Med Surg Unit 3 - Endocrine System
SIADH - teach and communicate
-Causes -Lung cancer or severe lung infections -Neurological disorders - stroke, trauma, meningitis, abscess -Psych medications (Tricyclic antidepressants, SSRIs, Antipsychotics) -Anti-epilepsy medications -Importance of fluid restriction until fluid balance stabilized -Monitor daily weight and take diuretics as prescribed. -Notify physician of signs of fluid overload/edema or dry mucous membranes/increased thirst for diuretic dose adjustment
Levothyroxine client teaching?
-Correct medication administration of thyroid replacement hormone -Take 1st thing in AM on empty stomach -magnesium containing antacids can decrease absorption -reduce digoxin potency -increased risk of bleeding with anticoagulants -increase potency and duration of narcotics/sedatives -Lifetime medication therapy -Importance of continuing to take the medications as prescribed even after symptoms improve -Nutrition and high-fiber diet to promote weight loss and normal bowel patterns -Follow-up lab testing with physician
Cushing's Disease vs Cushing's Syndrome
-EXCESS of hormone Cortisol -Making the patient look "Cushy" Body: Causes excessive levels of cortisol in the blood *Pituitary tumor secreting adrenocorticotropic hormone (ACTH) *Cancer tumors may produce ACTH *Adrenal Cortex Tumor secretes excess corticosteroid and aldosterone
What are important teaching for use of Mineralocorticoids (aldosterone) replacement?
-Given in morning -Adequate dose does not have side effects: tx hyperkalemia, hyponatrermai and fluid depletion -Too high dose can cause fluid retention, hypokalemia and hypernatremia
What other hormones does the pituitary gland produce and control?
-Growth hormone -Oxytocin -Prolactin -FSH -LH
Hypothyroid cues
-HR - low end of normal -BP - low end of normal -Neuro status - fatigue/confusion/depression/impaired memory -Temperature - Lower than normal -Hypoactive bowel Sounds - constipation -Lab work: -T3 and T4 levels low -TSH elevated if not pituitary cause, TSH low if pituitary cause -Cholesterol level increased
What are key assessments for a client with hypothyroidism?
-HR/BP/Respirations/O2 -Neurologic status/Depression -Temperature -Constipation/Bowel Sounds -Lab Values: T3 & T4 and TSH
What are the key assessments when caring for a client with hyperthyroidism?
-HR/ECG/BP -Respirations -Temperature -Bowel Sounds -Neurologic/Mood -Labs: T3/T4, TSH and Ca if post-thyroidectomy
What are possible complications post thyroidectomy?
•Tracheal Swelling/ Laryngospasm/Stridor •Keep tracheotomy set and oxygen equipment nearby •Bleeding/Hematoma •Repeated clearing of the throat or for complaints of difficulty swallowing •Hematoma at incision or dependent bruising •Thyroid storm •Excess thyroid hormone released by surgical manipulation •Usually first 12 hours post-thyroidectomy •Severe hypertension, tachycardia, fever, restlessness, nausea •Hypo/hyper calcium levels •Due to damage of parathyroid by surgery •Have calcium gluconate available at the patient's bedside if tetany develops.
Cushing's Disease vs Cushing's Syndrome
-EXCESS of hormone Cortisol -Making the patient look "Cushy"
Hyperthyroid Cues
-HR/ECG - Tachycardia, irregular heart rhythms -BP - Increased or hypertensive -Respirations - tachypneic -Neurologic - Tremors/nervousness or anxiety/Mood swings/insomnia -Temperature - Increased above normal, sweating -Bowel sounds - Hyperactive -Lab work - High T3 and T4 levels, Low TSH if healthy pituitary, High TSH if over-productive pituitary
What are the S/S of hyperaldosteronism?
-HTN -Hypernatremia -Hypokalemia -⬆️Weight (fluid retentio) -Lung sounds -Edema -Confusion/agitation/restlessness
What are worsening cues associated with pheochromocytoma?
-Hemorrhagic Stroke -Cardiac Failure -Respiratory Alkalosis
What are worsening cues of pheochromocytoma?
-Hemorrhagic stroke -Cardiac failure -Respiratory alkalosis
What to teach a client with hyperaldosteronism?
-How to check BP -Take Diuretics/Potassium supplements -Watch for signs of fluid overload/hypokalemia to report to provider -Low sodium diet -Daily weights -Frequent visits to physician for follow-up and lab work
Too much TSH secretion
-Hyperthyroid -Excess T4 /T3 production
Parathyroid GlandHypoparathyroid/Hyperparathyroid - Cues/Key Assessments
-Hypoparathyroid = SAME as Hypocalcemia -Hyperparathyroid = SAME as Hypercalcemia
What are worsening cues associated with Diabetes Insipidus (DI)?
-Hypotension due to severe dehydration (postural hypotension) -Renal Failure due to severe dehydration -Tachycardia
Too little TSH secretion
-Hypothyroid -Deficit T4/T3 production
What are the symptoms of adrenal crisis?
-Vascular Collapse (⬇️BP SBP <90) -⬇️Na (hyponatremia) -⬆️K (hyperkalemia) -Severe vomiting/diarrhea=Dehydration -Hypoglycemia (BG <70)
What foods promote diuresis that should be avoided when treated DI?
-Watermelon -Grapes -Garlic -Caffeine
SIADH is opposite of
DI, fluid overload would get diuretics because have too much ADH diluted labs, low, know S+S of electrolyte imbalances -oxygenation -perfusion
worsening cues of Addison's disease - Addison's crisis
-Addison's disease with acute stress or severe illness or abruptly stopping corticosteroid replacement -Life threatening hypotension (SBP < 90) -Hypoglycemia (Glucose < 70) -Hyperkalemia -Can cause dysrhythmias or cardiac arrest -Hyponatremia -Can cause cerebral edema and loss of consciousness -Severe vomiting and diarrhea - leading to dehydration n
What are important teaching for use of Glucocorticoid (cortisol) replacement?
-Adequate dose does not have side effects: tx hypoglycemia, GI and mood symptoms -Too high dose can cause Cushing's Syndrome -May need to increase steroid replacement during high stress/illness
What are interventions for a client with hyperaldosteronism?
-Adrenalectomy or nephrectomy (remove tumors) -TX fluid retention, hypokalemia, hypernatremia ---Potassium-sparing diuretics ---Oral potassium supplements ---Calcium channel blockers to decrease BP ---Sodium restrictions -Monitor ECG, HR, BP -Low Sodium/High Potassium diet -Daily weight
What to assess when caring for a client with Cushing's Syndrome/Disease?
-BG -BP -WBC -Weight/Appetite -Skin: Bruising, Edema, Fragility -Brittle bones
What are key assessments for treating a client with Addison's Disease?
-BP -BG -Electrolytes: Na & K -GI distress: N/V, appetite -Mentation & mood
Diabetes Insipidus Teach and communicate
-Causes -Brain trauma - stroke, head trauma, or surgery -Brain Tumors -Must take vasopressin daily as prescribed -Monitor urine output and notify provider if urine output is more than fluid intake or less than adequate amount (0.5 ml/kg/hr or 12 ml/kg/day) in case vasopressin dose needs to be adjusted. -Restrict foods that promote diuresis: watermelon, grapes, garlic, and caffeine (tea, energy drinks, coffee)
thryroid/parathyroid
- hypothyroid - myexdema - hyperthyroid - thyroid storm - parathyroid
Too little ATCH secretion
-Addison's Disease -Deficit of corticosteroid production
What hormones does the adrenal cortex release?
-cortisol -aldosterone -sex hormones **Retains NA+ & H2O **Loses K+
hypothyroidism interventions
-Levothyroxine IV or PO -If myxedema or coma -supportive treatment of bradycardia, low BP and respirations until medication levels are effective -High fiber diet
Too much ATCH secretion
Cushing's Disease -excess corticosteroid production
Hyperparathyroidism signs and symptoms
- fatigue, muscle weakness - cardiac dysrhythmias - emotional irritability - renal calculi - back and joint pain - pathological fractures - pancreatitis - peptic ulcer
What to communicate to a client about hyperthyroidism?
-Importance of follow-up lab work and physician appointments. -Ask about allergies to iodine (shellfish) -Iodine is used in contrast agents and radioactive iodine -Nutrition while treating hyperthyroid: -Well-balanced meals of small size, up to six meals a day. -Replace fluid lost through diarrhea and diaphoresis. -Over the counter diarrhea control -Avoid stimulant foods (coffee, tea, cola, and alcohol) Post Thyroid removal (Post-thyroidectomy or radioactive iodine) -Need for lifelong thyroid hormone replacement therapy -Need for healthy balanced diet to avoid weight gain in adjustment period from hyperthyroid to normal thyroid levels -Take the prescribed thyroid hormone replacement therapy and return for annual blood testing once the dosage has been stabilized. -Calcium supplements, if indicated.
What are the worsening cue to watch for in a client with Cushing's Syndrome/Disease?
-Infection (⬆️WBC without fever) -Severe hyperglycemia with dehydration -Severe hypertension: can cause ❤️ failure & hemorrhagic stroke
Diabetes Insipidus DI - DRY BODY - cues
-LACK of Antidiuretic hormone (ADH) -Polyuria: LOTS of urine 4L to 24 L per day -Diluted urine (low urine osmolality and specific gravity) -Dehydration -Thirst -Decreased weight -Decreased or orthostatic BP -Increased or orthostatic HR -Dry mucous membranes -Concentrated lab values due to low water levels
Teaching for post thyroidectomy?
-Lifelong thyroid hormone replacement therapy -Healthy balanced diet to avoid weight gain -Calcium supplements if indicated
What is the treatment for a client with SIADH?
-Loop Diuretics (Lasix) dose too high cause dehydration dose too low little improvement -Hypertonic 3% Saline diuretic first then 3% saline to pull fluid from tissue into vessels, loop diuretic IV anti-epilepsy meds involving brain -Seizure/Fall Precautions -Fluid Restriction -Strict I/O -Daily Weights
What are the symptoms associated with Lack of Cortisol in Addison's Disease?
-Low Blood Sugar -Neurologic: progressive weakness and extreme fatigue, irritability, depression (mood changes) -GI dysfunction: anorexia/weight loss, N/V, diarrhea, hyperpigmentation (darkening) of skin
What are the key assessments for a client with SIADH?
-Lung Sounds - crackles/rales -Urine Output: increase but not dehydration -Urine Osmolality/Specific Gravity: decrease -Weight/Edema: decrease but not dehydrated -BP/HR: baseline -Mucous Membrane: moist, watch for dehydration with tx -Electrolytes: normalize
Hypoparathyroidism signs and symptoms
-Numbness, -Tingling -Laryngeal stridor -Dyspnea -Cyanosis -Confusion -Lethargy -Emotional lability
What are the symptoms associated with Lack of Aldosterone in Addison's Disease?
-Orthostatic hypotension -Hyponatremia -Hyperkalemia
What are the worsening cues to watch for in a client with SIADH?
-Pulmonary Edema: rales, crackles, decreased O2 -Cerebral Edema: confusion, lethargy, combativeness, seizures
What are interventions for a client with hyperthyroidism?
-Radioactive Iodine -Anti-Thyroid medication: Methimazole or PTU -Thyroidectomy (surgical removal of thyroid gland) -BP control (beta blockers) -ECG monitoring -Cool, Dark room or Cooling blanket
Cushing's disease teach and communicate
-Reassure patient that physical changes and emotional lability will resolve when hormone levels return to normal -Infection control and how to stay healthy -How to check blood pressure -Well balanced diet and weight control -Frequent visits to physician for follow-up and labwork -Calcium supplements
What is the expectations post thyroidectomy?
-Semi Fowler or High Fowler position -Maintain neck in neutral position, not over-flexion or extension -Vocal cord edema/damage (hoarseness) -Pain management -JP drains -Advance diet as tolerated (cold fluids initially) -Monitor Calcium levels •Administer prophylactic postoperative antiemetics to prevent dry heaving/emesis
What are the worsening cues to monitor for in a client with hyperaldosteronism?
-Severe HTN -Pulmonary Edema -Cardiac dysrhythmia from hypokalemia
A client with pheochromocytoma; a tumor of the adrenal medulla. What are the key assessment/cues to recognize?
-Severe High BP (200/100's) -Severe Headache -Tachycardia (>120) -Profound sweating -Tremors -SOB -Anxiety or sense of doom
What are the worsening cue to watch for when treating a client with hyperthyroidism - Thyrotoxicosis / Thyroid Storm?
-Severe tachycardia and dysrhythmias over 120's -Severe HTN (200's/110's): can lead to❤️failure and hemorrhagic stroke -High Temperature -Agitation/Restlessness/Delirium -N/V, Diarrhea
Spells of pheochromocytoma maybe triggered by?
-Stress or severe illness -Foods high in Tyramine: cheeses, beers/wine, chocolate, dried/smoked meat -Caffeine and illegal drug use
What are the interventions for pheochromocytoma?
-Surgery to remove tumor -Alpha blockers: Doxazosin, prazosin *inhibit norepinephrine *prevent vasoconstriction to reduce BP -Beta blockers: atenolol, metoprolol, propranolol *Inhibit epinephrine *slow HR & cardiac output *relax blood vessels to ⬇️BP -Cool, dark room with ⬇️ stimulation -Frequent BP/HR monitoring -Monitor RR
What causes Addison's Disease?
-Surgical removal of adrenal glands -Infection of adrenal glands -TB, Cytomegalovirus & bacterial infections -Iatrogenic Drugs -Autoimmune response against adrenal cortex
SIADH - SI SOGGY BODY - cues
-TOO MUCH antidiuretic hormone (ADH) -Oliguria - LOW Urine output -Concentrated urine (high specific gravity and urine osmolality) -Fluid Excess in body o Serum (blood) osmolality low (diluted) o Weight - increased o BP - increased or hypertensive o HR - normal or tachycardic o Diluted lab values, especially sodium, due to high water levels
What is pheochromocytoma?
-Tumor of adrenal medulla - secretes Epinephrine and Norepinephrine
What are the key assessment when treating a client with DI?
-Urine output: decrease but stay adequate - Normal UOP (> 0.5 ml/kg) -Urine osmolality/Specific Gravity: increase to yellow clear urine, but not concentrated. -Weight: Increase but not fluid overload -BP/HR: normalize -Mucous membranes -Electrolytes: normalize
Pituitary gland produces
ACTH (adrenocorticotropic hormone)
The pituitary gland secretes
ACTH (adrenocorticotropic hormone), which stimulates the production and release of cortisol from the cortex of the adrenal gland.
Addison's disease pneumonics
ADrenal Deficiency - ADDison CORtex hormones - glucoCORticoid and mineralCORticoid ADDISONS = ADD CORtex hormones
What is the function of aldosterone?
Act on the kidney to regulate excretion of slat to maintain BP
What are interventions for a client with Addison's Disease?
Add Cortex Hormone -Glucocorticoids (corticoids): -PO dose to control Addison's Disease -*High-dose* hydrocortisone given IM or IV if Addison's Crisis -*Corticosteroids must be tapered, not stopped abruptly!* **IV if high dose for Addison's Crisis **Must taper** -Mineralocorticoids (aldosterone replacement): given in am -IV fluids (treat perfusion) -ECG monitor (dysrhythmias due to hyperkalemia) -Tx Hypoglycemia (dextrose 50% or encourage combo of quick and long acting carbs) -Anti-emetics
A client presents with bronze pigmentation (hyperpigmentation) and confusion. The client reports feeling fatigue, n/v and diarrhea. Lab values ⬆️ K, ⬇️ Na+, ⬇️ BG, ⬇️ weight, hypotension and hypovolemia. What condition does this client display?
Addison's Disease
adrenal diseases
Addison's, Cushing's, Hyperaldosteronism, Pheochromocytoma
Addison's Disease teach and communicate
Causes -Autoimmune response against adrenal cortex -TB, infarction, fungal infections, AIDS, metastatic cancer -Iatrogenic (drugs, adrenalectomy) -Glucocorticoid (Cortisol) replacement -Adequate doses have no side effects, and relieve hypoglycemia, GI and mood symptoms -Too high of a dose can cause Cushing's Syndrome -May need to increase steroid replacement dose during times of stress/illness with physician approval -Mineralocorticoids (Aldosterone) replacement -Usually given once in the morning -Adequate doses have no side effects and relieve hyperkalemia, hyponatremia and fluid depletion -Too high of a dose causes fluid retention, hypokalemia and hypernatremia -Risk of Addison's crisis if steroids stopped abruptly - Frequent visits to physician for follow-up and lab work -Monitor bone density due to increased risk of osteoporosis Inform all health care providers of corticosteroid requirements
What to teach a client about hyperthyroidism?
Causes: Graves disease, Too much iodine, Toxic nodular goiter, Thyroid replacement medication (toxicity) -Ask about iodine allergies -Well balanced small meals -avoid stimulant foods (coffee, tea, cola, alcohol)
What are the interventions for a client with Cushing's Syndrome?
Corticosteroid Drug Induced: ---Dose MUST be tapered gradually ---Convert to lower dose or alternate-day regimen -Monitor Blood Sugar - may need insulin or oral diabetic medications -Strict Infection control and antibiotics if increased WBC -BP reduction --Medications may include diuretic -Fall risk while tired/weak -Monitor skin for breakdown/healing of wounds
A client presents with thin fragile skin with bruising, brittle bones and weak tendons, and thicker body hair. Client also reports wound are taking longer to heal. Client complains he has had hyperglycemia, increase in weight noticing that his upper back (buffalo hump) and face (moon face) appear fuller/rounder. The client is moody, depressed, and anxious. Lab values Hyperglycemia, Hypernatremia, Hypokalemia, Hypocalcemia. WBC count high. Assessment of hypertension. What is condition does this client display?
Cushing's Syndrome/Disease
A client presents with polyuria and dehydration. Client has decreased BP and increased HR. Urinalysis results 1.001 (diluted urine). Further assessments dry mucous membrane, decreased skin turgor (>3 sec) and weakness. What condition does this client display?
Diabetes Insipidus (DI) "Dry Inside" diabetes insipidus lack ADH fluid balance —> electrolyte imbalance renal failure - high BUN, creatinine, GFR affected, etc. for labs (review renal failure)
What is Hyperaldosteronism?
Excess Aldosterone: retention of sodium and water; hypokalemia *adrenocortical adenoma *Renin-secreting tumors *renal disease
What is thyroid storm; usually first 12 hours post thyroidectomy?
Excess thyroid hormone released by surgical manipulation -Severe HTN -Tachycardia -Fever -Restlessness -Nausea
What is the treatment for hypothyroidism?
Hormone Replacement -Levothyroxine (synthroid or levothroid) -High fiber diet
An irritable client presents with increased appetite, weight loss, hair loss and feeling hot. The nurse notices the client has exophthalmos (bulging eyes) and a goiter. Upon assessment ⬆️HR, BP, RR and hyperactive bowel sounds. Lab values ⬆️ T3 & T4, ⬇️ TSH. What condition is this client experiencing?
Hyperthyroidism
A client presents with no energy/fatigue, lack of expressions/depression, weight gain, feeling cold and dry skin. Upon assessment ⬇️ HR, BP, temperature and hypoactive bowel sounds/function. Clients lab values ⬇️ T3 & T4, ⬇️ BG, ⬆️TSH. What condition does this client display?
Hypothyroidism
What are the causes of DI?
LACK of Antidiuretic Hormone (ADH) -head trauma/brain tumor -manipulation of pituitary: surgical ablation, sinus surgery, craniotomy, hypophysectomy -infections of CNS: meningitis, encephalitis, TB -failure of renal tubules to respond to ADH
What are the causes of hypothyroidism?
Low Production of Thyroid Hormone -Hashimoto's disease -Not enough iodine -Thyroidectomy -Anti-thyroid medications -Pituitary hormone
What is Cushing's Syndrome?
Medication: causes excess levels of cortisol in the blood *High dose or long term corticosteroid use
What are worsening cues to watch for in a client with hypothyroidism?
Myxedema Coma Infection, illness, stress along with untreated hypothyroidism -Bradycardia -Hypotension -Unresponsiveness -Hypothermia -Hypoglycemia -Decreased respirations
What are interventions for a client with Cushing's Disease?
Tumors: -Surgical removal or irradiation of pituitary adenoma -Adrenalectomy for adrenal tumors or hyperlasia -Removal of ACTH secreting tumors from elsewhere in the body
What is the key treatment for a client with DI?
Replace missing hormone -Desmopressin (DDAVP): too much cause fluid overload too little symptoms will return -IV Fluids -Strict I/O - fall precautions while severely hydrated
Wha tis the function of T4 in the body?
Responsible for your metabolism, mood, and body temperature.
What is the function of the adrenal medulla?
Secretes epinephrine and norepinephrine -triggers flight or fight response -Increase BP, HR, blood flow to muscles
A client presents with oliguria and excess fluid in the body. Client reports recent weight gain and nausea and vomiting. Labs revel low sodium levels and 1.060 specific gravity. VS indicate HTN and tachycardia. What condition does the client present?
Syndrome of Inappropriate Antidiuretic Hormone (SIADH) "Soaked Inside"
What are the causes of SIADH?
TOO Much ADH -Lung cancer -Severe Lung Infection: TB, severe pneumonia -Neurological disorders: stroke, trauma, meningitis, abscess -HIV -Psych medications (TIA, SSRI, Antipsychotics) -Anti-epilepsy meds
The pituitary gland produces TSH (Thyroid stimulating hormone). What is the function of TSH?
TSH (Thyroid stimulating hormone), which stimulates the production and release of T4 from the thyroid.
pituitary gland
The endocrine system's most influential gland. Under the influence of the hypothalamus, the pituitary regulates growth and controls other endocrine glands. DI, SIADH, ACTH, TSH
What is the function of cortisol in the body?
The primary stress hormone -controls blood sugar -burns proteins and fat -react to long term stressors like major illness or injury
SIADH
syndrome of inappropriate antidiuretic hormone
