Med Surg 2 EXAM 2
The nurse is caring for a patient schedule for a radioactive iodine uptake test. Which of the following should be included in patient instructions?
"Take special precautions when urinating, such as flushing the toilet at least twice." -Used to diagnose thyroid disorders -Tracer is normally eliminated in the urine in the first 24 hours. Patients do not need to avoid contact with others. -Oral or IV iodine is administered before the test The test will measure the rate of iodine uptake by the thyroid to determine thyroid function
A nurse is assessing a patient for hemorrhage after the patient underwent a transphendoidal hypophysectomy. Which of the following signs may be present? -Bloody stool -Bradycardia -Frequent swallowing -Petichiae of the face
- Frequent swallowing A hypophysetomy is the surgical removal of the pituitary gland due to a tumor. It is commonly removed transphenoidally, or through the nose - The nasal passages are generally packed after this surgery, and blood draining from the sinuses into the mouth and throat can cause the patient to frequently swallow
Adrenal Medulla Disorders
- Pheochromocytoma
Hypophysectomy (pituitary adenectomy, transsphenoidal pituitary surgery)
- Removal of a pituitary tumor via craniotomy or a transsphenoidal (endoscopic transnasal) approach (latter approach is preferred because it is associated with fewer complications - complications for craniotomy include increased ICP, bleeding, meningitis, and hypopituitarism -complications for the transsphenoidal surgery include cerebrospinal fluid leak, infection, and hypopituitarism
Interventions to decrease ICP
- administer mannitol as ordered -maintain neutral neck alignment and elevate the head of the bed -space out activities
CT preprocedure interventions
- ask client if they are allergic to shellfish, iodine, or contrast dyes - ask client if they are claustrophobic - remove objects from head/ remove jewelry -initiative IV if prescribed -instruct client to lie still and flat during test
Hypoparathyroidism
- decreased secretion of PTH due to destruction of the parathyroid glands (autoimmune or post- srugical), abnormal parathyroid hormone production and secretion
Why is metformin withheld during a CT scan
- metformin induced lactic acidosis
Meds for ADH (antidiuretic hormone) insufficiency
- need to stop excessive urination - urine is dilute -specific gravity is LOW - patient needs Vasopressin tannate (Pitressin) or desmopressin acetate (DDVAP, Stimate, Minirin)
findings of adrenal insufficiency
- weight loss -serum calcium level above the expected reference range -serum sodium level below the expected reference range
Diagnostic test for pheochromocytoma
-24 hour urine collection for vanillymandelic acid (VMA) a product of catecholamine metabolism, metanephrine, and catecholamines all of which are elevated in the presence of a pheochromocytoma; the normal range of urinary catecholamines is up to 14 mcg/ 100mL
Pathophysiology of Cushing's Syndrome
-Abnormal stimulation of the pituitary gland -Increase ACTH -Stimulate adrenal gland -Increase steroid hormone -hyperglycemia, hypernatremia, and hypokalemia
Spinal Shock
Also known as spinal shock syndrome. It is a complete but temporary loss of motor, sensory, reflex, and autonomic function that occurs immediately after injury as the cord's response to injury. It usually lasts less than 48 hours but can continue for several weeks
Guillain- Barre syndrome
An autoimmune disease that causes demyelination of nerves. The result is ascending paralysis that can affect the extremities, respiratory muscles, cranial nerves, and sometimes autonomic function. The exact cause of the condition is not clear, but can appear after a recent respiratory or GI infection, surgery, or immunization (such as influenza). The condition is usually reversible and the majority of patients have a complete recovery within the first year.
Unilateral Neglect
An inability to recognize a physical impairment on one side of the body. It occurs most commonly in clients who have had a right cerebral stroke; also known as neglect syndrome
Methimazole (Tapazole)
Anti-thyroid Medication
Potassium Iodide (SSKI, ThyroShield)
Anti-thyroid Medication
Sodium Iodide, 131 I
Anti-thyroid Medication
Strong Iodide Solution (lugol's solution)
Anti-thyroid Medication
Propylthiouracil (PTU)
Anti-thyroid Medication -causes agranulocytosis- contact the HCP if a fever or sore throat develops
Because of steroid excess, the client who has undergone a bilateral adrenalectomy is at an increased risk for A. Postoperative confusion. B. Delayed wound healing. (collagen matrix) C. Emboli. D. Malnutrition.
B. Delayed wound healing. (collagen matrix)
Which of the following test results would be consistent with a diagnosis of Cushing's disease? A. Postprandial hypoglycemia. B. Hypokalemia. C. Hyponatremia. D. Decreased urinary calcium level.
B. Hypokalemia.
In the early postoperative period after a bilateral adrenalectomy, the nurse should recognize that the most probable cause of temperature elevation is A. Dehydration. B. Poor lung expansion. C. Wound infection. D. Urinary tract infection
B. Poor lung expansion.
Which of the following symptoms might indicate that a client was developing tetany after a subtotal thyroidectomy? A. Pains in the joints of the hands and feet. B. Tingling in the fingers. C. Bleeding on the back of the dressing. D. Tension on the suture line
B. Tingling in the fingers.
A 60-year-old woman is diagnosed with hypothyroidism. Signs and symptoms of hypothyroidism include A. Tachycardia. B. Weight gain. C. Diarrhea. D. Nausea.
B. Weight gain
Hemianopsia
Blindness in half the visual field
When teaching a client newly diagnosed with primary Addison's disease, the nurse should explain that the disease results from A. Insufficient secretion of growth hormone(GH). B. Dysfunction of the hypothalamic pituitary. C. Idiopathic atrophy of the adrenal gland. D. Over-secretion of the adrenal medulla
C. Idiopathic atrophy of the adrenal gland.
The nurse asks the client to state her name as soon as she regains consciousness postoperatively after a subtotal thyroidectomy and at each assessment.The nurse does this primarily to monitor for signs of which of the following? A. Internal hemorrhage. B. Decreasing level of consciousness. C. Laryngeal nerve damage. D. Upper airway obstruction.
C. Laryngeal nerve damage.
A priority in the first 24 hours after a bilateral adrenalcotomy is A. Beginning oral nutrition. B. Promoting self-care activities. C. Preventing adrenal crisis. D. Ambulating in the hallway
C. Preventing adrenal crisis.
Which of the following findings would be typical of Addison's disease? A.Hypokalemia. B.Hypernatremia. C.Hypoglycemia. D.Decreased blood urea nitrogen (BUN) level.
C.Hypoglycemia.
Which of the following signs and symptoms would probably indicate that the client with Addison's disease is receiving too much glucocorticoid replacement? A. Anorexia. B.Dizziness. C.Rapid weight gain. D. Poor skin turgor.
C.Rapid weight gain.
Quadriplegia
Can occur in cervical injuries involving C1-C8 All limbs are paralyzed
Insulin Glargine
Cannot be administered IV! Should not be mixed with other insulins or solutions
Thyroid Gland
Enables the body to generate energy and regulate its temperature. It produces two hormones called triiodothyronine and thyronine, also known as T3 and T4. Attached to the thyroid are four smaller glands known as the parathyroids. They regulate the level of calcium in the blood by releasing the parathyroid hormone, which combines with calcitinin, a hormone produced by the thyroid.
Adrenal Cortex
Glucocorticoids (ex: cortisol) Mineralcorticoids (ex: aldosterone) Androgens (ex: testosterone)- sex hormones
Octreotide acetate (Sandostatin)
Growth Hormone Receptor Antagonist
Sign's of Hyperglycemia- 3Ps
HOT AND DRY SUGAR HIGH = polyphagia =polydipsia =polyuria
Pre-Procedure Interventions for lumbar puncture
-obtain informed consent -have the client empty their bladder
Diet for hypothyroidism
-roughage and fluids for constipation -low-calorie, low-cholesterol, low-sat fat
Overdose of thyroid meds
-tachycardia -chest pain -restlessness, nervousness, and insomnia
The nurse is administering the initial dose of a rapid-acting insulin to a client with type 1 diabetes. The nurse should assess the client for hypoglycemia within:
1 hour
Normal Volume of CSF
125-150mL
The nurse is assessing a patient suspected of having hypoparathyroidism. Which of the following signs and symptoms should the nurse be alert for? 1) Diarrhea 2) Excessive thirst 3) Gastritis 4) Paresthesia
4) Paresthesia Occurs from alteration in nerve conduction due to hypocalcemia Other common signs and symptoms include muscle cramps and spasms, fatigue, bone pain, abdominal pain, and insomnia
The nurse is caring for a patient with diabetic ketoacidosis. As part of the treatment plan, which action should the nurse take first? 1) Administer Iv insulin 2)Administer potassium 3) Determine the cause 4) Initiate Fluid Replacement
4) initiate fluid replacement fluid replacement is priority in order to prevent vascular collapse due to severe dehydration Insulin administration is important, but hydration is the priority Administering potassium may be needed after insulin therapy is initiated, but this is not a priority at this time. Insulin transports potassium into the cell, potentially causing hypokalemia
Normal pressure of CSF
50-175mm H20
Normal blood glucose range
70-120 mg/dL
GCS Score- Coma
A GCS score of eight or less defines coma. The lowest achievable score is three which means deep coma. Fifteen is a perfect score.
Unconscious Client
A state of depressed cerebral functioning with unresponsiveness to sensory and motor function. Causes include head trauma, cerebral toxins, shock, hemorrhage, tumor, or infections.
Which of the following should the nurse include in the teaching plan of a female client with bilateral adrenalectomy? A.Emphasizing that the client will need steroid replacement for the rest of her life. B.Instructing the client about the importance of tapering steroid medication carefully to prevent crisis. C.Informing the client that steroids will be required only until her body can manufacture sufficient quantities. D.Emphasizing that the client will need to take steroids whenever her life involves physical or emotional stress.
A. Emphasizing that the client will need steroid replacement for the rest of her life.
A nurse is caring for a patient diagnosed with myasthenia gravis. When caring for this patient, which of the following interventions are appropriate?
Have suction available at all times Monitor vital signs and watch for signs of myasthenia crisis: tachycardia, hypertension, and restlessness Schedule periods of rest into the day -Hallmark symptom of MG is fluctuating muscle weakness that worsens with effort or exercise and improves with rest.. Medical management of MG depends on the administration of cholinesterase inhibitors such as pyridostigmine and corticosteroids given at specific, spaced times to avoid exacerbation -Many patients experience of the facial, masticatory, speech, and neck muscles. Often times patients will get tired while chewing food and need to rest or will have difficulty swallowing food due to the weakness. It's always necessary to have suction set up for these patients - Patients must be monitored for signs of myasthenia crisis, a life- threatening complication in which the breathing muscles become too weak. Signs are an increase in heart rate, blood pressure, respiratory rate, cyanosis, increased secretions, or urinary and bowel incontinence -Periods of rest are important for these patients are they are at risk for extreme fatigue, so care should not be clustered
Calcitonin
Hormone produced by the thyroid- Reduces blood calcium
Hyperaldosteronism (Conn's Syndrome)
Hypersecretion of mineralocorticouds (aldosterone) from the adrenal cortex of the adrenal gland Most commonly caused by an adenoma (benign tumor) -hypokalemia, hyponatremia, and hypertension -headache, fatigue, muscle weakness, nocturia -polydipsia, polyuria -paresthesias -visual changes -low urine specific gravity and increased urinary aldosterone level -elevated serum aldosterone levels
A patient is seen in the clinic for a large mass on the anterior portion of the neck. The patient complains of constipation and depression. The nurse understands these signs and symptoms to be consistent with:
Hypothyroidism- A goiter, or enlarged thyroid, can occur with both hyperthyroidism and hypothyroidism - Depression and constipation are consistent with hypothyroidism -Parathyroid masses are usually not detectable on physical examination and tend to be asymptomatic
Direct action of Increased PTH
Increased Renal Absorption of Calcium Increased Osteoclastic Bone Resorption Leads to increased serum calcium
Increased Intracranial Pressure
Increased pressure within the skull caused by trauma, hemorrhage, growths, or tumors hydrocephalus, edema, or inflammation Increased pressure can impede circulation to the brain and absorption of cerebrospinal fluid and can affect nerve cell functioning, leading to brainstem compression and death.
GCS measurements
Independently evaluates three features including Best Eye Opening, Best Motor Response, and Best Verbal Response
Adrenal Glands
Located on top of the kidneys. They produce four hormones in total, which include glucocortoids, mineralocortoids, androgen and catecholamines. Glucocorticoids help to protect against stress, while mineralocorticoids work to maintain the right level of sodium in your body. Androgen helps to maintain muscle and body density, as well as general well-being. Catecholamines stop the body from crashing in "flight or fight" situations.
Homonymous hemianopsia
Loss of half of the field of view on the same side in both eyes
Lipoatrophy
Loss of subcutaneous fat and appears as slight dimpling or more serious pitting of subcutaneous fat; the use of human insulin helps prevent this complication
Kernig's Sign
Loss of the ability of a supine client to straighten the leg completely when its fully flexed at the knee and hip; indicates meningeal irritation
Spiranolactone (Aldactone)
May be prescribed to promote fluid balance and control hypertension; this is a potassium- sparing diuretic and aldosterone antagonist, and clients need to be monitored for hyperkalemia, particularly those with impaired renal function or excessive potassium intake -administer glucocorticoids pre-op for adrenalectomy -client will need glucocorticoids for life
Flaccid posturing
No motor response display in any extremity
Respiratory Paralysis
Occurs from injuries affecting C1-C4
Neurogenic Shock
Occurs most commonly in client's with injuries above T6 and usually is experienced soon after the injury. Massive vasodilation occurs, leading to pooling of blood in the blood vessels, tissue hypoperfusion, and impaired cellular metabolism.
Posterior Pituitary Hormones
Oxytocin and Vasopressin
NPH- isophane insulin suspension
Peaks in 6-8 hours Client should eat a bedtime snack to prevent hypoglycemia while sleeping
Addison's Disease
Primary adrenocortical insufficiency Hypofunction of the adrenal cortex causes decreased secretion of the mineralocorticoids, glucocorticoids, and sex hormones It is a relatively rare disease caused by: Idiopathic atrophy of the adrenal cortex possibly due to an autoimmune process Destruction of the gland secondary to tuberculosis or fungal infection
Radiation Therapy for Hyperthyroidism
Radiation therapy (Iodine131) -Isolation for few days; body secretions are radioactive contaminated. -This is NOT recommended in pregnant women because of potential teratogenic effects. -Pregnancy should be delayed for 6months after therapy
Mineralocorticoids: Aldosterone
Regulation of electrolyte balance by promoting sodium retention and potassium excretion
What is the most common cause of hypoparathyroidism?
SURGICAL- it is usually accompanied by hypocalcemia which occurs when parathyroid hormone (PTH) secretion is insufficient to act on kidney, bone, and intestine to normalize serum calcium
GCS Eye Opening Response
Spontaneous- 4 pts Opens to verbal command- 3 pts incomprehensible speech- 2 pts no response- 1 pt
Aldosterone
Steroid hormone that helps to regulate blood pressure
Mineralcorticoids- Fludrocortisone acetate (Florinef)
Steroid hormones that enhance the reabsorption of sodium and chloride and promote the excretion of potassium and hydrogen from the renal tubules -help maintain fluid and electrolyte balance -used for replacement therapy in primary and secondary adrenal insufficiency in Addison's disease
Decerebrate (extensor) posturing
Stiff extension of one or both arms and possibly the legs; indicates a brain stem lesion
Nuchal Rigidity
Stiff neck, flexion of the neck onto the chest causes intense pain
A client has recently been diagnosed with type 2 diabetes mellitus and is to take tolbutamide. When teaching the client about the drug, the nurse explains that tolbutamide is believed to lower the blood glucose level by which of the following actions?
Stimulating insulin release from functioning beta cells in the pancreas - oral hypoglycemic agents of the sulfanylure group, such as tolbutamide lower the blood glucose level by stimulating functioning beta cells in the pancreas to release insulin -increase insulin's ability to bind to the body's cells -can increase the number of insulin receptors in the body
Subtotal thyroidectomy
Subtotal Thyroidectomy - Usually about 5/6 of the gland is removed Pre-op Care •Promote euthyroid state -Control of thyroid disturbance -Stable vital signs •Administer Iodides as ordered -To reduce the size & vascularity of thyroid gland,thereby prevent post-op hemorrhage and thyroid crisis •ECG-Heart failure / cardiac damage results from HPN /tachycardia
Signs of hypoglycemia
TACHYCARDIA IRRITABILITY RESTLESSNESS EXCESSIVE HUNGER DIAPHORESIS: COLD AND CLAMMY- NEED SOME CANDY
Parathyroid Glands
They regulate the level of calcium in the blood by releasing the parathyroid hormone, which combines with calcitonin, a hormone produced by the thyroid (reduces blood calcium)
Liotrix (Thyrolar)
Thryoid Hormone
Levothyroxine sodium (Synthroid, Levothroid, Levoxyl)
Thyroid Hormone
Liothyronine Sodium (Cytomel, Triostat)
Thyroid Hormone
Thyroid (Armour Thyroid, Nature- Thyroid, Thyroid USP, Westhroid)
Thyroid Hormone
Treatment of hypothyroidism
Thyroid hormone replacement: Synthetic levothyroxine (Synthyroid) Supportive therapy: Avoid application of external heat(heating pads) Corticosteroid therapy (for associated adrenocorticosteroid insufficiency
The nurse is assessing a patient with Cushing's syndrome for complications associated with hypercortisolism including
bacterial or fungal infections diabetes hypertension obesity Cushing's syndrome occurs when there is an excess of cortisol due to either overproduction of ACTH by the pituitary glands or from the adrenal glands releasing too much cortisol Common complications of Cushing's syndrome includes hypertension (remember, cortisol is a stress hormone) obesity, diabetes and infections.
Propanolol
beta 2 andrenergic blocking agent that decreases the rapid heart rate caused by excessive thyroid stimulation
Cluster breathing- Biot's respiration
characterized by groups of quick, shallow breaths followed by periods of apnea. This is usually seen in patients with medulla damage and indicates a poor prognosis.
Chvostek's sign
contraction of the facial muscles elicited by tapping the facial nerve just anterior to the ear- causes facial twitching or spasm if hypocalcemia is present
T4
elevated in hyperthyroidism normal: 5-12 mcg/ dl
T3
elevated in hyperthyroidism normal: 80-230 ng/ dl
Hypothyroidism (Signs and Symptoms)
extreme fatigue•hair loss, brittle nails•dry skin•numbness, tingling sensation of the fingers•husky voice, hoarseness•amenorrhea•hypothermia
Bethamethasone (Celestone)
glucocorticoid
Cortisone acetate
glucocorticoid
Dexamethosone
glucocorticoid
Hydrocortisone
glucocorticoid
Methylprednisolone (Medrol)
glucocorticoid
Prednisolone (Millipred, Prelone)
glucocorticoid
Prednisone
glucocorticoid
Triamcinolone (Kenalog, Nasacort AQ)
glucocorticoid
Encephalitis
headache, fever, vomiting, and meningeal signs due to the inflammation of the brain caused by a virus
What drug is used to correct acute adrenal insufficiency?
hydrocortisone sodium succinate is used to replace the cortisol deficiency Rapid fluid replacement is indicated due to hypovolemia
Metabolic Syndrome (syndrome x)
individual has coexisting risk factors for developing type 2 diabetes mellitus; these risk factors include abdominal obesity, hyperglycemia, hypertension, high triglyceride level, and a lowered HDL (high density lipoprotein) cholesterol level
Lumbar Puncture
insertion of a needle into the spine- L3-L4 interspace into the lumbar subarachnoid space to obtain cereberospinal fluid; measure CSF fluid or pressure, or instill air, dye, or medications - CONTRAINDICATED in clients with increased ICP because the procedure will cause a rapid decrease in pressure in the CSF around the spinal cord, leading to brain herniation
Nasal sprays of calcitonin (Miacalcin)
instruct the client to use alternate nares
Early symptoms of hyperglycemia
polyphagia, polydipsia, polyuria, fatigue, and blurred vision
Pituitary Diabetes Insipidus
potential complication after pituitary surgery because of possible interference with production of ADH
Secondary Hyperparathyroidism
response to hypocalcemia
Late symptoms of hypoglycemia
seizures, loss of consciousness, or even death
Diagnostic Results for Addison's Disease
•Low cortisol levels •Hyponatremia •Hyperkalemia •Hypoglycemia
Dexamethasone
- can reduce of prevent cerebral edema -steroid
Goal HbA1c for diabetics
less than 7%
Primary Hyperparathyroidism
over-secretion due to a parathyroid tumor
ACTH stimulation test
standard test for addison's disease - it measures the cortisol response to ACTH - response is absent or very decreased who have primary adrenal insufficiency
Chronic hypoparathyroidism
- dry skin -brittle nails and hair - Parkinsonian syndrome -tooth enamel hypoplasia are all signs of chronic hypoparathyroidism
Adrenal Cortex Disorders
- Addison's Disease -Primary hyperaldosteronism (Conn's Syndrome) -Cushing's Disease -Cushing's Syndrome
Which of the following would the nurse associate with increased ICP?
- Altered respiration - Change in level of consciousness - Decorticate or decerebrate posturing -Increased blood pressure
A surgical floor nurse is caring for a post-op client who has undergone a total thyroidectomy? Which of the following are important nursing measures during post- op care?
- Assess the surgical site and the are under the client's neck and shoulders for drainage -Check for Trousseau's sign -Monitor the client for Chvostek's sign Assess for signs of latenty dye to calcium deficiency, including tingling of toes, fingers, lips, muscular twitches, positive Chvosteks's and Trousseau's signs; and decreased serum calcium levels. Trousseau's sign allows for more immediate reporting of positive responses -Danger of hemorrhage is greatest in the first 12-24 hours after surgery
Mineralocorticoids (interventions)
-monitor vitals -intake/output, weight, and for edema -monitor electrolyte and calcium levels -instruct client to take meds with food or milk -instruct client to consume a high-potassium diet -instruct client to report illness, such as severe diarrhea, vomiting, and fever -notify HCP if low blood pressure, weakness, cramping, palpitations, or changes in mental status occur -instruct the client to wear a medic-alert bracelet - do not stop taking meds abruptly- could result in adrenal insufficiency
Acute hypoparathyroidism
-numbness around the mouth, tingling in the hands and feet, and a positive Trousseau's sign are all indicative or acute hypoparathyroidism
Adverse effects of long term corticosteroid therapy
-osteoporosis is a long term effect due to the suppression of bone formation and the acceleration of bone resorption that corticosteroid therapy can cause -moon-shaped face, buffalo hump, potbelly -increased risk of infection b/c it causes a decreased number of circulating lymphocytes -weight gain -cloudy/ blurred vision
Diabetes Insipidus
-polyuria results from lack of ADH-results in insufficient water reabsorption by the kidneys -dehydration -involves excretion of large amounts of fluid -maintaining normal fluid and electrolyte balance is priority for this unit
Late symptoms of hyperglycemia
-pruritus, dry mouth, confusion, fruity odor of the breath, abdominal pain, or coma
Thyroid hormone replacement
-to promote proper absorption, the client should take the medication on an empty stomach and not eat or drink anything for 30-60 minutes after taking it -aluminum-containing antacids and calcium supplements can reduce the effectiveness of thyroid replacement therapy -the client should drink 2-3L of fluid daily
The nurse is educating a patient with hyperparathyroidism about diet modifications. Which of the following should the nurse emphasize? 1) Force fluids 2) Increase calcium intake 3) Restrict fluids 4) Restrict potassium intake
1) Force fluids - patients with hyperparathyroidism have increased serum calcium levels and are at risk for developing renal calculi -increasing fluid intake will prevent renal calculi formation
The nurse has administered several rapid fluid infusions to treat diabetes insipidus. The nurse assesses the patient for water intoxication- expecting to note 1) confusion 2)increased BUN 3)muscle tetany 4)sunken eyeballs
1) confusion The most common signs of water intox. are confusion and seizures due to cerebral edema Sunken eyeballs and increased BUN indicate dehydration
A patient with hyperaldosteronism asks the nurse about the cause of his disease. The nurse understands the most common cause of hyperaldosteronism is: 1) adrenal carcinoma 2) adrenal adenoma 3) juxtaglomerular cell tumor 4) renal artery stenosis
2) Adrenal adenoma the most common cause- followed by adrenal hyperplasia Benign tumor of the adrenal gland
The nurse is caring for a patient with Cushing's syndrome. The nurse should instruct the patient to 1) avoid weight bearing exercise 2) check for black or tarry stools 3) eat foods low in potassium 4) increase cholesterol intake
2) check for black or tarry stools Patient's with Cushing's syndrome are at risk for peptic ulcers due to increased gastric acid secretion, immunosuppresion, and poor wound healing. The patient should understand the signs of GI bleeding Hypercholesterolemia is a result of Cushing's Syndrome so the patient should be encouraged to decrease Cholesterol intake Potassium intake should be encouraged to prevent hypokalemia associated with Cushing's Weight bearing exercise should be encouraged to reduce the risk of osteoporosis, a common complication of Cushing's syndrome
A patient recently diagnosed with hyperthyroidism is receiving instructions from the nurse. The nurse should encourage the patient to 1)avoid stimulants and sedatives 2)eat a high-calorie diet and get adequate sleep 3) eat a low- calorie diet and avoid stimulants such as caffeine 4) never abruptly discontinue medication and eat a low- calorie diet
2) eat a high calorie diet and get adequate sleep Patients with hyperthyroidism suffer from an increased metabolic rate. A high- calorie diet and adequate sleep is recommended. Abruptly stopping medication can result in a thyroid storm Stimulants should be avoided due to the effects of hyperthyroidism (for instance, insomnia). Sedatives are not contraindicated.
A hospitalized patient is diagnosed with a pheochromocytoma, a tumor of the adrenal medulla. Which clinical manifestation should the nurse expect to observe? 1) elevated hemoglobin and hematocrit 2)hypertension 3)hypoglycemia 4)weight gain
2) hypertension a pheochromocytoma is a tumor of the adrenal medulla. It results in the hypersecretion of catecholamines, such as norepinephrine Signs and symptoms are related to the effects of increased catecholamines: tachycardia, hypertension, palpitations, headaches, weight loss, and hyperglycemia
Secondary Adrenal Insufficiency
ACTH is deficient- Adrenocorticopic Hormone not enough cortisol will be produced, although aldosterone may remain adequate
Antihypercalcemic agents
Avoid foods rich in calcium such as green, leafy vegetables; dairy products; shell-fish and soy
Cushing's disease is manifested by the excessive secretion of corticosteroids. The hormones involved are A. Glucocorticoids and aldosterone. B. Adrenocorticotropic hormone (ACTH). C. Glucocorticoids, aldosterone, and androgens. D. catecholamines
C. Glucocorticoids, aldosterone, and androgens.
Cholinergic Crisis
Cholinergic crisis: an acute exacerbation of muscle weakness caused by over-medication with cholinergic anticholinesterase drugs -Muscle twitching to the point of respiratory compromise -Priority to maintain respiratory function -Symptoms improve with anticholinergic medications (atropine) Cholinergic Emergency Crisis •Anticholinergic drugs are withheld while the client is maintained on a ventilator. -Atropine may be given and repeated, if necessary. Dries you up. •Observe for thickened secretions due to the drugs. •Improvement is usually rapid after appropriate drugs have been given. -can't cough
Cushing's Syndrome Diagnostic Tests
Cortisol levels increased •Slight hypernatremia •Hypokalemia •Hyperglycemia
Mecasermin (Increlex)
Growth Hormone
Somatotropin (Humatrope, Omnitrope)
Growth Hormone
Pegvisomant (Somavert)
Growth Hormone Receptor Antagonist
Indirect action of Increased PTH
Increased 1, 2 (OH)2 Vitamin D (CALCITROL) Increased GI absorption of calcium Leads to increased serum calcium
Pancreas
Involved in the endocrine system, even though it isn't a gland. It produces two important hormones known as insulin and glucagon, which control the level of glucose in the blood. When the pancreas fails to secrete these hormones it can lead to diabetes.
Rapid acting insulin
Onset in 15 minutes Peaks at 1 hour Lasts for 3 to 4 hours Rapid-acting insulin is administered right before or right after a meal
GCS Verbal Response
Oriented- 5 pts Confused conversation but able to answer questions- 4 pts Inappropriate responses- 3 points Incomprehensible speech- 2 pts No response- 1 pt
HYPOTHYROIDISM (MYXEDEMA )
Results from suboptimal levels of thyroid hormone•Commonly caused by auto immune thyroiditis (Hashimoto's disease) in adults.•Commonly occur in patient with previous hyperthyroidism who have been treated with radio iodine or anti thyroid medications or who had surgery.•Known as CRETINISM when is present at birth. Hashimoto's disease is a condition in which your immune system attacks your thyroid, a small gland at the base of your neck below your Adam's apple. The thyroid gland is part of your endocrine system, which produces hormones that coordinate many of your body's activities. The resulting inflammation from Hashimoto's disease, also known as chronic lymphocytic thyroiditis, often leads to an underactive thyroid gland (hypothyroidism). Hashimoto's disease is the most common cause of hypothyroidism in the United States.
Anterior Pituitary Hormones
TSH ACTH, LH FSH GH and prolactin
Edrophonium test
Test used to diagnose myasthenia gravis and to differentiate between myasthenic crisis and cholinergic crisis; may also be called the Tensilon test Edrophonium is a readily reversible acetylcholinesterase inhibitor. It prevents breakdown of the neurotransmitter acetylcholine and acts by competitively inhibiting the enzyme acetylcholinesterase, mainly at the neuromuscular junction.
Pineal Body
The pineal body is located in the center of the brain, and it secretes Melatonin which controls the body's sleeping cycles
Posterior lobe of pituitary gland
The posterior lobe produces oxytocin, which is responsible for uterine contractions and lactation, and vasopressin which promotes water reabsorption and increasing blood volume.
Five Quick Facts about the endocrine system
There are 30 different hormones in the body, each with their own function. The endocrine system has no ducts at all. It relies on the bloodstream to transfer all of the hormones it produces to different parts of the body. The exocrine glands are different from the endocrine glands, because they excrete hormones by way of a duct to the external environment. Examples of exocrine glands include sweat glands, salivary glands and mammary glands. Failures in the endocrine system can lead to variety of diseases related to reproduction, development and hormone maintenance. For example, if it produces too much growth hormone this can lead to diseases such as gigantism. Too little growth hormone can lead to growth hormone deficiency - where children grow more slowly than others. Diabetes, osteoporosis and polycystic ovary syndrome are some other examples of endocrine-related conditions. The endocrine and the nervous system work together to regulate bodily functions. The nervous system stimulates the hypothalmus, which in turn triggers the pituitary gland to release hormones.
Glands of the endocrine system
There are eight major glands that help in the functioning of the endocrine system. These are the pituitary gland, hypothalmus, thyroid, parathyroid, adrenals, pineal body and the reproductive glands (testes and ovaries)
Calcium Regulators such as alendronate sodium (Fosamax)
instruct the client to swallow the tablet whole with water at least 30 minutes before breakfast and not to lie down for at least 30 minutes
Cushing's Syndrome- What does the patient look like?
- buffalo hump -emotional disturbance -moon face -cardiac hypertrophy (hypertension) -obesity -adrenal tumor or hyperplasia -thin, wrinkled skin -abdominal striae -loss of menstrual cycle -muscle weakness -purpura -skin ulcers (poor wound healing)
Meds for thyroid storm
-iodides -propanolol -glucocorticoids -administer non-salicylate anti-pyretics (salicylates increase free thyroid hormone levels)
Diabetes 1 and alcohol consumption
- client should substitute two fat exchanges for every beverage containing alcohol -alcohol prevents liver production of glucose -consuming carbs while drinking alcoholic beverages helps prevent hypoglycemia -consuming alcohol increases triglyceride levels -client might need to decrease insulin dosage due to hypoglycemic effect of alcohol
The nurse is assessing a patient with hypoparathyroidism for electrolyte imbalances. The nurse notes a positive Chvostek's sign, indicating
- Positive Chvostek's sign occurs when the nurse taps the facial nerve at the angle of the jaw, resulting in the facial muscles contracting and twitching. This is caused by low serum calcium. -Hypoprathyroidism is caused by trauma, removal, or autoimmune destruction of the parathyroid gland -Hypoparathyroidism results in hypocalcemia due to increased urinary excretion and decreased absorption in the bowel. Hyperphosphatemia is also a result.
Expected findings of Cushing's disease
- elevated blood pressure -weight gain -increased hair growth/ hirsutism- expected finding due to increased androgen production -thinning of the skin
Frontal Craniotomy- Post Op
- administer oxygen at 2 liters oer minute - oxygen is needed to prevent hypoxia that could lead to cerebral edema - orders to administer dexamethasone would be expected because it can prevent or eliminate cerebral edema raising the head of the bed to 30 degrees reduces cerebral edema -patient fluid intake is restricted to 1-2l per day ( convert to ml/ hr)
Post pocedure interventions for CT scan
- assess for allergic reactions from the dye - rehydrate client due to suspected diuresis from the dye -assess dye injection site for bleeding or hematoma, and monitor the extremity for color, warmth, and the presence of distal pulses
Pathophysiology of Addison's Disease
- Atrophy of Adrenal Gland -Adrenocortical -Decrease steroid hormone--> hypoglycemia, hyponatremia, hyperkalemia, and cannot adapt to stress
A nurse is caring for a client with gastroenteritis and is documenting the clinical manifestations indicating dehydration. What would indicate the patient is dehydrated?
- Dry axilla, tongue, and oral mucosa -Flat jugular veins -Orthostatic hypotension -Rapid Weight Loss Each day, approximately 3-6 liters of fluid are secreted by the stomach, pancreas, gallbladder, and intestines into the lumen of the GI tract, with almost all being reabsorbed or if secretion exceeds the capacity for reabsorption due to either increased secretion or reduced reabsorption (ex: diarrhea) - Dehydrated patients often have a dry tongue and oral mucosa, and a dry axilla has been shown to be particularly indicative of the diagnosis -Orthostatic hypotension is one of the most sensitive indicators of decreased fluid volume -Flat jugular veins (venous pressure less than or equal to 5cm H20) in a supine position is noted in clients with dehydration -Rapid weight loss is an early and common result of fluid loss, because water is a major portion of body weight -Crackles can be heard on auscultation over the lungs when there is fluid overload. This is not associated with dehydration.
The nurse is providing discharge instructions to a patient with Addison's disease. Which of the following patient statements is correct?
- I need to wear a medic- alert bracelet -I will avoid strenuous exercise -I will call the physician before all dental procedures -I will call the physician if I feel severely week or fatigued Addison's disease involves insufficient production of Cortisol (primarily) as well as aldosterone - A medic alert bracelet provides HCPs with info if patient cant communicate -Adrenocortical insufficiency causes severe weakness and fatigue Flu - like symptoms should be reported because infections can cause additional stress and an increased steroid dosage may be needed STEROID THERAPY IS LIFE LONG avoid strenuous exercise because it will deplete the body of cortisol Dental procedures may require an increase in steroid therapy
Signs of Hyperkalemia
- MUSCLE WEAKNESS -URINE, OLIGURIA, OR ANURIA -RESPIRATORY DISTRESS -DECREASED CARDIAC CONTRACTILITY -EKG CHANGES (PEAKED T WAVES OR SMALL P WAVES_ -REFLEXES, HYPER OR HYPO
Pheochromocytoma- Interventions
- Montior vital signs, particularly BP and HR -Monitor for hypertensive crisis; monitor for complications that can occur with hypertensive crisis . such as stroke, cardiac dysrhythmias myocardial infarction -instruct the client not to smoke, drink caffeine. or change positions suddenly -prepare to administer B- adrenergic blocking agent "-olol" / ace inhibitors -monitor serum glucose levels -avoid abdominal palpitation
Assessment findings for a patient with a brain tumor
- headache that becomes worse in the morning, including straining and stooping, vomiting papilledema, seizures, changes in mental status and altered vision
Which insulins can be administered intravenously?
- lispro -aspart -glulisine -regular insulin Only short duaration inuslin
Meds for hyperthyroidism
-PTU -Iodine preps- INHIBIT release of thyroid hormone Radioactive iodine therapy destroys thyroid cells
Interventions during Lumbar Puncture
-Position the client in lateral recumbent position and have the client draw the knees up to the abdomen and the chin onto the chest; the prone position may be required for radiologically guided punctures -Assist with the collection of specimens (label the specimens in sequence) -Maintain strict asepsis
DIabetes Insipidus Findings
-Tachycardia -Increased hematocrit level -Increased urine output leads to dilute urine and a low specific gravity -Increase in BUN levels is an expected finding related to dehydration
Thyroid Scan
-Used to identify nodules or growths in the thyroid -tell patient they are not a harm to others -if iodine is used, have patient maintain NPO status after midnight on the day before the test and then for 45 minutes after the ingestion of the oral isotope- then the scan will be performed in 24 hours - if technetium is used, it will be administered IV 30 minutes before the scan -check with HCP regarding discontinuation of meds containing iodine for 14 days before the test -test is contraindicated in pregnancy
Causes of SIADH
-adrenal insufficiency -hypothyroidism -infections including meningitis -tuberculosis
Grave's Disease (Hyperthyroidism) - Signs and Symptoms
-irritability and apprehension •palpitation •poor heat tolerance (heat intolerance) •flushed skin (salmon color), warm, soft and moistskin•dry skin & diffuse pruritus ( in elderly ) •increase appetite •muscular fatigue & weakness •increase systolic BP, sinus tachycardia,dysrrhythmias •exopthalmos Accumulation of fluids, mucopolysaccharides at the fat-pads behind the eyeballs, pushing the eyeballs forward
Expected findings in clients with hypothyroidism
-likely to cause weight gain - likely to cause constipation -commonly causes bradycardia -hypotension
Cervical injuries between C5-C8
-likely to produce paralysis, weakness, or spasticity of the muscles used to perform respiration. Though neural control remains, in patients with quadriplegia, respiratory function is compromised, and edema above the area of the lesion may still cause respiratory depression or arrest in the first few days following the injury
Desmopressin nasal spray
-medication is absorbed through the nasal mucosa -the client should hold his breath while spraying the medication -by blowing nose gently prior to the use of the spray, the client avoids dilution of the medication by nasal secretions or improper absorption of the meds due to nasal blockage -client should sit upright when administering the spray -client should instill the meds every 8-24 hours -obtain weight weekly -fluid intake should be limited to no more than 3L per day
A client has moderate to sever hypotonic extracellular fluid loss. Whcih IV fluids can be administered to correct the fluid balance?
10% dextrose in water 5% dextrose and .45% normal saline 5% dextrose in 0.9% saline All are considered hypertonic solutions, raising the osmolality if ECF Hypotonic dehydration refers to depletion of fluids and electrolytes with greater losses of electrolytes, resulting in hypotonic extracellular fluid 1
Gonadotropin Releasing Hormone Hypothalamus
Gonadotropin-releasing hormone (GnRH), also known as follicle-stimulating hormone-releasing hormone (FSH-RH), luteinizing hormone-releasing hormone (LHRH), gonadoliberin releasing hormone responsible for the release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the anterior pituitary. GnRH is a tropic peptide hormone synthesized and released from GnRH neurons within the hypothalamus.
The client with Cushing's disease needs to modify dietary intake to control symptoms. In addition to increasing protein, which strategy would be most appropriate? A. Increase calories. B. Restrict sodium. C. Restrict potassium. D. Reduce fat to 10%
B. Restrict sodium.
Dexamethasone (steroid-antiinflammatory) suppression test on a patient with Cushing's syndrome
Administer the dexamethosone at night and measure serum cortisol the following morning -administered at around 23:00 and then serum levels are measured the following morning -measures the negative feedback mechanism between Cortisol and adrenocorticopic hormone -Normally an increase in cortisol will cause a decrease in ACTH secretion - Helps differentiate among the different types of Cushing's syndromes
Mannitol for ICP
Administering mannitol, an osmotic diuretic, will decrease the cerebral edema in the brain, and therefore decrease ICP - Mannitol makes the blood serum hypertonic, which pulls fluid from the intracellular (and intracranial) space to balance it out. The osmotic pressure of the glomerular filtrate inhibits reabsorption of water and electrolytes, so the patient eliminate excess fluid through urination. The therapeutic effect is decreased cerebral edema and decreased intracranial pressure.
The client who has undergone a bilateral adrenalectomy is ready to return home. She tells the nurse that she is concerned about persistent body changes and the fact that her moods are still so unpredictable. She says, "I thought surgery was supposed to fix all that." The nurse should base her teaching about recovery on which of the following concepts? A. The body changes are permanent and she will not be the same as before this condition. B. The body and mood will gradually return to normal. C. The physical changes are permanent, but the mood swings will disappear. D. The physical changes are temporary, but the mood swings are permanent.
B. The body and mood will gradually return to normal.
Signs and symptoms of Cushing's disease include A. Weight loss. B. Thin, fragile skin. C. Hypotension. D. Abdominal pain.
B. Thin, fragile skin.
Somatostatin Hypothalamus
Blocks the release of GHRH; Growth hormone Inhibiting Hormone
Which disease is caused by abnormally increased secretion (endogenous) of cortisol, caused by increased amounts of ACTH secreted by the pituitary gland?
Cushing's DISEASE
A client with Graves' disease is treated with radioactive iodine (RAI) in the form of sodium iodide. Which of the following statements by the nurse will explain to the client how the drug works? A."The radioactive iodine stabilizes the thyroid hormone levels before a thyroidectomy." B. "The radioactive iodine reduces uptake of thyroxine and thereby improves your condition." C."The radioactive iodine lowers the levels of thyroid hormones by slowing your body's production of them." D. "The radioactive iodine destroys thyroid tissue so that thyroid hormones are no longer produced."
D. "The radioactive iodine destroys thyroid tissue so that thyroid hormones are no longer produced."
When caring for a patient with syndrome of inappropriate antidiuretic hormone (SIADH), the nurse anticipates which electrolyte abnormality characteristic of the disease?
Hyponatremia - SIADH is the inappropriate secretion of antidiuretic hormone (ADH) despite normal or increased plasma volume that results in hyponatremia and hypoosmolality. These actions result in impaired water excretion. - The decrease in sodium is due to hemodilution, not due to a sodium deficiency. -Potassium and calcium concentrations generally remain within normal limits
Meds for hyperparathyroidism
Lasix (Furosemide)- lowers calcium levels Phosphates- interfere with calcium reabsorption (as prescribed) Calcitonin (Fortical; Miacalcin)- decrease skeletal calcium release and increase renal excretion of calcium
GCS Motor Responses
Obeys commands for movement- 6 pts Purposeful movement to painful stimulus- 5 pts Withdraws from pain- 4 pts abnormal/ spastic flexion or decorticate posture- 3 pts extensor(rigid) response or decerebrate posture- 2 pts no response- 1 pt
Anterior lobe of pituitary gland
The anterior lobe regulates the activity of the thyroid, adrenals and the reproductive glands.
Pituitary Gland
The pituitary gland is integral to the whole system. Situated in the base of the brain, it produces and secretes hormones according to the internal and external changes that affect the body. The hypothalamus, which is another brain based gland, notifies the pituitary gland of these changes. The pituitary gland consists of two parts, the anterior and the posterior lobes. The anterior lobe regulates the activity of the thyroid, adrenals and the reproductive glands. The posterior lobe produces oxytocin, which is responsible for uterine contractions and lactation, and vasopressin which promotes water reabsorption and increasing blood volume.
Reproductive Glands
The reproductive glands help to develop sexual characteristics at puberty, and they also facilitate reproductive functions such as the menstrual cycle. For men, their reproductive glands are situated in the testes, and they produce a hormone called testosterone. For women, their reproductive glands are based in the ovaries, and they produce oestrogen and progesterone.
Cushing's Syndrome
This is a condition resulting from excessive secretion of corticosteroids, particularly the glucocorticoid cortisol .•It occurs most frequently in females between ages 30—60. •Primary Cushing's syndrome caused by adrenocortical tumors or hyperplasia. •Secondary Cushing's syndrome (also called Cushing's disease): caused by functioning pituitary or non-pituitary neoplasm secreting ACTH, causing increased secretion of glucocorticoids. •The latrogenic: caused by prolonged use of corticosteroids
GHRH- Growth Hormone Releasing Hormone Hypothalamus
a large peptide hormone that exists in several forms that differ from one another only in the number of amino acids, which can vary from 37 to 44. Unlike other neurohormones (substances produced by specialized cells typical of the nervous system), GHRH is not widely distributed throughout the brain and is found only in the hypothalamus. The secretion of GHRH increases in response to physical and emotional stress, and its secretion is blocked by a powerful hypothalamic neurohormone called somatostatin. The secretion of GHRH is also inhibited by insulin-like growth factors, which are generated when tissues are exposed to growth hormone itself.
Myasthenic Crisis
an exacerbation of the myasthenic symptoms caused by under-medication with anticholinesterases Priority for nursing management is to maintain adequate respiratory function. Cholinesterase inhibiting drugs are ineffective during crisis and cause increase in secretions Myasthenic Emergency Crisis:* you have to hold the meds (increase secretions)* Need to remove the secretions* Maintain respiratory function. Tensilon test is performed. (will help improve muscle tone) Cholinesterase-inhibiting drugs are withheld because they increase respiratory secretions and are usually ineffective for the first few days after the crisis begins
Papilledema
is optic disc swelling that is caused by increased intracranial pressure. The swelling is usually bilateral and can occur over a period of hours to weeks.
DKA blood gas values
pH is low Carbon Dioxide is within the expected reference range and bicarbonate is low
Nursing Interventions for Addison's Disease
•Administer hormone replacement therapy as ordered. -Glucocorticoids (cortisone,hydrocortisone): to simulate diurnal rhythm of cortisol release -Mineralocorticoids: fludrocortisone acetate •Monitor vital signs. •Decrease stress in the environment. •Provide rest periods; prevent fatigue. •Monitor intake and output •Weigh daily. •Provide small, frequent feedings of diet high in carbohydrates, sodium,and protein to prevent hypoglycemia and hyponatremia and provide proper nutrition•Prevent exposure to infection Provide client teaching and discharge planning concerning Disease process; signs of adrenal insufficiency Use of prescribed medications for lifelong replacement therapy; never omit medications Need to avoid stress, trauma, and infections, and to notify physician if these occur as medication dosage may need to be adjusted Provide client teaching and discharge planning concerning Stress management techniques Diet modification (high in protein,carbohydrates, and sodium) Use of salt tablets (if prescribed) or ingestion of salty foods (potato chips) if experiencing increased sweating Importance of alternating regular exercise with rest periods Avoidance of strenuous exercise especially in hot weather
The client with Addison's disease should anticipate the need for increased glucocorticoid supplementation in which of the following situations? A. Returning to work after a weekend. B. Going on vacation. C. Having oral surgery. D. Having a routine medical checkup
C. Having oral surgery.
Primary Adrenal Insufficiency
Results from loss of both cortisol and aldosterone secretion due to: -Near total or total destruction of both adrenal glands
Which statement should the nurse make when teaching the client about taking oralglucocorticoids? A."Take your medication with a full glass of water." B."Take your medication on an empty stomach." C."Take your medication at bedtime to increaseabsorption." D."Take your medication with meals or with anantacid,"
D."Take your medication with meals or with anantacid,"
Hypervolemia
- fluid overload increases the volume of blood plasma due to an increase in total body sodium content with an increase in body weight - can manifest as an increased right atrial pressure or central venous pressure as consequence to a delayed emptying and filling of the right ventricle - excessive fluid in the lungs leads to coughing, dyspnea, and crackles that can be auscultated over the lung area -edema is palpable swelling produced by expansion of the interstitial fluid volume and can be generalized or localized
rebound fluid retention syndrome
- plasma volume drops too low, triggering the renin cascade
A client is prescribed exanetide (Byetta). The nurse should instruct the client to:
- review the one time set-up for each new pen - Inject in the thigh, abdomen, or upper arm -administer the drug within 60 minutes before morning and evening meals - client should NOT inject the drug after a meal -if a dose is missed, the client should resume treatment as prescribed with the next scheduled dose
CT scan- Computed Tomography
- type of brain scanning that may or may not require injection of a dye - used to detect intracranial bleeding, space-occupying lesions, cerebral edema, infarctions, hydrocephalus, cerebral atrophy, and shifts of brain structures
The nurse monitors the hypothalamic function of a patient with a head injury. Which assessment parameters should the nurse include in monitoring?
- urinary output and temperature - a patient with a head injury may have increased intracranial pressure (ICP) that causes hypothalamic dysfunction. This may lead to hypo/hyperthermia, SIADH, and diabetes insipidus - to monitor hypothalamic function, it is important to assess urinary output and temperature. The hypothalamus regulates body temperature, osmolality of body fluids, hunger, and satiety
Pharmacotherapy for hyperthyroidism
-Beta - blockers : Propranolol -These drugs are given to control tachycardia and HPN -Iodides : Lugol's solution SSKI (Saturated Solution of Potassium Iodide) -Are given to inhibit release of thyroid hormone -Mix with fruit juice with ice or glass of water to improve its palatability -Provide drinking straw to prevent permanent staining of teeth Side effects -Allergic reaction, Increased salivation, colds Thioamides- PTU and Methimazole PTU (Propylthiouracil) & Tapazole(Methimazole) -These are given to inhibit synthesis of thyroid hormones •Side effects of PTU AGRANULOCYTOSIS / NEUTROPENIA •This is manifested by unexplained Fever, Sorethroat, Skin rashes•The nurse must elicit these symptoms and if present, the physician must be alerted. Ca - channel blockers •For fever, Paracetamol is given. Aspirin must be avoided because it can displace the T3/T4 from the albumin in the plasma causing increased manifestations. Dexamethasone -Inhibit the action of thyroid hormones. -Steroids are given to prevent the conversion of T4 to T3 in the peripheral tissues
Diabetics and physical assessment
-Diabetic retinopathy, cataracts, and glaucoma are common complications in diabetics -eyes need to be assessed and examined -feet should be examined at each client encounter, monitoring for thickening, fissures, or breaks in the skin, ulcers, and thickened nails
Pheochromocytoma- Assessment
-HYPERGLYCEMIA -PAROXYSMAL OR SUSTAINED HTN -SEVERE HEADACHES -PALPITATIONS -FLUSHING AND PROFUSE DIAPHORESIS -PAIN IN THE CHEST OR ABDOMEN WITH NAUSEA AND VOMITING -HEAT INTOLERANCE -WEIGHT LOSS -TREMORS -HYPERGLYCEMIA
A client has an adrenal tumor and is scheduled for a bilateral adrenalectomy. During perioperative teaching, the nurse teaches the client how to do deep breathing exercises after surgery by telling the client to:
-Hold your abdomen firmly with a pillow and take several deep breaths -effective splinting for a high-incision reduces stress on the incision line, decreases pain, and increases the client's ability to deep- breathe effectively -Deep breathing should be done hourly by the client after surgery
What is the patient with Cushing's syndrome at risk for?
-Infection due to immonsupression caused by excessive glucocorticoid levels -Risk of hypertension, fluid volume excess, and urinary retention are elevated in patients with Cushing's syndrome
Expected lab findings in clients with Cushing's Disease
-Lymphocyte count- below the expected reference range -Serum potassium is below the expected reference range -Serum calcium below the expected reference range -blood glucose level is elevated
Assessment Findings- Addison's Disease
Fatigue, muscle weakness •Anorexia, nausea, vomiting, abdominal pain, weight loss •History of frequent hypoglycemic reactions •Hypotension, weak pulse •Bronze-like pigmentation of the skin •Decreased capacity to deal with stress
Nursing Interventions for Cushing's Syndrome
-Maintain muscle tone. -Provide ROM exercises. -Assist with ambulation. -Prevent accidents or falls and provide adequate rest -Protect client from exposure to infection -Maintain skin integrity - Provide meticulous skin care -Prevent tearing of skin: use paper tape if necessary -Minimize stress in the environment. -Monitor vital signs; observe for hypertension,edema. -Measure intake and output and daily weights. -Provide diet low in calories and sodium and high in protein, potassium, calcium, and vitamin supplements. -Monitor urine for glucose and acetone;administer insulin if ordered. -Provide psychological support and acceptance Prepare client for hypophysectomy or radiation if condition is caused by a pituitary tumor. -Prepare client for an adrenalectomy if condition is caused by an adrenal tumor or hyperplasia. -Provide client teaching and discharge planning concerning: -Diet modifications -Importance of adequate rest -Need to avoid stress and infection -Change in medication regimen (alternate day therapy or reduced dosage) if cause of the condition is prolonged corticosteroid therapy
Post-Procedure lumbar puncture
-Monitor vital signs and neurological signs to check for the presence of leakage of CSF and also monitor for headache -position he client flat as prescribed -encourage fluids to replace CSF obtained from the specimen collection of from leakage -monitor intake and output
A client is admitted to the ICU in DKA- which interventions are used to manage the acidosis?
-add potassium to replacement fluid therapy -administer insulin IV -administer sodium bicarbonate -start IV infusion of normal saline
Glucocorticoids
-affect glucose, protein, and bone metabolism; alter the normal immune response and suppress inflammation; produce antiinflammatory, antiallergic, and antistress effects -may be used as a replacement in adrenocortical insufficiency
Late signs of ICP
-alteration in pupil size and reactivity -decorticate or decerebrate posturing -Cushing's triad: widening pulse pressure, bradycardia, and a change in respirations
Client Education: Addison's Disease
-avoid individuals with infection -Diet: high protein and high carb + normal sodium intake -avoid strenuous exercise and stressfull situations -need for lifelong glucocorticoid therapy -avoid OTC meds -wear a medic-alert bracelet - S/S of complications such as underreplacement and overreplacement of hormones
Cerebral angiogram teaching
-bed rest must be maintained after the procedure for at least 4-6 hours - contrast medium will be injected during the procedure -the leg must be kept straight and immobilized for 4-6 hours after the procedure - the patient must be NPO 6-8 hours prior to the procedure
vanillymandelic acid test
-client does NOT have to fast before test -client should discard the first morning urine, and then collect all urine after that for 24 hours -the client should avoid aspirin because it can affect test results -client should avoid coffee and tea (even if decaffeinated), bananas, chocolate, and vanilla for 2-3 days prior to the test
glycosylated hemoglobin HbA1c testing
-client does not need to fast before blood sampling -HbA1c reflects the clients glucose levels over a 120- day period, which is the life span of RBCs -The term HbA1c refers to glycated haemoglobin. It develops when haemoglobin, a protein within red blood cells that carries oxygen throughout your body, joins with glucose in the blood, becoming 'glycated'. By measuring glycated haemoglobin (HbA1c), clinicians are able to get an overall picture of what our average blood sugar levels have been over a period of weeks/months. -clients who have diabetes mellitus should keep their HbA1c below 7% -the client should use capillary blood glucose levels to adjust daily insulin dose with provider's approval
If client is allergic to dye for CT scan- given anyway
-client is given antihistamine and corticosteroids to reduce the severity of a reaction
Managing diabetes during sick days
-client should take usual dose of insulin, even when not feeling well -client should check urine for ketones when blood glucose levels are greater than 240mg/ dL -client should call provider if blood glucose levels exceed 250 mg/ dL during illness -client should check their blood glucose level every 4 hours during illness
Early signs of increased ICP
-headache -nausea -vomiting -decreased LOC -blurred vision
Expected findings of hyperthyroidism
-heat intolerance -restless and irritable -tremors, diaphoresis, and insomnia -exophthalmos- causes a wide-eyed or startled appearance
Pheochromocytoma- Complications
-hypertensive crisis -hypertensive retinopathy -hypertensive nephropathy -cardiac enlargement -dysrhythmias -heart failure -myocardial infarction -increased platelet aggregation and stroke - death can occur from shock, stroke, renal, failure, dysrhythmias, or dissecting aortic aneurysm
Decorticate (flexor) posturing
Flexure of one or both arms on the chest and possibly stiff extension of the legs- indicates damaged cortex
Ventricles
Four ventricles- communicate between the subarachnoid spaces and produce and circulate cerebrospinal fluid
A nurse is caring for a patient on the floor who has just been admitted after sustaining a closed head injury in a motor vehicle accident. The patient was initially combative and pulled out an IV, but is now alert and cooperative. The nurse knows that the patient's plan of care should include:
Frequent monitoring and assessment at least every 30- 60 minutes.
Adrenal Medulla
Functions as part of the autonomic nervous system Catecholamines: epinephrine and norepinephrine
Diabetic Ketoacidosis
A form of metabolic acidosis Blood glucose is elevated because of insufficient insulin secretion Glucose cannot enter the cells so energy is produced by breaking down glycogen and fat Fat metabolism results in the formation of ketones, an acidotic substance
Propylthiouracil (PTU) is prescribed for a client with Graves' disease to decrease circulating thyroid hormone.The nurse should teach the client to immediately report which of the following signs and symptoms? A.Sore throat. B.Painful, excessive menstruation. C. Constipation. D. Increased urine output
A-Sore throat.
Which of the following is a priority outcome for the client with Addison's disease? A. Maintenance of medication compliance. B. Avoidance of normal activities with stress. C. Adherence to a 2-g sodium diet. D. Prevention of hypertensive episodes.
A. Maintenance of medication compliance.
Adrenal function is affected by the drug ketoconazole (Nizoral), an antifungal agent used to treat severe fungal infections. How is this effect manifested? A.Ketoconazole suppresses adrenal steroid secretion. B.Ketoconazole destroys adrenocortical cells,resulting in a "medical" adrenalectomy. C.Ketoconazole increases ACTH-induced corticosteroid serum levels. D.Ketoconazole decreases duration of adrenal suppression when administered with corticosteroids
A.Ketoconazole suppresses adrenal steroid secretion.
A 42 year old female client reports that she has gained weight and that her face and body are "rounder," while her legs and arms have become thinner. A tentative diagnosis of Cushing's disease is made. When examining this client, the nurse would expect to find A. Postural hypotension. B. Muscle hypertrophy in the extremities. C. Bruised areas on the skin. D. Decreased body hair.
C. Bruised areas on the skin.
Which of the following measures is most often recommended when preparing SSKI for administration? A. Pour the solution over ice chips. B. Mix the solution with an antacid. C. Dilute the solution with water, milk, or fruit juice and have the client drink it with a straw. D. Disguise the solution in a pureed fruit or vegetable
C. Dilute the solution with water, milk, or fruit juice and have the client drink it with a straw.
The nurse is completing a health assessment of a 42-year-old woman with suspected Graves' disease. The nurse should assess this client for A.Anorexia. B.Tachycardia. C.Weight gain. D.Cold skin.
B- Tachycardia
A client with thyrotoxicosis says to the nurse, "I am so irritable. I am having problems at work because I lose my temper very easily." Which of the following responses by the nurse would give the client the most accurate explanation of her behavior? A."Your behavior is caused by temporary confusion brought on by your illness." B."Your behavior is caused by the excess thyroid hormone in your system." C."Your behavior is caused by your worrying about the seriousness of your illness." D. "Your behavior is caused by the stress of trying to manage a career and cope with illness."
B. "Your behavior is caused by the excess thyroidhormone in your system."
A client with a large goiter is scheduled for a subtotal thyroidectomy to treat thyrotoxicosis. Saturated solution of potassium iodide (SSKI) is prescribed pre-operatively for the client. The primary reason for using this drug is that it helps A. Slow progression of exophthalmos. B. Reduce the vascularity of the thyroid gland. C. Decrease the body's ability to store thyroxine. D. Increase the body's ability to excrete thyroxine.
B. Reduce the vascularity of the thyroid gland.
Thyroid Stimulating Hormone- test
Blood test is used to differentiate the diagnosis of pimary hypothyroidism Normal value is 0.2-5.4 microunits/ mL (normal findings vary among laboratories) Elevated values indicate primary hypothyroidism Decreased values indicate hyperthyroidism or secondary hypothyroidism
A patient admitted for a head injury develops dry skin and a urine output of 400mL/ hr. Prioritize the nurse's next actions:
Complete a Neuro Assessment Notify the Physician Assess the patient's urine specific gravity and blood sodium levels Start IV fluids and administer desmopressin (DDAVP) A urine output of 400ml/ hr after sustaining a head injury may be indicative of diabetes insipidus. DI is the failure to produce an antidiuretic hormone due to damage to the pituitary gland from increased ICP. With a recent head injury, the nurse should first perform a neuro exam Notifying the physician is appropriate in order for the nurse to obtain orders for additional tests The nurse should then gather information by assessing for low specific gravity and elevated serum osmolality, as ordered by the physician The physician may order treatments including IV fluids and DDAVP
An elderly client on steroids has secondary diabetes and chronic kidney disease (CKD) and takes insulin. The client has had episodes of hypoglycemia. The nurse should:
Continue to monitor the client's blood glucose values. Prevent the client from continuing to experience hypoglycemia -one of the risk factors for hypoglycemia is decreased insulin clearance as with impaired kidney function and/ or renal failure -Increased glucose utilization when there is too much activity or exercise without enough food -protein is digested slower than carbohydrate
CRH- Corticotropin-releasing hormone (CRH) also known as corticotropin-releasing factor (CRF) or corticoliberin Hypothalamus
Corticotropin-releasing hormone (CRH) also known as corticotropin-releasing factor (CRF) or corticoliberin is a peptide hormone and neurotransmitter involved in the stress response. It is a releasing hormone that belongs to corticotropin-releasing factor family. In humans, it is encoded by the CRH gene.[3] Its main function is the stimulation of the pituitary synthesis of ACTH, as part of the HPA Axis.
Which metabolic disorder results from the chronic and excessive production of cortisol by the adrenal cortex or the administration of glucocorticoids in large doses for several weeks or longer (exogenous or iatrogenic)?
Cushing's syndrome
Serum concentrations of thyroid hormones and thyroid-stimulating hormone (TSH) are tests ordered for the client with thyrotoxicosis. Which of the following laboratory values are indicative of thyrotoxicosis? A. Elevated thyroid hormone concentrations and normal TSH. B. Elevated TSH and normal thyroid hormone concentrations. C. Decreased thyroid hormone concentrations andelevated TSH. D. Elevated thyroid hormone concentrations and decreased TSH.
D. Elevated thyroid hormone concentrations and decreased TSH.
The nurse should teach the client with Addison's disease that the side effect of bronze - colored skin is thought to be caused by which of the following? A. Hypersensitivity to sun exposure B. Increased serum bilirubin level C. Side effects of the glucocorticoid therapy D. Increased secretion of adrenocorticotropic hormone (ACTH)
D. Increased secretion of adrenocorticotropic hormone (ACTH)
When discussing recent onset of feelings of sadness and depression in a client with hypothyroidism, the nurse should inform the client that these feelings are A. The effects of thyroid hormone replacement therapy and will diminish over time. B. Related to the thyroid hormone replacement therapy and will not diminish over time. C. A normal part of having a chronic illness. D. Most likely related to low thyroid hormone levels and will improve with treatment
D. Most likely related to low thyroid hormone levels and will improve with treatment
A client who has undergone a subtotal thyroidectomy is subject to complications in the first 48 hours after surgery. The nurse should obtain and keep at the bedside equipment to A. Begin total parenteral nutrition. B. Start a cutdown infusion C. Administer tube feedings. D. Perform a tracheostomy
D. Perform a tracheostomy
Appropriate nursing diagnoses for a client with hypothyroidism would probably include which of the following? A. Risk for Injury (corneal abrasion) related to incomplete closure of eyelid. B. Imbalanced Nutrition: Less Than Body Requirements related to hypermetabolism. C. Deficient Fluid Volume related to diarrhea. D.Activity Intolerance related to fatigue associated with the disorder.
D.Activity Intolerance related to fatigue associated with the disorder.
A patient has developed syndrome of inappropriate antidiuretic hormone (SIADH) after suffering a traumatic brain injury. After treatment has been initiated the nurse assesses the patient for signs of improvement, including:
Decreased urine osmolality Increased SERUM sodium Increased urine output SIADH is a disorder of impaired water excretion (which causes water retention) caused by excessive secretion of ADH ADH secretion results in a reduced volume of concentrated urine. Urine osmolality is above 100 mosmol/kg SIADH is characterized by dilutional hyponatremia, and sodium is also lost as the body attempts to compensate for fluid volume excess with further sodium excretion
Hyperosmolar Hyperglycemic nonketotic syndrome
Dehydration, when combined with hyperglycemia and illness, can lead to HHNS. The patient should stay hydrated and be alert of signs of hyperglycemia occurs when extreme hyperglycemia causes severe dehydration, increased osmolarity, and coma or death. It is usually precipitated by infecdtion, illness, or stress. More common in patients with type 2 diabetes Managed with oral antidiabetic agents and do not usually require blood glucose monitoring
Lipohypertrophy
Development of fibrous fatty masses at the injection site and is caused by repeated use of an injection site - instruct client to avoid injecting insulin into affected sites - instruct client about the importance of rotating insulin injection sites
A 32 year old male is admitted to the hospital with diabetes insipidus. The nurse would anticipate the physician ordering the administration of 1) bumetanide 2)furosemide 3)insulin 4)vasopressin
Diabetes insipidus is characterized by a deficiency of antidiuretic hormone (ADH) Treatment includes administration of vasopressin (ANOTHER NAME FOR ADH)
Babinski Reflex
Dorsiflexion of the big toe with extension elicited by firmly stroking the lateral aspect of the sole of the foot
Neuroleptic Malignant Sydnrome
FEVER ENCEPHALOPATHY VITALS UNSTABLE ELEVATED ENZYMES (CK) RIGIDITY OF MUSCLES
Brudzinski's sign
Is noted by flexion of the hip and knee at 90 degree angles, and pain causes the patient to resist extension when the knee is straightened by the physician performing the assessment
Trousseau's Sign
Medical sign observed in patient's with low calcium To elicit the sign, a blood pressure cuff is placed around the arm and inflated to a pressure greater than the systolic blood pressure and held in place for 3 minutes. This will occlude the brachial artery. In the absence of blood flow, the patient's hypocalcemia and subsequent neuromuscular irritability will induce spasm of the muscles of the hand and forearm. The wrist and metacarpophalangeal joints flex, the DIP and PIP joints extend, and the fingers adduct.
Nursing Interventions for hypothyroidism
Modifying activity: encourage patient to participate in activities within established tolerance level Monitor physical status Promote physical comfort provide extra clothing and blankets Provide emotional support Promote home and community -based care. provide dietary instruction assess patient's and family's understanding of the importance of prescribed long term medication therapy report signs and symptoms indicating inadequate or excessive thyroxine hormone
Collaborative Management of Thyroid Storm/ Crisis
Monitor temperature, I and O, neurologic status, cardiovascular status every hour •Administer increasing doses of oral PTU(200 to 300 mg. q 6 hours) as ordered, following a loading dose of 800 to 1,200 mg./ p.o as ordered•Administer iodide preparation as ordered•Administer dexamethasone to help inhibit the release of thyroid hormone Administer propranololto controlhypertension and tachycardia•Implement measures to lower fever,e.g. cooling devises, cold baths,acetaminophen (avoid aspirin)•Administer oxygenas needed•Maintain quiet, calm, cool, privateenvironment until crisis is over
Cushing's Syndrome Assessment Findings
Muscle weakness, fatigue, obese trunk with thin arms and legs, muscle wasting•Irritability, depression, frequent moodswings •Moon face, buffalo hump, pendulous abdomen •Purple striae on trunk, acne, thin skin•Signs of masculinization in women;menstrual dysfunction, decreased libido •Osteoporosis, decreased resist to infection •Hypertension, edema•↑ skin and blood vessel friability
Grave's Disease (Hyperthyroidism)
Result from an excessive output of thyroid hormones caused by abnormal stimulation of thyroid gland by circulating immunoglobulin Affects women 8x more frequently than men.
What stimulates insulin release?
PRIMARILY GLUCOSE certain drugs amino acids acetylcholine
Propylthiouracil
PTU (ANTITHYROID AGENT) supresses the production of thyroid hormones and therefore, allows for weight gain -causes a decrease in diaphoresis -cause a decrease in bowel movements -reduction in appetite -It can treat Graves' disease and too much thyroid hormone (hyperthyroidism) in patients who have already been treated with medications such as methimazole that did not work well -TREATS HYPERTHYROIDISM AND GRAVES DISEASE/ GOITER
Post- Op Thyroidectomy
Post-op Care •Position : Semi - Fowler's with head, neck &shoulder erect•Prevent Hemorrhage -Ice collar over the neck •Keep tracheostomy set available for the first48 hours post-op•Ask the patient to speak every hour -To assess for recurrent laryngeal nerve damage •Keep Ca gluconate readily available -Tetany occurs if hypocalcemia is present. -This may be secondary to the removal of theparathyroid gland. •Monitor Body Temperature -Hyperthermia is an initial sign of thyroid crisis Monitor BP (hypertension may be a manifestation of thyroid storm)•Assess for Trousseau's sign (hypocalcemia) Observe for signs and symptoms of potential complications. -Hemorrhage -Airway obstruction -Tetany -Recurrent laryngeal nerve damage -Thyroid crisis / storm / thyrotoxicosis -Myxedema
Glucocorticoids: Cortisol, Cortisone, Corticosterone
Responsible for glucose metabolism. protein metabolism, fluid and electrolyte balance, suppression of the inflammatory response to injury, protective immune response to invasion by infectious agents, and resistance to stress
autonomic dysreflexia
Syndrome characterized by paroxysmal hyptertension, bradycardia, excessive sweating, facial flushing, nasal congestion, pilomotor responses, and headache. The syndrome occurs with spinal lesions above T6 AFTER THE PERIOD OF SPINAL SHOCK IS COMPLETE Triggers include visceral stimulation from a distended bladder or impacted rectum. The syndrome is a neurological emergency and must be treated immediately to prevent a hypertensive stroke. It is also known as autonomic hyperreflexia.
TRH- Thyrotropin releasing hormone Hypothalamus
Thyrotropin-releasing hormone (TRH), also called thyrotropin-releasing factor (TRF) or thyroliberin, is a releasing hormone, produced by the hypothalamus, that stimulates the release of thyrotropin (thyroid-stimulating hormone or TSH) and prolactin from the anterior pituitary. It is a tropic, tripeptidal hormone.
Thyroid Crisis or Storm
Uncontrolled and potentially life -threatening hyperthyroidism• Causes: Stress, Infection and Unprepared thyroid surgery Assessment Elevated temperature (initial sign)Tachycardia, dysrhythmias Tremors, apprehension, restlessness Delirium, psychotic state, coma Elevated BP
A patient has developed diabetes insipidus after suffering a traumatic brain injury. After treatment has been initiated, the nurse assesses the patient for signs of improvement including:
Urine output of less than 150ml/ hr - indicates that the patient is able to retain fluid -tachycardia, hypotension, and polydipsia are signs of diabetes insipidus indicating that the treatment has not been effective
Urine ketones
late sign of complications when there is a profound insulin deficiency
Goal blood pressure for diabetics
less than 130/80 mm Hg