Ch 39 med surge

Why would heart failure occur with hypothyroidism?

Decreased pumping strength of the heart. Altered fat metabolism causes hyperlipidemia, which can lead to cardiovascular disease.

What do we always instruct the patient to do after surgery?

Deep-breathing exercises or use of an incentive spirometer.

Diabetes Insipidus (DI)

Deficiency of ADH, adequate reabsorption of water is prevented, leading to diuresis. Patients can urinate from 3 to 15 L per day.

True/False Thyrotoxic crisis can result in death in as little as 4 hours if untreated.

False, it is little as 2 hours if untreated.

What can happen if your osmolality of the blood is low?

Fluid can leak out of the vessels and cause brain swelling. If untreated, this results in lethargy, confusion, seizures, coma, and death.

The patient should be in a ______________ before undergoing a thyroidectomy in order to avoid complications during and after surgery. This is accomplished with the use of antithyroid medication such as methimazole (Tapazole).

euthyroid state

The most significant sign of Addison disease is?

hypotension

If a ___________________________ is present, surgical removal or radiation therapy to the pituitary gland may be employed.

pituitary or ACTH-secreting tumor

ADH levels can be measured in ______ or ______ after administration of hypertonic saline or fluid restriction. The normal response would be elevated ADH; if it is not elevated, DI is suspected.

plasma or urine

What does the patient at home need to do during radioactive iodine?

Avoid close contact with family members and to use careful hand hygiene after urinating. Oral contact with others should be avoided, and eating utensils should be washed thoroughly with soap and water. Pregnancy should be avoided for a year.

How would you assess a goiter on a patient?

Be careful to assess the effect of the goiter on breathing and swallowing. Collaborate with the dietitian to provide soft foods that are easy to swallow.

How does a patient develop tetany?

Can occur if the parathyroid glands are accidentally removed during thyroid surgery. absence of the parathyroid hormone (PTH), serum calcium levels drop and tetany results. IV calcium gluconate is given to treat acute tetany.

What is tetany?

Caused by low calcium levels and is characterized by tingling in the fingers and perioral area (around the mouth), muscle spasms, twitching, and cardiac arrhythmias.

What causes Cushing syndrome?

Cortisol also causes insulin resistance and stimulates gluconeogenesis, which results in glucose intolerance. Muscle wasting and thin skin with purple striae occur as a result of cortisol's catabolic effect on tissues. Cortisol has anti-inflammatory and immunosuppressive actions, the patient is at risk for infection. Sodium and water retention are related to the mineralocorticoid effect. As sodium is retained, potassium is lost in the urine, causing hypokalemia. Androgen effects include acne, growth of facial hair, and amenorrhea (absence of menses) in women.

Instructions on how to administer the hormones and side effects to report, examples are?

-Expect a small amount of bloody or mucous drainage from your nose. -If you must blow your nose, do so very gently. Blowing can injure the surgical site and cause bleeding or spinal fluid leakage. -Take stool softeners as needed to prevent straining for bowel movements. -Take cough suppressants as directed to prevent coughing. -If an upper lip incision was used, wait until the incision line is healed to brush teeth with a toothbrush. Floss and mouth rinses can be used instead. -Take all medications as prescribed. You will be on lifelong hormone therapy to replace the hormones made by your pituitary gland. -Call immediately if you develop a fever, if you have more than a small amount of blood drainage from the incision site, if you have clear drainage, if you feel very thirsty or urinate more than usual (a sign of diabetes insipidus), or if any other symptoms that concern you.

What are the four groups that can cause SIADH?

-Nervous system disorders such as head trauma and meningitis -Cancers such as lung and brain cancer (some tumors actually secrete an ADH-like substance) -Pulmonary diseases such as cystic fibrosis and chronic obstructive pulmonary disease (COPD) -Medications such as antipsychotics and histamines.

Cushing syndrome

Cortisol is hypersecreted without regard to stress or time of day. When levels of cortisol are very high, effects related to excess aldosterone and androgens are also seen.

What is hypoparathyroidism?

A decrease in PTH causes a decrease in bone resorption of calcium, a decrease in calcium absorption by the gastrointestinal tract, and decreased resorption in the kidneys. This means that calcium stays in the bones instead of being moved into the blood, and more calcium is excreted from the body. The result is a decreased serum calcium level.

What are the long-term treatment for hypoparathyroidism?

A high-calcium diet, with oral calcium and vitamin D supplements. Magnesium is given if hypomagnesemia is present.

What would the HCP order for the patient with Cushing syndrome?

A high-potassium, low-sodium, high-protein diet. Potassium supplements may be ordered. If the patient has high blood sugar, appropriate therapy for diabetes is instituted.

For a patient that developed Cushing syndrome by administration of steroid medication, what intervention would the nurse do?

A lower dose, an every-other-day schedule, or once-a-day dosing in the morning may reduce side effects. Usually steroids are prescribed as a last resort for chronic disorders that are unresponsive to other treatment.

What is stridor?

A whistling sound, may be heard if the airway is obstructed.

How would you treat a patient with thyrotoxic crisis?

Acetaminophen is given for the fever. Aspirin is avoided because it binds with the same serum protein as T4, freeing additional T4 into the circulation. IV fluids and a cooling blanket may be ordered to cool the patient. A beta-adrenergic blocker such as propranolol is given for tachycardia and symptom control. Oxygen is administered, and the head of the bed is elevated because the high metabolic rate requires more oxygen.

What is often the first symptom noticed is a change in ring or shoe size, the nose, jaw, brow, hands, and feet enlarge?

Acromegaly

What is Addison disease?

Adrenocortical insufficiency (AI) is the insufficient production of the hormones of the adrenal cortex. Primary AI is called Addison disease. AI is associated with reduced levels of cortisol, aldosterone, or both hormones. A deficiency in androgens may also exist.

How would the serum sodium levels appear with diabetes insipidus?

Appears low., the actual amount of sodium in the blood may be normal, but it appears elevated in relation to the decreased amount of water.

The priority for the nurse then is to?

Approach the patient with respect while assessing current problems that may need attention.

What is the amount of time patients avoid contact with others?

Depends on the dose of radiation received. If the treatment is being administered for hyperthyroidism, inform the patient that symptoms should subside in about 6 to 8 weeks.

What leads to dehydration and increased serum osmolality (concentrated blood).

Diabetes Insipidus (DI)

During therapy for Addison's, if your patient has stress or illness, what needs to happen with there doses of medication?

Doses need to be increased to two to three times normal.

What causes SIADH to happen?

Excess water to be reabsorbed by the kidney tubules and collecting ducts and back into the blood, leading to decreased urine output and fluid overload.

What is hyperthyroidism?

Excessive amounts of circulating TH (thyrotoxicosis), problem within the thyroid gland causes excess hormone release.

What is Polydipsia?

Extreme thirst

When diagnosing a growth hormone deficiency, what tests would you do?

GH levels in the blood can be measured by a routine laboratory test. GH stimulation test that measures GH in response to induced hypoglycemia. An MRI scan can help determine the presence of a tumor; radiographic studies may be used to determine bone age. Genetic testing may also be done.

What causes a person to develop hyperthyroidism?

High level of TH increases the metabolic rate. It also increases the number of beta-adrenergic receptor sites in the body, which enhances the activity of epinephrine and norepinephrine. The resulting fight-or-flight response is the cause of many of the symptoms of hyperthyroidism.

Excessive hormone activity can be the result from?

Hyperactive gland, ectopic hormone production, or self-administration fo too much replacement hormone.

Insufficient hormone activity can be a result from?

Hypofunction of an endocrine gland or insensitivity of the target tissue to its hormone.

With a temperature less than 95°F (35°C), and has a decreased respiratory rate, depressed mental function, and lethargy, patient can become?

Hypothermic

What can be ordered to replace intravascular volume without adding extra sodium?

Hypotonic intravenous (IV) fluids such as 0.45% saline solution.

If fluid balance is not restored for a patient with diabetes insipidus?

Hypovolemic shock

Complications of Addison's disease would included?

If a patient is exposed to stress, such as infection, trauma, or psychological pressure, the body may be unable to respond normally with secretion of cortisol, and an adrenal crisis can occur. Loss of large amounts of sodium and water and the resulting fluid volume deficit cause profound hypotension, dehydration, and tachycardia. Potassium retention can cause cardiac arrhythmias. Hypoglycemia may be severe. Coma and death result if treatment is not initiated.

How would you treat a patient with SIADH?

If a tumor is secreting ADH, surgery may happen. Restricting fluids to 800 to 1000 mL per 24 hours. Hypertonic saline fluids may be administered via IV, and an oral sodium tablet may be prescribed to maintain the serum sodium level. A loop diuretic such as furosemide (Lasix) increases water excretion. A vasopressin receptor antagonist such as conivaptan (Vaprisol) may be used to block the action of ADH in the kidney.

What can happen if you don't recognize symptoms of tetany?

If the problem is not recognized quickly, death can result.

What signs and symptoms would someone with Addison's disease have?

In primary AI, increased ACTH may produce hyperpigmentation of the skin, causing the patient to have a tanned or bronze appearance. Anorexia, nausea, and vomiting may also occur, possibly as the result of electrolyte imbalances. Women may have decreased body hair because of low androgen levels. Patients may report craving salt.

You have a patient that are showing signs and symptoms of hyperparathyroidism, what would be the symptoms for this disorder?

Include fatigue, depression, confusion, increased urination, anorexia, nausea, vomiting, kidney stones, and cardiac arrhythmias. The increased serum calcium level also causes gastrin secretion, resulting in abdominal pain and peptic ulcers. Because calcium is being removed from bones, bone and joint pain and pathological fractures can occur. Severe hypercalcemia can result in coma and cardiac arrest.

What are the side effects of radioactive iodine?

Include sore throat, dry mouth or eyes, and nausea.

What is the treatment for a patient in myxedema coma?

Intubation and mechanical ventilation. The patient is slowly rewarmed with blankets. IV fluids and IV levothyroxine (Synthroid) are given, and the underlying cause is treated.

Chronic hypocalcemia causes?

Lead to lethargy; calcifications in the brain, leading to psychosis; cataracts; and convulsions. Bone changes may be evident on x-ray examination. Electrocardiogram (ECG) changes and heart failure can develop because of the importance of calcium to cardiac function. Death can result from laryngospasm if treatment is not effective.

Long-term treatment for Addison's disease would include?

Long-term treatment consists of replacement of glucocorticoids (hydrocortisone) and mineralocorticoids (fludrocortisone [Florinef]). Some patients also receive androgen therapy. Patients will need hormone replacement therapy for the rest of their lives.

If treatment for hyperthyroidism is not begun, patient can become?

Manic or psychotic

How would you assess for Cushing syndrome during nursing process?

Monitor vital signs and complications related to fluid and sodium excess. Auscultate the lungs for crackles, and assess extremities for edema. Assess skin integrity, and monitor capillary glucose as ordered by the HCP. Watch for signs of infection.

How would you assess your patient during nurses process?

Monitor vital signs and daily weights or I&O to track fluid status. Monitor serum glucose levels and symptoms of hyperkalemia and hyponatremia. Report changes in mental status. If the patient is in crisis, monitor vital signs closely and report any signs of fluid volume deficit such as orthostatic hypotension or poor skin turgor to the HCP immediately.

What do you need to do postoperative for your patient after a thyroidectomy?

Monitor vital signs, oxygen saturation, drain (if present), and dressing every 15 minutes initially, progressing to every 4 hours, Tachycardia and fever, along with mental status changes, can indicate thyrotoxic crisis. Check the back of the neck for pooling of blood, observe for signs of respiratory distress, including an increase in respiratory rate, dyspnea, or stridor. Ask the patient to speak to detect hoarseness of the voice, which can indicate trauma to the recurrent laryngeal nerve. Monitor the patient's serum calcium levels and watch for evidence of tetany. Report abnormal findings to the RN or HCP immediately.

What is the major complication of hypothyroidism?

Myxedema coma, the metabolic rate drops so low that it becomes life threatening

In advanced hypothyroidism disease,

Myxedema develops, which is a nonpitting edema of the face, hands, and feet.

What is nocturia?

Night time urination

Hypothyroidism is easily treated with?

Oral thyroid replacement hormone. Most patients now take synthetic thyroid hormone (levothyroxine [Synthroid]). Doses are started low and slowly increased to prevent symptoms of hyperthyroidism or cardiac complications.

How is radioactive iodine given and what should be avoided during therapy?

Orally in one dose. Limit time spent with the patient and maintain a safe distance when providing direct care. Pregnant caregivers. Urine, vomitus, and other body secretions are contaminated and should be disposed of according to hospital policy. Flush the toilet twice after disposal of contaminated material.

What is hyperparathyroidism?

Overactivity of one or more of the parathyroid glands causes an increase in PTH, with a subsequent increase in the serum calcium level (hypercalcemia).

What is the postoperative care after a hypophysectomy?

Perform routine neurologic assessments to monitor the patient for changes from the baseline assessment. Check urine for specific gravity because DI can occur following pituitary surgery. If a patient has had transsphenoidal surgery, nasal packing and a "mustache dressing" will be present. These are left in place and not removed unless ordered by the HCP. Monitor the dressing for signs of cerebrospinal fluid (CSF) leakage. CSF contains glucose, so glucose testing strips can be used to determine whether drainage is actually CSF or just nasal discharge.

What symptoms will the patient have with diabetes insipidus?

Polyuria, polydipsia, dehydration, dilute urine

How would you treat your patient that is experiencing an adrenal crisis?

Rapidly restoring fluid volume and cortisol levels. IV fluids (containing glucose) and large doses of IV glucocorticoids are administered. Electrolytes are replaced as needed. The cause of the crisis should be identified and treated.

What is Acromegaly?

Rare condition resulting from excess secretion of growth hormone (GH). Bones increase in size, leading to enlargement of facial features, hands, and feet. Long bones grow in width but not length because the epiphyseal disks are closed.

What are the causes for Addison's disease?

Remember that aldosterone causes sodium and water retention in the kidney and potassium loss. If aldosterone is deficient, sodium and water are lost and hypotension and tachycardia result. Low cortisol levels cause hypoglycemia, weakness, fatigue, weight loss, confusion, and psychosis.

What is hypophysectomy?

Removal of the pituitary gland

What is Hypophysectomy?

Removal of the pituitary gland, most often done using minimally invasive endoscopic surgery, via the nose or a small incision just under the upper lip. This allows access through the sphenoid sinus to the pituitary gland, without disturbing brain tissue.

Fluid overload, such as weight gain without edema and dilutional hyponatremia is the symptom of?

SIADH

If you noticed your patient has signs of stridor, what can you do as a nurse?

Should be reported to the HCP immediately. A swallowing study might be ordered. This will assist a speech pathologist or other expert in making specific recommendations for safe swallowing.

What are the treatments for the side effects of radioactive iodine?

Sore throat is easily treated with acetaminophen, and nausea usually lasts only a day or two. Dry eyes can be relieved with moisturizing eye drops. Encourage the patient to drink plenty of fluids and void frequently to help remove RAI from the body and reduce radiation exposure to the bladder.

What do you need to assess for with diabetes insipidus?

Special attention to fluid balance. Checking for skin turgor, may be poor and mucous membranes will be dry. Monitor vital signs for shock, monitor urine specific gravities with reagent strip (dipstick) or urinometer. Also monitor serum electrolytes and osmolality for changes in consciousness.

Never abruptly stop?

Steroids

What are the many signs and symptoms of hyperthyroidism?

Such as heat intolerance, increased appetite with weight loss, and increased frequency of bowel movements. Nervousness, tremor, tachycardia, and palpitations are caused by the increase in sympathetic nervous system activity and may be more common in younger patients.

What is the result of too much ADH in the body?

Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

Your patient has serum osmolality is less 275mOsm/kg, has electrolyte imbalance that may cause muscle cramps and weakness. What could this patient be diagnose with?

Syndrome of Inappropriate Antidiuretic Hormone (SIADH), the urine is concentrated because water is not being excreted.

Why would a patient with hyperthyroidism might develop heart failure?

Tachycardia and the inefficient pumping of the heart.

What would you need to look for if a patient is having thyrotoxic crisis?

Tachycardia, high fever, extreme hypertension (with eventual heart failure and hypotension), dehydration, restlessness, delirium, or coma.

What are the signs in acute case for hypoparathyroidism?

Tetany can occur, with numbness and tingling of the fingers, tongue, and lips; muscle spasms; and twitching. Positive Chvostek and Trousseau signs are early indications of tetany.

How do you a water-deprivation test?

The patient is deprived of water for up to 6 hours. Body weight and urine osmolality are tested hourly. If the urine continues to be diluted, even though the patient is not drinking and is losing weight as a result of volume depletion, DI is suspected.

What symptoms would you see for hypothyroidism?

The reduced metabolic rate and include fatigue, weight gain, bradycardia, constipation, mental dullness, feeling cold, shortness of breath, decreased sweating, and dry skin and hair

What are some of the other signs of Acromegaly?

The teeth may be displaced, causing difficulty chewing, or dentures may no longer fit. The tongue becomes thick, causing difficulty in speaking and swallowing (dysphagia). The patient may develop sleep apnea. Visual disturbances can occur because of tumor pressure on the optic nerve. Headaches result from tumor pressure on the brain. Diabetes mellitus may develop because GH increases blood glucose and causes an increased workload for the pancreas.

What is Goiter?

The thyroid gland may enlarge in response to increased TSH levels or sometimes in response to the autoimmune process that occurs in Graves disease.

What do we need to be alert for in older adults with hyperthyroidism?

These patients may present with heart failure, atrial fibrillation, fatigue, apathy, and depression.

What is Graves disease?

Thickening of the skin on the anterior legs and exophthalmos (bulging of the eyes) caused by swelling of the tissues behind the eyes. Other eye changes include photophobia and blurred or double vision.

If a patient is untreated or who develop another illness for hyperthyroidism, what could they develop?

Thyrotoxic crisis (sometimes called thyroid storm) is a severe hyperthyroid state.

What is important to tell the patient preoperative care for hypophysectomy?

To avoid any actions that increase pressure on the surgical site, such as coughing, sneezing, nose blowing, straining to move bowels, or bending from the waist.

What is interventions for acute case for hypoparathyroidism?

Treated with IV calcium gluconate.

Patients with long-standing, untreated hypothyroidism and can be?

Triggered by stress such as infection, trauma, or exposure to cold.

True/False Thyrotoxic crisis may occur after thyroid surgery in patients who have been inadequately prepared with antithyroid medication.

True

True/False Hypothyroidism can occur up to 15 years after the treatment.

True, because symptoms of hypothyroidism may occur.

What is Polyuria?

Urinates frequently

How do you rule out diabetes mellitus?

Urine glucose level is checked.

How would you diagnose a patient with diabetes insipidus?

Urine specific gravity, urine and plasma osmolality, water deprivation test

What would you do in acute cases with diabetes insipidus?

Vasopressin, a synthetic form of ADH, is given via the IV or subcutaneous route, along with IV fluid replacement.

What are the obvious signs for Cushing syndrome?

Weight gain, central obesity with thin arms and legs, fat pads on the upper back (buffalo hump), and a round, moon-shaped face result from deposits of adipose tissue at these sites.

What is hypothyroidism?

When the thyroid gland fails to produce enough TH even though enough thyroid-stimulating hormone (TSH) is being secreted by the pituitary gland.

How would you treat a patient with hyperthyroidism?

With extra fluids to dilute calcium, monitoring for bone changes and decline in renal function, and weight-bearing exercise to keep calcium in the bones. Oral calcium and vitamin D supplements may be prescribed. Estrogen therapy might be used in women, although side effects must be considered. Surgery will likely be done to remove the diseased parathyroid glands (parathyroidectomy).