CHAPTER 13 Endocrine Emergencies

Suzanne M. Wall, RN, MS, CEN, COHN-S, FNP

MAJOR TOPICS

General Strategy

Assessment

Analysis: Differential Nursing Diagnoses/Collaborative Problems

Planning and Implementation/Interventions

Evaluation and Ongoing Monitoring

Documentation of Interventions and Patient Response

Age-Related Considerations

Specific Endocrine Emergencies

Adrenal Crisis

Diabetic Ketoacidosis

Hyperosmolar Hyperglycemic Nonketotic Coma

Hypoglycemia

Myxedema Coma

Thyroid Storm

I. GENERAL STRATEGY

A. Assessment

1. Primary and secondary assessment/resuscitation (see Chapter 1)

2. Focused assessment

a. Subjective data collection

1) History of present illness/chief complaint

a) Pain: PQRST (see Chapter 9)

b) Fatigue, malaise

c) Vomiting

d) Altered mental status or decreased level of consciousness

e) Fever

f) Dyspnea

g) Weakness

h) Weight loss

i) Associated symptoms: anorexia, pruritus, diarrhea

j) Efforts to relieve symptoms

(1) Home remedies

(2) Alternative therapies

(3) Medications

(a) Prescription

(b) Over-the-counter/herbal

2) Past medical history

a) Current or preexisting diseases/illness

(1) Diabetes

(2) Alcoholism

(3) Renal disease

(4) Thyroid disease or surgery

b) Recent major trauma

c) Previous similar episodes

d) Smoking history

e) Substance and/or alcohol use/abuse

f) Last normal menstrual period: female patients of childbearing age

g) Current medications

(1) Prescription

(2) Over-the-counter/herbal

h) Allergies

3) Psychological, social, and environmental factors

a) Age: illness more severe in very young and very old

b) Family history

c) Stressors: surgery, trauma, illness, and psychosocial factors

d) Possible/actual assault, abuse, or intimate partner violence situations (see Chapter 3)

b. Objective data collection

1) General appearance

a) Level of consciousness, behavior, affect

b) Vital signs, including orthostatic blood pressure and pulse

c) Odors: breath and body

d) Gait

e) Hygiene

f) Level of distress/discomfort

2) Inspection

a) Neck veins

b) Mucous membranes

3) Auscultation

a) Breath sounds: clear, wheezes, crackles, other sounds

b) Bowel sounds: normal, hyperactive, hypoactive, absent

c) Heart sounds: S₁ and S₂, other sounds (e.g., murmurs)

4) Palpation

a) Abdominal distention

b) Areas of edema

c) Areas of tenderness

d) Areas of hyperthermia

e) Arteries: equality of peripheral pulses

f) Veins: venous filling and varicosities

g) Lymph nodes

3. Diagnostic procedures

a. Laboratory studies

1) Complete blood count (CBC) with differential

2) Serum chemistries including glucose, blood urea nitrogen (BUN), and creatinine

3) Arterial blood gas (ABG) values

4) Urinalysis; pregnancy test in female patients of childbearing age

5) Alcohol level

6) Serum and urine toxicology screen: therapeutic level and toxic ingestions

7) Coagulation profile: partial thromboplastin time (PTT) and prothrombin time (PT)

8) Liver enzyme levels

9) Serum ketone levels

10) Serum osmolality

11) Cultures: blood, sputum, wound, throat, nasopharyngeal, viral

12) Thyroid function studies

13) Cortisol level

b. Imaging studies

1) Chest radiograph

2) Head computed tomography (CT) scan

3) Abdominal CT scan

c. Other

1) 12- to 15-lead electrocardiogram (ECG)

2) Lumbar puncture

B. Analysis: Differential Nursing Diagnoses/Collaborative Problems

1. Impaired gas exchange

2. Ineffective breathing pattern

3. Decreased cardiac output

4. Deficient fluid volume

5. Ineffective tissue perfusion

6. Decreased intracranial adaptive capacity

7. Risk for infection

8. Deficient knowledge

C. Planning and Implementation/Interventions

1. Determine priorities of care

a. Maintain airway, breathing, and circulation (seeChapter 1)

b. Provide supplemental oxygen as indicated

c. Establish intravenous (IV) access for administration of crystalloid fluid/medications as needed

d. Obtain and set up equipment and supplies

e. Prepare for/assist with medical interventions

f. Administer pharmacologic therapy as ordered

2. Relieve anxiety/apprehension

3. Allow significant others to remain with patient if supportive

4. Educate patient and significant others

D. Evaluation and Ongoing Monitoring (see Appendix B)

1. Continuously monitor and treat as indicated

2. Monitor patient response/outcomes, and modify nursing care plan as appropriate

3. If positive patient outcomes are not demonstrated, reevaluate assessment and/or plan of care

E. Documentation of Interventions and Patient Response

F. Age-Related Considerations

1. Pediatrics

a. Growth or development related

1) Neonates, infants, and toddlers are more susceptible to illness and injury but also have more recuperative capacity

2) Infants have decreased glycogen stores in comparison with adults

3) Brain development is not complete until about age 20, so more susceptibility to injury exists

4) Fluid and electrolyte composition: 75% to 80% of body weight in infants is fluid, making them more susceptible to dehydration

b. “Pearls”

1) Pediatric patients are developmentally unable to care for themselves during illness (e.g., maintaining adequate fluid intake)

2) Inborn errors of metabolism may manifest as severe metabolic acidosis between the second and fifth day of life; late-onset errors of metabolism may manifest as gastroenteritis or recurrent “culture-negative” sepsis in toddlers

3) Parents know their children better than anyone: it is essential to listen to them

4) Most therapeutic choice is often reassurance

2. Geriatrics

a. Aging related

1) In healthy elderly people, physiologic decreases in function are usually apparent only under stress

2) Reserve capacity for responding to stress decreases

3) Immune system is compromised

4) Reduced ability to metabolize and clear medications leads to frequent occurrence of toxicity and adverse reactions

5) Neurologic system: loss of nonreplicating cells (neurons) may lead to permanent deficit

a) Dopaminergic neurons are lost, impairing gait and balance and increasing susceptibility to side effects of medication

b) Loss of other neurotransmitter systems leads to autonomic dysfunction and alterations in neuroendocrine control and mental function

6) Cardiovascular system

a) Decreases in heart rate are accompanied by increases in end-diastolic and end-systolic volumes; reserve mechanisms to increase cardiac output are used routinely and may be overwhelmed by illness

b) Baroreceptor reflex sensitivity decreases, altering response of system to changes in intravascular volume

(1) Greater risk exists during rapid volume expansion

(2) Orthostatic hypotension is more prevalent

7) Pulmonary system: elasticity of small airways is lost

a) Increasing tendency for alveoli to collapse

b) By age 65 years, not all alveoli are open during regular breathing, thus increasing susceptibility to atelectasis and pneumonia

8) Endocrine system

a) Glucose intolerance, insulin resistance, and abnormal regulation of insulin secretion occur

b) Metabolic clearance of thyroid hormone decreases; in thyroid disease, must decrease dose of exogenous thyroxine obtained from thyroid medication

c) Decreased estrogen level alters bone metabolism, leading to osteoporosis

9) Fluid and electrolytes: adaptive mechanisms are impaired, although balance (volume and number of solutes) is unchanged

a) Nephron loss and decrease in renin and aldosterone levels contribute to increased sodium loss before compensatory mechanisms can be fully activated

b) Decreased glomerular filtration rate, baroreceptor reflex sensitivity, and insulin and beta-adrenergic responsiveness increase risk of hyperkalemia

c) Water conservation and urine-concentrating ability, as well as thirst mechanism, are impaired, resulting in increased susceptibility to dehydration

d) Increased osmoreceptor sensitivity with higher set point for vasopressin (antidiuretic hormone) increases risk of syndrome of inappropriate antidiuretic hormone (SIADH) in patients taking certain drugs and in pulmonary and neurologic diseases

10) Renal system: renal blood flow, glomerular filtration rate, and creatinine clearance are decreased

11) Vision and hearing

a) Decreased visual acuity, changes in refractive power, loss of accommodation, cataracts, and decreased tear secretion influence ability to see adequately

b) Hearing loss occurs as a result of changes in peripheral auditory system and cerebral cortex

b. “Pearls”

1) Decreased activity and less emotional involvement in activity or roles occur

2) Elderly patients have increased concern with immediate environment, health, and factors affecting them directly

II. SPECIFIC ENDOCRINE EMERGENCIES

A. Adrenal Crisis

Acute adrenal insufficiency or adrenal crisis occurs in response to an acute stressor, such as infections, hemorrhage, trauma, surgery, burns, pregnancy, or abrupt cessation of long-term steroid use. Adrenal insufficiency occurs when the adrenal cortex ceases to produce glucocorticoid and mineralocorticoid hormones. Primary causes of adrenal insufficiency may include autoimmune adrenalitis (Addison’s disease), tuberculosis, acquired immunodeficiency syndrome (AIDS), metastatic lung or breast cancer, and adrenal hemorrhage. Secondary causes of adrenal insufficiency may include sarcoidosis, pituitary tumor, chronic steroid use, pituitary stroke, and rarely, postpartum pituitary necrosis. Adrenal crisis should be suspected in patients who have hypotension unresponsive to fluid resuscitation and vasopressor medications. Death occurs because of circulatory collapse and hyperkalemia-induced dysrhythmia.

1. Assessment

a. Subjective data collection

1) History of present illness/chief complaint

a) Fever

b) Pain (see Chapter 9): nonspecific abdominal pain; may simulate acute abdomen

c) Nausea, vomiting, diarrhea

2) Past medical history

a) Current or preexisting diseases/illness

(1) Primary adrenal insufficiency

(2) Possible hypothyroidism

b) Abnormal skin coloring

c) Weakness, fatigue, lethargy

d) Anorexia and weight loss

e) Salt craving

f) Recent stressful events

g) Medications: recent discontinuation of cortisol medication

h) Allergies

b. Objective data collection

1) Physical examination

a) General appearance

(1) Level of consciousness, behavior, affect: confusion

(2) Hypotension, but may have warm extremities

(3) Tachycardia

(4) Tachypnea

(5) Orthostasis

(6) Elevated temperature

(7) Severe distress/discomfort, critically ill

b) Inspection

(1) Hyperpigmentation of skin

c) Auscultation

(1) Heart sounds: very soft

2) Diagnostic procedures

a) CBC with differential

b) Serum chemistries including glucose, BUN, and creatinine

(1) Hyponatremia

(2) Hyperkalemia

(3) Hypercalcemia

(4) Blood glucose level: hypoglycemia

(5) BUN: elevated (azotemia secondary to dehydration): creatinine

c) Urinalysis; pregnancy test in female patients of childbearing age

d) Blood cultures

e) Plasma cortisol level: diagnostic if low

f) Adrenocorticotropic hormone (ACTH) level: stimulation test

(1) Elevated: primary adrenal insufficiency

(2) Decreased: secondary adrenal insufficiency

g) ECG

(1) Low voltage

(2) Flat or inverted T wave

(3) Prolonged QT interval, QRS complex, or PR interval

h) Chest radiograph

i) Abdominal CT scan: if diagnosis not clear

(1) May indicate adrenal hemorrhage, calcification, or metastasis

j) Head CT scan

2. Analysis: differential nursing diagnoses/collaborative problems

a. Deficient fluid volume

b. Ineffective tissue perfusion: cardiopulmonary and cerebral

3. Planning and implementation/interventions

a. Maintain airway, breathing, and circulation (seeChapter 1)

b. Provide supplemental oxygen as indicated

c. Establish IV access for administration of crystalloid fluid/medications as needed

1) Rapid infusion of normal saline solutions or lactated Ringer’s solution

2) Maintenance volume replacement: dextrose 5% in normal saline solution

d. Obtain initial weight if possible, especially if patient will be in emergency care area for prolonged period

e. Prepare for/assist with medical interventions

1) Institute cardiac and pulse oximetry monitoring

2) Insert gastric tube and attach to suction as indicated

3) Insert indwelling urinary catheter as indicated

4) Assist with hospital admission and other procedures as indicated by underlying cause of crisis (acute stressor)

f. Administer pharmacologic therapy as ordered

1) Hydrocortisone (Solu-Cortef) 100 mg IV (2 mg/kg for children) immediately, then every 6 hours

2) Dexamethasone (Decadron)

a) May be administered instead of hydrocortisone if reason for crisis is unknown

b) Does not interfere with subsequent ACTH stimulation testing

3) Corticotropin

4) Dextrose 50%

5) Possible electrolyte replacement

6) Vasopressors

7) Fludrocortisone acetate (Florinef): if hypotension, hyponatremia, and hyperkalemia persist after initial treatment

8) Levothyroxine (Synthroid): if concurrent hypothyroidism present

4. Evaluation and ongoing monitoring (see Appendix B)

a. Level of consciousness: brain dehydration and injury can develop with rising sodium levels

b. Hemodynamic status, including orthostatic blood pressure and pulse

c. Breath sounds and pulse oximetry

d. Cardiac rate and rhythm

e. Intake and output

f. Electrolytes and glucose levels

B. Diabetic Ketoacidosis

Diabetic ketoacidosis is a result of insulin deficiency and stress hormone excess. It typically occurs in insulin-dependent diabetes (type 1), but it may also occur in non–insulin-dependent diabetes (type 2). Lack of insulin causes decreased cellular glucose uptake, release of free fatty acids, and increased gluconeogenesis by the liver. Hyperglycemia promotes osmotic diuresis with dehydration, hyperosmolality, and electrolyte depletion. Counterregulatory (stress) hormones (glucagon, catecholamines, cortisol, and growth hormone) have anti-insulin effects and stimulate the release of free fatty acids. Free fatty acids are converted to ketone bodies, which release hydrogen ions, thereby contributing to metabolic ketoacidosis. Acidosis decreases myocardial contractility and cerebral function. Infection and stressful events are the usual precipitating factors, along with omission of insulin and new-onset diabetes. The goal of therapy is a gradual, even return to normal metabolic balance. Complications of therapy such as cerebral edema, hypoglycemia, and electrolyte imbalance may contribute to death during treatment.

1. Assessment

a. Subjective data collection

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