Cue Cards on Endocrine
Hyperparathyroidism: Post-op care
- Hydration and ambulation to maintain bone density - Monitor for hypocalcemia AEB tight, rigid muscles
Hyperthyroidism: Eye care for exophthalmos
- Hypoallergenic tape may be applied to help close their eyelids - Dark glasses may be worn if photosensitivity is present - Artificial tears are used to prevent drying out Note: tx of hyperthyroidism is not curative for any eye or vision problems.
Hypoparathyroidism: Treatment
- IV Ca+ - Phosphate binding drugs (sevelamer hydrochloride)
Addison's disease: Nursing care
- Increase dietary Na+ intake (Processed fruit juice and broth are both good salty choices) - Promote H2O intake - I&Os - Daily wts - Monitor S/S of FVD (potential for shock): hypotension, wt loss, and dehydration
Hyperthyroidism diagnostic tests?
- Laboratory evaluation of serum TSH, T3 and T4, - - Thyroid scan (DC iodine containing meds 1 wk prior and wait 6 wks to restart if an iodine contrast is used) - US/MRI/CT Pharm note: An example of an iodine containing med is amiodarone (Cordarone) which is used for tx of arrhythmias.
Thyroidectomy (full or partial): Post-operative care
- Trach kit @ bedside - ↑ HOB 30-45° to ↓ edema around surgical site - ↑ calories r/t their hypermetabolic state - Keep personal items close so they don't put stress on their suture lines - Neck supports with pillows
Pheochromocytoma: Diagnostics
- VMA (vanillylmandelic acid) test - Metanephrine (MN) test Nothing with vanilla in it; no caffeine, Vitamin B, fruit juices, or bananas for several days to a week before the test - 24 hr UO collection Discard the 1st void and keep the last; need all 24 hrs since the secretions come in waves AVOID palpating the abdomen of a pt with suspected pheochromocytoma as it may cause the sudden release of epi/norepi and cause severe HTN.
Hypothyroidism treatment: Medications
- levothyroxine (Synthroid) - liothyronine (Cytomel) Admin: take on an empty stomach and start at a low dose to prevent complications*. May take these meds for the rest of their life. *Pts w/ hypothyroidism tend to have CAD 2° ↑ LDL lvls → worry about an MI when meds are started since ↑ BP & HR will occur.
Addison's disease: Medication
- prednisolone (Prednisone) Admin: BID in split doses (2/3 in AM and 1/3 in PM to mimic natural release of cortisol) - fludrocortisone = aldosterone Daily: BP and wt (monitor for daily wt ↑ > 2 lbs/day or 5 lbs/wk)
Hyperthyroidism supportive therapy: Beta Blockers
- propranolol (Inderal) Use: tx of S/S specifically ↓ myocardial contractility/↓ CO = ↓ HR and ↓ BP Used in hyperthyroid tx because it also ↓ anxiety. Pharm note: Do NOT give beta blockers to asthmatics (it can precipitate an asthma attack) or to diabetics (it can mask s/s of hypoglycemia: ↑ HR, cold, clammy skin, nervousness, shaky or jittery behavior).
Where is TSH produced?
Anterior pituitary gland
S/S of Cushing's syndrome
Too many steroids (glucocorticoids, mineralocorticoids, and androgens) - Hypokalemia 2° excess aldosterone which causes us to lose K+ and retain Na+ & H2O - Retained Na+ & H2O → wt ↑ and FVE → CHF and BP ↑ - 24 hr UO collection would show ↑ cortisol lvls
Hyperthyroidism treatment: Radioactive iodine therapy
- 1 dose PO (liquid or tab) - Rule out pregnancy first MOA: destroys all the thyroid cells → hypothyroidism is induced basically Radioactive precautions: avoid babies and no kissing for 1 week Monitor for rebound effect: thyrotoxicosis or thyrotoxic crisis = EMERGENCY SITUATION A thyroid storm is hyperthyroidism x 100 and a really high potential for MI is present.
Cushing's syndrome: Treatment
- Adrenalectomy (total or bilateral) - Surgery to remove tumor - Drug or radiation therapy
Adrenal cortex: Glucocorticoids
1) Change your mood - depressed, psychotic, euphoric, insomniac 2) Alter defense mechanisms - immunosuppressed/ suppressed inflammatory response - ↑ risk for infection 3) Breaks down fats & proteins 4) Inhibits insulin - hyperglycemic → requires blood glucose monitoring
Adrenal cortex: Problems
1) Not enough steroids 2) Hyperkalemia (2° insufficient aldosterone which causes us to lose Na+ & H2O and retain K+) 3) Shock 4) Hypoglycemia (steroids inhibit insulin)
What is priority for the client experiencing hyperparathyroid crisis? 1. Support for airway and breathing. 2. Continuous cardiac monitoring for arrhythmias. 3. Provide safety precautions. 4. Prepare for emergency tracheostomy.
1. Correct: Always remember ABC, if it is relevant, and it is with hyperparathyroidism. 2. Incorrect: Circulation is important. This priority comes after attention has been directed toward airway and breathing. What good would come of circulating deoxygenated blood, and how long can the heart muscle last without oxygen? Always remember ABC when prioritizing in emergency situations. 3. Incorrect: Muscle weakness, thus risk for falls is a concern, but airway takes priority! 4. Incorrect: Trach would be more likely with hypoparathyroidism. Remember, in hypoparathyroidism, the client would have rigid and tight muscles which would cause laryngospasms.
A client with acute pancreatitis is prescribed total parenteral nutrition (TPN), methylprednisolone, and sliding scale insulin. What is the rationale for the insulin prescribed? SATA. 1. Impaired endocrine function of the pancreas 2. Inability of the liver to convert glucose 3. Steroid therapy side effects 4. Dextrose concentration of TPN 5. Re-establish serum potassium level
1., 3., & 4. Correct: Really what we are saying here is why would the client be on insulin? Well, the pancreas is damaged and so the endocrine function of the pancreas is impaired. We know that hyperglycemia or pseudo diabetes is a side effect of steroid therapy and TPN is high in glucose and may require additional insulin. These are the three rationales for why they might need insulin. 2. Incorrect: If the liver can't convert glucose that will decrease the insulin need so that one is false. 5. Incorrect: Is not related at all. The NCLEX people want you to say,"I remember something about potassium and glucose, but I am not sure what. Don't fall for that, this is false. The rationale for the Insulin order is not to re-establish potassium in this question.
What is the primary electrolyte imbalance that the nurse should monitor for in a client who is receiving an insulin infusion? 1. Hypernatremia 2. Hypokalemia 3. Hypocalcemia 4. hypophosphatemia
2. Correct: Insulin causes movement of potassium into the cells, which can lead to a severe reduction in serum potassium if not regulated appropriately. A severe decrease in serum potassium could be fatal. 1. Incorrect: Although insulin has been shown to increase sodium reabsorption in the kidneys, the change is not as rapid and not as life threatening as the change in potassium. 3. Incorrect: A significant change in the calcium level is not anticipated with the insulin infusion. 4. Incorrect: A significant change in the phosphorus level is not anticipated with the insulin infusion.
Adrenal cortex: Mineralocorticoids (Aldosterone)
Promote reabsorption of Na+ & H2O Excretion of K+ Too much aldosterone? - FVE - Serum K+ ↓ (hypokalemia) Not enough aldosterone? - FVD - Serum K+ ↑ (hyperkalemia)
Adrenal medulla: Hormones
Secretes epinephrine and norepinephrine
Hyperparathyroidism: Treatment
Surgical removal of parathyroid glands → PTH secretion ↓
Pheochromocytoma: Treatment
Surgical removal of tumor
Standard orders on the nurse's unit include an intravenous infusion of 1000 mL normal saline with 20 mEq (20 mmol) potassium chloride to run at 100 mL per hour. These IV fluids would be appropriate for which client diagnosis? SATA. 1. Addison's crisis 2. Renal insufficiency 3. Abdominal cramping with diarrhea 4. Graves' disease 5. Hypokalemia
3., 4. & 5. Correct: Clients with abdominal cramping with diarrhea, Graves' disease, and hypokalemia are safe to receive normal saline with potassium chloride. 1. Incorrect: Clients with Addison's disease can have hyperkalemia if they experience an Addisonian crisis due to lack of aldosterone. When aldosterone is not secreted, sodium and water is released and potassium levels elevate in response to the hyponatremia. 2. Incorrect: With diminished renal function the client is at risk for sodium and potassium retention.
Adrenal glands
A pair of endocrine glands that sit just above the kidneys and secretes hormones that help arouse the body in times of stress.
S/S of hypothyroidism
Fatigue Mental sluggishness Lack of facial expression Slow, slurred speech ↓ GI motility Hypothermia and cold intolerance Dry flaky skin and thinning nails Weight ↑ Amenorrhea
Hyperthyroidism treatment: Medications
Thioamides: - methimazole (Tapazole) - propylthiouracil (PTU) MOA: stops the thyroid from making hormones Use: pre-op to stun thyroid into a normal state Iodine compounds: - potassium iodide (SSKI and Lugol's solution) MOA: ↓ the size and vascularity of the thyroid gland Admin: give in milk or juice and use a straw to prevent staining of the teeth
S/S of pheochromocytoma
↑ BP ↑ HR Palpitations Flushing/diaphoretic Headache
S/S of hyperthyroidism
↑ BP & HR Arrhythmia & palpitations ↑ thyroid gland size Nervousness, anxiety, and ↓ attention span ↑ sweating and heat intolerance ↑ appetite/GI motility with weight ↓ Exophthalmos
Adrenocorticotropic hormone (ACTH)
ACTH released from the pituitary gland → stimulates adrenal cortex → secretes glucocorticoids ↑ ACTH = ↑ glucocorticoids ↑ steroids = Hypercortisolism
Cushing's syndrome: Nursing care
- Check labs for: hypernatremia, hypokalemia, hypocalcemia, hyperglycemia, and glycosuria - Diet: ↑ protein, ↑ potassium, ↑ calcium, and ↓ in calories, carbs & sodium - Daily wts and I&O's - Monitor for infection → currently immunosuppressed - Quiet environment → prevent emotional stress
Adrenal cortex: Androgens (sex hormones)
- Testosterone - Estrogen - Progesterone Too many sex hormones? - Hirsutism - Acne Not enough sex hormones? - ↓ axillary/pubic hair - ↓ libido
Addisonian crisis precipitated by?
1) Physiological stress (ex: infection) 2) Physical stress (ex: exertion) 3) Emotional stress 4) Sudden withdrawal of steroids (must be tapered off) Alert: monitor for severe hypotension & vascular collapse
An elderly, bed-bound client receiving G-tube feeding at home is transported to the emergency department after onset of behavioral changes and hallucinations. Which nursing action is priority while diagnostic testing is underway? 1. Initiate seizure precautions 2. Discontinue G-tube feeding 3. Administer oxygen 4. Obtain blood work for troponin level
1. Correct: Feeding tube clients tend to get dehydrated, especially clients on bed rest, because bed rest induces diuresis! If the client is already having neurological signs, a grand mal seizure may be next! Better take seizure precautions while awaiting the serum sodium results. 2. Incorrect: You may do this; however, seizure precautions will take priority. 3. Incorrect: The priority here is seizure precautions. 4. Incorrect: This data should lead to the suspicion of dehydration and hyponatremia, not MI.
A client has been prescribed levothyroxine sodium. What should the nurse teach the client about this medication? SATA. 1. Therapy will last six month to one year. 2. Notify the primary healthcare provider of chest pain. 3. Take medication ½ hour before breakfast. 4. Do not take medication with calcium supplements. 5. Improvement of symptoms will occur within days.
2., 3. & 4. Correct: YES! Get medical help immediately if the side effect of chest pain occurs. It could be an MI. It is preferable to take medication on an empty stomach, ½ - 1 hr before breakfast. Should not be administered within 4 hours of calcium supplements. 1. Incorrect: No, therapy is for a lifetime. 5. Incorrect: It may take several weeks for symptoms to improve.
A nurse is reviewing serum laboratory data for four clients. Which client would require the most immediate assessment? Client 1: 12 mU/L Thyroid-stimulating hormone (TSH) Range: 2 -10 mU/L Client 2: 5.0 ng/dL Free T4 (thyroxine) Range: 0.8 - 2.8 ng/dL Client 3: 8 ng/mL Growth hormone Range: 0-6 ng/mL Client 4: 150 mg/dL Glucose Range: 70 - 110 mg/dL
2. Correct: An excess of thyroid hormone is the most life-threatening of the findings listed due to its effects on the cardiovascular system of hypertension and tachycardia. The client should be assessed for impending thyroid storm. 1. Incorrect: An elevated TSH level occurs in hypothyroidism. TSH is needed to ensure proper synthesis and secretion of the thyroid hormones which are essential for life. Not life-threatening. 3. Incorrect: An elevated growth hormone produces acromegaly with resulting bone and soft tissue deformities and enlarged viscera. But this is not life threatening. 4. Incorrect: Though the glucose level is elevated, a level of 150 mg/dL (8.3 mmol/L) does not require immediate assessment or intervention.
The nurse is caring for a client with Addison's disease that is taking fludrocortisone 0.1mg/day. What assessment data by the nurse would suggest that the client's dose is too high? SATA. 1. Weight loss of 2 lbs (0.907 kg)/24 hours 2. Elevated serum sodium level 3. Bilateral pedal edema 4. Crackles in the lung fields bilaterally 5. Elevated blood pressure
2., 3., 4., & 5. Correct: Now, remember that with Addison's disease the client does not have enough steroids, so we have to ADD steroids. All of these options indicate the client is holding onto fluid, and we would expect the client to hold onto fluid when their steroid dose is too high. 1. Incorrect: We would expect weight gain with this client, and what is the amount of weight gain we worry about? That's right, anything over 2-3 lbs (0.907 - 1.360 kg) in 24 hours.
A nurse is caring for a client who is diagnosed with diabetic ketoacidosis (DKA). Which primary healthcare provider prescription is appropriate during the first 24 hours of treatment for this client? 1. 0.9% saline solution at 50 mL/hr 2. 3% saline solution at 125 mL/hr 3. 0.9% saline solution at 1,000 mL/hr × 2 4. Dextrose 5% in lactated Ringer's solution at 125 mL/hr when blood glucose reaches 500 mg/dL
3. Correct: 0.9% saline solution should be infused at a rate of at 1,000 mL/hr times 2, up to a total of 10 L in the first 24 hours of treatment. This client will be in a fluid volume deficit or shock and fluid replacement is essential. 1. Incorrect. 0.9% saline would not be administered at 50 mL/hr because the first goal of fluid therapy in DKA is to restore volume in a severely volume depleted client, thus 50 mL/hr would be an inappropriate rate. 2. Incorrect. 3% saline solution would be contraindicated in this client because it is a hypertonic solution that would worsen the client's dehydration. 4. Incorrect. Dextrose 5% in lactated Ringer's solution at 125 mL/hr when blood glucose reaches 500 mg/dL is inappropriate because the blood sugar is still too high for infusion of a dextrose containing solution.
Adrenal medulla: Pheochromocytoma
A benign tumor of the adrenal medulla that causes the gland to produce excess epinephrine and norepinephrine. Tend to be familial so screen the family. Avoid any activities that increase stress.
Parathyroid hormone (PTH)
A hormone of the parathyroid gland that regulates the metabolism of calcium and phosphorus in the body.
S/S of Addison's disease
Adrenocortical insufficiency → not enough steroids (glucocorticoids, mineralocorticoids, and androgens) - Hyperkalemia 2° insufficient aldosterone which causes us to lose Na+ & H2O and retain K+
What do thyroid hormones do?
Give us energy (regulate metabolism)
Adrenal cortex: Hormones
Glucocorticoids → corticosteroids Mineralocorticoids → aldosterone Androgens → sex hormones
Hyperthyroidism surgery: Thyroidectomy (partial or complete) post-op priorities?
Hemorrhage - Pt report of pressure in neck - Bleeding at the incision site or pooling underneath their neck/head Laryngeal nerve damage - ↑ in hoarseness - ↑ in weakening of voice - Potential for vocal cord paralysis Airway obstruction - Paralysis of both vocal cords - Requires immediate tracheostomy
Hyperparathyroidism = ________calcemia = ________phosphatemia
Hypercalcemia = Hypophosphatemia Too much PTH ↑ serum Ca+ ↓ serum P
Hypoparathyroidism = _______calcemia = _______phosphatemia
Hypocalcemia = Hyperphosphatemia Not enough PTH ↓ serum Ca+ ↑ serum P
Hyperthyroidism post-op care: TRACH @ PT BEDSIDE
Indicated use in: - Swelling of the airway - Recurrent laryngeal nerve damage AEB vocal cord paralysis - Hypocalcemia r/t laryngospasms (tightening of the smooth muscles in the airway) 2° possible parathyroid gland removal
What does calcitonin do?
Lowers serum calcium levels by taking calcium out of the blood and pushing it back into the bone
Parathyroid glands
Small pea-like organs that regulate calcium and phosphate balance in blood, bones, and other tissues.
What are the 3 thyroid gland hormones?
T3, T4, & calcitonin
Hyperthyroidism lab levels for T4 and TSH?
T4 ↑ TSH ↓
Hypothyroidism lab levels for T4 and TSH?
T4 ↓ TSH ↑