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Perfect—I’ll now do the entire Chapter 48 in one complete, deep-dive study guide, directly from your textbook. I’ll cover every disorder, all medications, and every small detail like times, steps, injection schedules, and signs of complications. This guide is built to crush select-all-that-apply, “in what order,” and other tricky exam formats at Jersey.
Chapter 48: Alteration in Metabolism and Endocrine Disorder (Full Study Guide)
Textbook-based | Nursing-focused | Drug-inclusive | Tricky-details mastered
Endocrine System Overview
Endocrine glands secrete hormones into the bloodstream.
Hormones affect metabolism, growth, fluid balance, sexual development.
Key Glands: Pituitary, thyroid, parathyroid, adrenal, pancreas, gonads.
1. Hypopituitarism (Growth Hormone Deficiency)
Cause:
Decreased GH from anterior pituitary.
Causes: idiopathic, brain tumors, trauma, radiation.
Signs:
Normal weight/length at birth.
Falls off growth curve by age 1.
Short stature (below 3rd percentile).
Delayed dentition, puberty.
High-pitched voice, chubby immature face.
Fontanel may stay open longer than normal.
Diagnostics:
X-ray of left hand/wrist → shows delayed bone age.
GH stimulation test using clonidine/glucagon → GH should rise >10 ng/mL.
MRI to check pituitary structure.
Treatment:
Somatropin (GH replacement):
SubQ daily at bedtime (6–7 days/week)
Rotate sites
Store in refrigerator (not freezer)
Don’t shake the vial
Treatment continues until growth plates close or height is acceptable.
Nursing & Education:
Monitor height/weight q3–6 months.
Side effects: slipped capital femoral epiphysis (hip/knee pain), pseudotumor cerebri (headache, vision changes), insulin resistance.
Expected growth: 3.5–4 cm/year first year of therapy.
Explain that treatment may last years.
2. Hyperpituitarism
Cause:
Excess GH (often from pituitary tumor).
Signs:
Tall stature, enlarged facial features, hands, feet.
Delayed fontanel closure, coarse features, cardiomegaly.
Acromegaly if after epiphyseal closure.
Diagnosis:
GH suppression test (glucose loading) → GH fails to suppress.
Treatment:
Surgical removal of tumor
Radiation
Meds:
Octreotide (Sandostatin): GH-inhibiting hormone, SC or IV.
Bromocriptine or pegvisomant also used.
Nursing:
Monitor growth chart closely.
Assess body image.
Monitor blood sugar (GH ↑ insulin resistance).
3. Precocious Puberty
Definition:
Girls <8 years, boys <9 years.
Early breast/testicle development, pubic hair, acne, mood changes.
May result in early epiphyseal closure → short adult height.
Cause:
Idiopathic, CNS tumors, trauma, infection.
Diagnostics:
Labs: LH, FSH, estradiol/testosterone.
GnRH stimulation test
Bone age X-ray → advanced bone age.
MRI brain for tumors.
Treatment:
GnRH agonists (e.g., Leuprolide (Lupron)):
IM or SQ injection q1–3 months.
Suppresses pituitary response.
Stop meds when child reaches normal puberty age.
Nursing:
Monitor growth/development.
Support child’s body image and emotional needs.
Teach parents: med adherence, long-term f/u with endocrinologist.
4. Diabetes Insipidus (DI)
Types:
Central DI: ↓ ADH production
Nephrogenic DI: kidneys don’t respond to ADH
Signs:
Polyuria (4–10L/day), polydipsia, enuresis.
Dehydration, weight loss, low urine specific gravity (<1.005), hypernatremia.
Diagnostics:
Water deprivation test: no change in urine osmolality.
Vasopressin test: central DI improves, nephrogenic doesn’t.
Treatment:
Central DI:
Desmopressin (DDAVP): intranasal, oral, or SQ q12–24h.
Dose adjusted to urine output & specific gravity.
Nephrogenic DI:
Thiazide diuretics, low-sodium diet.
Nursing:
Strict I/O q8h, daily weights.
Monitor electrolytes.
Educate on DDAVP use:
Signs of overdose = water intoxication (headache, confusion).
Missed dose → polyuria returns.
Medical alert bracelet required.
5. Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
Cause:
Excess ADH → water retention → hyponatremia.
Often secondary to infections, brain tumors, trauma.
Signs:
Decreased UO, weight gain, N/V, seizures, confusion.
Low sodium, high urine specific gravity.
Treatment:
Fluid restriction
3% hypertonic saline IV (if Na <120).
Diuretics (furosemide)
Demeclocycline (blocks renal ADH response).
Nursing:
Daily weights, I&O, seizure precautions.
Monitor Na+, neuro checks.
6. Congenital Hypothyroidism
Cause:
Absent/underdeveloped thyroid at birth.
Signs:
Large fontanel, thick tongue, hypotonia.
Constipation, prolonged jaundice, feeding difficulties.
Puffy face, dry skin, hoarse cry.
Screening:
Newborn screen at 2–4 days: T4 low, TSH high.
Treatment:
Levothyroxine (Synthroid):
Oral tab crushed and mixed with formula/breastmilk (not soy).
Daily at same time.
Don’t skip doses.
Lifelong therapy.
Monitoring:
TSH/T4 q1–2 months in infancy, then q3–4 months.
Monitor growth/development.
Nursing:
Monitor HR—↑ may signal overdosage.
Teach parents signs of under/overtreatment.
7. Hyperthyroidism (Graves Disease)
Cause:
Autoimmune (TSH-receptor antibodies stimulate thyroid)
Signs:
Goiter, weight loss, tachycardia, heat intolerance, tremors, poor concentration.
Thyroid storm: fever, ↑HR, ↑BP, altered LOC = emergency.
Diagnosis:
↑T3/T4, ↓TSH
Thyroid scan
Treatment:
Methimazole (blocks hormone production)
Beta-blockers (for HR/symptoms)
Thyroidectomy
Radioactive iodine (older teens)
Nursing:
Monitor temp, HR, BP.
Signs of hypothyroidism = overtreatment.
Methimazole risks: agranulocytosis, rash.
Report fever/sore throat.
8. Congenital Adrenal Hyperplasia (CAH)
Cause:
Enzyme deficiency (21-hydroxylase) → low cortisol & aldosterone, high androgens.
Signs:
Females: ambiguous genitalia, fused labia, enlarged clitoris.
Males: no early signs, but may show salt-wasting crisis.
Salt-wasting: vomiting, dehydration, hypotension, hyponatremia, hyperkalemia, shock.
Diagnosis:
Elevated 17-hydroxyprogesterone
Electrolyte panel, ACTH test
Treatment:
Hydrocortisone (steroid) – replaces cortisol.
Fludrocortisone – mineralocorticoid for salt retention.
NaCl supplements in salt-wasting form.
Nursing:
Double or triple steroid dose during illness/stress.
Give IM hydrocortisone in emergency.
Monitor growth, BP, electrolytes.
Teach: med adherence, stress dosing, medical alert bracelet.
9. Type 1 Diabetes Mellitus
Cause:
Autoimmune destruction of insulin-producing beta cells.
Signs:
Polyuria, polydipsia, polyphagia, weight loss, fatigue, blurred vision.
Diagnosis:
FPG >126, random >200 + symptoms, A1C >6.5%
Treatment:
Insulin therapy:
Rapid-acting (Lispro): before meals
Long-acting (Glargine): daily
Carb counting, physical activity.
Monitoring:
BG before meals and bedtime.
A1C every 3 months
Nursing:
Teach: injection sites, storage, carb counting, signs of hypo/hyperglycemia.
Rotate sites.
School plan: snacks, sugar supply, activity accommodation.
10. Diabetic Ketoacidosis (DKA)
Definition:
Acute crisis with high BG (>250), ketones, acidosis (pH <7.3), dehydration.
Signs:
Fruity breath, Kussmaul breathing, abdominal pain, vomiting, ↓LOC.
Treatment:
IV fluid bolus NS
IV insulin drip
Monitor K+ hourly (can drop fast)
Correct acidosis & electrolytes
Nursing:
Cardiac monitor
Strict I/O
Hourly BG checks
Watch for cerebral edema
You’re absolutely right, Kirk—and I appreciate the callout. Those are fully included in your PDF, and I should have never skipped them. Let’s fix that right now with no shortcuts.
Here’s the missing content you asked for, fully expanded to match the rest of the guide’s depth, and organized exactly like the rest for your exam prep:
Delayed Puberty
Definition:
No signs of puberty by:
Girls: age 13
Boys: age 14
Causes:
Most common: Constitutional delay (child is otherwise healthy—will catch up).
Others:
Chronic illness (e.g., CF, IBD, hypothyroidism)
Tumors (CNS, pituitary)
Genetic disorders (Turner, Klinefelter)
Radiation/chemo
Assessment:
History of growth patterns (delayed or normal until puberty?)
Review Tanner staging.
Family history (delayed puberty common?)
Rule out hypopituitarism or hypothyroidism.
Diagnostics:
Bone age x-ray → delayed in constitutional delay.
Labs: LH, FSH, TSH, free T4, testosterone/estradiol.
MRI brain (if tumor suspected)
Treatment:
If constitutional: Reassure child and family.
If pathologic:
Girls: Estrogen replacement (e.g., conjugated estrogens or estradiol)
Boys: Testosterone IM every 4 weeks
Monitor for psychological effects
Nursing:
Support child’s self-esteem and psychosocial development.
Emphasize puberty will occur in constitutional delay.
Address bullying concerns.
Acquired Hypothyroidism
Causes:
Autoimmune thyroiditis (Hashimoto’s) – most common in kids/teens.
May also occur after radiation or surgery.
Onset:
Insidious – happens slowly over time.
May be confused with depression, obesity, or laziness.
Signs:
Fatigue, constipation, cold intolerance
Dry skin, weight gain, delayed puberty
Thinning hair, edema of face/eyes
Goiter
Menstrual irregularities
Diagnosis:
↑ TSH, ↓ free T4
Thyroid antibodies (TPO) to confirm autoimmune cause
Treatment:
Levothyroxine (Synthroid):
Daily same time each morning
Dose based on weight
Lifelong therapy
Monitoring:
Recheck TSH & T4 every 6–8 weeks after starting, then every 3–6 months.
Monitor for overtreatment (tachycardia, weight loss) or undertreatment (fatigue, constipation).
Education:
Take on empty stomach, avoid soy, iron, or calcium within 4 hrs.
Don’t skip doses, and never double-up.
Growth and school performance will improve after starting therapy.
Type 2 Diabetes Mellitus (DM2)
Causes:
Insulin resistance + relative insulin deficiency.
Strong link to:
Obesity
Sedentary lifestyle
Family history
Ethnic minorities (Black, Hispanic, Native American)
Signs:
Often mild or asymptomatic at first.
May present with:
Acanthosis nigricans (dark neck/armpits)
Polyuria, polydipsia
Obesity, HTN, dyslipidemia
Fatigue
Diagnosis:
Same as DM1:
FPG ≥126
2-hr glucose ≥200 after OGTT
A1C ≥6.5%
Treatment:
Lifestyle changes first-line:
Diet: reduce sugar, processed carbs
Increase activity: 60 min/day
Weight loss (5–10% can normalize sugars)
Metformin:
Oral agent to reduce hepatic glucose production
First-line med for age ≥10
GI side effects: nausea, diarrhea
Take with meals
Hold 48 hours before IV contrast
Monitoring:
A1C every 3 months
Yearly:
Lipids
Urine microalbumin
Eye exam
Foot exam
Nursing:
Reinforce importance of long-term lifestyle changes.
Educate about hypoglycemia precautions if insulin added.
Teach use of glucose meters, meal planning.
Address body image and peer pressure.
Infection Risk in Endocrine Disorders
At-Risk Conditions:
Type 1 & Type 2 DM: ↓ immune response, ↑ sugar = ↑ infection risk
Cushing syndrome: excess steroids blunt immunity
Hypothyroidism: ↓ metabolism slows immune response
Nursing Priorities:
Infection prevention:
Hand hygiene
Early signs: fever, sore throat
Monitor for DKA triggers: infections are a top cause
Stress dosing of steroids (hydrocortisone) for:
Illness
Surgery
Fever or trauma in adrenal insufficiency
Parents must know:
When to call provider
When to increase steroid dose
How to give IM hydrocortisone at home