Addisons/Cushings/Thyroid

• Adrenal gland


  • Lies on top of each kidney
  • Consists of a capsule, medulla and cortex
  • Controlled by anterior pituitary gland and ACTH
  • Adrenal glands secrete: Cortisol, Aldosterone, Epinephrine and norepinephrine, Androgens, Estrogens
• Cortisol - The Stress Hormone


  1. Individual is faced with a stressor

  2. Complex hormonal cascade ensues, and the adrenals secrete cortisol

  3. Cortisol prepares the body for a fight-or-flight response by flooding it with glucose, supplying an immediate energy source to large muscles

  4. Cortisol inhibits insulin production in an attempt to prevent glucose from being stored, favoring its immediate use

  5. Cortisol narrows the arteries while the epinephrine increases heart rate, both of which force blood to pump harder and faster

  6. Individual addresses and resolves the situation

  7. Hormone levels return to normal
• Cortisol release occurs in a circadian fashion, so it's naturally highest in the morning, when a burst of energy is needed to wake up and get out of bed, and declines throughout the day, with its lowest point being at night just before sleep
• Addison's Disease


  • Caused by a lack of production of the adrenocorticotropic hormones (cortisol and aldosterone) by the adrenal gland
  • Affects the balance of water, sodium and potassium in the body
  • Affects the body's ability to control blood pressure
  • Affects the body's ability to react to stress
  • Loss of androgens may cause a loss of body hair in women
  • Hypoglycemia, hyponatremia
• Addison's Risk Factors


  • Female
  • 30-50 years old
  • Nonspecific autoimmune destruction of adrenal gland
  • Abrupt discontinuation of corticosteroid medications
• Addison's Disease Clinical Manifestations


  • Overwhelming exhaustion
  • Weakness
  • Weight loss
  • Deepening skin pigmentation (looking like they a sun tan even when they haven't been out in the sun)
  • Dizziness on standing
  • Low blood pressure
  • Poor appetite
  • Nausea or vomiting
  • Difficulty concentrating
  • Muscle weakness with cramps
  • Salt cravings
  • Headaches
  • Stomach pains
• Adrenal Crisis/Addisonian Crisis


  • Life threatening emergency
  • Severe hypovolemia and hypotension
  • Caused by underlying adrenal hypofunction and added stress such as surgery, infection, illness or stopping hormone replacement suddenly
  • Additional doses of glucocorticoid may be required during times of stress, infection, surgery, etc.
• Addison's Medical Management


  • Definitive treatment is the replacement of cortisol
  • IV fluids, IV dextrose, IV glucocorticoids in crisis
• The nurse recognizes that which patient is at greatest risk for adrenal insufficiency?

  A 35-year-old female
• Cushing's Disease (Adrenal Cortex Hyper-function)


  • Cushing syndrome usually results from taking corticosteroids to treat a medical disorder or from a tumor in the pituitary or adrenal gland that causes the adrenal glands to produce excessive corticosteroids
  • Cushing syndrome can also result from tumors in other locations (such as the lungs)
  • Females are five times more likely to develop Cushing's
  • Peak incidence between 25-40 years old
• Cushing's Disease Risk Factors


  • Obesity
  • Type II diabetes
  • Depression
  • High blood pressure
  • Long-term use of steroids
  • Female gender
  • Age 20-50
• Cushing's Clinical Manifestations


  • Hyperglycemia
  • "moon face"
  • Abnormal fat distribution
  • Buffalo hump
  • Fluid retention
  • Hypokalemia
  • Virilization in females (development of male sex characteristics)
  • Breast atrophy
  • Deepening voice
  • Amenorrhea
  • Decreased immune response
• Cushing's Medical Management


  • Medications that interfere with ACTH and glucocorticoid production
  • Slowly decreasing steroid use if possible
  • Surgery/removal of pituitary tumors
  • Prevention of complications: Fluid overload, Poor immune response, Skin integrity, Hypertension, Osteoporosis, Changes in body structure
• Cushing's Patient Education


  • Take medication at the same time every day – EXACTLY on time
  • Modify salt intake as directed by provider – excessive salt may cause in increase in fluid retention
  • Eat a healthy diet that is high in protein and calcium. This can help prevent muscle and bone loss caused by the high cortisol levels in your body. Talk to your doctor about whether you should take a calcium and vitamin D supplement for bone health.
  • Get exercise. Walking is a good choice to start with. Talk with your doctor about how much exercise is safe for you.
  • Get regular eye exams to check for glaucoma and cataracts.
  • See your doctor regularly to help diagnose and treat diabetes, high blood pressure, and other possible complications.
• Which of the following may be a complication of Cushing's syndrome?

  Osteoporosis
• The Thyroid Gland


  • Thyroid hormones affect three fundamental physiologic processes: cellular differentiation, growth, and metabolism
  • The thyroid gland also produces another hormone called calcitonin, and the parathyroid glands secrete parathyroid hormone. Parathyroid hormone and calcitonin participate in control of calcium and phosphorus homeostasis and have significant effects on bone physiology
  • Thyrotropin-releasing hormone
• The Thyroid Hormones


  • Triiodothyronine, also known as T3
  • Tetraiodothyronine, also called thyroxine or T4
  • Calcitonin
• T3 and T4


  • T4 is the primary form of thyroid hormone circulating in the blood (about 95%). To exert its effects, T4 is converted to T3 by the removal of an iodine atom; this occurs mainly in the liver and in certain tissues where T3 acts, such as in the brain
  • T3 normally accounts for about 5% of thyroid hormone circulating in the blood
• The Thyroid Hormones


  T3 and T4 increase the basal metabolic rate. They make all of cells in the body work harder, so the cells need more energy too. This has the following effects, for example: Body temperature rises, Faster pulse and stronger heartbeat, Food is used up more quickly because energy stored in the liver and muscles is broken down, The brain matures (in children), Growth is promoted (in children), Activation of the nervous system leads to improved concentration and faster reflexes
• Hypothyroidism


  • Low levels of thyroid hormone with varied etiologies and manifestations
  • Primary hypothyroidism: The thyroid gland is not able to produce adequate amounts of thyroid hormone
  • Secondary (central) hypothyroidism: The thyroid gland is normal, there is a problem with the pituitary gland or hypothalamus
• Hypothyroidism Risk Factors


  • Autoimmune Process (Hashimoto's Thyroiditis)
  • Thyroid surgery
  • Radioactivity
  • Iodine deficiencies
  • Occurs in women 7-10 times more than men
  • Occurs most often between 30-60 years of age
• Hypothyroidism Clinical Manifestations


  • Decreased metabolism
  • Decreased energy
  • Increased sleep/fatigue
  • Weight gain
  • Susceptibility to cold temperatures
  • Lethargy
  • Constipation
  • Abdominal Distention
  • Lack of sweating
  • Dry coarse skin
  • Thin fragile hair/hair loss
  • Thin eyebrows
• Myxedema


  • Severely advanced hypothyroidism
  • Rare, but can be fatal
  • Multiple organ abnormalities and progressive mental deterioration
  • Swelling of the skin and soft tissues
  • Can lead to myxedema coma
  • Altered mentation
  • Dry, cool, doughy skin
  • Hypothermia
  • Bradycardia
  • Hypotension
  • Hypoventilation/hypoxia
  • Generalized swelling
  • Macroglossia
  • Periorbital edema
  • Coarse, sparse hair
  • Non-pitting edema
  • Facial puffiness
  • Vocal changes
• Hypothyroidism Goiter


  • A goiter is a benign (harmless) process. A simple goiter may disappear on its own or may become large
  • It may be caused by hypothyroidism and the thyroid trying to compensate by making more hormones
  • Over time, hypothyroidism (not enough thyroid hormone) may develop due to destruction of the normal thyroid tissue. This can be treated with medications to replace the thyroid hormone
  • Usually associated with lack of dietary iodine
• Hypothyroidism


  • Diagnosed by lab values –T3, T4 and TSH
  • History and physical / symptoms
  • Managed by replacement of thyroid hormones
• The nurse recognizes that which patient is at the greatest risk for hypothyroidism?

  An 80-year-old female
• The nurse correlates which clinical manifestation to the pathophysiology of hypothyroidism?

  Cold intolerance
• Hyperthyroidism


  • Increased secretion of thyroid hormones
  • Can originate from thyroid, or from anterior pituitary gland
  • 10timesmore prevalent in women than in men
  • Usually diagnosed between 20-40 years old
  • Grave's disease is the most common cause (autoimmune disorder)
• Hyperthyroidism Clinical Manifestations


  • Goiter –thyroid gland enlargement from over activity
  • Tachycardia
  • Increased gastric activity
  • Weight loss
  • Nervousness
  • Heat intolerance
  • Insomnia
  • Light or absent menses
  • Hair loss
  • Exophthalmos
  • Increased serum levels of thyroid hormone
  • Frequent mood changes
• Graves' disease is an autoimmune condition, which is where the immune system mistakenly attacks healthy tissue. In the case of thyroid eye disease, the immune system attacks the muscles and fatty tissues around and behind the eye, making them swollen
• Thyroid Storm (Thyrotoxicosis)


  • Extreme excess of thyroid hormones
  • Can be triggered by pregnancy, thyroid gland trauma, surgery, infection
  • Extremely high fever, tachycardia, hypertension, abdominal pain, altered LOC
  • Chest pain, shortness of breath
  • Can lead to seizures and cardiac dysrhythmias
  • Airway management and fluid resuscitation are priority
  • Hyperthermia management
  • Medications can lower levels of thyroid hormones
  • Monitor patient closely for life threatening complications
• Treatment of Hyperthyroidism


  • Management of cardiac function and body temperature are priority
  • Beta-blockers
  • Adequate fluid intake
  • Anti-thyroid medications
  • Surgery to remove tumors, sub total or total thyroidectomy
  • May need thyroid replacement medication after thyroidectomy
• Vocabulary


  • Hirsutism – excessive hair growth
  • Exophthalmos – bulging or protruding eyeballs
  • Euthyroid – having a normally functioning thyroid gland