Exam 4

Diabetes - Chronic Condition - Diabetic Neuropathy

- 60% to 70% of patients with diabetes have some degree of neuropathy. - Nerve damage due to metabolic derangement of diabetes. - Sensory Neuropathy - loss of protective sensation in the lower extremities & significantly increases the risk for complications that result in lower limb amputation. - Autonomic Neuropathy - can affect all body systems, gastroparesis (delayed gastric emptying), cardiac (causes postural hypotension, resting tachycardia, & painless myocardial infarction), erectile dysfunction, bladder (neurogenic bladder).

Diabetes - What is it?

- A chronic multisystem disease related to abnormal insulin production, or impair insulin utilization, or both. - Body's inability to make or use insulin. - Serious health problem & prevalence is rapidly increasing. - Two most common types - Type 1 or Type 2. - Other types - gestational, prediabetes, & secondary Diabetes.

Diabetes Mellitus (DM), Type 2

- A metabolic disorder characterized by high levels of glucose resulting from defects in insulin secretion, insulin action, or both. - Characterized by hyperglycemia. - Results from progressive secretory insulin deficit &/or defect in insulin uptake. - Many clients with Type 2 DM use insulin, but retain some degree of pancreatic function. - Obesity is a major risk factor.

Diabetes Mellitus (DM), Type 1

- A metabolic disorder characterized by high levels of glucose resulting from defects in insulin secretion, insulin action, or both. - Characterized by hyperglycemia. - Affects the metabolidm of protein, carbs, & fats. - Results from the destruction of B cells.

Addison's Disease

- Adrenocortical insufficiency. - Autoimmune or idiopathic atrophy. - Can be caused by inadequate ACTH from pituitary. - Therapeutic use of steroids. - Manifestations - muscle weakness, anorexia, dark pigmentation, hypotension, hypoglycemia, low sodium levels, low potassium levels. - Can result in Addisonian Crisis.

Diabetes - Pancreatic Cells

- Alpha - secrete glucagon (elevate blood glucose levels). - Beta - store & release insulin (responds to high glucose levels). - Delta - make somatostatin (inhibits glucagon & insulin).

Insulin Dependent Diabetes Mellitus (IDDM), Type 1 Diabetes - Nursing Plans & Interventions

- Assist with diagnosis (fasting blood glucose > 120 mg/dl). - If child is ketoacidosis, provide care - monitor VS & neurologic status, monitor blood glucose, pH, & serum electrolytes, administer IV fluids, insulin, & electrolytes as prescribed, ass hydration status, strict I&O. - Initiate home teaching program - involve family & child, teach insulin administration (child usually receives multiple doses daily, may be administered subcut or via pump). - Teach dietary management - carb counting preferred, meals & snacks, growth & exercise needs, 4 basic food groups, not concentrated sweets, & advice from nutritionist. - Teach about exercise - regular, planned activities, diet modification (snacks before or during exercise). - Teach about home glucose monitoring & urine testing. - Teach S/S of hyperglycemia & hypoglycemia. - Initiate program for school age child - physical education class & exercise, scheduled time for meals & snacks, cooperation with teachers & school nurses, & need to be like peers. - Teach that school age child should be responsible for most management. - Instruct to wear MedicAlert bracelet.

Diabetes - Chronic Complications - Diabetic Nephropathy

- Associated with damage to small blood vessels that supply to glomeruli of the kidney. - Leading cause of end stage renal disease. - Risk factors hypertension, genetic predisposition, smoking, & chronic hyperglycemia. - Screened annually with a random spot urine collection to assess for albuminuria & measure albumin to creatinine ratio. - Critical factors for prevention/delay - tight glucose control & blood pressure management. - Angiotension converting enzyme (ACE) inhibitors - anginotensin II receptor - treat hypertension & delay the progression of nephropathy.

Diabetes - Diet

- Carbs - carbs & monounsaturated fats should provide 45% to 65% of total energy intake, low carb diets are not recommended for diabetics. - Fats - no more than 25% to 30% of meal plans total calories. - Alcohol - high in calories, not nutritive value, promotes hypertriglyceridemia, detrimental effects on liver, can cause severe hypoglycemia, because of inhibitory effect on glucose production by the liver.

Diabetes - DKA

- Cause - too high blood sugar. - Blood sugar level - greater than 250, acidotic. - Population - Type 1 Diabetic. - Treatment - rehydrate, IV regular. - Teaching to prevent - monitor blood sugar. - Elevated ketones present in this disease is caused by the incomplete oxidation of free fatty acids.

Diabetes - HHNS

- Cause - too high blood sugar. - Blood sugar level - greater than 600, no acidosis. - Population - Type 2. - Treatment - rehydrate, IV regular. - Teaching to prevent - monitor blood sugar.

Addisonian Crisis

- Circulatory shock. - Pallor, apprehension, weak & rapid pulse, rapid respirations, low blood pressure, headache, nausea, abdominal pain, & diarrhea. - Can be brought on by overexertion, exposure to cold, acute infection, decrease in salt intake.

Metabolic Syndrome

- Cluster of abnormalities that increase risk for cardiovascular disease & diabetes. - Characterized by insulin resistance. - Elevated insulin levels, elevated triglycerides, increased LDLS, decreased HDLS, & hypertension. - Risk Factors - central obesity, sedentary lifestyle, urbanization, & certain ethnicities.

Signs & Symptoms of Hypoglycemia

- Confusion. - Heart Palpitations. - Shakiness. - Anxiety. - Sweating.

Congenital Hypothyroidism

- Congenital condition resulting from inadequate thyroid tissue development in utero. Cognitive impairment & growth failure occur if it is not detected & treated in early infancy.

Diabetes - Education

- Cornerstone of care for a patient with diabetes. - Most challenging for many people. - Recommended that diabetic nurse educators & registered dietitian with diabetes experience be member of the team.

Hormones - Adrenal Cortex

- Corticosteriods - targets all body tissues, promote metabolism, increased in response to stress, anti inflammatory. - Androgens - targets reproductive organs, promote growth spurt in adolescence, secondary sex characteristics, & libido. - Mineralcorticoids - targets kidney, regulates sodium & potassium balance, & thus water balance.

Diabetes Insipidus - Nursing Management

- DDAVP - intranasal BID, can be given IV if necessary (every 24 to 96 hours, can cause lipodystrophy). - Diabenses & thiazide diuretics in mild disease as they potentiate the action of ADH. - If renal in origin - thiazide diuretics, NSAIDS, & salt depletion may help. - Educate patient about actions of medications & how to administer medications, wear MedicAlert Bracelet.

Diabetes Insipidus

- Deficiency of ADH hormone. - Excessive thirst, large volumes of dilute urine. - Can occur secondary to brain tumors, head trauma, infections of the CNS, & surgical ablation or radiation. - Nephrogenic DI - relates to failure of the renal tubules to respond to ADH, can be related to hypokalemia, hypercalcemia, & to medications (lithium demeocycline).

Diabetes Mellitus (DM) - Nursing Plans & Interventions

- Determine base line lab data - serum glucose, electrolytes, creatinine, BUN, cholesterol (LDL & HDL), triglycerides, & ABGs as indicated. - Teach injection technique &/or oral medications - identify prescribed dose & type of insulin. - For insulin - lift skin, 90 degree angle (if very thin or using 5/16 inch needle, use 45 degree angle), & may reuse syringes for same person, recapping should only be done by person using the syringe, & rotator injection sites, & draw regular insulin into syringe first when mixing insulin. - Teach about medical nutrition therapy - work with dietitian, make healthy nutritional choices & eat varied diet, encourage carb counting for those on complex insulin regimes, teach that meals should be timed according to medication peak times. - Teach about sick days - illness raises blood glucose, teach client to keep taking insulin, monitor glucose more frequently, watch for signs of hyperglycemia. - Teach exercise regimen - exercise decreases blood sugar levels, exercise after mealtime, monitor blood glucose. - Teach signs & symptoms of hyper/hypoglycemia. - Teach about foot care - check & clean daily, moisturize with lanolin product (not between toes), calluses should be removed by a professional, & nails should be cut or filed straight across. - Encourage regular health care follow ups. - Teach immediate attention should be sought at sign of infection.

Gestational Diabetes

- Develops during pregnancy. - Have a high risk for C sections delivery & their babies have an increased risk for perinatal death, birth injury, & neonatal complications. - High risk individuals are those who are obese, are of advanced maternal age, or have a family history of. - Women are screened using an OGTT at 24 to 28 weeks gestation.

Diabetic Ketoacidosis - Assessment Finding

- Dry mouth. - Thirst. - Abdominal pain. - Nausea & vomiting. - Gradually increasing restlessness, confusion, lethargy. - Flushed, dry skin. - Eyes appearing sunken. - Breath odor of ketones. - Rapid, weak pulse. - Laboring breathing (Kussmaul respirations). - Fever. - Urinary frequency. - Serum glucose > 250 mg/dl. - Glucosuria & ketonuria.

Addisonian Crisis - Assessment & Diagnosis Findings

- Early morning serum cortisol & plasma ACTH are performed, will distinguish between primary & secondary adrenal insufficiency. In primary, will have elevated ACTH levels & below normal cortisol levels. - If the adrenal cortex is not stimulated by the pituitary, a normal response to doses of exogenous ACTH. - Blood sugar levels & electrolyte values.

Diabetes - Exercise

- Essential part of diabetes management - increase insulin receptor sites, lowers blood glucose levels, contributes to weight loss. - Several small carb snacks can taken every 30 minutes during exercise to prevent hypoglycemia. - Best done after meals. - Exercise plans should be started. - Slowly with gradual progression.

Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)

- Excessive ADH secretion. - Retain fluids & develop a dilution as hyponatremia. - Often non endocrine in origin - such as bronchogenic carcinoma. - Causes - disorders of the CNS (head injury, brain surgery, tumors, infections, & medications, such as vincristine, phenothizines, TCAs, or thiazide diuretics). - Medications can either affect the pituitary or increase sensitivity to renal tubules to ADH. - Management - eliminate cause, give diuretics (Lasix), fluid restriction, I&O, daily weights, & lab chemistries. - Restoration of electrolytes must be gradual (may use 3% NaCl in conjunction with Lasix).

Hyperthyroidism (Grave's Disease, Goiter)

- Excessive activity of thyroid gland, resulting in an elevated level of circulating thyroid hormones. POssibly long term or lifelong treatment. - Hyperthyroidism can result from a primary disease state, from the ise of replacement hormone therapy, or from excess thyrod stimulating hormone being produced by an anterior pituitary tumor. - Graves disease is though to be an autoimmune process & accounts for most cases. - Diagnosis is made of the basis of serum hormone levels. - Common treatment for hyperthyroidism - goal is to create a euthyroid state (thyroid ablation by medication, rediation, thyroidectomy, adenectomy of portion of anterior pituitary where TSH producing tumor is located. - All treatments make the client hypothyroid, requiring hormone replacement.

Diabetes Mellitus (DM) - Diagnosis

- Fasting Plasma Glucose greater than or equal to 126 mg/dl. - Glycosylated Hgb (HgA1C) greater than or equal to 6.5%. - Random Blood Glucose greater than or equal to 200 mg/dl in a client with classic symptoms of hyperglycemia. - Oral Glucose Tolerance Test greater than 200 - use plasma glucose, not finger sticks, to diagnosis diabetes, results should be confirmed on a subsequent visit. - Prediabetes - blood glucose levels when fasting are 100 to 125 mg/dl or HgA1C of 5.7% to 6.4%.

Addison Disease - Nursing Assessment

- Fatigue, weakness. - Weight loss, anorexia, nausea, vomiting. - Postural hypotension. - Hypoglycemia. - Hyponatremia. - Hyperkalemia. - Hyperpigmentation of mucous membranes & skin. - Signs of shock. - Loss of body hair. - Hypovalemia - hypotension, tachycardia, & fever.

Hypothyroidism - Nursing Assessment

- Fatigue. - Thin, dry hair; dry skin. - Thick, brittle nails. - Constipation. - Bradycardia, hypotension. - Goiter. - Periorbital edema, facial puffiness. - Cold intolerance. - Weight gain. - Dull emotions & mental processes. - Diagnosis - T3 (below 70), low T4 (below 5), & presence of T4 antibody (indicating that T4 is being destroyed by the body). - Husky voice. - Slow speech.

Diabetes Insipidus - Assessment & Diagnostic Findings

- Fluid Deprivation Test - withhold fluids for 8 to 12 hours, weight patient frequently, inability to slow down the urine output & fail to concentrate urine are diagnostic. Stop test is patient is tachycardic or hypotensive. - Trial of desmopressin & IV hypertonic saline. - Monitor serum & urine osmolaity & ADH levels.

Type 1 Diabetes Mellitus

- Formerly known as juvenile onset or insulin Dependent Diabetes. - Most often occurs in people under 30 years of age. - Peak onset between 11 & 13 years of age. - End result of a long standing process - progressive destruction of pancreatic cells by body's own T cells, autoantibodies cause a reduction of 80% to 90% of normal cells function before manifestations occurs. - Causes - genetic predisposition (related to human leukocyte antigens) or exposure to a virus.

Disorders of Anterior Pituitary Gland - Acromegaly

- Gaintism. - Overproduction of growth hormone in adulthood. - Enlargement of hands & feet, thickening & enlargement of face & head, as well as bony & soft tissue, sleep apnea, signs of Diabetes Mellitus, cardiomegaly, & hypertension. - Treatment focuses on returning GH levels to normal by surgical radiation, or drug therapy. - Surgical - hypophysectomy, best chance for cure. - Radiation - surgery fails, offered in combination with drugs that reduce levels. - Drug - Octerotide, primary drug used, a somatostain analog that reduces GH levels to normal for many patients. - Prognosis depends on age of onset.

Type 2 Diabetes - Manifestations

- Gradual onset - person may go many years with undetected hyperglycemia. - Osmotic fluid/electrolyte loss from hyperglycemia may become serve - hyperosmolar coma. - Classic symptoms - polyuria, polyphagia, polydipsia. - Weakness, fatigue. - Recurrent infections. - Recurrent vaginal yeast or monilia infections. - Prolonged wound healing. - Visual changes.

Disorders of Anterior Pituitary Gland - Pituitary Dysfunction

- Growth hormone deficiency. - Occurs in children. - Treatment is replacement of growth hormone (daily subcut injections, can cost 20,000 to 30,000 dollars/year). - May see growth of 3.5 to 4 cm/year.

Insulin - Problems with

- Hypoglycemia. - Allergic reactions. - Lipodstrophy. - Somogyi Effect - low BG in the morning or middle of the night, didn't eat a snack before bed, check blood glucose between 2 & 4 AM for hypoglycemia. - Dawn Phenomenon - rise in glucose, high BG in the morning, counter regulator hormones (growth & cortisol) excreted in increased amounts in the early morning hours are responsible.

Hypoglycemia - Treatment

- If alert enough to swallow, 15 to 20 g of a simple carb (4 to 6 oz of fruit juice, regular soft drink). - Avoid foods with fat - decrease absorption of sugar. - Recheck blood glucose in 15 minutes. - If above 70, eat snack or meal. - If no improvement after 2 to 3 doses of simple carb or patient is not alert enough to swallow, administer 1 mg of glucagon IM or suburb (side effect rebound hypoglycemia). - Have patient ingest a complex carb after recovery. - In acute care setting, 20 to 50 ml of 50% dextrose IV push.

Cushing Syndrome - Management of

- If pituitary source, may warrant transpheniodal hypophysectomy. - Radiation of pituitary if appropriate. - Adrenalectomy may be needed in cases of adrenal hypertrophy. - Temporary replacement therapy therapy with hydrocortisone or florinef. - Adrenal enzyme reducers may be indicated if source is ectopic & inoperable. - If cause if related to excessive steroid therapy, tapering slowly to a minimum dosage.

Type 1 Diabetes - Etiology & Pathophysiology

- Immune mediated disease. - Caused by autoimmune destruction of the pancreatic B cells, the site of insulin production. - A genetic predisposition & exposure to a virus are factors that may contribute to the pathogenesis of immune related type 1 diabetes.

Endocrine System

- In the older adult, glands atrophy & decrease the rate of secretion. The impact is unclear, except it is more prevalent in women than in men due to the decline of estrogen, which causes menopause. - Consists of the thyroid, parathyroid, pituitary, adrenal, & pineal glands the thymus, & the endocrine pancreas. - Thyroid activity decreases. Symptoms are commonly undiagnosed in the older adult because they are attributed to being normal for age. - Metabolic rate slows. - Estrogen production ceases with menopause; ovaries, uterus, & vaginal tissue atrophy. - Gonadal secretion of progesterone & testosterone decreases. - Insulin production decreases or insulin resistance increases. - T4 & T3 secreted by the thyroid glad remain unchanged with aging, however the metabolic clearance rate is decreased. Production of parathyroid hormone decreases, which is made evident by osteoporosis. - Adrenal changes may affect circadian patterns of adrenonocorticotropic hormone.

Prediabetes

- Increased risk for developing type 2 diabetes. - Blood glucose levels are elevated, but not high enough to meet diagnostic criteria for diabetes. - Long term damage already occurring - heart & blood vessels. - Usually present wth no symptoms. - Must watch for diabetes symptoms - polyuria, polyphagia, & polydipsia. - Encourage patient to undergo screenings & provide instructions about managing risk factors for diabetes.

Diabetes - Normal Insulin Metabolism

- Insulin - promotes glucose transport from blood stream across cell membrane to cytoplasm of cell. - Decreases glucose in the blood stream - increases insulin after a meal. - Lowers blood glucose & stabilizes normal glucose range, 70 to 120 mg/dl. - Average amount of insulin secretion is 0.6 U/kg of body weight. - Stimulates storage of glucose as glycogen in liver & muscle. - Inhibits gluconeogenesis. - Enhances fat deposition. - Increases protein synthesis. - Skeletal muscles & adipose tissue have specific receptors for insulin, insulin is required to unlock these receptor sites, allowing the transport of glucose into the cells to be used for energy. - Counter regulatory hormones - oppose effects of insulin, increases blood glucose levels, provide a regulated release of glucose for energy, help maintain normal blood glucose levels. - Examples - glucagon, epinephrine, growth hormone, & cortisol.

Types of Insulin - Exogenous

- Insulin from an outside source. - Required for Type 1 Diabetes. - Prescribed for patients with type 2 diabetes who cannot control blood glucose by other means. Types of insulin: - Rapid acting - lispro, aspart, & glulisine (onset 10-30 min, peak 30 min-3 hr, & duration 3-5 hr). - Short acting - regular (onset 30-1 hr, peak 2-5 hrs, duration 5-8 hrs). - Intermediate acting - NPH (onset 1.5-4 hrs, peak 4-12 hrs, & duration 14-18 hrs). - Long acting - glargine, detemir (onset 1-4 hrs, peak 6 hrs, duration 18-26 hrs). -Closely mimics endogenous insulin production is basal bolus - long acting basal is once a day, rapid/short acting insulin before meals.

Diabetes Mellitus (DM) - Nursing Assesment

- Integumentary - skin infections, wounds that do not heal, acanthosis. - Oral - periodontal disease, candidiasis (raised, white patchy areas on mucous membranes). - Eyes - cataracts, retinopathy. - Cardiopulmonary- angina, dyspnea, HTN. - Periphery - hair loss on extremities, indicating poor perfusion (also coolness, skin shininess & thinness, weak or absent pulses, ulcerations on extremities, pallor, thick nails with ridges). - Kidneys - edema of face, hands, & feet, symptoms of UTI, symptoms renal failure (edema, anorexia, nausea, fatigue, difficulty contracting). - Neuromuscular - neuropathies, symptoms of neuropathies, numbness, tingling, pain, burning. - Gastrointestinal- night time diarrhea, gastroparesis (faulty absorption). - Reproductive - impotence (male), vaginal dryness, frequent vaginal infections, menstrual irregularities (female). - Psychosocial - depressions (persons with DM have a high rate of depression, contributes to poor DM regimen adherence, feelings of helplessness, & poor health outcomes), increased risk of developing anorexia nervous & bulimia nervous in women with type 1 DM.

Diagnosing Diabetes - Fasting Plasma Glucose

- Level greater than 126 mg/dl (fasting is defined as no caloric intake for at least 8 hours). - Random or casual plasma glucose measurement greater than or equal to 200 mg/dl plus symptoms (in patient with classic symptoms of hyperglycemia, polyuria, polydipsia, or recent weight loss). - 2 hour OGTT level greater than 200 mg/dl using a glucose load of 75 g.

Type 1 Diabetes Mellitus - Onset & Manifestations

- Long preclinical period. - Antibodies present for months or years before symptoms occur. - Manifestations develop when pancreas can no longer produce insulin. - Rapid onset of symptoms - present in ER with ketoacidosis. - History of recent, sudden weight loss. - Classic symptoms - polydipsia, polyuria, & polyphagia. - Patient may complain of fatigue. - Require exogenous insulin to sustain life.

Diabetes - Acute Complications - Hypoglycemia

- Low blood glucose. - Too much insulin in proportion to glucose in the blood. - Blood glucose level less than 70 mg/dl. - Common Manifestations - confusion, irritability, diaphoresis, hunger, weakness, visual disturbances. - Can mimic alcohol intoxication. - If left untreated, can progress to loss of consciousness, seizures, coma, & death. - Causes - mismatch in timing of food intake & peak action of insulin or oral hypoglycemic agents. - At first sign, check blood glucose. If 70 mg/dl, investigate further for cause of signs & symptoms. If monitoring equipment is not available, treatment should be initiated.

Diabetes - Chronic Complications - Angiopathy

- Macrovascular. - Disease of large & medium sized blood vessels. - Occur with greater frequency & with an earlier onset in diabetes. - Risk factors obesity, smoking, hypertension, high fat intake, & sedentary lifestyle. - Yearly screening is recommended. - Development promoted by altered lipid metabolism common to diabetes. - Smoking cessation, weight loss, exercise, nutritional therapy to treat hyperlipidemia.

Insulin Dependent Diabetes Mellitus (IDDM), Type 1 Diabetes

- Metabolic disorder in which the insulin producing cells of the pancreas are non functioning as a result of some insult. - Heredity, viral infections, & autoimmune processes are implicated in Diabetes Mellitus. - Diabetes causes altered metabolism of carbohydrates, proteins, & fats. - Insulin replacement, dietary management, & exercise are the treatments.

Diabetes - Chronic Complications - Diabetic Retinopathy

- Microvascular damage to retina. - Result of chronic hyperglycemia. - Most common cause of new cases of blindness in people 20 to 74 years of age. - Earliest & most treatable stages often produce no changes in vision. - Must have annual dilated eye exam. - Best approach to management is prevention by maintaining good glycemic control & managing hypertension.

Diabetes - Chronic Complications - Angiopathy

- Microvascular. - Result from thickening of vessel membranes in capillaries & arterioles. - In response to chronic hyperglycemia. - Is specific to diabetes unlike marcovascular. - Most noticeably affected are the eyes, the kidneys, & the skin.

Types 2 Diabetes

- Most prevalent type of diabetes. - Over 90% of patients with diabetes. - Usually occur in people over 35 years of age. - 80% to 90% of patients are overweight. - Prevalence increases with age. - Genetic basis. - Greater in some ethnic populations. - Increased rate in African Americans, Asian Americans, Hispanic Americans, & Native Americans.

Type 2 Diabetes - Risk Factors

- Obesity (abdominal & visceral) - most powerful risk factor. - Genetic mutations - lead to insulin resistance, increased risk for obesity. - Individuals with metabolic syndrome are at an increased risk for types 2 diabetes.

Cushing Syndrome - Assessment & Diagnostic Findings

- Overnight dexamethasone suppression test is frequently used, administered at 11 PM & cortisol level checked at 8 AM, suppression of cortisol to less than 5 mg/dl indicates normal functioning. - Measurement of plasma ACTH in conjunction with dexamethasone depression test helps distinguish pituitary vs. ectopic sites of ACTH. - MRI & CT also help detect tumors of adrenal or pituitary.

Hormones - Posterior Pituitary

- Oxytocin - targets uterus, stimulates milk production & uterine contractility. - Antidiuretic Hormone (ADH) - targets renal tubules, promotes reabsorption of water, vasoconstriction.

Type 2 Diabetes - Etiology & Pathophysiology

- Pancreas continues to produce some endogenous insulin. - Insulin produced is either insufficient or poorly utilized by tissue. - Major distinction between type 1 & type 2 - type 2 still continues to produce some insulin.

Hormones - Parathyroid

- Parathyroid - targets bone, intestine, & kidneys, regulates calcium & phosphorus blood levels, promotes bone demineralization & increases intestinal absorption of Ca, increases Ca levels.

Insulin Dependent Diabetes Mellitus (IDDM), Type 1 Diabetes - Nursing Assessment

- Polydipsia. - Polyphagia. - Polyuria - enuresis (bed wetting) in previously continent child. - Irritability, fatigue. - Weight loss. - Abdominal complaints, nausea, & vomiting. - Usually occurs in school age children, but can occur in infancy.

Disorders of Anterior Pituitary Gland - Hypopituitarism

- Rare disorder. - Decrease in one or more of the Pituitary hormones. - Most common deficiencies associated with hypopituarism involve GH & gonadotropins. - Usual cause is a Pituitary hormone. - Manifestations include headaches, visual changes, loss of smell, nausea & vomiting, & seizures. - Treatment is surgery (for tumor) & lifelong hormone replacement. - Somatropin - recombinant human GH, used for long term hormone therapy in adults with GH deficiency.

Hyperthyroidism - Nursing Management

- Reassurance related to emotional reactions experienced. - May need eye care if has exophtalmos. - Adequate calorie intake. - Managing potential complications such as dysrhythmias or tachycardia. - Educate about potential signs & symptoms of hypothyroidism following any antithyroid treatment.

Regulation of Hormones - Positive Feedback

- Regulates hormone synthesis & release. - Rising a hormone level causes another gland to release a hormone, then stimulating further release of the first hormone. - A mechanism for shutting off release of the first hormone is required or it will continue to be released.

Hyperthyroidism - Surgical Management

- Reserved for special circumstance (large goiter, those who cannot take antithyroid medications, or those who need rapid normalization). - Before surgery, give PTU until S/S of hyperthyroidism have disappeared. - Iodine may be used to decrease vascularity.

Addisonian Crisis - Nursing Management

- Restore circulatory status - fluids, steroids. - May need antibiotics if infection precipitated crisis. - May need lifelong steroid therapy & mineralcorticoid therapy. - May need additional salt intake. - Check orthostatic. - Daily weights. - Aware that stressors can precipitate crises. - Wear MedicAlert bracelet.

Diabetes Mellitus (DM), Type 2 - Characteristics & Treatment

- Results from either the inadequate production of insulin by the body or lack of sensitivity to the insulin being produced. - Rare development of ketoacidosis. - With extreme hyperglycemia, hyperosmolar hyperglycemia nonketotic syndrome (HHNKS). - Clinical Characteristics - hyperglycemia >600 mg/dl, plasma hyperosmolality, dehydration, changed mental status, absent ketone bodies. - Treatment - usually with isotonic IV fluid replacement & careful monitoring of potassium & glucose levels, & intravenous insulin given until blood glucose stable at 250 mg/dl.

Cushing Syndrome

- Results from excessive adrenocortical activity. - May be related to recessive use of corticosteroid medications or due to hyperplasia of the adrenal cortex. - Oversecretion of corticosteroids can also be caused by pituitary tumor. - Can be caused by a bronchogenic carcinoma or other malignancy. - Manifestations - cataracts, glaucoma, hypertension, heart failure, truncal obesity, moon face, buffalo hump, sodium retention, hyperglycemia, negative nitrogen balance, altered calcium metabolism, decreased inflammatory responses, impaired wound healing, increased susceptibility to infections, osteoporosis, compression fractures, peptic ulcers, pancreatitis, thinning of skin, striae, acne, mood alterations.

Diabetes Mellitus (DM), Type 1 - Characteristics & Treatment

- Results from the progressive autoimmune based destruction of beta cells. - Can become hyperglycemia & ketones prone relatively easily. - Precipitating factors for diabetic ketoacidosis (DKA) include infection & inadequate or under management of glucose. - Characteristics of DKA - serum glucose of 250 & above, ketonuria in large amounts, arterial pH of <7.30 & HCO3 <15 mEq/L, nausea, vomiting, dehydration, abdominal pain, kussmaul's respirations, acetone odor to breath. - Treatment - usually isotonic IV fluids, 0.9% NaCl solution until BP stabilized & urine output 30 to 60 mL/hr, slow IV infusion by IV pump of regular insulin, too rapid infusion of insulin to lower serum glucose can lead to cerebral coma, & careful replacement of potassium based on lab data.

Diabetes - Acute Complications - Stress & Illness

- Stress of illness & surgery increases blood glucose levels. - Continue regular meal plan. - Increase intake of no caloric fluids. - Continue taking oral agents & insulin. - Frequent monitoring of blood glucose. - Ketone testing if glucose > 240 mg/dl. - Patients undergoing surgery or radiologic procedures, requiring contrast medium should hold their metformin 48 hours before & after surgery (begun after serum creatinine has been checked & is normal).

Hormones - Thyroid

- T4 - targets all body tissues, precursor to T3. - T3 - targets all body tissues, regulates metabolic rate of all cells & processes of cell growth & tissue. - Calcitonin - targets bone tissue, regulates calcium & phosphorus blood levels, decreases calcium levels.

Diabetes - Monitoring Blood Glucose

- Types 1 Diabetes - meal plan based on individuals usual food intake & is balanced with insulin & exercise, insulin regimen is managed day to day. - Type 2 Diabetes - emphasis based on achieving glucose, lipid, & blood pressure goals, calories reduction. - Self Monitoring Blood Glucose - enables patient to make self management decisions regarding diet, exercise, & medication, important for detecting episodic hyperglycemia & hypoglycemia, patient training is crucial, supplies immediate information about blood glucose levels.

Diabetic Keotacidosis - Etiology

- Undiagnosed diabetes mellitus. - Inadequate treatment of existing diabetes mellitus. - Insulin not taken as prescribed infection. - Change in diet, insulin, or exercise regimen.

Diagnosing Diabetes - Hemoglobin A1C

- Useful in determining glycemic levels over time. - Not diagnostic, but monitors success of treatment. - Blood glucose levels are elevated over time, the amount of glucose attached to hgb molecules increases. - Shows the amount of glucose attached to hemoglobin molecules over RBC life span (90 to 120 days). - Provides measurement of glycemic control over the pervious 2 to 3 months. - Regular assessment is required to determine the success of current treatment plans & make changes to the plan if glycemic goals are not achieved. - Ideal goal is less than or equal to 6.5%.

Insulin - Patient & Caregiver Teaching

- Wash hands. - Always inspect insulin bottle before using it. Make sure that it is the proper type & concentration, expiration date has not passed, top of bottle in perfect condition. - If insulin solutions are cloudy, gently roll the insulin bottle between the palms of hands to mix the insulin. - Select proper injection site. - Cleanse the skin. - Pinch up the skin & push the needle straight into the pinched up area (90 degree). If very thin or using 5/16 inch needle, you may need to use a 45 degree angle. - Push plunger all the way down, let go of pinched skin, leave needle in place for 5 seconds, then remove. - Destroy & dispose of single use syringe safely.

What is the nurse's best response about developing diabetes to the patient whose father has type 1 diabetes mellitus? a. "You have a greater susceptibility for development of the disease because of your family history." b. "Your risk is the same as the general population, because there is no genetic risk for development of type 1 diabetes." c. "Type 1 diabetes is inherited in an autosomal dominant pattern. Therefore the risk for becoming diabetic is 50%." d. "Because you are a woman and your father is the parent with diabetes, your risk is not increased for eventual development of the disease. However, your brothers will become diabetic."

ANS: A Even though type 1 diabetes does not follow a specific genetic pattern of inheritance, those with one parent with type 1 diabetes are at an increased risk for development of the disease.

The nurse instructs a patient with type 1 diabetes mellitus to avoid which of the following drugs while taking insulin? a. Furosemide (Lasix) b. Dicumarol (Bishydroxycoumarin) c. Reserpine (Serpasil) d. Cimetidine (Tagamet)

ANS: A Furosemide is a loop diuretic and can increase serum glucose levels; its use is contraindicated with insulin. Dicumarol, an anticoagulant; reserpine, an anti-hypertensive; and cimetidine, an H2 receptor antagonist, do not affect blood glucose levels.

Which of the following would be included in the assessment of a patient with diabetes mellitus who is experiencing a hypoglycemic reaction? (Select all that apply.) a. Tremors b. Nervousness c. Extreme thirst d. Flushed skin e. Profuse perspiration f. Constricted pupils

ANS: A, B, E When hypoglycemia occurs, blood glucose levels fall, resulting in sympathetic nervous system responses such as tremors, nervousness, and profuse perspiration. Dilated pupils would also occur, not constricted pupils. Extreme thirst, flushed skin, and constricted pupils are consistent with hyperglycemia.

The nursery nurse identifies a newborn at significant risk for hypothermic alteration in thermoregulation because the patient is a. large for gestational age. b. low birth weight. c. born at term. d. well nourished.

ANS: B Low birth weight and poorly nourished infants (particularly premature infants) and children are at greatest risk for hypothermia. A large for gestational age infant would not be malnourished. An infant born at term is not considered at significant risk. A well nourished infant is not at significant risk.

Strategies to include in a community program for senior citizens related to dealing with cold winter temperatures would include a. avoiding hot beverages. b. shopping at an indoor mall. c. using a fan at low speed. d. walking slowly in the park.

ANS: B Shopping indoors where there is protection from the elements and temperature control is one strategy to avoid cold temperatures. Hot beverages can help an individual deal with cold weather. Avoiding breezes and air currents is recommended to conserve body temperature. Physical activity can increase body temperature, and if the senior is going to walk in the park, weather-appropriate (warm) clothing and a usual or brisk pace, not a slow pace, would be recommended.

The most appropriate measure for a nurse to use in assessing core body temperature when there are suspected problems with thermoregulation is a(n) a. oral thermometer. b. rectal thermometer. c. temporal thermometer scan. d. tympanic membrane sensor.

ANS: B The most reliable means available for assessing core temperature is a rectal temperature, which is considered the standard of practice. An oral temperature is a common measure but not the most reliable. A temporal thermometer scan has some limitations and is not the standard. The tympanic membrane sensor could be used as a second source for temperature assessment.

A diabetic patient is brought into the emergency department unresponsive. The arterial pH is 7.28. Besides the blood pH, which clinical manifestation is seen in uncontrolled diabetes mellitus and ketoacidosis? a. Oral temperature of 38.9° Celsius b. Severe orthostatic hypotension c. Increased rate and depth of respiration d. Extremity tremors followed by seizure activity

ANS: C Ketoacidosis decreases the pH of the blood, stimulating the respiratory control area of the brain to buffer the effects of the increasing acidosis. The rate and depth of respirations are increased (Kussmaul's respirations) to excrete more acids by exhalation.

During orientation to an emergency department, the nurse educator would be concerned if the new nurse listed which of the following as a risk factor for impaired thermoregulation? a. Impaired cognition b. Occupational exposure c. Physical agility d. Temperature extremes

ANS: C Physical agility is not a risk factor for impaired thermoregulation. The nurse educator would use this information to plan additional teaching to include medical conditions and gait disturbance as risk factors for hypothermia, because their bodies have a reduced ability to generate heat. Impaired cognition is a risk factor. Recreational or occupational exposure is a risk factor. Temperature extremes are risk factors for impaired thermoregulation.

The nurse associates which assessment finding in the diabetic patient with decreasing renal function? a. Ketone bodies in the urine during acidosis b. Glucose in the urine during hyperglycemia c. Protein in the urine during a random urinalysis d. White blood cells in the urine during a random urinalysis

ANS: C Urine should not contain protein. Proteinuria in a diabetic heralds the beginning of renal insufficiency or diabetic nephropathy with subsequent progression to end stage renal disease. Chronic elevated blood glucose levels can cause renal hypertension and excess kidney perfusion with leakage from the renal vasculature. This leaking allows protein to be filtered into the urine.

The nurse admitting a patient to the emergency department on a very hot summer day would suspect hyperthermia when the patient demonstrates a. decreased respirations. b. low pulse rate. c. red, sweaty skin. d. slow capillary refill.

ANS: C With hyperthermia, vasodilatation occurs causing the skin to appear flushed and warm or hot to touch. There is an increased respiration rate with hyperthermia. The heart rate increases with hyperthermia. With hypothermia there is slow capillary refill.

The nurse planning care for a patient with hypothermia would consider knowledge of similar exemplars including a. heat exhaustion. b. heat stroke. c. infection. d. prematurity.

ANS: D Prematurity, frost bite, environmental exposure, and brain injury are considered exemplars of hypothermia. Heat exhaustion is an exemplar of hyperthermia. Heat stroke is an exemplar of hyperthermia. Infection is an exemplar of hyperthermia.

A volunteer at the senior center asks the visiting nurse why the senior citizens always seem to be complaining about temperatures. The nurse's best response is that older people have a diminished ability to regulate body temperature because of a. active sweat glands. b. increased circulation. c. peripheral vasoconstriction. d. slower metabolic rates.

ANS: D Slower metabolic rates are one factor that reduces the ability of older adults to regulate temperature and be comfortable when there are any temperature changes. As the body ages, the sweat glands decrease in number and efficiency. Older adults have reduced circulation. The body conserves heat through peripheral vasoconstriction, and older adults have a decreased vasoconstrictive response, which impacts ability to respond to temperature changes.

The priority nursing intervention for a patient suspected to be hypothermic would be to a. assess vital signs. b. hydrate with intravenous (IV) fluids. c. provide a warm blanket. d. remove wet clothes.

ANS: D The first thing to do with a patient suspected to be hypothermic is to remove wet clothes, because heat loss is five times greater when clothing is wet. Assessing vital signs is important, but the wet clothes should be removed first. Hydration is very important with hyperthermia and the associated danger of dehydration, but there is not a similar risk with hypothermia. A warm blanket over wet clothes would not be an effective warming strategy.

The nurse recognizes which patient as having the greatest risk for undiagnosed diabetes mellitus? a. Young white man b. Middle-aged African-American man c. Young African-American woman d. Middle-aged Native American woman

ANS: D The highest incidence of diabetes in the United States occurs in Native Americans. With age, the incidence of diabetes increases in all races and ethnic groups.

A client with multiple myeloma who is receiving chemotherapy has a temperature of 102.2° F. The temperature was 99.2° F when it was taken six hours ago. A priority nursing intervention is to:

Administer the prescribed antipyretic and notify the primary health care provider

A 6-year-old boy is sent to the school nurse on a snowy below-freezing day because he arrived without a coat, wearing shorts, a T-shirt, and sandals. What is the first nursing intervention?

Checking the child for frostbite

A health care provider prescribes the application of a warm soak to an intravenous (IV) site that has infiltrated. What principle does the nurse determine is in operation when the application of local heat transfers temperature to the body?

Conduction

A client with hypothermia is brought to the emergency department. What treatment does the nurse anticipate?

Core rewarming with warm fluids

A client's temperature is 100.4° F 12 hours after a spontaneous vaginal birth. What does the nurse suspect is the cause of the increased temperature?

Dehydration

Diabetes Insipidus Vs. SIADH

Diabetes Insipidus: - Low ADH, low water in body. - Polyuria. - High sodium. - High H&H & serum osmolarity from dehydration. - Risk of Hypovalemic shock. - Treatment - DDVAP. SIADH: - High ADH, water intoxication. - Oliguria. - Low sodium. - Low serum osmolarity. - Weight gain. - Risk for seizures. - Treatment - fluid restrictions.

Collaborative Care - Diabetes Mellitus

Diagnostic: - History & physical. - Blood tests. - Urinalysis. - Blood pressure. - ECG. - Funduscopic exam (dilated eye exam). - Dental exam. - Neurologic exam. - Foot exam. - Monitoring of weight. Therapy: - Patient & caregiver teaching & follow up program. - Nutritional therapy. - Exercise therapy. - Self monitoring of blood glucose. - Drug therapy.

What are the initial nursing actions after the birth of a preterm baby with an Apgar score of 6?

Drying the infant and placing the infant in a warm controlled environment

Immediately after birth, a newborn is dried before being placed in skin-to-skin contact with the mother. What type of heat loss does this intervention prevent?

Evaporation

Which is a characteristic of the glands that secrete a thick substance in response to emotional stimulation and become odoriferous due to bacterial action?

Grow in conjunction with axillary hair follicles

Soon after admission to the hospital with a head injury, a client's temperature increases to 102.2° F (39° C). The nurse considers that the client has sustained injury to what structure?

Hypothalamus

A client gives birth to a full-term male with an 8/9 Apgar score. What should the immediate nursing care of this newborn include?

Identifying the infant, assessing respirations, and keeping him warm

Diabetic Ketoacidosis - Interventions

Initial: - Ensure patent airway. - Administer O2 via nasal cannula or non rebreather mask. - Establish IV access with large bore catheter. - Begin fluid resuscitation with 0.9% NaCl solution 1 L/hr until BP stabilized & urine output 30-60 mL/hr. - Begin continuous regular insulin drip 0.1 u/kg/hr. - Identify history of diabetes, time of last food, & time & amount of last insulin injection. Ongoing Monitoring: - Monitor VS, LOC, cardiac rhythm, O2 saturation, & urine output. - Assess breath sounds for fluid overload. - Monitor serum glucose & serum potassium. - Administer potassium to correct hypokalemia. - Administer sodium bicarbonate if severe acidosis (pH <7.0)>

While assessing a term infant a few hours after birth, the nurse finds a body temperature of 95.5° F. What does the nurse do in this situation?

Keep the infant in a double-walled incubator for a few hours

Diabetes - Nursing Assessment

Subjective Data: - Past Health History - mumps, rubella, coxsackievirus, or other viral infections, recent trauma, infection, or stress, pregnancy, gave birth to infant > 9lbs, chronic pancreatitis, Cushing syndrome, acromegaly, family history of diabetes. - Medications - use of adherence to regimen with insulin or OAs, corticosteroids, diuretics, phenytoin. - Recent surgery. Functional Health Patterns: - Health perception - positive family history, malaise, date of last eye & dental exam. - Nutritional - obesity, weight loss, weight gain, thirst, hunger, nausea & vomiting, poor healing, adherence to diet in patients with perilously diagnosed diabetes. - Elimination - constipation or diarrhea, frequent urination, frequent bladder infections, nocturia, urinary incontinence. - Activity - muscle weakness, fatigue. - Sexuality - erectile dysfunction, frequent vaginal infections, decreased libido. - Coping - depression, irritability, apathy. - Value - commitment to lifestyle changes. Objective Data: - Eyes - soft, sunken eyeballs, vitro all hemorrhages, cataracts. - Integumentary - dry, warm, inelastic skin, pigmented lesions, ulcers, loss of hair on toes. - Respiratory - rapid, deep respirations. - Cardiovascular - hypotension, weak, rapid pulse. - GI - dry mouth, vomiting, fruity breath. - Neurologic - altered reflexes, restlessness, confusion, stupor, coma. - Musculoskeletal - muscle wasting.

Disorders of the Thyroid - Hypothyroidism

- A deficiency of thyroid hormone that causes a general slowing of the metabolic rate. - Most common cause is Hashimoto's Thyroiditis. - Common in those previously treated for hyperthyroidism. - Atrophy of gland with aging. - Medications like lithium, iodine compounds, antithyroid medications can cause. - Most common in women, especially over age 50. - Can be caused by infiltrative disease like amyloidosis, scleroderma, iodine deficiency & excess, & hypothalamic or Pituitary abnormality. - Manifestations range from mild symptoms to myxedema. - S/S - fatigue, hair loss, dry skin, brittle nails, numbness & tingling of the fingers, amenorrhea, weight gain, decreased heart rate & temperature, lassitude, cognitive changes, elevated cholesterol levels, constipation, & hypotension. - Myxedema - accumulation of mucopolysaccharides in subcut & interstitial tissues, extreme form of hypothyroidism, can progress to shock. - Pharmacological Management - levothyroxine is preferred (dosage based on TSH).

Disorders of Anterior Pituitary Gland - Hypophysectomy

- A procedure to access & remove the pituitary gland. - To access it, an incision is made beneath the patient's upper lip to enter the nasal cavity. - A speculum is inserted & special forceps are used to to remove the Pituitary tumor. Nursing Care: - elevate head of the bed, 30 to 45 degrees. - avoidance of vigorous coughing, sneezing, & straining at stool to prevent CSF leakage at entry site. - frequent neurologic assessment. - mild analgesic for headaches. - no tooth brushing for 10 days. If Pituitary gland is damaged, ADH, cortisol, & thyroid replacement may be needed. - radiation therapy. - drug therapy - somatostatin analogs, GH receptor antagonist, & dopamine agonist (reduce GH levels).

Insulin Dependent Diabetes Mellitus - Nursing Plans & Interventions

- Assist with diagnosis. If child is ketoacidosis, provide care for seriously ill child: - monitor VS & neurologic status. - monitor blood glucose, pH, serum electrolytes. - administer IV fluids, insulin, & electrolytes as prescribed. - assess hydration status. - maintain strict I&O. Initiate home teaching program as soon as possible, involve child & family: - teach insulin administration - child usually receives multiple doses daily & may be administered subcutaneously or via insulin pump. - teach dietary management - meals & snacks, growth & exercise needs, 4 basic food groups, no concentrated sweets, advice for nutritionist. - teach about exercise - regular planned exercise, diet modification (snacks before or during exercise). - Teach about home glucose monitoring & urine testing. - Teach the signs & symptoms of hyperglycemia & hypoglycemia. Initiate program for school age child: - identify issues specific to school - physical education class & exercise, scheduled time for meals & snacks, cooperation with teachers & school nurses, & need to be like peers. - teach that a school age child should be responsible for most management. - instruct child to wear MedicAlert ID bracelet.

Addison Disease (Primary Adrenocortical Deficiency)

- Autoimmune process commonly found in conjunction with other endocrine diseases of an autoimmune nature, a primary disorder, hypofunction of the adrenal cortex. - Sudden withdrawal from Corticosteriods may precipitate symptoms of Addison disease. - Addison disease is characterized by lack of cortisol, aldosterone, & androgens. - Definitive diagnosis is made suing an ACTH stimulation test. - If ACTH production by the anterior pituitary has failed, it is considered secondary to Addison's disease.

Phenylketonuria (PKU)

- Autosomal recessive disorder in which the body cannot metabolize the essential amino acid phenylalanine. - The build up of serum phenylalanine leads to CNS damage, most notable mental retardation. - Decreased melanin produces light skin & blond hair.

Insulin Dependent Diabetes Mellitus - Nursing Assessment

- Classic 3 P's - Polydipsia, polyphagia, polyuria. - Irritability, fatigue. - Weight loss. - Abdominal complaints, nausea, vomiting. - Usually occurs in school age, but can occur in infancy.

Crushing Syndrome - Nursing Plans & Interventions

- Encourage the client to protect himself or herself from exposure to infection. - Wash hands, use good handwashing. - Monitor client for infection. - Teach safety measures. - Provide goof skin & perineal care. - Provide low sodium diet, encourage consumption of foods that contain vitamin D & calcium. - Discuss possibility of weaning from steroids. - Encourage selection of clothing that minimizes visible aberrations, encourage maintenance of normal physical appearance. - Monitor I&O. - Provide ulcer prophylaxis.

Endocrine System - Nursing Plans & Interventions

- Encourage thyroid testing for older clients who seem depressed. Hypothyroidism is often dismissed as depression. - Older clients may have difficulty with lifelong medication regimes. Develop memory cues for medication & caution against abrupt withdrawal. - Encourage annual physical exam with routine lab tests. - Encourage annual eye exams. - Teach daily foot care & monthly toenail care.

Hyperthyroidism - Nursing Assessment

- Enlarged thyroid gland. - Acceleration of body processes, weight loss, increased appetite, diarrhea, heat intolerance, tachycardia, palpitations, increased BP, diaphoresis, wet or moist skin, nervousness, & insomnia. - Exophthalmos. - T3 elevated above 220 ng/dl. - T4 elevated above 12 mcg/dl. - Low level of TSH indicates primary disease, elevated T4 level suppresses TSH secretion. If source is anterior pituitary, both will be elevated. - Radioactive iodine uptake (indicating presence of goiter). - Thyroid scan (indicating presence of goiter).

Hormones - Adrenal Medulla

- Epinephrine - targets sympathetic effectors, increases in response to stress, enhances & prolongs effects of sympathetic nervous system. - Norepinephrine- targets sympathetic effectors, increases in response to stress, enhances & prolongs effects of sympathetic nervous system.

Hormones - Gonads

- Estrogen - targets the reproductive systems & breast, stimulates development of secondary sex characteristics, preparation of uterus for fertilization & fetal development, stimulates bone growth. - Progesterone - targets reproductive system, maintains lining of uterus necessary for successful pregnancy. - Testosterone - targets reproductive system, stimulates development of secondary sex characteristic, spermatogensis.

Cushing Syndrome

- Excess andrenocorticoid activity. - Cause is usually chronic administration of corticosteroids. - Cushing syndrome can also be caused by adrenal, pituitary, or hypothalamus.

Hormones - Anterior Pituitary

- Growth Hormone - targets all body cells, promotes protein anabolism (growth & tissue repair), lipid mobilization, & catabolism. - Thyroid Stimulating Hormone - targets thyroid gland, stimulates synthesis & release of thyroid function. - Adrenocorticotropic Hormone - targets adrenal cortex, fosters growth of adrenal cortex, stimulates secretion of corticosteriods. - Gonadotropic Hormones - targets reproductive organs, stimulates sex hormone secretion, reproductive organ growth. - Melanocyte Stimulating - targets melanocytes in skin,increases melanin production in melanocytes. - Prolactin - targets ovaries & testes, stimulates milk production, stimulates testicular function.

Disorders of the Thyroid - Hyperthyroidism

- Hyperactivity of the thyroid gland with sustained increase in synthesis & release of thyroid hormones. - Antibodies seen in Hashimoto's, Grave's, & other auto immune disorders. - Radioactive Iodine Uptake Test measures the rate of iodine uptake, patients with hyperthyroidism exhibit a high uptake, hypothyroidism will have a low uptake. - Thyroid Screening Test - helps determine the location, size, & shape of the gland, "hot areas" (increased function) & "cold areas" (decreased function) can assist in diagnosis. - Manifestations - intolerance to heat, bulging eyes, facial flushing, tachycardia, increased systolic BP, weight loss, muscle wasting, tremors, diarrhea, finger clubbing, & localized edema. - Treatment includes reducing thyroid hyperactivity - usually use radioactive iodine, anti thyroid medications, beta blockers, or surgery. - Patient can relapse with antithyroid medications.

Hypothyroidism (Hashimoto Disease, Myxedema)

- Hypofunction of the thyroid gland, with resulting insufficiency of the thyroid hormone. - Early symptoms of hypothyroidism are nonspecific but gradually intensify. - Hypothyroidism is treated by hormone replacement. - Endemic goiter a occur in individuals living in areas where there is a deficit of iodine. Iodized salt has helped to prevent this problem.

Thyroid - Assessment of

- Inspect gland. - Observe for goiter - iodine deficiency. - Check TSH, serum T3 & T4. - T3 resin uptake test is useful in evaluating thyroid hormone levels in patients who have received diagnostic or therapeutic dose of iodine. - Estrogens, Dilantin, Tagmet, Heparin, amiodarone, PTU, steroids, & Lithium can cloud accuracy of uptake test. - T3 is more accurate indicator of hyperthyroidism.

Hormones - Pancreas

- Insulin - targets general cells, promotes movement of glucose out of blood & into cells. - Amylin - targets liver & stomach, decreases gastric motility, glucagon secretion, & endogenous glucose release from liver. - Glucagon - targets general cells, stimulates glycogenolysis & gluconegonesis. - Somatostatin - targets pancreas cells, inhibits insulin & glucagon secretion. - Pancreatic Polypeptide - targets general cells, influences regulation of pancreatic exocrine function & metabolism of absorbed nutrients.

Disorders of the Parathyroid - Hypoparathyroidism

- Manifestations - irritability of neuromuscular system, tetany (hypertonic muscle contractions), numbness, tingling, cramps in extremities, laryngeal spasm, bronchospasm, carpopedal spasm (flexion of the elbows & wrists, dorsiflexion of the feet), & seizures. - Assessment & Diagnostic - Trousseau's Sign (check with BP cuff), Chvostek's Sign (tapping of facial nerve causes spasm of mouth, nose, & eyes), lab studies may reveal calcium levels of 5-6 mg/dl or lower, & serum phosphate levels will be decreased.

Insulin Dependent Diabetes Mellitus (Type 1 Diabetes)

- Metabolic disorder in which the insulin producing cells of the pancreas are nonfunctioning as a result of some insult. - Heredity, viral infections, & autoimmune processes are implicated in diabetes mellitus. - Diabetes causes altered metabolism of carbs, proteins, & fats. - Insulin replacement, dietary management, & exercise are the treatments.

Cushing Syndrome - Nursing Assessment

- Moon face. - Truncal obesity. - Buffalo hump. - Abdominal striae. - Muscle atrophy. - Thinning of the skin. - Hirsutism in females. - Hyperpigmentation. - Amenorrhea. - Edema, poor wound healing. - Impotence. - Bruises easily. - HTN. - Susceptibility to multiple infections. - Osteoporosis. - Peptic ulcer formation. - Many false positives & false negative in lab testing.

Regulation of Hormones - Simple Feedback

- Negative feedback. - Relies on the blood levels of a hormone. - Gland increasing or decreasing the release of a hormone. - Similar to a thermostat (cold air in a room activates the thermostat to release heat).

Congenital Hypothyroidism - Nursing Assessment

- Newborn screening reveals low T4 & high TSH. - Symptoms in the Newborn - long gestation, large hypoactive infant, delayed meconium passage, feeding problems, prolonged physiologic jaundice, hypothermia. - Symptoms in Early Infancy - large, protruding tongue, coarse hair, lethargy, sleepiness, flat expression, & constipation.

Phenylketonuria (PKU) - Nursing Assessment

- Newborn screening using the Guthrie test - positive result, serum phenylalanine level of 4 mg/dl. - Frequent vomiting, failure to gain weight. - Irritability, hyperactivity. - Musty odor of urine.

Hyperthyroidism - Antithyroid Medications

- PTU - blocks synthesis of hormones. - Tapazole - blocks synthesis of hormones, more toxic than PTU. - Sodium Iodine Suppresses - release of thyroid hormone SSKI, suppresses release of hormones & decreases vascularity of the thyroid. - Dexamethazone - suppresses release of thyroid hormones.

Parathyroid Gland

- Parathyroid hormone - regulated serum calcium. - Parathyroid glands are small glands of the endocrine system which are located in the neck behind the thyroid. - Control the calcium in the body. - Calcium is the most important element in our bodies, so it is regulated very carefully.

Congenital Hypothyroidism - Nursing Plans & Interventions

- Perform newborn screening programs before discharge. - Assess newborn for signs of congenital hypothyroidism. - Teach family about replacement therapy with thyroid hormone - explain that child will have a lifelong need for therapy, tell parents to give child a single dose in the morning, teach family to check child's pulse daily before giving thyroid medication, & periodic thyroid testing is necessary. - Signs of overdose include rapid pulse, irritability, fever, weight loss, & diarrhea. - Signs of underdose include lethargy, fatigue, constipation, & poor feeding.

Phenylketonuria (PKU) - Nursing Plans & Interventions

- Perform newborn screening test at birth & again at about 3 weeks of age. Teach Family Dietary Management: - Stress the importance of strict adherence to prescribed low phenylalanine diet. - Instruct family to provide special formulas for infant (Lofemalac). - Instruct family to provide phenyl free milk substitute after the age of 2 years. - Teach family to avoid foods high in phenylalanine - high protein foods (milk, meat, dairy products, & eggs). - Teach family to offer foods low in phenylalanine (vegetables, fruits, juices, cereals, breads, & starches). - Encourage family to work with a nutritionist. - Teach that diet must be maintained at least until brain growth is complete (age 6 to 8). - Refer for genetic counseling.

Hyperthyroidism - Nursing Plans & Interventions

- Provide a calm, restful environment. - Observe for signs of thyroid storm (sudden over secretion of thyroid hormone, life threatening). - Teach - hypothyroidism will require daily hormone replacement, client should wear MediAlert jewelry, sign of hormone replacement overdosage are signs for hyperthyroidism, signs of hormone replacement underdone are the signs of hypothyroidism. - Explain to client the recommended diet - high calorie, high protein, low caffeine, low fiber diet (if diarrhea is present). - Perform eye care for exophthalmos - artificial tears to maintain moisture, sunglasses when in bright light, & annual eye examinations. - Thyroid Ablation - PTU & Tapazole act by blocking synthesis of T3 & T4, dosage is calculated based on body weight & is given over several months, & the expected effect is to make the client euthyroid, often given to prepare the client for thyroidectomy. - Radiation - 131 I is given to destroy thyroid cells, 131 I is very irritating to the GI tract, clients commonly vomit, place client on radiation precautions. - Thyroidectomy - check frequently for bleeding, irregular breathing, neck swelling, frequent swallowing, & sensation of fullness, support neck when moving, check for laryngeal edema damage by watching for hoarseness or inability to speak clearly, monitor Trousseau & Chvostek signs, as removal of parathyroid may lead to tetany, & keep drainage devices empty. - Adenectomy - TSH secreting pituitary tumors are rescue tend using a transnasal approach.

Disorders of the Parathyroid - Hypercalcemic Crisis

- Seen with levels greater than 15 mg/dl. - Can result in life threatening neurologic, cardiovascular, & renal symptoms. - Treatment - hydration, loop diuretics to promote excretion of calcium, phosphate therapy to promote calcium deposition in bone & reducing GI absorption of calcium, give calcitonin or mithramycin to decrease serum calcium levels quickly.

Endocrine System - Nursing Assessment

- Signs & symptoms of diabetes in older adults - dehydration & confusion. - History of recurrent infections, fatigue, & nausea, delayed wound healing, & paresthesia. - Weight loss or gain without change in eating pattern. - Lab Values - hemoglobin A, aldosterone, & cortisol levels. - Bone density testing. - Sleeping pattern. - Depression.

Addison Disease - Nursing Plans & Interventions

- Take vital signs frequently. - Monitor I&O & weigh daily. - Instruct client to rise slowly because of possibility of postural hypotension. - During crises, administer IV glucose with parenteral hydrocortisone, a steroid with both mineralocorticoid & glucocorticoid properties, requires large fluid volume replacement. - Monitor serum electrolyte levels. - Maintain low stress environment. - Teach - need for lifelong hormone replacement, need for close medical supervision, need for MedicAlert, S/S of overdose & underdose, diet requirements (high sodium, low potassium, & high carb), & fluid replacement - intake of at least 3 L of fluid per day. - Provide ulcer prophylaxis.

Hypothyroidism - Nursing Plans & Interventions

- Teach the following - medication regimen, medication effects & side effects, ongoing follow up to determine serum hormone levels, & S/S of myxedema coma (hypotension, hypothermia, Hyponatremia, hypoglycemia, & respiratory failure). - Develop a bowel elimination plan to prevent constipation - fluid intake to be 3 L/day, high fiber diet, increased activity, little or no use of enemas & laxatives. - Avoid sedating client.

Thyroid - Function of

- Thyroid T3 & T4 - needed for iodine for synthesis of hormones. - Thyroid is controlled by TSH - cellular metabolism, brain development, normal growth, affect every organ in the body. - T3 is five times more potent as T4. - Calcitonin - secreted in response to high levels of serum calcium, increases deposition in the bone. - TSH is similar to a thermostat - too much hormone secretion, TSH production & secretion slow in attempt to slow the release of the thyroid hormone.

A person sustains severe burns of the arms and is waiting for emergency services to arrive. A nurse bystander responds to the scene. Another bystander is getting ready to apply butter to the burns, stating that it will provide soothing relief. An appropriate response by the nurse is, "I wouldn't advise putting the butter on. Our focus should be on

... covering up the victim with one of those tablecloths.

The nurse has initiated an intravenous antibiotic on a client with hyperpyrexia and diminished urine output. The nurse concludes that the probable cause of the diminished urine output is:

A compensatory response to fever

After surgery for insertion of a coronary artery bypass graft (CABG), a client develops a temperature of 102° F (38.8° C). What priority concern related to elevated temperatures does a nurse consider when notifying the health care provider about the client's temperature?

A fever increases the cardiac output

When a diabetic patient asks about maintaining adequate blood glucose levels, which of the following statements by the nurse relates most directly to the necessity of maintaining blood glucose levels no lower than about 74 mg/dl? a. "Glucose is the only type of fuel used by body cells to produce the energy needed for physiologic activity." b. "The central nervous system cannot store glucose and needs a continuous supply of glucose for fuel." c. "Without a minimum level of glucose circulating in the blood, erythrocytes cannot produce ATP." d. "The presence of glucose in the blood counteracts the formation of lactic acid and prevents acidosis."

ANS: B The brain cannot synthesize or store significant amounts of glucose; thus a continuous supply from the body's circulation is needed to meet the fuel demands of the central nervous system.

A nurse must continually assess a preterm infant's temperature and provide appropriate nursing care because, unlike the full-term infant, the preterm infant:

Has a limited supply of brown fat available to provide heat

A parent of a preterm infant asks a nurse in the neonatal intensive care unit why the baby is in a bed with a radiant warmer. The nurse explains that preterm infants are at increased risk for hypothermia because they

Lack the subcutaneous fat that usually provides insulation

A nursing instructor provides education for the students on thermoregulation in the nursery. The students determine that in the healthy full-term neonate, heat production is accomplished by:

Metabolism of brown fat

The nurse is measuring the body temperature of four neonates born at term in a pediatric health setting. Which neonate has normal body temperature?

Neonate 3 The normal body temperature of term neonates is in the range of 36.5° to 37.5° C. Therefore, a body temperature of 37.1° C is a normal finding. The body temperatures of 35.5° C and 36.0° C in neonates 1 and 2 indicate hypothermia. The body temperature of 38.5° C in neonate 4 indicates hyperthermia

A client has been diagnosed with hyperthyroidism. The nurse expects the client to exhibit which clinical manifestations? Select all that apply

Nervousness Increased appetite

A nurse assesses the vital signs of a 50-year-old female client and documents the results. Which of the following are considered within normal range for this client? Select all that apply.

Oral temperature of 98.2° F Apical pulse of 88 beats per minute and regular Blood pressure of 116/78 mm Hg while in a sitting position

The nurse is reassessing a newborn who had an axillary temperature of 97° F (36° C) and was placed skin to skin with the mother. The newborn's axillary temperature is still 97° F (36° C) after 1 hour of skin-to-skin contact. Which intervention should the nurse implement next?

Placing the newborn under a radiant warmer in the nursery

A preterm neonate is receiving oxygen by way of an overhead hood. What should the nurse do to protect the infant under the oxygen hood?

Put a hat on the infant's head to avoid hypothermia

A preterm infant is receiving oxygen from an overhead hood. What nursing care is required while the infant is under the hood?

Putting a hat on the infant's head

A nurse is caring for a mother and neonate. What is the priority nursing action to prevent heat loss in the neonate immediately after birth?

Putting the naked newborn on the mother's skin and covering the infant with a blanket

An unresponsive older adult is admitted to the emergency department on a hot, humid day. The initial nursing assessment reveals hot, dry skin, a respiratory rate of 36 breaths/min, and a heart rate of 128 beats/min. What is the initial nursing action?

Remove the clothing.

On the day after surgery for insertion of a ventriculoperitoneal shunt to treat hydrocephalus, an infant's temperature increases to 103.0° F (39.4° C). The nurse immediately notifies the practitioner. What is the next nursing action?

Removing excess clothing from the infant

During the assessment of a preterm neonate the nurse determines that the infant is experiencing hypothermia. What should the nurse do?

Rewarm gradually

After surgery a client's fever does not respond to antipyretics. The health care provider prescribes that the client be placed on a hypothermia blanket. A response to hypothermia therapy that the nurse should prevent is:

Shivering

Endocrine System - Focused Assessment

Subjective: - excessive or increased thirst. - excessive or decreased urination. - excessive hunger. - intolerance to heat or cold. - excessive sweating. - recent weight gain or loss. Objective - Diagnostic: - potassium level. - glucose level. - sodium level. - glycosylated hemoglobin. - thyroid studies. Objective - Physical Exam: - body temperature. - height & weight. - alertness & emotional state. - skin for changes in color & texture. - hair for changes in color, texture, & disturbance. Auscultation: - heart rate. - blood pressure. Palpate: - extremities for edema. - skin for texture & temperature. - neck for thyroid size, shape.

While assessing a newborn, the nurse notes that the skin is mottled. What should the nurse do first?

Warm the environment.

What is the nurse's initial action immediately after assisting with a precipitous birth in the triage area of the emergency department?

Warming the newborn