med surg endocrine

Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

Excessive secretion of antidiuretic hormone (ADH) from the pituitary or non-endocrine sources (e.g., bronchogenic cancer, viral pneumonia).

• ADH causes the kidneys to retain water, leading to dilutional hyponatremia and fluid overload.

• Common triggers: head injury, infection, surgery, bronchogenic cancer or viral pneumonia.

S/S: fluid retention, decreased urine output.

• Dilutional hyponatremia → confusion, lethargy, seizures, coma.

• Weight gain without edema, concentrated urine.

Assessment/Diagnostics: Low serum sodium.

• Concentrated urine with high specific gravity > 1.030

• Signs of fluid overload and neurological changes.

Medical Management: Treat underlying cause.

• Fluid restriction.

• Hypertonic saline (3% NaCl) for severe hyponatremia to prevent seizures.

Nursing Interventions: Strict I&O, daily weights.

• Monitor urine/blood chemistry (especially Na+).

• Frequent neuro checks for seizure activity or mental status changes.

Diabetes Insipidus (DI)

Deficiency or resistance to ADH (vasopressin) → kidneys can’t conserve water.

• Causes include head trauma, brain surgery, tumors, inflammation, or nephrogenic causes (lithium toxicity, hypercalcemia, hypokalemia).

Clinical Manifestations (S/S): Polyuria (>250 mL/hr), very dilute urine (specific gravity 1.001–1.005).

• Polydipsia (extreme thirst).

• Dehydration, dry mucous membranes, hypotension, tachycardia.

• Hypernatremia and increased serum osmolality.

• Loss of fluids can lead to hypovolemic shock

Assessment/Diagnostics:

• Fluid deprivation test: inability to concentrate urine after fluid restriction.

• Low urine osmolality and specific gravity.

• Plasma ADH levels decreased (neurogenic) or normal (nephrogenic).

Medical Management: Replace ADH with desmopressin (DDAVP).

• Maintain adequate fluid intake and electrolyte balance (normal saline or LR)

• Identify and treat underlying cause.

Nursing Interventions: Monitor vital signs, I&O, urine specific gravity.

• Observe for dehydration and hypovolemic shock.

• Educate on medication use and signs of dehydration. 

• EKGs for ischemia!

Hypothyroidism

Deficiency in thyroid hormone production (T3, T4).

• Most common cause: Hashimoto’s disease (autoimmune thyroiditis).

• Can occur after thyroidectomy or radioactive iodine therapy.

• Leads to decreased metabolism affecting all body systems.

Clinical Manifestations (S/S): Fatigue, lethargy, cold intolerance, weight gain.

• Bradycardia, constipation, dry skin, slow speech.

• Mental apathy, depression.

• Myxedema coma (severe cases): hypothermia, hypotension, hypoventilation, hyponatremia.

• Elevated cholesterol levels in severe cases

Assessment/Diagnostics: ↑ TSH, ↓ T3 and T4.

• Thyroid antibodies (if autoimmune).

• Thyroid scan or biopsy if indicated.

• Increased mucopolysaccarides (attracts water)

Hypothyroidism treatment

Thyroid hormone replacement:

• Levothyroxine (Synthroid).

• Hydrocortisone

• Manage contributing conditions (hyperlipidemia, CAD).

• Avoid oversedation and respiratory depression.

Nursing Interventions: Encourage deep breathing, coughing, and mobility.

• Assess HR, rhythm, temperature, and cholesterol levels.

• Provide warm environment (NO heating pads).

• High-fiber diet, fluids, and medication education.

• Monitor for signs of myxedema coma.

Myxedema Coma

Severe hypothyroidism, can be with or without coma. Severe lethargy and may progress to coma

• Usually triggered by infection, trauma, surgery,

S/S: Facial puffiness, periorbital edema, dry skin, brittle hair.

Depressed respiratory drive, CO2 retention, Hypoventilation

• Hypoventilation (hypercapnia)

• Hypotension (dec. cardiac output)

• Hypothermia (warm blankets)

•  Hypoactive BS

• Hyponatremia?

Intravenous (IV) administration of levothyroxine (T4) or liothyronine (T3)

Glucose and corticosteroids for adrenal support

Hyperthyroidism (Graves’ Disease, Thyrotoxicosis)

Excessive secretion of thyroid hormones (T3, T4).

• Common causes: Graves’ disease (autoimmune), multinodular goiter, adenoma, thyroiditis.

• Graves’ = antibodies overstimulate thyroid → excessive hormone output and goiter formation.

Clinical Manifestations (S/S): Weight loss, heat intolerance, diaphoresis.

• Tachycardia, palpitations, hypertension, tremors.

• Anxiety, irritability, insomnia.

• Exophthalmos (eye protrusion).

• Enlarged thyroid with bruit.

• ↓ TSH, ↑ T3 and T4.

Assessment/Diagnostics: Thyroid function tests.

• Radioactive iodine uptake (high in Graves’).

Hyperthyroidism treatment

Antithyroid drugs: Propylthiouracil (PTU, blocks T4 to T3), THEN Methimazole.

Iodine preparations/ Lugols Solution: SSKI, Sodium/Potassium Iodide.

Beta-blockers/inderal: Propranolol for symptom control. Blocks hyperthyroidism effects on heart, lowering BP and HR, LIVESAVER

Radioactive iodine therapy: destroys thyroid tissue (avoid in pregnancy).

• Can cause a thyroid storm since thyroid hormones STORED in muscle, it releases the T3/T4

• Surgery: thyroidectomy if unresponsive.

Nursing Interventions: Monitor cardiac function, BP, HR, palpitations.

• Monitor signs of CHF: can lead to pulmonary edema and CARDIOGENIC shock

• Use Tylenol for fever (NO aspirin).

• Maintain calm environment; prevent overstimulation.

• High-calorie, high-protein diet.

• Monitor for thyroid storm or postoperative hypothyroidism.

Thyroid Storm

Extreme increase in thyroid hormone levels and metabolic rate. Life-threatening condition due to untreated hypothyroidism.

Triggered by infection, trauma, surgery, stress, or manipulation of the thyroid gland during surgery.

S/S: High fever (up to 106°F / 41°C).

• Severe tachycardia, atrial fibrillation, heart failure.

• Hypertension initially → later hypotension from cardiac collapse.

• Restlessness, agitation, delirium, psychosis, coma.

• Nausea, vomiting, diarrhea, dehydration.

Medical Management:

• Antithyroid drugs: Propylthiouracil (PTU), Methimazole to block hormone synthesis.

• Iodine solution (SSKI) to block thyroid hormone release (given after PTU).

• Beta-blockers (Propranolol) to reduce HR and anxiety.

• Corticosteroids to reduce conversion of T4 → T3 and prevent adrenal insufficiency.

• IV fluids and cooling blankets (avoid aspirin – it increases free T4).

• Treat underlying precipitating cause.

Thyroid Tumors / Goiter / Cancer

Benign or malignant growths of the thyroid gland.

• Simple goiter: iodine deficiency → thyroid enlargement.

• Nodular goiter: overgrowth of thyroid tissue, sometimes malignant.

• Thyroid cancer: hard, fixed nodule with lymphadenopathy.

Clinical Manifestations (S/S):

• Neck swelling, dysphagia, hoarseness.

• Symptoms of hyper- or hypothyroidism depending on function.

Assessment/Diagnostics:

• Thyroid function tests, ultrasound, needle biopsy.

Medical Management:

• Surgical removal (thyroidectomy).

• Radiation (oral radioactive iodine or external therapy).

• Chemotherapy rarely used.

Postoperative Nursing Interventions:

• Assess airway and breathing — keep tracheostomy set at bedside.

• Monitor for bleeding (look under neck and back).

• Keep IV calcium gluconate at bedside for hypocalcemia.

• Support head and neck during movement; avoid neck strain.

• Monitor for Chvostek’s and Trousseau’s signs.

• Limit talking to reduce vocal cord edema.

Hypoparathyroidism

Deficiency of parathormone (PTH) due to removal/damage of parathyroid glands (often after thyroid surgery) or autoimmune destruction.

• Results in hypocalcemia and hyperphosphatemia.

Clinical Manifestations (S/S):

• Tetany (muscle spasms, twitching, cramps).

• Numbness, tingling, laryngospasm, bronchospasm.

• Chvosteks sign: tapping on facial nerve causes twitching of mouth, nose, eye, face on that side.

• Trousseau sign: carpopedal spasm occurs when blood flow to lower arm is obstructed (BP cuff) for three minutes

• Cardiac arrhythmias.

Assessment/Diagnostics: Low calcium, high phosphate levels.

Medical Management:

• Calcium, magnesium, and calcitriol (vitamin D) supplementation.

• Thiazide diuretics to reduce calcium excretion.

• Aluminum hydroxide/carbonate to bind phosphate and promote excretion

Nursing Interventions:

• Keep tracheostomy kit and calcium gluconate at bedside.

• Diet high in calcium and low in phosphorus (avoid milk, eggs, spinach).Goal is 10mg/dl.

• Post-op care and medication teaching.

Hyperparathyroidism

Overproduction of parathormone (PTH) → bone decalcification and high serum calcium.

• Common cause: adenoma (benign tumor).

Clinical Manifestations (S/S): All associated with hypercalcemia

• Fatigue, apathy, muscle weakness.

• Constipation, hypertension, cardiac arrhythmias.

• Nephrolithiasis (kidney stones)

Assessment/Diagnostics:

• ↑ Serum calcium, ↓ phosphate.

• Decreased bone density on imaging.

Medical/Surgical Management:

• Parathyroidectomy (surgical removal).

• Hydration ≥ 2 L/day to prevent stones.

• Oral phosphates to reduce calcium.

Nursing Interventions:

• Encourage mobility (keeps calcium in bones).

• Monitor for renal calculi.

• Post-op: same as thyroidectomy care; monitor calcium levels.

Pheochromocytoma

Rare, usually benign tumor of the adrenal medulla that secretes excessive catecholamines (epinephrine, norepinephrine).

• Causes episodic or sustained hypertension.

Clinical Manifestations (S/S):

• Classic triad: headache, diaphoresis, palpitations.

• Severe hypertension, tachycardia, anxiety, tremors.

Assessment/Diagnostics: Imaging to locate tumor.

• Elevated urine/plasma catecholamines.

Medical Management:

• Control BP pre-op with alpha blockers (doxazosin) and calcium channel blockers (nifedipine).

• Surgical removal of tumor (adrenalectomy).

• Corticosteroid replacement if adrenal gland removed to prevent Adrenal Insufficiency or Adrenal Crisis.

Nursing Interventions:

• Monitor for hypotension and hypoglycemia post-op bc of sudden withdrawal of catecholamines.

• Monitor VS, glucose, ECG, and fluid balance.

• Elevate head of bed during hypertensive attacks.

Adrenal Glands

Two glands located on top of each kidney. Each gland consists of:

Adrenal Cortex – secretes:

• Glucocorticoids (Cortisol): increases blood sugar.

• Mineralocorticoids (Aldosterone): retains sodium and excretes potassium.

• Sex hormones.

Adrenal Medulla – part of the autonomic nervous system; secretes epinephrine (adrenaline).

Controlled by the hypothalamic-pituitary-adrenal (HPA) axis:

• Hypothalamus releases CRH → stimulates pituitary to release ACTH → stimulates adrenal cortex to release cortisol.

Addison’s Disease (Adrenocortical Insufficiency)

Insufficient production of adrenal cortex hormones (cortisol and aldosterone).

Result of a dysfunction of the hypothalamus - pituitary gland - adrenal gland feedback loop.

• Causes: autoimmune destruction, TB, adrenalectomy, medications (rifampin, barbiturates), or abrupt steroid withdrawal.

Clinical Manifestations (S/S): Weakness, fatigue, GI upset, weight loss.

• Hypotension, dehydration, ↓ ECF

• Hyponatremia: d/t loss of aldosterone, excretes Na

• Hyperkalemia: d/t loss of aldosterone, holds K+, ECG changes

• Hypoglycemia: d/t loss of cortisol

• Hyperpigmentation of skin d/t increase in ACTH (bronzing)

• Addisonian Crisis: shock, cyanosis, fever, circulatory collapse.

Assessment/Diagnostics:

• ↓ Cortisol, ↑ ACTH.

• ↓ Sodium, ↑ Potassium, ↓ Glucose.

Addison’s Disease treatment

If adrenal gland does not restore function: lifelong corticosteroids and mineralocorticoids

• IV fluids (NS) and IV hydrocortisone.

• Vasopressors if needed to maintain BP

• Antibiotics if infection present.

Nursing Interventions:

• Monitor BP and orthostatics.  (a decrease in systolic BP of 20 indicates hypovolemia)

• Patient flat with legs elevated

• Daily weights, I&O, assess for dehydration.

• Diet: high sodium, low potassium, then high protein/carb.

• Avoid activity in humid, hot weather

• Educate about stress management and med adherence.

Addisonian Crisis/Adrenal Crisis

Acute adrenocortical insufficiency characterized by hypotension, cyanosis, fever, signs of shock

• Life-threatening, resulting in shock and circulatory collapse

• Hyponatremia, hypoglycenia, hyperkalemia

Medical Management: Steroids (Hydrocortisone IV, IM or PO)

• Normal Saline

• Calcium chloride (CENTRAL line)

• Insulin + glucose (tx hyperkalemia)

• K-exelate (tx hyperkalemia)

Cushing’s Syndrome/Cushing’s Disease

Excess cortisol (endogenous or from corticosteroid therapy).

Cushing’s Disease: pituitary tumor causing ACTH overproduction.

Cushing’s Syndrome: prolonged corticosteroid use.

Clinical Manifestations (S/S):

• Central obesity, moon face, buffalo hump.

• Muscle wasting, heavy trunk, thin extremities.

• Fragile skin, purple striae, bruising.

• Hypertension, hyperglycemia.

• Fluid retention, weight gain.

Assessment/Diagnostics:

• ↑ Cortisol, ↑ Sodium, ↓ Potassium.

• 24-hour urine cortisol test.

• Dexamethasone suppression test.

Cushing’s treatment

Cushing’s Disease: remove adrenal pituitary tumor. (post-op caution of adrenal insuff)

Cushing’s Syndrome: taper corticosteroids.

• Insulin for hyperglycemia if needed.

Nursing Interventions:

• Monitor BP, glucose, and electrolytes (esp. potassium).

• Prevent infection (immunosuppressed). corticosteroids may hide the s/s

• Low-sodium, high-potassium diet.

• Protect from injury (fragile skin, muscle weakness).