Angelite Nurses

• Hypopituitarism
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• Hyperpituitarism
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• Hypophysectomy
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• Diabetes Insipidus
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• Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)
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• Addison's Disease
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• Addisonian Crisis
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• Cushing's Syndrome
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• Primary Aldosteronism (Conn's Syndrome)
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• Pheochromocytoma
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• Adrenalectomy
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• Simple Goiter
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• Hypothyroidism (Myxedema)
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• Hyperthyroidism (Grave's Disease)
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• Thyroidectomy
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• Hyperparathyroidism
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• Diabetes Mellitus
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• Ketoacidosis (DKA)
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• Insulin Reaction/Hypoglycemia
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• Hyperglycemic Hyperosmolar Nonketotic Coma (HHNK)

1. General information
1. Complication of diabetes, characterized by hyperglycemia and a hyperosmolar state without ketosis
2. Occurs in non-insulin-dependent diabetics or nondiabetic persons (typically elderly clients)
3. Precipitating factors: undiagnosed diabetes; infections or other stress; certain medications (e.g., Dilantin, thiazide diuretics); dialysis; hyperalimentation; major burns; pancreatic disease
2. Assessment findings
1. Similar to ketoacidosis but without Kussmaul respirations and acetone breath
2. Laboratory tests
1. Blood glucose level extremely elevated
2. BUN, creatine, hct elevated (due to dehydration)
3. Urine positive for glucose
3. Nursing interventions: treatment and nursing care is similar to DKA, excluding measures to treat ketosis and metabolic acidosis.

1. General information
1. Abnormally low blood sugar, usually below 50 mg/dl
2. Usually caused by insulin overdosage, too little food, nutritional and fluid imbalances from nausea and vomiting, excessive exercise
3. Onset rapid; may develop in minutes to hours
2. Assessment findings
1. Headache, dizziness, difficulty with problem solving, restlessness, hunger, visual disturbances
2. Slurred speech; alterations in gait; decreasing LOC; pallor, cold, clammy skin; diaphoresis
3. Diagnostic test: serum glucose level 50-60 mg/dl or lower
3. Nursing interventions
1. Administer oral sugar in the form of candy or orange juice with sugar added if the client is alert.
2. If the client is unconscious, administer 20-50 ml 50% dextrose IV push, or 1 mg glucagon IM, IV, or SC, as ordered.
3. Explore with client reasons for hypoglycemia and provide additional diabetic teaching as indicated

1. General information
1. Acute complication of diabetes mellitus characterized by hyperglycemia and accumulation of ketones in the body; causes metabolic acidosis
2. Occurs in insulin-dependent diabetic clients
3. Precipitating factors: undiagnosed diabetes, neglect of treatment; infection, cardiovascular disorder; other physical or emotional stress
4. Onset slow, may be hours to days
2. Assessment findings
1. Polydipsia, polyphagia, polyuria
2. Nausea, vomiting, abdominal pain
3. Skin warm, dry, and flushed
4. Dry mucous membranes; soft eyeballs
5. Kussmaul's respirations or tachypnea; acetone breath
6. Alterations in LOC
7. Hypotension, tachycardia
8. Diagnostic tests
1. Serum glucose and ketones elevated
2. BUN, creatinine, hct elevated (due to dehydration)
3. Serum sodium decreased, potassium (may be normal or elevated at first)
4. ABGs: metabolic acidosis with compensatory respiratory alkalosis
3. Nursing interventions
1. Maintain a patent airway.
2. Maintain fluid and electrolyte balance.
1. Administer IV therapy as ordered.
1. normal saline (0.9% NaCl), then hypotonic (0.45% NaCl) sodium chloride
2. when blood sugar drops to 250 mg/dl, may add 5% dextrose to IV.
3. potassium will be added when the urine output is adequate.
2. Observe for fluid and electrolyte imbalances, especially fluid overload, hypokalemia, and hyperkalemia.
3. Administer insulin as ordered.
1. Regular insulin IV (drip or push) and/or subcutaneously (SC).
2. If given IV drip, give with small amounts of albumin since insulin adheres to IV tubing.
3. Monitor blood glucose levels frequently.
4. Check urine output every hour.
5. Monitor vital signs.
6. Assist client with self-care.
7. Provide care for the unconscious client if in a coma (see Interventions, Care of the Unconscious Client).
8. Discuss with client the reasons ketosis developed and provide additional diabetic teaching if indicated.

1. General information
1. Diabetes mellitus represents a heterogenous group of chronic disorders characterized by hyperglycemia.
2. Hyperglycemia is due to total or partial insulin deficiency or insensitivity of the cells to insulin.
3. Characterized by disorders in the metabolism of carbohydrate, fat, and protein, as well as changes in the structure and function of blood vessels.
4. Most common endocrine problem; affects over 11 million people in the U.S.
5. Exact etiology unknown; causative factors may include
1. genetics, viruses, and/or autoimmune response in type I
2. genetics and obesity in type II
6. Types
1. Type I (insulin-dependent diabetes mellitus [IDDM])
1. secondary to destruction of beta cells in the islets of Langerhans in the pancreas resulting in little or no insulin production; requires insulin injections.
2. usually occurs in children or in nonobese adults.
2. Type II (non-insulin-dependent diabetes mellitus [NIDDM])
1. may result from a partial deficiency of insulin production and/or an insensitivity of the cells to insulin.
2. usually occurs in obese adults over 40.
3. Diabetes associated with other conditions or syndromes, e.g., pancreatic disease, Cushing's syndrome, use of certain drugs (steroids, thiazide diuretics, oral contraceptives).
7. Pathophysiology
1. Lack of insulin causes hyperglycemia (insulin is necessary for the transport of glucose across the cell membrane).
2. Hyperglycemia leads to osmotic diuresis as large amounts of glucose pass through the kidney; results in polyuria and glycosuria.
3. Diuresis leads to cellular dehydration and fluid and electrolyte depletion causing polydipsia (excessive thirst).
4. Polyphagia (hunger and increased appetite) results from cellular starvation.
5. The body turns to fats and protein for energy; but in the absence of glucose in the cell, fats cannot be completely metabolized and ketones (intermediate products of fat metabolism) are produced.
6. This leads to ketonemia, ketonuria (contributes to osmotic diuresis), and metabolic acidosis (ketones are acid bodies).
7. Ketones act as CNS depressants and can cause coma.
8. Excess loss of fluids and electrolytes leads to hypovolemia, hypotension, renal failure, and decreased blood flow to the brain resulting in coma and death unless treated.
8. Acute complications of diabetes include diabetic ketoacidosis, insulin reaction, hyperglycemic hyperosmolar nonketotic coma.
2. Medical management
1. Type I: insulin, diet, exercise
2. Type II: ideally managed by diet and exercise; may need oral hypoglycemics or occasionally insulin if diet and exercise are not effective in controlling hyperglycemia; insulin needed for acute stresses, e.g., surgery, infection
3. Diet (see Exchange Lists, Appendix)
1. Type I: consistency is imperative to avoid hypoglycemia
2. Type II: weight loss is important since it decreases insulin resistance
3. High fiber, low fat diet also recommended
4. Drug therapy
1. Insulin: used for Type I diabetes (also occasionally used in Type II diabetes)
1. types (Table 4.23)
1. short acting: used in treating ketoacidosis; during surgery, infection, trauma; management of poorly controlled diabetes; to supplement longer-acting insulins
2. intermediate: used for maintenance therapy
3. long acting: used for maintenance therapy in clients who experience hyperglycemia during the night with intermediate-acting insulin
2. various preparations of short-, intermediate-, and long-acting insulins are available (see Table 4.23)
3. insulin preparations can consist of a mixture of beef and pork insulin, pure beef, pure pork, or human insulin. Human insulin is the purest insulin and has the lowest antigenic effect.
4. human insulin is recommended for all newly diagnosed Type I diabetics, Type II diabetics who need short-term insulin therapy, the pregnant client, and diabetic clients with insulin allergy or severe insulin resistance.
5. insulin pumps are small, externally worn devices that closely mimic normal pancreatic functioning. Insulin pumps contain a 3 ml syringe attached to a long (42 inch), narrow-lumen tube with a needle or Teflon catheter at the end. The needle or Teflon catheter is inserted into the subcutaneous tissue (usually on the abdomen) and secured with tape or a transparent dressing. The needle or catheter is changed at least every 3 days. The pump is worn either on a belt or in a pocket (see Figure 4.21). The pump uses only regular insulin. Insulin can be administered via the basal rate (usually 0.5-2.0 units/hr) and by a bolus dose (which is activated by a series of button pushes) prior to each meal.
2. Oral hypoglycemic agents (Table 4.24)
1. used for Type II diabetics who are not controlled by diet and exercise
2. increase the ability of islet cells of the pancreas to secrete insulin; may have some effect on cell receptors to decrease resistance to insulin
5. Exercise: helpful adjunct to therapy as exercise decreases the body's need for insulin.
3. Assessment findings
1. All types: polyuria, polydipsia, polyphagia, fatigue, blurred vision, susceptibility to infection
2. Type I: anorexia, nausea, vomiting, weight loss
3. Type II: obesity; frequently no other symptoms
4. Diagnostic tests
1. Fasting blood sugar
1. a level of 140 mg/dl or greater on at least two occasions confirms diabetes mellitus
2. may be normal in Type II diabetes
2. Postprandial blood sugar: elevated
3. Oral glucose tolerance test (most sensitive test): elevated
4. Glycosolated hemoglobin (hemoglobin A_1c) elevated
4. Nursing interventions
1. Administer insulin or oral hypoglycemic agents as ordered; monitor for hypoglycemia, especially during period of drug's peak action.
2. Provide special diet as ordered.
1. Ensure that the client is eating all meals.
2. If all food is not ingested, provide appropriate substitutes according to the exchange lists or give measured amount of orange juice to substitute for leftover food; provide snack later in the day.
3. Monitor urine sugar and acetone (freshly voided specimen).
4. Perform finger sticks to monitor blood glucose levels as ordered (more accurate than urine tests).
5. Observe for signs of hypo/hyperglycemia.
6. Provide meticulous skin care and prevent injury.
7. Maintain I&O; weigh daily.
8. Provide emotional support; assist client in adapting to change in life-style and body image.
9. Observe for chronic complications and plan care accordingly.
1. Atherosclerosis: leads to coronary artery disease, MI, CVA, and peripheral vascular disease.
2. Microangiopathy: most commonly affects eyes and kidneys.
3. Kidney disease
1. recurrent pyelonephritis
2. diabetic nephropathy
4. Ocular disorders
1. premature cataracts
2. diabetic retinopathy
5. Peripheral neuropathy
1. affects peripheral and autonomic nervous systems
2. causes diarrhea, constipation, neurogenic bladder, impotence, decreased sweating
10. Provide client teaching and discharge planning concerning
1. Disease process
2. Diet
1. client should be able to plan meals using exchange lists before discharge
2. emphasize importance of regularity of meals; never skip meals
3. Insulin
1. how to draw up into syringe
1. use insulin at room temperature.
2. gently roll vial between palms of hands.
3. draw up insulin using sterile technique.
4. if mixing insulins, draw up clear insulin before cloudy insulin.
2. injection technique
1. systematically rotate sites to prevent lipodystrophy (hypertrophy or atrophy of tissue).
2. insert needle at a 45° or 90° angle depending on amount of adipose tissue.
3. may store current vial of insulin at room temperature; refrigerate extra supplies.
4. provide many opportunities for return demonstration.
4. Oral hypoglycemic agents
1. stress importance of taking the drug regularly.
2. avoid alcohol intake while on medication.
5. Urine testing (not very accurate reflection of blood glucose level)
1. May be satisfactory for Type II diabetics since they are more stable.
2. Use Clinitest, Tes-tape, Diastix for glucose testing.
3. Perform tests before meals and at bedtime.
4. Use freshly voided specimen.
5. Be consistent in brand of urine test used.
6. Report results in percentages.
7. Report results to physician if results are greater than 1%, especially if experiencing symptoms of hyperglycemia.
8. Urine testing for ketones should be done by Type I diabetic clients when there is persistent glycosuria, increased blood glucose levels, or if the client is not feeling well (Acetest, Ketostix).
6. Blood glucose monitoring
1. Use for Type I diabetic clients since it gives exact blood glucose level and also detects hypoglycemia.
2. Instruct client in finger-stick technique, use of monitor device (if used), and recording and utilization of test results.
7. General care
1. perform good oral hygiene and have regular dental exams.
2. have regular eye exams.
3. care for "sick days" (e.g., cold or flu)
1. do not omit insulin or oral hypoglycemic agents since infection causes increased blood sugar.
2. notify physician.
3. monitor urine or blood glucose levels and urine ketones frequently.
4. if nausea and/or vomiting occurs, sip on clear liquids with simple sugars.
8. Foot care
1. wash feet with mild soap and water and pat dry.
2. apply lanolin to feet to prevent drying and cracking.
3. cut toenails straight across.
4. avoid constricting garments such as garters.
5. wear clean, absorbent socks (cotton or wool).
6. purchase properly fitting shoes and break new shoes in gradually.
7. never go barefoot.
8. inspect feet daily and notify physician if cuts, blisters, or breaks in skin occur.
9. Exercise
1. undertake regular exercise; avoid sporadic, vigorous exercise.
2. food intake may need to be increased before exercising.
3. exercise is best performed after meals when the blood sugar is rising.
10. Complications
1. learn to recognize signs and symptoms of hypo/hyperglycemia.
2. eat candy or drink orange juice with sugar added for insulin reaction (hypoglycemia).
11. Need to wear a Medic-Alert bracelet.

TABLE 4.23 Characteristics of Insulin Preparations

FIGURE 4.21 Insulin infusion pump

TABLE 4.24 Oral Hypoglycemic Agents

Hyperparathyroidism

1. General information
1. Increased secretion of PTH that results in an altered state of calcium, phosphate, and bone metabolism
2. Most commonly affects women between ages 35-65
3. Primary hyperparathyroidism: caused by tumor or hyperplasia of parathyroid glands
4. Secondary hyperparathyroidism: caused by compensatory oversecretion of PTH in response to hypocalcemia from chronic renal disease, rickets, malabsorption syndrome, osteomalacia
2. Assessment findings
1. Bone pain (especially at back), bone demineralization, pathologic fractures
2. Renal colic, kidney stones, polyuria, polydipsia
3. Anorexia, nausea, vomiting, gastric ulcers, constipation
4. Muscle weakness, fatigue
5. Irritability, personality changes, depression
6. Cardiac arrhythmias, hypertension
7. Diagnostic tests
1. Serum calcium levels elevated
2. Serum phosphate levels decreased
3. Skeletal x-rays reveal bone demineralization
3. Nursing interventions
1. Administer IV infusions of normal saline solution and give diuretics as ordered; monitor I&O and observe for fluid overload and electrolyte imbalances.
2. Assist client with self-care: provide careful handling, moving, and ambulation to prevent pathologic fractures.
3. Monitor vital signs; report irregularities.
4. Force fluids; provide acid-ash juices, e.g., cranberry juice.
5. Strain urine for stones.
6. Provide low-calcium, high-phosphorus diet.
7. Provide care for the client undergoing parathyroidectomy (see Thyroidectomy).
8. Provide client teaching and discharge planning concerning
1. Need to engage in progressive ambulatory activities
2. Increased intake of fluids
3. Use of calcium preparations and importance of high-calcium diet following a parathyroidectomy

Hypoparathyroidism

1. General information
1. Disorder characterized by hypocalcemia resulting from a deficiency of parathormone (PTH) production
2. May be hereditary, idiopathic, or caused by accidental damage to or removal of parathyroid glands during surgery, e.g., thyroidectomy
2. Assessment findings
1. Acute hypocalcemia (tetany)
1. Tingling of fingers and around lips, painful muscle spasms, dysphagia, laryngospasm, seizures, cardiac arrhythmias
2. Chvostek's sign: sharp tapping over facial nerve causes twitching of mouth, nose, and eye
3. Trousseau's sign: carpopedal spasm induced by application of blood pressure cuff for 3 minutes
2. Chronic hypocalcemia
1. Fatigue, weakness, muscle cramps
2. Personality changes, irritability, memory impairment
3. Dry, scaly skin; hair loss; loss of tooth enamel
4. Tremor, cardiac arrhythmias, cataract formation
5. Diagnostic tests
1. serum calcium levels decreased
2. serum phosphate levels elevated
3. skeletal x-rays reveal increased bone density
3. Nursing interventions
1. Administer calcium gluconate by slow IV drip as ordered for acute hypocalcemia.
2. Administer medications for chronic hypocalcemia.
1. Oral calcium preparations: calcium gluconate, lactate, carbonate (Os-Cal)
2. Large doses of vitamin D (Calciferol) to help absorption of calcium
3. Aluminum hydroxide gel (Amphogel) or aluminum carbonate gel, basic (Basaljel) to decrease phosphate levels
3. Institute seizure and safety precautions.
4. Provide quiet environment free from excessive stimuli.
5. Monitor for signs of hoarseness or stridor; check for Chvostek's and Trousseau's signs.
6. Keep emergency equipment (tracheostomy set, injectable calcium gluconate) at bedside.
7. For tetany or generalized muscle cramps, may use rebreathing bag to produce mild respiratory acidosis.
8. Monitor serum calcium and phosphate levels.
9. Provide high-calcium, low-phosphorus diet.
10. Provide client teaching and discharge planning concerning
1. Medication regimen; oral calcium preparations and vitamin D to be taken with meals to increase absorption
2. Need to recognize and report signs and symptoms of hypo/hypercalcemia
3. Importance of follow-up care with periodic serum calcium levels

1. General information
1. Partial or total removal of the thyroid gland
2. Indications
1. Subtotal thyroidectomy: hyperthyroidism
2. Total thyroidectomy: thyroid cancer
2. Nursing interventions: preoperative
1. Ensure that the client is adequately prepared for surgery.
1. Cardiac status is stable.
2. Weight and nutritional status are normal.
2. Administer antithyroid drugs as ordered to suppress the production and secretion of thyroid hormone and to prevent thyroid storm.
3. Administer iodine preparations (Lugol's or potassium iodide solution) to reduce the size and vascularity of the gland and prevent hemorrhage.
3. Nursing interventions: postoperative
1. Monitor vital signs and I&O.
2. Check dressings for signs of hemorrhage; check for wetness behind neck.
3. Place client in semi-Fowler's position and support head with pillows.
4. Observe for respiratory distress secondary to hemorrhage, edema of the glottis, laryngeal nerve damage, or tetany; keep tracheostomy set, oxygen, and suction nearby.
5. Assess for signs of tetany due to hypocalcemia secondary to accidental removal of parathyroid glands; keep calcium gluconate available (see Hypoparathyroidism, below).
6. Encourage the client to rest voice.
1. Some hoarseness is common.
2. Check every 30-60 minutes for extreme hoarseness or any accompanying respiratory distress.
7. Observe for thyroid storm due to release of excessive amounts of thyroid hormone during surgery.
8. Administer IV fluids as ordered until the client is tolerating fluids by mouth.
9. Administer analgesics as ordered for incisional pain.
10. Relieve discomfort from sore throat.
1. Cool mist humidifier to thin secretions.
2. Administer analgesic throat lozenges before meals and prn as ordered.
3. Encourage fluids.
11. Encourage coughing and deep breathing every hour.
12. Assist the client with ambulation: instruct the client to place hands behind neck to decrease stress on suture line if added support necessary.
13. Provide client teaching and discharge planning concerning
1. Signs and symptoms of hypo/hyperthyroidism
2. Self-administration of thyroid hormones if total thyroidectomy performed
3. Application of lubricant to the incision once sutures are removed
4. Performance of ROM neck exercises 3-4 times a day
5. Importance of regular follow-up care

Thyroid Storm

1. General information
1. Uncontrolled and potentially life-threatening hyperthyroidism caused by sudden and excessive release of thyroid hormone into the bloodstream
2. Precipitating factors: stress, infection, unprepared thyroid surgery
3. Now quite rare
2. Assessment findings
1. Apprehension, restlessness
2. Extremely high temperature (up to 106°F [40.7°C]), tachycardia, CHF, respiratory distress, delirium, coma
3. Nursing interventions (see also Care of the Patient with Hyperthermia)
1. Maintain a patent airway and adequate ventilation; administer oxygen as ordered.
2. Administer IV therapy as ordered.
3. Administer medications as ordered: antithyroid drugs, corticosteroids, sedatives, cardiac drugs.

1. General information
1. Secretion of excessive amounts of thyroid hormone in the blood causes an increase in metabolic processes
2. Overactivity and changes in the thyroid gland may be present
3. Most often seen in women between ages 30-50
4. Cause unknown, but may be an autoimmune process
5. Symptomatic hyperthyroidism may also be called thyrotoxicosis
2. Medical management
1. Drug therapy
1. Antithyroid drugs (propylthiouracil and methimazole ([Tapazole]): block synthesis of thyroid hormone; toxic effects include agranulocytosis
2. Adrenergic blocking agents (commonly propanolol [Inderal]): used to decrease sympathetic activity and alleviate symptoms such as tachycardia
2. Radioactive iodine therapy
1. Radioactive isotope of iodine (e.g., ¹³¹I) given to destroy the thyroid gland, thereby decreasing production of thyroid hormone
2. Used in middle-aged or older clients who are resistant to, or develop toxicity from, drug therapy
3. Hypothyroidism is a potential complication
3. Surgery: thyroidectomy performed in younger clients for whom drug therapy has not been effective
3. Assessment findings
1. Irritability, agitation, restlessness, hyperactive movements, tremor, sweating, insomnia
2. Increased appetite, hyperphagia, weight loss, diarrhea, intolerance to heat
3. Exophthalmos (protrusion of the eyeballs), goiter
4. Warm, smooth skin; fine, soft hair; pliable nails
5. Tachycardia, increased systolic blood pressure, palpitations
6. Diagnostic tests
1. Serum T₃ and T₄ levels elevated
2. RAIU increased
4. Nursing interventions
1. Monitor vital signs, daily weights.
2. Administer antithyroid medications as ordered.
3. Provide for periods of uninterrupted rest.
1. Assign to a private room away from excessive activity.
2. Administer medications to promote sleep as ordered.
4. Provide a cool environment.
5. Minimize stress in the environment.
6. Encourage quiet, relaxing diversional activities.
7. Provide a diet high in carbohydrates, protein, calories, vitamins, and minerals with supplemental feedings between meals and at bedtime; omit stimulants.
8. Observe for and prevent complications.
1. Exophthalmos: protect eyes with dark glasses and artificial tears as ordered.
2. Thyroid storm: see below.
9. Provide client teaching and discharge planning concerning
1. Need to recognize and report signs and symptoms of agranulocytosis (fever, sore throat, skin rash) if taking antithyroid drugs
2. Signs and symptoms of hyper/hypothyroidism

1. General information
1. Slowing of metabolic processes caused by hypofunction of the thyroid gland with decreased thyroid hormone secretion; causes myxedema in adults and cretinism in children (see Congenital Hypothyroidism, in Unit 5).
2. Occurs more often in women between ages 30-60
3. Primary hypothyroidism: atrophy of the gland possibly caused by an autoimmune process
4. Secondary hypothyroidism: caused by decreased stimulation from pituitary TSH
5. Iatrogenic: surgical removal of the gland or overtreatment of hyperthyroidism with drugs or radioactive iodine
6. In severe or untreated cases, myxedema coma may occur
1. Characterized by intensification of signs and symptoms of hypothyroidism and neurologic impairment leading to coma
2. Mortality rate high; prompt recognition and treatment essential
3. Precipitating factors: failure to take prescribed medications; infection; trauma, exposure to cold; use of sedatives, narcotics, or anesthetics
2. Medical management
1. Drug therapy: levothyroxine (Synthroid), thyroglobulin (Proloid), dessicated thyroid, liothyronine (Cytomel)
2. Myxedema coma is a medical emergency.
1. IV thyroid hormones
2. Correction of hypothermia
3. Maintenance of vital functions
4. Treatment of precipitating causes
3. Assessment findings
1. Fatigue; lethargy; slowed mental processes; dull look; slow, clumsy movements
2. Anorexia, weight gain, constipation
3. Intolerance to cold; dry, scaly skin; dry, sparse hair; brittle nails
4. Menstrual irregularities; generalized interstitial nonpitting edema
5. Bradycardia, cardiac complications (CAD, angina pectoris, MI, CHF)
6. Increased sensitivity to sedatives, narcotics, and anesthetics
7. Exaggeration of these findings in myxedema coma: weakness, lethargy, syncope, bradycardia, hypotension, hypoventilation, subnormal body temperature
8. Diagnostic tests
1. Serum T₃ and T₄ level low
2. Serum cholesterol level elevated
3. RAIU decreased
4. Nursing interventions
1. Monitor vital signs, I&O, daily weights; observe for edema and signs of cardiovascular complications.
2. Administer thyroid hormone replacement therapy as ordered and monitor effects.
1. Observe for signs of thyrotoxicosis (tachycardia, palpitations, nausea, vomiting, diarrhea, sweating, tremors, agitation, dyspnea).
2. Increase dosage gradually, especially in clients with cardiac complications.
3. Provide a comfortable, warm environment.
4. Provide a low-calorie diet.
5. Avoid the use of sedatives; reduce the dose of any sedative, narcotic, or anesthetic agent by half as ordered.
6. Institute measures to prevent skin breakdown.
7. Provide increased fluids and foods high in fiber to prevent constipation; administer stool softeners as ordered.
8. Observe for signs of myxedema coma; provide appropriate nursing care.
1. Administer medications as ordered.
2. Maintain vital functions: correct hypothermia, maintain adequate ventilation.
9. Provide client teaching and discharge planning concerning
1. Thyroid hormone replacement
1. take daily dose in the morning to prevent insomnia.
2. self-monitor for signs of thyrotoxicosis.
2. Importance of regular follow-up care
3. Need for additional protection in cold weather
4. Measures to prevent constipation

1. General information
1. Enlargement of the thyroid gland not caused by inflammation or neoplasm
2. Types
1. Endemic: caused by nutritional iodine deficiency, most common in the "goiter belt" (midwest, northwest, and Great Lakes regions), areas where soil and water are deficient in iodine; occurs most frequently during adolescence and pregnancy
2. Sporadic: caused by
1. ingestion of large amounts of goitrogenic foods (contain agents that decrease thyroxine production): e.g., cabbage, soybeans, rutabagas, peanuts, peaches, peas, strawberries, spinach, radishes
2. use of goitrogenic drugs: propylthiouracil, large doses of iodine, phenylbutazone, para-amino salicylic acid, cobalt, lithium
3. genetic defects that prevent synthesis of thyroid hormone
3. Low levels of thyroid hormone stimulate increased secretion of TSH by pituitary; under TSH stimulation the thyroid increases in size to compensate and produces more thyroid hormone.
2. Medical management
1. Drug therapy
1. Hormone replacement with levothyroxine (Synthroid) (T₄), dessicated thyroid, or liothyronine (Cytomel) (T₃)
2. Small doses of iodine (Lugol's or potassium iodide solution) for goiter resulting from iodine deficiency
2. Avoidance of goitrogenic foods or drugs in sporadic goiter
3. Surgery: subtotal thyroidectomy (if goiter is large) to relieve pressure symptoms and for cosmetic reasons
3. Assessment findings
1. Dysphagia, enlarged thyroid, respiratory distress
2. Diagnostic tests
1. Serum T₄ level low-normal or normal
2. RAIU uptake normal or increased
4. Nursing interventions
1. Administer replacement therapy as ordered.
2. Provide care for client with subtotal thyroidectomy (see Thyroidectomy) if indicated.
3. Provide client teaching and discharge planning concerning
1. Use of iodized salt in preventing and treating endemic goiter
2. Thyroid hormone replacement

1. General information
1. Removal of one or both adrenal glands
2. Indications
1. Tumors of adrenal cortex (Cushing's syndrome, hyperaldosteronism) or medulla (pheochromocytoma)
2. Metastatic cancer of the breast or prostate
2. Nursing interventions: preoperative
1. Provide routine pre-op care.
2. Correct metabolic/cardiovascular problems.
1. Pheochromocytoma: stabilize blood pressure.
2. Cushing's syndrome: treat hyperglycemia and protein deficits.
3. Primary hyperaldosteronism: treat hypertension and hypokalemia.
3. Administer glucocorticoid preparation on the morning of surgery as ordered to prevent acute adrenal insufficiency.
3. Nursing interventions: postoperative
1. Provide routine post-op care.
2. Observe for hemorrhage and shock.
1. Monitor vital signs, I&O.
2. Administer IV therapy and vasopressors as ordered.
3. Prevent infections (suppression of immune system makes clients especially susceptible).
1. Encourage coughing and deep breathing to prevent respiratory infection.
2. Use meticulous aseptic technique during dressing changes.
4. Administer cortisone or hydrocortisone as ordered to maintain cortisol levels.
5. Provide general care for the client with abdominal surgery.
4. Provide client teaching and discharge planning concerning
1. Self-administration of replacement hormones
1. Bilateral adrenalectomy: lifelong replacement of glucocorticoids and mineralocorticoids
2. Unilateral adrenalectomy: replacement therapy for 6-12 months until the remaining adrenal gland begins to function normally
2. Signs and symptoms of adrenal insufficiency
3. Importance of follow-up care

1. General information
1. Functioning tumor of the adrenal medulla that secretes excessive amounts of epinephrine and norepinephrine
2. Occurs most commonly between ages 25-50
3. May be hereditary in some cases
2. Assessment findings
1. Severe headache, apprehension, palpitations, profuse sweating, nausea
2. Hypertension, tachycardia, vomiting, hyperglycemia, dilation of pupils, cold extremities
3. Diagnostic tests
1. Increased plasma levels of catecholamines; elevated blood sugar; glycosuria
2. Elevated urinary catecholamines and urinary vanillylmandelic acid (VMA) levels
3. Presence of tumor on x-ray
3. Nursing interventions
1. Monitor vital signs, especially blood pressure.
2. Administer medications as ordered to control hypertension.
3. Promote rest; decrease stressful stimuli.
4. Monitor urine tests for glucose and acetone.
5. Provide high-calorie, well-balanced diet; avoid stimulants such as coffee, tea.
6. Provide care for the client with an adrenalectomy (see below) as ordered; observe postadrenelectomy client carefully for shock due to drastic drop in catecholamine level.
7. Provide client teaching and discharge planning: same as for adrenalectomy.

1. General information
1. Excessive aldosterone secretion from the adrenal cortex
2. Seen more frequently in women, usually between ages 30-50
3. Caused by tumor or hyperplasia of adrenal gland
2. Assessment findings
1. Headache, hypertension
2. Muscle weakness, polyuria, polydipsia, metabolic alkalosis, cardiac arrhythmias (due to hypokalemia)
3. Diagnostic tests
1. Serum potassium decreased, alkalosis
2. Urinary aldosterone levels elevated
3. Nursing interventions
1. Monitor vital signs, I&O, daily weights.
2. Maintain sodium restriction as ordered.
3. Administer spironolactone (Aldactone) and potassium supplements as ordered.
4. Prepare the client for an adrenelectomy if indicated.
5. Provide client teaching and discharge planning concerning
1. Use and side effects of medication if the client is being maintained on spironolactone therapy
2. Signs of symptoms of hypo/ hyperaldosteronism
3. Need for frequent blood pressure checks and follow-up care

1. General information
1. Condition resulting from excessive secretion of corticosteroids, particularly the glucocorticoid cortisol
2. Occurs most frequently in females between ages 30-60
3. Primary Cushing's syndrome caused by adrenocortical tumors or hyperplasia
4. Secondary Cushing's syndrome (also called Cushing's disease): caused by functioning pituitary or nonpituitary neoplasm secreting ACTH, causing increased secretion of glucocorticoids
5. Iatrogenic: caused by prolonged use of corticosteroids
2. Assessment findings
1. Muscle weakness, fatigue, obese trunk with thin arms and legs, muscle wasting
2. Irritability, depression, frequent mood swings
3. Moon face, buffalo hump, pendulous abdomen
4. Purple striae on trunk, acne, thin skin
5. Signs of masculinization in women; menstrual dysfunction, decreased libido
6. Osteoporosis, decreased resistance to infection
7. Hypertension, edema
8. Diagnostic tests: cortisol levels increased, slight hypernatremia, hypokalemia, hyperglycemia
3. Nursing interventions
1. Maintain muscle tone.
1. Provide ROM exercises.
2. Assist with ambulation.
2. Prevent accidents or falls and provide adequate rest.
3. Protect client from exposure to infection
4. Maintain skin integrity.
1. Provide meticulous skin care.
2. Prevent tearing of skin: use paper tape if necessary.
5. Minimize stress in the environment.
6. Monitor vital signs; observe for hypertension, edema.
7. Measure I&O and daily weights.
8. Provide diet low in calories and sodium and high in protein, potassium, calcium, and vitamin D.
9. Monitor urine for glucose and acetone; administer insulin if ordered.
10. Provide psychologic support and acceptance.
11. Prepare client for hypophysectomy or radiation if condition is caused by a pituitary tumor.
12. Prepare client for an adrenalectomy if condition is caused by an adrenal tumor or hyperplasia.
13. Provide client teaching and discharge planning concerning
1. Diet modifications
2. Importance of adequate rest
3. Need to avoid stress and infection
4. Change in medication regimen (alternate day therapy or reduced dosage) if cause of the condition is prolonged corticosteroid therapy

1. General information
1. Severe exacerbation of Addison's disease caused by acute adrenal insufficiency
2. Precipitating factors
1. Strenuous activity, infection, trauma, stess, failure to take prescribed medications
2. Iatrogenic: surgery on pituitary or adrenal glands, rapid withdrawal of exogenous steroids in a client on long-term steroid therapy
2. Assessment findings: severe generalized muscle weakness, severe hypotension, hypovolemia, shock (vascular collapse)
3. Nursing interventions
1. Administer IV fluids (5% dextrose in saline, plasma) as ordered to treat vascular collapse.
2. Administer IV glucocorticoids (hydrocortisone [Solu-Cortef]) and vasopressors as ordered
3. If crisis precipitated by infection, administer antibiotics as ordered.
4. Maintain strict bed rest and eliminate all forms of stressful stimuli.
5. Monitor vital signs, I&O, daily weights.
6. Protect client from infection.
7. Provide client teaching and discharge planning: same as for Addison's disease.

1. General information
1. Primary adrenocortical insufficiency; hypofunction of the adrenal cortex causes decreased secretion of the mineralocorticoids, glucocorticoids, and sex hormones
2. Relatively rare disease caused by
1. Idiopathic atrophy of the adrenal cortex possibly due to an autoimmune process
2. Destruction of the gland secondary to tuberculosis or fungal infection
2. Assessment findings
1. Fatigue, muscle weakness
2. Anorexia, nausea, vomiting, abdominal pain, weight loss
3. History of frequent hypoglycemic reactions
4. Hypotension, weak pulse
5. Bronzelike pigmentation of the skin
6. Decreased capacity to deal with stress
7. Diagnostic tests: low cortisol levels, hyponatremia, hyperkalemia, hypoglycemia
3. Nursing interventions
1. Administer hormone replacement therapy as ordered.
1. Glucocorticoids (cortisone, hydrocortisone): to stimulate diurnal rhythm of cortisol release, give 2/3 of dose in early morning and 1/3 of dose in afternoon
2. Mineralocorticoids: fludrocortisone acetate (Florinef)
2. Monitor vital signs.
3. Decrease stress in the environment.
4. Prevent exposure to infection.
5. Provide rest periods; prevent fatigue.
6. Monitor I&O.
7. Weigh daily.
8. Provide small, frequent feedings of diet high in carbohydrates, sodium, and protein to prevent hypoglycemia and hyponatremia and provide proper nutrition.
9. Provide client teaching and discharge planning concerning
1. Disease process; signs of adrenal insufficiency
2. Use of prescribed medications for lifelong replacement therapy; never omit medications
3. Need to avoid stress, trauma, and infections, and to notify physician if these occur as medication dosage may need to be adjusted
4. Stress management techniques
5. Diet modification (high in protein, carbohydrates, and sodium)
6. Use of salt tablets (if prescribed) or ingestion of salty foods (potato chips) if experiencing increased sweating
7. Importance of alternating regular exercise with rest periods
8. Avoidance of strenuous exercise especially in hot weather

1. General information
1. Hypersection of ADH from the posterior pituitary gland even when the client has abnormal serum osmolality.
2. SIADH may occur in persons with bronchogenic carcinoma or other nonendocrine conditions.
2. Medical management
1. Treat underlying cause if possible
2. Diuretics and fluid restriction
3. Assessment findings
1. Persons with SIADH cannot excrete a dilute urine
2. Fluid retention and sodium deficiency.
4. Nursing interventions
1. Administer diuretics (furosemide [Lasix]) as ordered
2. Restrict fluids to promote fluid loss and gradual increase in serum sodium.
3. Monitor serum electrolytes and blood chemistries carefully
4. Careful intake and output, daily weight
5. Monitor neurologic status

1. General information
1. Hypofunction of the posterior pituitary gland resulting in deficiency of ADH
2. Characterized by excessive thirst and urination
3. Caused by tumor, trauma, inflammation, pituitary surgery
2. Assessment findings
1. Polydipsia (excessive thirst) and severe polyuria with low specific gravity
2. Fatigue, muscle weakness, irritability, weight loss, signs of dehydration
3. Tachycardia, eventual shock if fluids not replaced
4. Diagnostic tests
1. Urine specific gravity less than 1.004
2. Water deprivation test reveals inability to concentrate urine
3. Nursing interventions
1. Maintain fluid and electrolyte balance.
1. Keep accurate I&O.
2. Weigh daily.
3. Administer IV/oral fluids as ordered to replace fluid losses.
2. Monitor vital signs and observe for signs of dehydration and hypovolemia.
3. Administer hormone replacement as ordered.
1. Vasopressin (Pitressin) and vasopressin tannate (Pitressin tannate in oil); given by IM injection
1. warm to body temperature before giving.
2. shake tannate suspension to ensure uniform dispersion.
2. Lypressin (Diapid): nasal spray
4. Provide client teaching and discharge planning concerning
1. Lifelong hormone replacement; lypressin as needed to control polyuria and polydipsia
2. Need to wear Medic-Alert bracelet