacks, the patient is extremely anxious, tremulous,
and weak.
o The patient may experience headache, vertigo, blurring of vision,
tinnitus, air hunger, and dyspnea. Other symptoms include polyuria,
nausea, vomiting, diarrhea, abdominal pain, and a feeling of
impending doom
30
 o Palpitations and tachycardia are common Blood pressures exceeding diffusion of excess catecholamines into the circulation, bypassing normal
250/150 mm Hg have been recorded. Such blood pressure elevations storage and release mechanism
are life threatening and can cause severe complications, such as ▪ In patients with pheochromocytoma, clonidine does not suppress the
cardiac arrhythmias, dissecting aneurysm, stroke, and acute kidney release of catecholamines
failure ▪ Imaging studies, such as CT, MRI, and ultrasonography, may also be carried
out to localize the pheochromocytoma and to determine whether more than
one tumor is present
Assessment and Diagnostic Findings
▪ “five Hs”: hypertension, headache, hyperhidrosis (excessive sweating), Medical Management
hypermetabolism, and hyperglycemia. ▪ During an episode or attack of hypertension, tachycardia, anxiety, and the
▪ Measurements of urine and plasma levels of catecholamines and other symptoms of pheochromocytoma, bed rest with the head of the bed
metanephrine (MN), a catecholamine metabolite, are the most direct and elevated is prescribed to promote an orthostatic decrease in blood
conclusive tests for overactivity of the adrenal medulla pressure.
▪ Collection 24-hour urine sample - to detect free catecholamines ▪ Pharmacologic Therapy
o A number of medications and foods, such as coffee and tea o Preoperatively, the patient may begin treatment with a low dose of an
(including decaffeinated varieties), bananas, chocolate, vanilla, and alpha adrenergic blocker, either phenoxybenzamine or doxazosin, 10
aspirin, may alter the results of these tests; therefore, careful to 14 days or longer prior to surgery
instructions to avoid restricted items must be given to the patient o Potential for adverse effects of these medications, which include
o Urine collected over a 2- or 3-hour period after an attack of orthostasis, nasal stuffiness, increased fatigue, and retrograde
hypertension can be assayed for catecholamine content ejaculation in men
o Total plasma catecholamine (epinephrine and norepinephrine) o Medication dosages are started at a low dose and increased every 2 to 3
concentration is measured with the patient supine and at rest for 30 days as needed to control blood pressure. Patients may be required to
minutes. consume a high-sodium diet or take salt supplement
o prevent elevation of catecholamine levels resulting from the stress o Age and comorbid disease should be taken into consideration when
of venipuncture, a butterfly needle, scalp vein needle, or venous establishing and evaluating targets. Propranolol and metoprolol may
catheter may be inserted 30 minutes before the blood specimen is be administered with caution to achieve the target heart rate
obtained. o Additional medications that may be used preoperatively include
o Factors that may elevate catecholamine concentrations must be catecholamine synthesis inhibitors, such as alpha-methyl-p-tyrosine
controlled to obtain valid results; these factors include consumption (metyrosine).
of coffee or tea (including decaffeinated varieties), the use of o These are occasionally used if adrenergic blocking agents (i.e., alpha-
tobacco, emotional and physical stress, and the use of many and beta-blockers) are not effective.
prescription and over-the-counter medications (e.g., o Long-term use of metyrosine may result in many adverse effects,
amphetamines, nose drops or sprays, decongestant agents, including sedation, depression, diarrhea, anxiety, nightmares,
bronchodilators). dysuria, impotence, elevated aspartate aminotransferase, anemia,
▪ total plasma catecholamine concentration - thrombocytopenia, crystalluria, galactorrhea (breast discharge), and
▪ clonidine suppression test may be performed if the results of plasma and extrapyramidal signs (e.g., drooling, speech impairment, tremors)
urine tests of catecholamines are inconclusive ▪ Surgical Management
▪ Clonidine is a centrally acting antiadrenergic medication that suppresses o definitive treatment of pheochromocytoma is surgical removal of the
the release of neurogenically mediated catecholamines. The suppression tumor, usually with adrenalectomy (removal of one or both adrenal
test is based on the principle that catecholamine levels are normally glands); surgical treatment is considered high risk in this patient
increased through the activity of the sympathetic nervous system. In population.
pheochromocytoma, increased catecholamine levels result from the o Surgery may be performed using a laparoscopic approach or an open
operation. The laparoscopic approach is the preferred method for
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 patients with pheochromocytomas including large tumors because of ▪ In 70% to 90% of cases, the cause is an autoimmune disorder but tuberculosis
the decreased blood loss, decreased hospitalization time, and and histoplasmosis are also associated with destruction of adrenal tissue;
decreased morbidity therefore, both should be considered in the diagnostic workup.
o Bilateral adrenalectomy may be necessary if tumors are present in both ▪ Other causes include:
adrenal glands. Patient preparation includes control of blood pressure and o surgical removal of both adrenal glands
blood volumes; usually, this is carried out over 10 to 14 days, as described o medications such as rifampin
previously. A calcium channel blocker (nicardipine) can be given o barbiturates, ketoconazole
intraoperatively exclusively or in combination with the alpha- and beta- o tyrosine kinase inhibitors
blockers to control blood pressure. o metastatic cancers such as lung, breast, colon, and melanoma
o A hypertensive crisis, however, can still arise as a result of manipulation of the ▪ Secondary adrenal insufficiency may result from the sudden cessation of
tumor during surgical excision, causing a release of stored epinephrine and exogenous adrenocortical hormonal therapy, which suppresses the body’s
norepinephrine, with marked increases in blood pressure and changes in heart normal response to stress and interferes with normal feedback mechanisms.
rate ▪ Treatment with daily administration of corticosteroids for 2 to 4 weeks may
o Corticosteroid replacement is required if bilateral adrenalectomy has been suppress function of the adrenal cortex; therefore, adrenal insufficiency should
necessary. Corticosteroids may also be required for the first few days or weeks be considered in any patient who has been treated with corticosteroids
after removal of a single adrenal gland. IV administration of corticosteroids
(methylprednisolone) may begin on the evening before surgery and continue
during the early postoperative period to prevent adrenal insufficiency. Oral
preparations of corticosteroids (prednisone) are prescribed after the acute
stress of surgery diminishes.
o Hypotension and hypoglycemia may occur in the postoperative period because
of the sudden withdrawal of excessive amounts of catecholamines
o Hypertension may continue if not all pheochromocytoma tissue was removed,
if pheochromocytoma recurs, or if the blood vessels were damaged by severe
and prolonged hypertension. Several days after surgery, urine and plasma
levels of catecholamines and their metabolites are measured to determine
whether the surgery was successful.

Nursing Management
▪ patient is monitored until stable with special attention given to ECG
changes, arterial pressures, fluid and electrolyte balance, and blood
glucose levels. IV access will be required for administration of fluids and
medications Clinical Manifestations
▪ loss of mineralocorticoids leads to increased excretion of sodium,
chloride, and water with increased retention of potassium
▪ loss of glucocorticoids results in hypoglycemia with complaints of muscle
Adrenocortical Insufficiency (Addison’s Disease)
weakness, lethargy, and GI symptoms including anorexia, weight loss,
⎯ is the result of dysfunction of the hypothalamus–pituitary gland–adrenal nausea and vomiting.
gland feedback loop which results in insufficient production of steroids by the ▪ In addition, the increase in levels of ACTH results in hyperpigmentation of
adrenal gland the skin and mucous membranes, especially of the knuckles, knees, and
▪ Addison’s disease is considered rare skin folds

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 ▪ Patients with Addison’s disease are at risk to develop an Addisonian • Patients who are undergoing stressful procedures, surgery, significant
crisis, a life-threatening complication in which severe hypotension, illnesses, or are in the third trimester of pregnancy require additional
cyanosis, fever, nausea, vomiting, and signs of shock develop supplementary therapy with corticosteroid medications to prevent
▪ patient may have pallor; complain of headache, abdominal pain, and Addisonian crisis.
diarrhea; and may show signs of confusion and restlessness. • In addition, dietary intake may need to be supplemented with additional
▪ Even slight overexertion, exposure to cold, acute infection, or a decrease salt to manage GI losses of fluids through vomiting and diarrhea
in salt intake may lead to circulatory collapse, shock, and death, if
untreated Nursing Management
▪ The stress of surgery or dehydration resulting from preparation for ➢ Assessing the Patient
diagnostic tests or surgery may precipitate an Addisonian or hypotensive • health history and examination focus on the presence of symptoms of
crisis because of the inhibited feedback loop. fluid imbalance and the patient’s level of stress.
• The nurse should monitor the blood pressure and pulse rate as the
Assessment and Diagnostic Findings patient moves from a lying, sitting, and standing position to assess for
• Although the clinical manifestations presented appear specific, the onset inadequate fluid volume. A decrease in systolic pressure (20 mm Hg or
of Addison’s disease usually occurs with nonspecific symptoms more) may indicate depletion of fluid volume, especially if accompanied
• Diagnosis is confirmed by laboratory test results by symptoms.
• Combined measurements of early morning serum cortisol and plasma • The skin should be assessed for changes in color and turgor, which
ACTH are performed to differentiate primary adrenal insufficiency from could indicate chronic adrenal insufficiency and hypovolemia.
secondary adrenal insufficiency and from normal adrenal function. • The patient is assessed for change in weight, muscle weakness, fatigue,
• Patients with primary insufficiency have a greatly increased plasma ACTH and any illness or stress that may have precipitated the acute crisis
level and a serum cortisol concentration lower than the normal range or in
the low-normal range ➢ Monitoring and Managing Addisonian Crisis
• Other laboratory findings include hypoglycemia, hyponatremia, • The patient at risk is monitored for signs and symptoms indicative of
hyperkalemia, and leukocytosis Addisonian crisis, which can include shock; hypotension; rapid, weak
pulse; rapid respiratory rate; pallor; and extreme weakness.
Medical Management • Physical and psychological stressors such as cold exposure, overexertion,
• Immediate treatment is directed toward combating circulatory shock: infection, and emotional distress should be avoided.
o restoring blood circulation • The patient with Addisonian crisis requires immediate treatment with IV
o administering fluids and corticosteroids administration of fluid, glucose, and electrolytes, especially sodium;
o monitoring vital signs replacement of missing steroid hormones; and vasopressors.
o placing the patient in a recumbent position with the legs elevated • The nurse anticipates and meets the patient’s needs to promote return to
• Hydrocortisone is administered by IV, followed by 3 to 4 L of normal a precrisis state
saline or 5% dextrose solution.
• Vasopressors may be required if hypotension persists ➢ Restoring Fluid Balance
• Antibiotics may be given if infection has precipitated adrenal crisis in a • The nurse encourages the patient to consume foods and fluids that assist
patient with chronic adrenal insufficiency in restoring and maintaining fluid and electrolyte balance which in turn
• Oral intake may be initiated as soon as tolerated. maintains adequate cardiac output.
• IV fluids are gradually decreased after oral fluid intake is adequate to • Along with the dietitian, the nurse helps the patient select foods high in
prevent hypovolemia. sodium during GI disturbances and in very hot weather.
• If the adrenal gland does not regain function, the patient needs lifelong • The nurse educates the patient and family to administer hormone
replacement of corticosteroids and mineralocorticoids to prevent replacement as prescribed and to modify the dosage during illness and
recurrence of adrenal insufficiency. other stressful situations.

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 • Written and verbal instructions are provided about the administration of ▪ However, overproduction of endogenous glucocorticoids may be caused by
exogenous glucocorticoids (i.e., corticosteroid medications such as several mechanisms, including a tumor of the pituitary gland that produces
hydrocortisone, cortisone, and prednisone) and mineralocorticoids ACTH and stimulates the adrenal cortex to increase its hormone secretion
(fludrocortisone) as prescribed. despite production of adequate amounts
• The patient should be instructed to take prescribed corticosteroids with ▪ Primary hyperplasia of the adrenal glands in the absence of a pituitary tumor is
antacids or meals. less common.
• The patient should be informed that the steroid therapy usually corrects ▪ Another less common cause of Cushing’s syndrome is the ectopic production
the mood swings and mental status changes which adrenal insufficiency of ACTH by malignancies; bronchogenic carcinoma is the most common type.
frequently causes Regardless of the cause, the normal feedback mechanisms that control the
function of the adrenal cortex become ineffective, and the usual diurnal pattern
➢ Improving Activity Tolerance of cortisol is lost.
• Until the patient’s condition is stabilized, the nurse takes precautions to ▪ The signs and symptoms of Cushing’s syndrome are primarily a result of
avoid unnecessary activity and stress that could precipitate another over-secretion of glucocorticoids and androgens, although mineralocorticoid
hypotensive episode. secretion may be affected as well
• Efforts are made to detect signs of infection or the presence of other
stressors.
• Explaining the rationale for minimizing stress during the acute crisis
assists the patient to increase activity gradually.

➢ Educating Patients About Self-Care

• Because of the need for lifelong replacement of adrenal cortex hormones
to prevent Addisonian crises
• In addition, the patient, family, and caregivers are educated about the
signs of excessive or insufficient hormone replacement.
• Stress can precipitate an Addisonian crisis, and in times of stress the
usual dose may need to be adjusted. The patient should have an emergency
kit available with syringe and either hydrocortisone or dexamethasone as
prescribed by the primary provider.
• Specific verbal and written instructions about how and when to use the
injection are also provided to the patient and family or caregivers.
Clinical Manifestations
• When overproduction of the adrenocortical hormone occurs, arrest of
Cushing’s Syndrome growth, obesity, and musculoskeletal changes occur along with glucose
⎯ Cushing's syndrome is a condition where your body is exposed to too much of intolerance.
a hormone called cortisol. This can be because your body is making too much • The classic picture of Cushing’s syndrome in the adult is that of central-
cortisol or because you have taken a lot of oral corticosteroid medicines. type obesity, with a fatty “buffalo hump” in the neck and supraclavicular
▪ most common cause of Cushing’s syndrome (also known as Cushing’s disease) areas, a heavy trunk, and relatively thin extremities.
is the use of corticosteroid medications, but the syndrome can also be due to • The skin is thin, fragile, and easily traumatized; ecchymoses (bruises) and
excessive glucocorticoid production secondary to hyperplasia of the adrenal striae develop. The patient complains of weakness and lassitude. Sleep is
cortex disturbed because of altered diurnal secretion of cortisol

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 • Excessive protein catabolism occurs, producing muscle wasting and the urinary cortisol test are three times the upper limit of the normal range
osteoporosis. and one other test is abnormal, Cushing’s syndrome can be assumed.
• Kyphosis, backache, and compression fractures of the vertebrae may result. • An overnight dexamethasone suppression test is used to diagnosis pituitary
Retention of sodium and water occurs as a result of increased and adrenal causes of Cushing’s syndrome. It can be performed on an
mineralocorticoid activity, producing hypertension and heart failure. outpatient basis. Dexamethasone (1 or 8 mg) is given orally late in the
• The patient develops a “moon-faced” appearance and may experience evening or at bedtime, and a plasma cortisol level is obtained at 8 am the
increased oiliness of the skin and acne. Hyperglycemia or overt diabetes next morning. Suppression of cortisol to less than 5 mg/dL indicates that
may develop. the hypothalamic pituitary–adrenal axis is functioning
• The patient may also report weight gain, slow healing of minor cuts, and • Stress, obesity, depression, and medications such as anticonvulsant agents,
bruises. estrogen (during pregnancy or as oral medications), and rifampin can
• Women between the ages of 20 and 40 years are five times more likely than falsely elevate cortisol levels.
men to develop Cushing’s syndrome. In females of all ages, virilization may • Indicators of Cushing’s syndrome include an increase in serum sodium
occur as a result of excess androgens. and blood glucose levels and a decrease in serum potassium, a reduction in
• Virilization is characterized by the appearance of masculine traits and the the number of blood eosinophils, and disappearance of lymphoid tissue.
recession of feminine traits. Measurements of plasma and urinary cortisol levels are obtained.
• Hirsutism (excessive growth of hair on the face) occurs, the breasts • Several blood samples may be collected to determine whether the normal
atrophy, menses cease, the clitoris enlarges, and the voice deepens. Libido diurnal variation in plasma levels is present; this variation is frequently
is lost in men and women. absent in adrenal dysfunction. If several blood samples are required, they
• Distress and depression are common and are increased by the severity of must be collected at the times specified, and the time of collection must be
the physical changes that occur with this syndrome. noted on the requisition slip.
• If Cushing’s disease is a consequence of pituitary tumor, visual
disturbances may occur because of pressure of the growing tumor on the Medical Management
optic chiasm. • If Cushing’s syndrome is caused by pituitary tumors rather than tumors of
the adrenal cortex, treatment is directed at the pituitary gland.
• Surgical removal of the tumor by transsphenoidal hypophysectomy is the
Assessment and Diagnostic Findings treatment of choice.
• Three tests used to diagnose Cushing’s syndrome are: • Radiation of the pituitary gland has also been successful, although it may
o serum cortisol take several months for control of symptoms.
o urinary cortisol • Adrenalectomy is the treatment of choice in patients with unilateral
o low-dose dexamethasone suppression tests primary adrenal hypertrophy.
• Two of these three tests need to be unequivocally abnormal to diagnose • Medical management is recommended for bilateral adrenal dysplasia.
Cushing’s syndrome. • Postoperatively, symptoms of adrenal insufficiency may begin to appear
• If the results of all three tests are normal, the patient likely does not have 12 to 48 hours after surgery because of reduction of the high levels of
Cushing’s syndrome (but may have a mild case, or the manifestations may circulating adrenal hormones.
be cyclic). For these patients, further testing is not recommended unless • Temporary replacement therapy with hydrocortisone may be necessary
symptoms progress. If test results are either slightly abnormal or for several months, until the adrenal glands begin to respond normally to
discordant, further testing is recommended. the body’s needs.
• Serum cortisol levels are usually higher in the early morning (6 to 8 am) • Adrenal enzyme inhibitors (e.g., metyrapone, aminoglutethimide,
and lower in the evening (4 to 6 pm). This variation is lost in patients with mitotane, and ketoconazole) may be used to reduce hyperadrenalism if the
Cushing’s syndrome syndrome is caused by ectopic ACTH secretion by a tumor that cannot be
• A urinary cortisol test requires a 24-hour urine collection. The nurse eradicated.
instructs the patient how to collect and store the specimen. If the results of

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 • Close monitoring is necessary, because symptoms of inadequate adrenal
function may result, and side effects of the medications may occur.
• If Cushing’s syndrome is a result of the administration of corticosteroids,
an attempt is made to reduce or taper the medication to the minimum
dosage needed to treat the underlying disease process (e.g., autoimmune
or allergic disease, rejection of a transplanted organ)
• Frequently, alternate-day therapy decreases the symptoms of Cushing’s
syndrome and allows recovery of the adrenal glands’ responsiveness to
ACTH.
• Diabetes and peptic ulcer are common in patients with Cushing’s
syndrome. Therefore, insulin therapy and medication to prevent or treat
peptic ulcer are initiated if needed.
• Before, during, and after surgery, blood glucose monitoring and
assessment of stools for blood are carried out to monitor for these
complications.
• If the patient has other symptoms of Cushing’s syndrome, these are
considered in the preoperative preparation. For example, if the patient has
experienced weight gain, special instruction is given about postoperative
breathing exercises.

Addisonian Crisis.
The patient with Cushing’s syndrome whose symptoms are treated by withdrawal of
corticosteroids, by adrenalectomy, or by removal of a pituitary tumor is at risk for adrenal
hypofunction and Addisonian crisis. If high levels of circulating adrenal hormones have
suppressed the function of the adrenal cortex, atrophy of the adrenal cortex is likely. If the
circulating hormone level is decreased rapidly because of surgery or abrupt cessation of
corticosteroid agents, manifestations of adrenal hypofunction and Addisonian crisis may
develop. Therefore, the patient with Cushing’s syndrome should be assessed for signs and
symptoms of Addisonian crisis as discussed previously. If Addisonian crisis occurs, the
patient is treated for circulatory collapse and shock

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