Hmmmm 2040

Symptoms of Thyroid Storm

: fever, severe tachycardia, heart failure, systolic hypertension (also, abdominal pain, N & V, and diarrhea) As storm progresses: agitated & anxious...restless, confused, psychotic, & may have seizures. Even with treatment...mortality rate 25%

Preoperative teaching for the patient scheduled for subtotal thyroidectomy include: A. How to support the head with the hands when moving B. Coughing should be avoided to prevent pressure on incision C. Tingling around the lips or fingers after surgery is expected and temporary D. Head/neck need remain immobile until incision heals A. To prevent strain on the suture line pts head must be manually supported when turning and moving in bed.

A

Conditions or events precipitating myxedema coma:

Acute major systemic illness, infection Drugs, Especially Opioids/Sedatives Exposure to cold hypothermia Surgery/Anesthesia Chronic autoimmune thyroiditis (Hashimoto dx) Rapid withdrawal of thyroid medications Untreated or inadequately treated hypothyroidism Pituitary/hypothalamic failure

Myxedema Coma: Emergency Care

Assess LOC and ability to maintain a patent airway Monitor respiratory status, ABG levels. Administer supplemental oxygen as ordered Anticipate need for intubation and mechanical ventilation Monitor VS and cardiac arrhythmias Administer IVF, monitor FV status, electrolytes, blood glucose Give IV levothyroxine Administer IV Hydrocortisone 100 mg q8 Monitor temperature closely until patient is stable, institute warming device Assess for possible sources of infection— Blood, sputum, urine

When discharging pt with Addison's dx, the nurse identifies need for additional instruction when pt says: A. I should always call Dr. if I develop vomiting/diarrhea B. If my wgt goes down , my dose of steroid is too high C. I should double or triple my steroid dose if I undergo rigorous physical exercise D. I need to carry an emergency kit with injectable hydrocortisone if I cant take PO Weight reduction may indicate fluid loss and dose of replacement therapy is too low rather than too high

B

A patient is scheduled for Bilateral Adrenalectomy. Post-op the nurse would expect admininstration of corticosteroids to be: A. Reduced to promote wound healing B. Increased to promote adequate response to the stress of surgery C. Reduced because excessive hormones are released during surgical manipulation The stress of surgery require high doses of cortisone be administered several days postop

C

Pheochromocytoma

Caused by a catecholamine producing tumor, usu. unilateral, right side, most often benign, occurs > freq. in women. Manifestations: HTN, HA, diaphoresis, flushing, palpitations, tachycardia, hyperglycemia. Dx: Urine-24 hr catecholamine Implementation: surgical removal Teach avoid stimulants (caffeine, nicotine)

What is an appropriate treatment measure for a patient with addisonian crisis? A. IVF replacement B. IV corticosteroids C. Blood glucose management D. All of the above All of the therapies are first line treatment measures

D

Cushing's Syndrome: Pathophysiology

Exaggerates the normal actions of glucocorticoids, causing widespread problems Excessive stimulation of ACTH = adrenocorticaltropic hormone hyperplasia....loss in normal hormone secretion rhythms. Increase in body fat: "Buffalo Hump" & "Moon Face"

Hypothyroidism Clinical Features

Fatigue, lethargy, impaired memory, may appear depressed Decreased CO and contractility Anemia, SOB, DOE Decrease GI motility leads to constipation Cold intolerance, hair loss, dry course skin Brittle nails, hoarseness, muscle weakness Weight gain r/t decrease metabolic rate

Cushing's Syndrome: Etiology

Group of clinical problems caused by an excess of cortisol, secreted by the adrenal cortex (endogenous) or administered for another clinical disorder (exogenous or iatrogenic) Women are affected eight times more often than men Steroid or ETOH abuse can produce the clinical & chemical features of Cushing's Syndrome

Clinical Features of Hyperthyroidism

Heat intolerance Facial flushing, palpitations Fine straight hair Tachycardia, nervousness, tremors Enlarged thyroid Diarrhea, weight loss Exophthalmos (protrusion of eyeballs)

Hyperthyroidism

Hyperactivity of the thyroid gland Results from excess T4, T3 Graves Dx most common form More common in women Excess hormone increases metabolism Thyrotoxicosis is clinical syndrome of hypermetabolism

Manifestations of Addisonian Crisis

Hyperkalemia Hyponatremia Hypotension Hypoglycemia Severe Volume Depletion Shock Pathophysiology of acute adrenal crisis is caused by sudden sharp decrease in adrenocortical hormones Triggered by stress (infection, surgery, trauma, hemorrhage), sudden withdrawal of corticosteriods Iatrogenic Addison's Dx can be R/T bilateral adrenal hemorrhage... Na falls & K rises rapidly...severe hypotension R/T blood loss, tachycardia, dehydration, circulatory collapse, shock

Cushing's Syndrome & Pheochromocytoma:

Hypersecretion by the adrenal cortex may result in excessive amounts of glucocorticoids, leading to hypercortisolism= Cushing's Syndrome Hypersecretion of the adrenal medulla caused by a tumor (Pheochromocytoma) results in excessive catecholamines, of which 80% is epinephrine and remainder is norepinephrine

Adrenal Crisis: Emergency Care

IVF Resuscitation: administer large volumes of IVF usually NS 2-4 L over first 24 hrs. to correct hypotension and reverse shock. Careful monitoring of BP, fluid status and serum sodium, potassium levels. Monitor Orthostatic VS High dose steroids: Hydrocortisone 50-100 IV q 6-8 hrs for 1-3 days Provide quiet, non-stressful environment Administer glucose as needed to correct hypoglycemia Identify trigger Once medically stable, normal dosing regimen can be resumed Prior to treatment obtain CBC, Chem 7, cortisol, ACTH, glucose levels.

Hypothyroidism

Insufficient circulating thyroid hormone Iodine deficiency (Iodine is necessary for synthesis of thyroid hormone) Atrophy of thyroid gland with aging Hashimoto's thyroiditis and Graves dx are autoimmune disorders that destroy thyroid gland over time and result in hypothyroid

Addisonian Crisis

Life threatening emergency: physiological need for glucocorticoid and mineralocorticoid hormones is greater than the available supply Sudden withdrawal of steroid replacement (pt lack knowledge lifelong replacement) Triggered by stress (infection, surgery, hemorrhage, trauma) After adrenal surgery Pituitary gland destruction

Thyroid Storm (Thyrotoxic Crisis)

Life threatening event that occurs with uncontrolled hyperthyroidism and represents severe thyrotoxicosis with organ system decompensation. Usually triggered by major stressor such as trauma or infection, surgery, in patient with preexisting hyperthyroidism. Untreated may progress to coma, shock and death. Rare postoperatively because patients receive: anti thyroid drugs, beta blockers, steroids, and iodine before thyroid surgery to prevent thyroid storm S/S caused by excessive thyroid hormone release that leads to a large increase in metabolic rate

Addison's Disease

Long Term Drug Therapy: Cortisone: 25-37.5 mg/day orally or Hydrocortisone: 15-30 mg/day (2/3 am and 1/3 pm) or Prednisone: 2.5-5 mg/day or Dexamethasone: 0.25-0.75 mg/day -AND Fludrocortisone 0.1-0.2mg/day (Mineralcorticoid)

Thyroid Storm: Emergency Care

Maintain a patent airway & adequate ventilation High doses of anti thyroid medication: propylthioracil (PTU), 300-900 grams/day; Methimazole (Tapazole) up to 60 mg daily sodium iodine solution: 1 G/day IV , potassium iodide (SSKI) 50-500 mg PO tid Give Beta-blockers Propanolol (Inderal) 1-3mg IV patient on telemetry, & central venous catheter in place RAI Radioactive iodine therapy damages thyroid tissue Corticosteriods 80% patients after treatment are hypothyroid and require lifelong replacement Monitor continually for cardiac arrhythmias Ensure adequate oxygenation Adequate hydration, IVF to replace F/E losses (esp. N/V) Monitor vital signs every 30 minutes Comfort measures; cooling blanket Antipyretic Management of CHF Endocrinologist consult

Postoperative Care:Thyroidectomy

Monitor dressing for potential bleeding; and hematoma formation; check posterior dressing Monitor respirations and protect airway Assess pain and provide pain relief measures Use semi-fowler's position and support head pillows Avoid flexion of neck and any tension on sutures Assess voice, but discourage talking Potential hypocalcemia related to injury or removal of parathyroid glands; monitor for hypocalcemia Assess for tetany, pain management

Addison's Disease Patient Teaching

Patient Teaching imperative, stress importance of lifelong replacement and medical ID device, lifelong medical supervision. Stress management, Teach pt. during illness and increased physiologic stress; Stress Doses of Steroids are needed to prevent Crisis. Teach pt. conditions that require increasing medication: Surgery, Trauma, Infection, Emotional Crisis

Cushing's Syndrome: Physical Assessment & Diagnosis

Physical changes: truncal obesity, moon face, buffalo hump, thinner arms & legs, & abdominal striae Diagnosis: Elevated plasma cortisol levels...additional tests done as this is elevated in acute illness & trauma. ACTH may be low, normal or elevated depending on cause of Cushings Inc glucose, WBC, lymphocyte ct, & Na level. Decreased serum Ca & serum K levels 24 HR urine free cortisol level >120 indicate Cushings Dexamethasone suppression testing may be done if borderline urine results CT or MRI of adrenals and pituitary Radiation therapy: external & internal Surgical therapy: hypophysectomy (removal of pituitary gland); adrenalectomy (removal of adrenal gland) Treatment of choice Drug Therapy: Used for only palliation: Mitane (Lyrosoden) adrenal cytotoxic agent used with tumors or Aminoglutehimide (Elipten, Cytadren) adrenal enzyme inhibitor that decreases cortisol production

Addison's Disease

Primary Adrenocortical insufficiency (hypofunction of adrenal cortex) All three classes of corticosteroids are reduced (glucocorticoids, mineralocorticoids and androgens) Most common cause is autoimmune usually other endocrine conditions are present

Problems associated with Myxedema Coma

Problems associated with this condition: Coma (mental slowing to severe obtundation) Hypoventilation/Respiratory failure Hypotension and bradycardia Hyponatremia Hypothermia Hypoglycemia

Myxedema Coma

Serious complication of untreated or inadequately treated hypothyroidism Slow, gradual progression usually precipitated by infection, sedative use, cold exposure Result: Cardiomegaly: decreased cardiac output, decreased perfusion to brain & other vital organs Life threatening emergency; mortality rate is very high

Cushing's Syndrome: Preventing Complications

Skin breakdown: lotion, position change, avoid trauma, monitor for infection Pathological fractures: secondary to demineralization = osteoporosis = high calorie, high calcium & Vit. D. Avoid ETOH & caffeine GI Bleeding: Use H2 receptor blocking agents (Pepcid) or PPI's (Protonix)...Avoid NSAID's Patient Teaching: Medical alert bracelet, lifelong hormone replacement post bilateral adrenalectomy

Thyroidectomy

Treatment of choice for thyroid cancer Cancer surgery may include modified or radical neck dissection, and may include treatment with radioactive iodine to minimize metastasis Preoperative goals include the reduction of stress and anxiety to prevent thyroid storm Preoperative teaching includes dietary guidance to meet patient metabolic needs and to avoid caffeinated beverages and other stimulants, explanation of tests, and procedures, and demonstration of proper postoperative head support

Cushing's Syndrome: Clinical Manifestations

Truncal obesity or generalized obesity Moon Face (Facial Fullness) Purple striae of abdomen Decreased muscle mass, atrophic skin & bone density loss Increased androgen production causes acne, hirsutism, & oligomenorrhea

A patient is experiencing thyroid storm. Which drug is contraindicated: A. IV Beta-adrenergic blockers B. Aspirin C. Propylthiouracil D. Corticosteroids Aspirin is contraindicated because it blocks the binding of T3 and T4

b