Med/Surg II - Test #2 - Endocrine and Cardiac

Agents for Replacement Therapy in Adrenocortical Insufficiency

*Hydrocortisone—Synthetic steroid* Adverse effects—Low doses are devoid of adverse effects; large chronic doses can be highly toxic, with effects including adrenal suppression and Cushing's syndrome *Fludrocortisone (Florinef)* Potent mineralocorticoid Adverse effects related primarily to salt and water retention Oral only

Ventricular Tachycardia (VT)

*LIFE THREATENING!!!!* Rate > 100 bpm but not usually over 250 bpm Rhythm: Regular No P waves; QRS > or = 0.12 Sustained vs. unsustained

Nursing Management - PVC - *TEST*

*3 or more PVCs in a row = run of VT* Monitor EKG closely - R on T phenomenon Identify cause (hypoxia, electrolyte imbalance) May require beta blockers, amiodarone, lidocaine PVCs do not generate sufficient ventricle contraction for peripheral pulse - might note a pause when palpating radial pulse Check apical-radial pulse rate

Patient Example - A. fib T.J. is an 81 yo male, whose only history is hyperthyroidism, and was admitted for palpitations 2 days ago. His EKG on admit confirmed A. fib. Today T.J. c/o acute onset of L sided weakness. CT confirmed embolic stroke. What was the probable cause for T.J's stroke and why? *A. Fib increases risk for thrombosis.* SVT causes blood stasis in the heart. Hyperthyroidism is a risk factor for stroke. Warfarin is administered to prevent stroke.

*A. Fib increases risk for thrombosis.*

Drugs for Dysrhymias: Atropine, Epinepherine, Vasopressin

*Atropine * - anticholinergic - Used in sx bradycardia, AV blocks, asystole *Epinepherine* - Increases HR, conduction, contractility, vasodilation - Used in pulseless VT, VF, bradyarrhythmias *Vasopressin* - Antidiuretic hormone - Used in VF, pulseless VT, PEA (Pulseless electrical activity)

Antidysrhythmic drugs: Beta-adrenergic blockers & Ca channel blockers

*Beta-adrenergic blockers* - Decrease automaticity of SA; Decrease conduction velocity of AV; Reduces contractility of heart atenolol (Tenormin), carvedilol (Coreg), metoprolol (Lopressor), Sotalol (Betapace) *Ca channel blockers* - Decrease conduction through AV; Reduce automaticity of SA node diltiazem (Cardizem), verapamil (Calan), amlodipine (Norvasc), nifedipine (Procardia)

Collaborative care and nursing management for Diabetes Insipidus (DI)

*Collaborative Care:* Treat cause Central DI Fluid replacement Hormone replacement Desmopressin acetate (DDAVP) - stop constant peeing. PO, IV, nasal spray Vasopressin AKA (ADH) - vasoconstrictor *Nursing Management:* Early detection Fluids Accurate I & O Daily weights Pt. education ADH replacement

Disorders of Adrenal Cortex

*Glucocorticoids* Regulate metabolism Increase blood glucose Stress response *Mineralocorticoids* Regulate Na and K balance - act on the kidneys *Aldosterone* Androgens Growth and development, sexual activity in women *"Corticosteroid"* Refers to any of these 3 hormones

Hyperthyroidism

A sustained increase in synthesis and release of thyroid hormones by thyroid gland Occurs more often in women Highest frequency between ages 20 to 40 years

Patient Example - Brady

A.B. is a 72 yo female with a hx of MI, constipation, and diabetes. The night RN does her hourly midnight rounding and notices A.B.'s rhythm below 60. What is the RN's next action? a. Code blue, start CPR *b. Check patient's VS* c. Administer atropine d. Place pacer pads

Etiology & Risk Factors - Ventricular Fibrillation (VF)

Acute MI and myocardial ischemia HF Cardiomyopathy Hypoxia Hyperkalemia Drug toxicity Electrical shock Hypothermia *R-on-T PVCs* Untreated VT Post cardiac catheterization Post coronary artery perfusion from fibrinolytics

Patient Example - VF Mrs. Q is 47 yo with an extensive cardiac hx. She develops the rhythm below. A CODE Blue is called, CPR is initiated. The rhythm has been refractory to two shocks thus far and no medication has been given. What is the next action? Continue with two consecutive shocks. Administer epinephrine 1mg. Monitor vital signs. Complete a rhythm check.

Administer epinephrine 1mg.

Adult tachycardia - flow chart

General

*Preoperative Care* for hyperthyroidism and thyroid surgery?

Administer medications to achieve euthyroidism Administer iodine to ↓ vascularity Assess for signs of iodine toxicity Patient teaching Comfort and safety measures Leg exercises, head support, neck ROM Routine postoperative care When subtotal thyroidectomy is the treatment of choice, the patient must be adequately prepared to avoid postoperative complications. Before surgery, antithyroid drugs, iodine, and β-adrenergic blockers may be administered to achieve a euthyroid state. Iodine reduces vascularization of the thyroid gland, thereby reducing the risk of hemorrhage. Iodine is mixed with water or juice, sipped through a straw, and administered after meals. Assess the patient for signs of iodine toxicity such as swelling of the buccal mucosa and other mucous membranes, excessive salivation, nausea and vomiting, and skin reactions. If toxicity occurs, iodine administration should be discontinued and the health care provider notified. Preoperatively, teach the patient about comfort and safety measures. Teach the patient the importance of performing leg exercises. Instruct the patient how to support the head manually while turning in bed, because this maneuver minimizes stress on the suture line after surgery. Range-of-motion exercises of the neck should be practiced. Explain routine postoperative care such as IV infusions. Tell the patient that talking is likely to be difficult for a short time after surgery.

Adrenocortical Insufficiency: Assessment

Adrenal crisis or Addison's crisis Hyperkalemia Hyponatremia Hypoglycemia Fluid volume deficit can lead to Shock Low BP - risk for falls Treat with D5NS or saline *Give glucose* - D5 *Corticosteroids* - give prednisone Patient Teaching

Etiology and Risk Factors - *Sinus Bradycardia*

Athletes Inferior wall MI Hypothyroidism Increased ICP Diabetes Vagal stimulation (severe constipation) Carotid sinus massage Drugs (beta blockers, Ca channel blockers) Hypothermia

Hyperthyroidism: *Grave's Disease*

Autoimmune disease of unknown etiology Thyroid enlargement Precipitating factors: Insufficient iodine Infections Genetic factors Increased Stress! Infection Cigarrette smoking

ICDs

Battery powered pulse generator 1-3 lead (one lead in atrium and a lead in one or both ventricles) Monitors HR & rhythm, detects lethal dysrhythmia, delivers 25 joule shock to patient's heart

Conduction - PF

Bundle of His > L & R bundle branches> Purkinje fibers Purkinje fibers - Runs along the myocardium - Stimulates ventricular depolarization resulting in ventricular contraction - Generates an impulse of 20-40 bpm

Etiology & Risk Factors - Atrial Flutter (A. flutter)

CAD COPD HTN Mitral valve disorders Pulmonary Embolism Ischemic heart disease Acute MI Hypoxia Digoxin toxicity Cor pulmonale Cardiomyopathy Rarely occurs in a healthy heart - some disease process

Disorders of Posterior Pituitary SIADH: Over secretion of ADH

Clinical Manifestations Dilution hyponatremia - can get very low! Fluid retention Serum hypoosmolality Weight gain - excess fluid Diagnostic Studies Urine and serum osmolality Electrolytes - specifically sodium BUN, creatinine clearance - make sure its not a kidney problem

Diabetes Insipidus (DI)

Clinical Manifestations Polydipsia Polyuria Excrete large amounts of dilute urine with a low SP Elevated serum osmolality Diagnostic studies Serum labs Water deprivation test

ICD Nursing Diagnoses

Decrease CO r/t alterations in HR Ineffective cardiopulmonary tissue perfusion r/t acute myocardial ischemia Activity intolerance r/t cardiopulmonary dysfunction Acute pain r/t transmission and perception of impulses Compromised family coping r/t critically ill family member Knowledge deficit r/t lack of previous exposure to information

Nursing Dx for Pacemakers

Decreased CO r/t alterations in heart rhythm Ineffective cardiopulmonary tissue perfusion r/t acute myocardial ischemia Risk for infection r/t invasive monitoring device Anxiety r/t threat to biologic, psychological, or social integrity Deficient knowledge r/t management of permanent or temporary monitoring device

P wave

Depolarization of both atria Represents generation of electrical impulse Smooth and rounded Abnormal P waves may be peaked or notched and indicate CHF, COPD, valvular disease

Nursing Management & Diagnostic Evaluation

Determine if hemodynamically stable Continuous telemetry and observe for ectopic beats Monitor VS 12 lead EKG Labs: Basic, Mg, Phos, CBC, Trops CXR Echo

Patient Manifestations - *TEST*

Hypotension Pallor Cool skin Dizziness or syncope Chest pain Weakness Confusion or disorientation Dyspnea Hypoxia

Etiology & Risk Factors - *Sinus Tachycardia*

Hypoxia Exercise Fever Hypotension Hypovolemia Anemia Myocardial ischemia Heart failure Hyperthyroidism Anxiety Drugs (epi, norepi, atropine, caffeine, theophylline, amphetamines, pseudoephedrine)

Nursing Management - Asystole

Initiate CPR using ACLS protocols Drug therapy includes epinephrine, atropine Transcutaneous pacing

*Hypothyroidism*

Insufficient thyroid hormone Common medical problem Causes: Primary or Secondary Common Causes: Iodine deficiency Atrophy of the gland Treatment for hyperthyroidism Drugs Cretinism if occurs in infancy Hypothyroidism is a deficiency of thyroid hormone that causes a general slowing of the metabolic rate. About 4% of the United States population have mild hypothyroidism, and approximately 0.3% have more severe disease. Hypothyroidism is more common in American women than in men. Hypothyroidism can be classified as primary or secondary. Primary hypothyroidism is caused by destruction of thyroid tissue or defective hormone synthesis. Secondary hypothyroidism is caused by pituitary disease with decreased TSH secretion or hypothalamic dysfunction with decreased thyrotropin-releasing hormone (TRH) secretion. Hypothyroidism may also be transient and related to thyroiditis or discontinuance of thyroid hormone therapy. Iodine deficiency is the most common cause of hypothyroidism worldwide. In the United States, the most common cause of primary hypothyroidism is atrophy of the thyroid gland. This atrophy is the end result of Hashimoto's thyroiditis or Graves' disease. These autoimmune diseases destroy the thyroid gland. Hypothyroidism also may develop as a result of treatment for hyperthyroidism, specifically the surgical removal of the thyroid gland or RAI therapy. Drugs such as amiodarone (Cordarone) (which contains iodine) and lithium (which blocks hormone production) can cause hypothyroidism. Hypothyroidism that develops in infancy (cretinism) is caused by thyroid hormone deficiencies during fetal or early neonatal life. All infants in the United States are screened for decreased thyroid function at birth.

EKG Interpretation

Is the rhythm regular or irregular? Is it too fast? Too slow? should be 60-100 Is there a P wave for every QRS Complex?

Primary Adrenocortical Insufficiency Increased Pigmentation

Jack Kennedy: Low Weight & Hyperpigmentation. Progressive weakness

Ventricular Fibrillation (VF) - *The worst rhythm!*

LIFE THREATENING!!! NO PULSE.....EVER No rate or rhythm; no waveforms; no organized activity Ventricle is "quivering" > no ventricle contraction > no cardiac output > patient clinically expired

Patient Presentation - blocks

May be asymptomatic - with 1AVB, 2AVB Most likely symptomatic with 3AVB Can include: - Palpations - Dizziness - Syncope - Chest pain - Fatigue - Diaphoresis - Mental status changes

Patient Example: Mr. T is a 61 yo male with a hx of reoccurring symptomatic VT and spinal stenosis. He is s/p ICD placement. He is stable and his physician has written for discharge home today. After the RN has completed ICD teaching. What statement by the patient indicates further teaching is required by the RN? I will notify my PCP if I notice discharge from my incision. I will have my PCP cancel my f/u MRI for my back. My fast HR is fixed and my family and I don't have to worry about knowing CPR. I will always wear a medical alert bracelet for my safety.

My fast HR is fixed and my family and I don't have to worry about knowing CPR.

Cardiac Output normal vs decreased

Normal CO = 4-6L/min HR and rhythm WNL (60-100 bpm) BP WNL (90-140/60-90) Urine output WNL (30ml/hr) Decreased HR and rhythm - 1+ weak and thready BP - hypotensive UO - decreased

Permanent Pacemaker

Place subcutaneously over patient's pectoral muscle Leads threaded transvenously through R atrium to one or both ventricles Single or Dual chamber

Nursing Management - A. fib

Tachy - leading to decreased output Control rate w/beta blockers, Ca channel blockers (diltiazem, metoprolol, digoxin) Convert rate with antiarrhythmics (amiodarone, ibutilide) Anticoagulation (Warfarin, pradaxa, aspirin) - Long term aspirin used in pts < 65 yo Cardioversion

Nursing Care for Pacemakers

Temporary Pacemaker - EKG/telemetry monitoring - Pacing leads and bridging cable properly secured to patient - RN inspect for loose connections - Battery life and battery replacement - Reduce sources of electromagnetic interference (e.g. MRI, TENS) - RN handle pacing wires with gloves to reduce risk of stray electrical conduction

Disorders of the Thyroid Gland - Physiology

Thyroid hormones regulate *energy metabolism and growth and development* Thyroxine (T4) Triiodothyronine (T3) *Synthesized from iodine* also secretes calcitonin - when there is high calcium levels

Disorders of the Thyroid Gland - Physiology: Negative Feedback Loop

Thyroxine (T4) (thī-räk-sēn, -sən) 90% Majority is bound to plasma proteins Triiodothyronine (T3) 10% T4 converts to T3 in liver, kidneys, & peripheral tissues Biologically active

Patho of the thyroid gland

Thyroxine (T4) (thī-räk-sēn, -sən) 90% Majority is bound to plasma proteins Triiodothyronine (T3) 10% T4 converts to T3 in liver, kidneys, & peripheral tissues Biologically active The follicular cells in the thyroid gland perform all of the functions required for thyroid hormone synthesis. Iodide is transported from the circulation into the inner core along with the protein thyroglobulin, which is synthesized within the cells. Follicles also produce a thyroid peroxidase enzyme and secrete it on the apical surface next to the colloid. Thyroid peroxidase activates and attaches iodides to tyrosine amino acids in the thyroglobulin. Two iodotyrosines are then coupled together, but remain attached to thyroglobulin. Simulation by TSH initiates a cascade that induces the follicle cell to endocytose some of the colloid, followed by combining it with a lysosome that cleaves the T3 and T4from the thyroglobulin. T3 and T4 can then diffuse from the cell into the circulation.

Asystole

Total absence of ventricular activity Occasional P waves or agonal beats seen Etiology includes cardiac conduction disturbance> cardiac arrest ASSESS YOUR PATIENT!!! - confirm asystole

Pacemaker Interrogation

Used to identify pacer rate and mode Real time lead and battery impedance Trends, event counters Histograms detailing the percentage of time sensed/paced, automatic mode-switch episodes, and atrial and/or ventricular arrhythmias Real-time and stored intracardiac electrograms

Nursing Management - PAC

Usually no tx if patient asymptomatic Withdraw sources of stimulation (i.e. caffeine, stress) Introduce beta adrenergic blockers (lopressor, inderal) to decrease PAC occurrences Lifestyle changes (e.g. reduce stress, caffeine)

Nursing Management - SVT

Vagal maneuvers (valsalva - bear down, coughing) Convert rhythm - Adenosine - Antiarrhythmics (amiodarone) - Beta blockers (Betapace), Ca channel blockers (Cardizem) - decrease HR Cardioversion if drug therapy fails and symptoms persist Ablation management

Electrocardiogram

Waveforms Measuring Putting all together 12 lead Waveforms seen on EKG include P, QRS, T Other components include: PR interval, and the ST segment

2nd Degree Type I AVB

Wenckebach PR interval prolongs with each beat until QRS complex dropped QRS complex and QT interval measurements not affected Wenckebach Song:

Again...

What's the HR on this 6 sec strip? 130

And one more...

What's the HR on this 6 sec strip? 50

Let's Practice

What's the HR on this 6 sec strip? 90

Surprise! One more...

What's the HR this 6 sec strip? 170-180

Case Study - Cushing Syndrome

You are working with a home care agency and visiting a 60-year-old man with COPD related to cigarette smoking. He has been on home oxygen for several years. He began oral steroid therapy 10 months ago. In addition to his usual signs and symptoms due to COPD, you observe some new findings during your assessment. His BP is 180/94 He has striae over his trunk and thighs. He has a full-looking face. He has developed truncal obesity with supraclavicular and posterior upper back fat and thin extremities.

Cardioversion

a medical procedure by which an abnormally fast heart rate or other cardiac arrhythmia is converted to a normal rhythm using electricity or drugs

Ambulatory and Discharge Teaching - hypothyroidism

Written instructions important Need for lifelong therapy Thyroid medicine in morning on empty stomach Side effects of medication Signs and symptoms of hypothyroidism and hyperthyroidism Regular follow-up care Do not switch brands Comfortable, warm environment Measures to prevent skin breakdown Emphasize need for warm environment Avoid sedatives or use lowest dose possible Measures to minimize constipation Avoid use of enemas Patient teaching is essential for the patient with hypothyroidism and the caregiver. Initially, the hypothyroid patient may have difficulty processing complex instructions. It is important to provide written instructions, repeat the information often, and assess the patient's comprehension level. Discuss the need for lifelong drug therapy to the patient and caregiver and to avoid abrupt discontinuation of drugs. Thyroid hormone should be taken in the morning before food. Instruct the patient in expected and unexpected side effects. In the teaching plan include the signs and symptoms of hypothyroidism or hyperthyroidism that indicate hormone imbalance. Clearly define toxic symptoms, which are the same as manifestations of hyperthyroidism. Need for regular follow-up care Caution the patient not to switch brands of the hormone unless this is prescribed, as the bioavailability of thyroid hormones may differ. Emphasize the need for a comfortable, warm environment because of intolerance to cold. Teach measures to prevent skin breakdown. Soap should be used sparingly, and lotion should be applied to skin. Caution the patient, especially if an older adult, to avoid sedatives. If they must be used, suggest that the lowest dose be used. Caregiver should closely monitor mental status, level of consciousness, and respirations. Discuss with the patient and caregiver measures to minimize constipation. Suggestions should include the following: Gradual increase in activity and exercise Increased fiber in diet Use of stool softeners Regular bowel elimination time Tell patient to avoid using enemas because they produce vagal stimulation, which can be hazardous if cardiac disease is present.

Measuring PR and QRS

http://www.practicalclinicalskills.com/ekg-lesson.aspx?coursecaseorder=8&courseid=301

Nursing Management - Atrial Flutter (A. flutter)

Rate control w/Ca channel blockers, beta adrenergic blockers Antiarrhythmics (amiodarone) Anticoagulation (Warfarin) - for blood pooling, labs (PT/INR want 2-3, Vitamin K antidote) Cardioversion EP Lab for ablation (finding the ectopic area and stopping it) -Risk for HF if pumping mechanism not working.

Ventricular Dysrhythmias - Premature Ventricular Contraction (PVC) - *TEST!!*

Rate dependent on underlying rhythm Rhythm variable - One in a row: isolated - Two in a row: couplet - Three or more in a row: V tach - Every other: bigeminy - Every third: trigeminy Not accompanied by P wave QRS > 0.12 ST & T are often opposite direction of QRS

Atrial Dysrhythmias - *Premature Atrial Contraction (PAC)*

Rate usually < 100 bpm Irregular P waves are early and upright Normal PR interval and QRS complex measurements A P for every QRS Conducted (causes contractions), nonconductor (doesn't cause contraction), aberrantly (sometimes it does sometimes it doesn't. not usually)

Atrial Flutter (A. flutter)

Rate: Atrial 200-350 bpm Ventricle ~ 150 bpm Rhythm: Atrial - regular Ventricle - regular or irregular P waves unidentifiable; F waves "saw tooth", uniform QRS complex usually normal Usually fixed ratio of F waves to QRS (2:1, 3:1)

Atrial Fibrillation (A. Fib)

Rate: Atrial 350-600 bpm Ventricle varies - 60-100 bpm (rate controlled); >100 bpm (rapid ventricle rate or RVR) Rhythm: Irregularly irregular No discernible P waves; F waves seen QRS complex usually normal measurement Lots of ectopic areas - all over the place

Atrial pacing

Pacer artifact appears just before P wave

Dual pacing

Pacer artifact appears prior to both P wave and QRS complex

Ventricular pacing

Pacer artifact occurs just before QRS complex

Failed Capture

Pacer generates an impulse but the patient's intrinsic rhythm fails to respond

Cardiac Dysrhythmias - overview

*Heart Structure and Assessment* Conduction Assessment- Physical exam Electrocardiogram *Pathology- Dysrhythmias* Sinus origin Atrial Ventricular AV nodal block *Treatment* Antiarrhythmic drugs Electrolyte disturbances Cardioversion and defibrillation Pacemakers

Collaborative care: Thyroid Hormone Therapy - hypothyroidism

*Levothyroxine* (lee voe thye rox' een) (Synthroid) Dosage and administration Orally on empty stomach for absorption (morning) IV for myxedema coma Begin dosage low and increase Evaluate with TSH levels Life long treatment Adverse effects Levothyroxine (Synthroid) is the drug of choice to treat hypothyroidism. When thyroid hormone therapy is initiated, it is important that the initial dosages are low to avoid increases in resting heart rate and blood pressure. In a young and otherwise healthy patient, the maintenance replacement dose is adjusted according to the patient's response and laboratory findings. In a patient with compromised cardiac status, careful monitoring is needed when the dosage is started and adjusted because the usual dose may increase myocardial oxygen demand. The increased oxygen demand may cause angina and cardiac dysrhythmias. Carefully monitor patients with cardiovascular disease who take this drug. Monitor heart rate, and report pulse faster than 100 beats/min or an irregular heartbeat. Promptly report chest pain, weight loss, nervousness, tremors, and insomnia. In a patient without side effects, the dose is increased at 4- to 6-week intervals. It may take up to 8 weeks before the full effect of hormone therapy is experienced. It is important that the patient regularly take replacement medication. Lifelong thyroid therapy is usually required.

Cushing Syndrome

*Range of clinical abnormalities* Caused by excess corticosteroids (glucocorticoids) *Causes* Iatrogenic (illness from healthcare) exogenous corticosteroids (prednisone) - on high doses, taper off, don't take too long! Pituitary tumor (secretes ACTH) Adrenal tumors Cushing's disease *High levels of hormones*

Describe *Diabetes Insipidus (DI)*

*Under secretion of ADH (antidiuretic hormone)* Makes you loose fluids!!! Etiology and Pathophysiology Deficiency of ADH Fluid and electrolyte imbalance Classifications Central (neurogenic) DI Lesion of pituitary Nephrogenic DI Kidney is nonresponsive Dispogenic DI Excessive water intake

Antidysrhythmics: digoxin (Lanolin) & adenosine (Adenocard)

*digoxin (Lanoxin)* - Cardiac glycoside - Slow Na influx and allows Ca influx - Increases contractibility - Dlow HR and AV conduction - Dig toxicity *adenosine (Adenocard)* - Push hard, push fast - Causes temporary AV block to restore sinus rhythm - Initial dose 6mg, if insufficient then 12mg (very fast half life)

Nursing Management - pacemakers

- Ensure pacer wires properly insulated (e.g. terminal ends covered with caps or taped securely) - Inspect pacer wire site for infection - Perform site care as ordered by provider or institution policy - Educate patient: handling of exposed leads, complications of lead displacement, infection and site care, limit electrical equipment from home (i.e. razor, computer)

Conduction - Atrioventricular node (AV)

- Generates an impulse of 40-60 bpm - Receives an electrical impulse from SA node - Short delay time at the AV node allows for ventricle filling - Sends an impulse to the Bundle of His

Conduction - Internal pacemaker (SA node)

- Generates an impulse of 60-100 bpm - SA fires when depolarized - SA rests when repolarization - Causes atrial contraction

Permanent Pacemaker pre-op information

- Informed consent - Use of local anesthesia - Procedure performed in OR or Cath Lab - EGK monitoring while in hospital - Post-op complications - Detecting pacemaker malfunction - RN must know pacemaker's programmable mode and lower rate setting

Measuring EKGs - EKG paper

- Time is measured on horizontal axis - 1 small square = .04 seconds - 1 large square (or 5 small squares) = .20 seconds - Lines at top of ECG paper are 3 seconds apart

Case Study Discussion Questions - *Cushing syndrome*. What syndrome has he likely developed? What is the most probable cause of this change? What is his primary nursing management? Cushing syndrome can affect memory. Patients can easily forget to take medications. What can you do to help him remember to take his pills as prescribed?

1. Cushing syndrome. 2. Use of oral steroids. 3. Education about Cushing syndrome and the need to call his health care provider about changing his medications. 4. Help him fill a weekly medication organizer with the medications.

Case Study Discussion Questions: What are some possible causes of her symptoms? No obvious irregularities are found in her cardiopulmonary assessment. Her TSH levels come back to 20.9 IU/L. She is diagnosed with hypothyroidism. What can you tell her about the treatment and follow-up? What teaching will you need to do with her before she leaves the clinic?

1. Depression, hypothyroidism, anemia, cardiac disease, F/E imbalance, and allergies 2. She will need to take thyroid medication every day for the rest of her life, but this medication will manage her symptoms well. 3. Discuss the signs of hyperthyroidism, so she can be aware if she develops them.

Case Study Discussion Questions What problem do her symptoms and lab values suggest? What treatments may the patient require? What follow-up will she need with these treatments? What important patient teaching should you do following these treatments?

1. Hyperthyroidism. A sustained increase in synthesis and release of thyroid hormones by thyroid gland. Female gender, age between 20 and 40, smoker 2. RAI, antithyroid drugs, or iodine. 3. She will need to monitor her thyroid hormone levels regularly to avoid hypothyroidism. 4. The importance of follow-up care and monitoring of thyroid hormone levels.

Rhythm? Rate? P for every QRS? 2

1. irregular, yes pw, 40 2. irregular, 130-140, no pw 3. regular, 130-140, yes pw

Rhythm? Rate? P for every QRS? 3

1. reg, 70, no pw 2. irregular, no hr, no qrs, no pw 3. Asystole, can't/no tell rate, qrs or p-wave

Rhythm? Rate? P for every QRS? 1

1. reg, 90, yes p-wave 2. reg, 170, no p-wave 3. irregular, 180, no p-wave

Which of the following items would be least important to the nurse who is assessing the therapeutic effectiveness of vasopressin (Pitressin)? 1.Blood albumin 2.Blood pressure 3.Specific gravity 4.Intake and output

1.Blood albumin

12 Lead EKG

12 views of heart Relation between leads and view of heart *Indications for 12 lead* - Chest Pain - SOB - Telemetry changes

The nurse prepares to administer a prescribed dose of desmopressin (DDAVP) intranasally to a client who has which of the following conditions? 1.Syndrome of inappropriate antidiuretic hormone 2.Diabetes insipidus 3.Primary nocturnal enuresis 4.Diabetes mellitus

2.Diabetes insipidus

Cushing Syndrome: Diagnostic Studies

24-hour urine collection for urinary free cortisol excretion - will be elevated! Dexamethasone suppression test (at night), (in the morning) if there are levels Cushings is suspected Plasma cortisol, ACTH CT, MRI - is there a tumor on the pituitary or the adrenal cortex

Case Study - hyperthyroidism

28-year-old woman visits her primary care physician's office. States she is always hungry, yet has lost 15 lbs in the past few months. She also claims to always be tired. Her skin is warm and moist. Her nails have become brittle. She has a bounding pulse and a slight heart murmur. Palpation of her thyroid reveals a nodular goiter. Labs reveal ↓ TSH ↑ free thyroxine (free T4)

Case Study - hypothyroidism

38-year-old woman enters a community outpatient clinic. She is complaining of overwhelming fatigue that is not relieved by rest. She is attending graduate school and is very sedentary. She is so exhausted that she has difficulty waking for classes and trouble concentrating when studying. Her face is puffy, and her skin is dry and pale. She is dressed inappropriately for warm weather. She also complains of generalized body aches and pains with frequent muscle cramps and constipation. Vital signs BP 142/84 Heart rate 52 Respiratory rate 12 Temperature 96.8 degrees F

Procedure and Nursing/ Collaborative Care: Defibrillation

Always an emergency - Begin CPR - Defib arrives (remove all nitro paste patches if applicable), apply pads to patient - Turn on defib - Select appropriate energy level (monophasic: 360 joules initial; biphasic 120-250joules) - Charge paddles and recheck EKG rhythm - LOOK and call out "ALL CLEAR" - Discharge button and deliver shock to patient - Resume CPR

The nurse determines that the patient in acute adrenal insufficiency is responding favorably to treatment when: 1. The patient appears alert and oriented. 2. The patient's urinary output has increased. 3. Pulmonary edema is reduced as evidenced by clear lung sounds. 4. Laboratory tests reveal elevations of potassium and glucose serum levels and a decrease in the sodium level.

Answer: 1 Rationale: The patient in acute adrenal insufficiency will have the following clinical manifestations: Hypotension, tachycardia, dehydration, hyponatremia, hyperkalemia, hypoglycemia, fever, weakness, and confusion. Collaborative care will include administration of corticosteroids. An outcome that would indicate patient improvement would be improved level of consciousness (i.e., alert and oriented).

An IV hydrocortisone infusion is started before a patient is taken to surgery for a bilateral adrenalectomy. The nurse explains to the patient that this is done to: 1. Prevent sodium and water retention after surgery. 2. Prevent clots from forming in the legs during recovery from surgery. 3. Provide substances to respond to stress after removal of the adrenal glands. 4. Stimulate the inflammatory response to promote wound healing.

Answer: 3 Rationale: Hydrocortisone is administered IV during and after a bilateral adrenalectomy to ensure adequate responses to the stress of the procedure.

When assessing a patient who is returned to the surgical unit following a thyroidectomy, the nurse would be most concerned if the patient: 1. Complains of thirst 2. States her throat is sore 3. Holds her head when she moves in bed 4. Makes harsh, vibratory sounds when she breathes

Answer: 4 Rationale: After thyroid surgery, the patient may experience an airway obstruction related to excess swelling, hemorrhage, hematoma formation, or laryngeal stridor (harsh, vibratory sound). The patient should have emergency equipment at the bedside, including oxygen, suction equipment, and a tracheostomy tray.

Assessment and Postoperative Care for hyperthyroidism and thyroid surgery?

Assess every 2 hours during first 24 hours for signs of hemorrhage or tracheal compression Semi-Fowler's position Support head with pillows Avoid neck flexion and tension on suture line Important nursing interventions after a thyroidectomy include the following: 1. Assess the patient every 2 hours for 24 hours for signs of hemorrhage or tracheal compression such as irregular breathing, neck swelling, frequent swallowing, sensations of fullness at the incision site, choking, and blood on the anterior or posterior dressings. 2. Place the patient in a semi-Fowler's position (30 to 45 degrees), support the patient's head with pillows, and avoid flexion of the neck and any tension on the suture lines. 3. NPO initially; Start liquids slowly (aspiration risk) 4. Avoid jerky movements & hyperextension

Etiology & Risk Factors - A. fib

CAD Rheumatic heart disease HTN Cardiomyopathy HF Pericarditis Hypoxia Acute MI Valvular disease Are they symptomatic is the question...

Case Study - *Addison's disease* 30-year-old woman arrives in the ED with syncope after standing up. Her skin is hyperpigmented over her joints and on her palms. Lab values reveal ↓ ACTH ↓ plasma cortisol ↓ Na ↓ glucose ↑ K

Case Study Discussion Questions: Based on the findings, what are her possible diagnoses? What is her primary acute nursing management? What critical patient teaching should you do with her about her home care? What lifestyle modifications should she make? 1. Addison's disease. 2. Frequent nursing assessment and protection from extremes. 3. Discuss the serious nature of the disease and the need for lifelong replacement therapy *(see Table 50-18 for major areas that must be included in the teaching plan).* typical pattern of cortisol secretion showing a diurnal (circadian) rhythm, with highest secretion occurring in the morning upon awakening and lowest levels in the late evening. 4. Always carry an emergency kit. (IM injection of a steroid with them)

Disorders of Posterior Pituitary - SIADH

Collaborative Care Treat cause - whats going on? Restrict fluids Administer saline if severe hyponatremia - pull fluid out of the vascular spaces. don't high BP. Nursing Management Assess low UOP, high BP, sudden wt. gain Fluid restriction Hard candy

Conduction

Conductivity: ability to conduct an impulse resulting in stimulation of adjacent cells Depolarization: cells become more positive on the inside Repolarization: cells become more negative on the inside Electrical Pathway: SA > AV > His Bundle > RLBB (right and left bundle branch) > PF A beat initiated outside the electrical pathway is known as an *ectopic beat*

Cushing Syndrome: Clinical Manifestations - Know for *TEST!*

Excess corticosteroids Appearance Skin - thin, *poor wound healing* CV - HTN, edema, HF GI - never hungry Urinary - glucose, glycosuria, increased risk for kidney stones Musculoskeletal - muscle wasting, bones brittle (fractures and osteoporosis) Fluids/lytes - sodium and water retention, *low potassium* Metabolic - high glucose Emotional - mood alterations Reproductive - menstrual irregularities, men have gynecomastia Truncal obesity moon face

Cushing Syndrome: Clinical Manifestations #2

Cushing syndrome. Facies include a rounded face ("moon face") with thin, reddened skin. Hirsutism may also be present. Cushing syndrome. Truncal obesity; broad, purple striae; and easy bruising (left antecubital fossa).

Myxedema

Due to the accumulation of hydrophilic mucopolysaccharides in the dermis and other tissues Can develop myxedema coma Patients with severe long-standing hypothyroidism may display myxedema, which is the physical appearance of the skin and subcutaneous tissues. Myxedema is due to the accumulation of hydrophilic mucopolysaccharides in the dermis and other tissues. Common features of myxedema. Dull, puffy skin; coarse, sparse hair; facial and periorbital edema; and prominent tongue and masklike effect. Individuals with hypothyroidism may describe an altered self-image related to their disabilities and altered appearance. The mental sluggishness, drowsiness, and lethargy of hypothyroidism may progress gradually or suddenly to a notable impairment of consciousness or coma. This situation, termed myxedema coma, is a medical emergency. Myxedema coma can be precipitated by infection, drugs (especially opioids, tranquilizers, and barbiturates), exposure to cold, and trauma. It is characterized by subnormal temperature, *hypotension, and hypoventilation*. Cardiovascular collapse can result from *hypoventilation, hyponatremia, hypoglycemia, and lactic acidosis*. For the patient to survive a myxedema coma, vital functions must be supported, and IV thyroid hormone replacement must be administered. The patient who develops myxedema coma requires acute nursing care, often in an intensive care setting. Mechanical respiratory support and cardiac monitoring are frequently necessary. Administer thyroid hormone therapy and all other medications IV because *paralytic ileus* may be present in myxedema coma. Monitor the core temperature because hypothermia often occurs in myxedema coma.

Pacemakers

Electronic device used in patients with a damaged pathway Used for brady arrhythmias and override ability for tachy arrhythmias Indications include: - AV block (2nd and 3rd degree) - A fib with slow ventricular response - BBB - bundle branch block - Cardiomyopathy - HF - SA node dysfunction - Tachyarrhythmia

Syndrome of Inappropriate ADH (SIADH): Over secretion of ADH

Etiology & Pathophysiology Abnormal production of ADH - not a lot of urine out put, high specific gravity Occurs most often in elderly Most common cause of hyponatremia in elderly Causes Small cell lung cancer Head trauma Drugs

About Hyperthyroidism: Grave's Disease

Excess hormones Antibodies to TSH receptor stimulate release of T3, T4, or both Leads to clinical manifestations of thyrotoxicosis Remissions and exacerbations May progress to destruction of thyroid tissue In Graves' disease the patient develops antibodies to the TSH receptor. These antibodies attach to the receptors and stimulate the thyroid gland to release T3, T4, or both. The excessive release of thyroid hormones leads to the clinical manifestations associated with thyrotoxicosis. The disease is characterized by remissions and exacerbations with or without treatment. It may progress to destruction of the thyroid tissue, causing hypothyroidism.

Thyrotoxicosis (Thyrotoxic Crisis)

Excessive amounts hormones released Life-threatening emergency Death rare when treatment initiated Results from stressors Thyroidectomy patients at risk Thyrotoxicosis (also called thyrotoxic crisis or thyroid storm) is an acute, severe, and rare condition that occurs when excessive amounts of thyroid hormones are released into the circulation. Although it is considered a life-threatening emergency, death is rare when treatment is initiated early. Thyrotoxicosis is thought to result from stressors (e.g., infection, trauma, surgery) in a patient with preexisting hyperthyroidism, either diagnosed or undiagnosed. Patients particularly prone to thyrotoxic crisis are those undergoing thyroidectomy, in as much as manipulation of the hyperactive thyroid gland results in an increase in hormones released.

Practice Makes Permanent

For more practice with measuring EKGs please visit http://skillstat.com/tools/ecg-simulator#/-home http://www.rnceus.com/course_frame.asp?exam_id=16&directory=ekg

Cardiac Output

HR that is either too fast or too slow compromises *cardiac output (CO)* HR too fast > inability of ventricles to fill > decreased CO HR too slow > decreased stimulation to pump enough blood out > decreased CO

What are the clinical Manifestations of *hyperthyroidism*?

HYPERthyroidism: Signs and Symptoms (mnemonic)-"THYROIDISM" T = Tremor H = Heart rate up Y = Yawning [fatigability] R = Restlessness O = Oligomenorrhea & amenorrhea I = Intolerance to heat, D= Diarrhea I = Irritability S = Sweating M = Musle wasting & weight loss E = Exophthalmos - bulging eyes

3rd Degree AVB (Complete HB)

Heart block (HB) No communication between atrial and ventricle conduction system SA node generate impulse but does not stimulate the AV node Ventricle contraction is conducted either through AV node or the ventricle

What is the typical nutritional Therapy for *Hyperthyroidism*?

High-calorie diet (4000 to 5000 cal/day) Six full meals/day with snacks in between Protein intake: 1 to 2 g/kg ideal body weight Increased carbohydrate intake Avoid highly seasoned and high-fiber foods, caffeine Dietitian referral With the increased metabolic rate in hyperthyroid patients, there is a high potential for the patient to have a nutritional deficit. A high-calorie diet (4000 to 5000 cal/day) may be ordered to satisfy hunger, prevent tissue breakdown, and decrease weight loss. This can be accomplished with six full meals a day and snacks high in protein, carbohydrates, minerals, and vitamins. The protein content should be 1 to 2 g/kg of ideal body weight. Increase carbohydrate intake to compensate for increased metabolism. Carbohydrates provide energy and decrease the use of body-stored protein. Teach the patient to avoid highly seasoned and high-fiber foods because these foods can further stimulate the already hyperactive GI tract. Instruct the patient to avoid caffeine-containing liquids such as coffee, tea, and cola to decrease the restlessness and sleep disturbances associated with these fluids. Refer the patient to a dietitian for help in meeting individual nutritional needs.

Diagnostic Studies - hypothyroidism

History and physical examination TSH and free T4 TSH ↑ with primary hypothyroidism TSH ↓ with secondary hypothyroidism Thyroid antibodies The most common and reliable laboratory tests for thyroid function are TSH and free T4. These values, correlated with symptoms gathered from the history and physical examination, confirm the diagnosis of hypothyroidism. Serum TSH levels help determine the cause of hypothyroidism. Serum TSH is high when the defect is in the thyroid and low when it is in the pituitary or hypothalamus. The presence of thyroid antibodies suggests an autoimmune origin of the hypothyroidism. Other abnormal laboratory findings are elevated cholesterol and triglyceride levels, elevated creatine kinase level, and anemia.

Describe Hyperthyroidism

Hyperthyroidism is hyperactivity of the thyroid gland with sustained increase in synthesis and release of thyroid hormones. Hyperthyroidism occurs more in women than in men; the frequency is highest in persons 20 to 40 years old.

Adrenocortical *Insufficiency*

Hypofunction of adrenal cortex *Low levels of hormones* Primary *(Addison's disease)* Autoimmune destruction (#1) Tuberculosis Infections of the adrenal glands Spread of cancer to the adrenal glands Bleeding into the adrenal glands Secondary Diseased pituitary gland

What are the clinical manifestations of Hypothyroidism?

Hypometabolism Often slow changes Fatigue, lethargy Mental changes Cardiac GI Cold intolerance Skin: dry, cold Weight gain Regardless of the cause, hypothyroidism has systemic effects characterized by a slowing of body processes. Manifestations vary depending on the severity and the duration of thyroid deficiency, as well as the patient's age at the onset of the deficiency. The onset of symptoms may occur over months to years unless hypothyroidism occurs after a thyroidectomy, thyroid ablation, or during treatment with antithyroid drugs. A low-calorie diet is also indicated to promote weight loss or prevent weight gain.

Nursing Management - Ventricular Tachycardia (VT)

Identify the rhythm ASSESS YOUR PATIENT - Check for pulse! If pulse - patient stable but interventions are required Monitor, monitor, monitor! Apply pacing pads If hemodynamically stable, tx the cause (ischemia, hypoxia - provide O2, correct electrolyte imbalance) Meds include epinephrine (increase HR and contractility), vasopressin, procainamide (NR), amiodarone (NR), lidocaine, beta blockers ICD implantation management If patient has no pulse - VT is then treated like V Fib CODE Blue initiated CPR and rapid defibrillation is first line tx followed by vasopressors (epinephrine) and antidysrhythmics (amiodarone) Want to get the heart into a normal rhythm

Cushing Syndrome: Collaborative Care #2

If Cushing syndrome develops during use of corticosteroids Gradually discontinue therapy Decrease dose Convert to an alternate-day regimen Gradual tapering avoids potentially life-threatening adrenal insufficiency Health promotion: Who is at risk? anyone who is taking corticosteroids. AKA Prednisone - patient education! Interventions: Glycemic control; cardiovascular effects; body image changes Home Care (refer to text) Wear medic alert bracelet

Procedure and Nursing/ Collaborative Care: Synchronized Cardioversion - emergent

If emergent - *Remove all nitro paste/patches from patient* - Place defib pads on pt (under R of the sternum below clavicle and to the L of the apex) - Turn defib on and select "synch" mode - Select appropriate voltage (usually starts about 50 -100 joules) - Charge the paddles, check the EKG rhythm, and ensure the QRS complex is sensed - LOOK around and call out "ALL CLEAR" - Discharge a shock to patient - Reassess patient and EKG rhythm

Procedure and Nursing/ Collaborative Care: Synchronized Cardioversion - non-emergent

If non-emergent (similar procedure with exceptions) - Informed consent - Complete physical assessment prior to procedure - Anticoagulation hx - Mg and K prior to procedure - Patient NPO about 8 hours prior to cardioversion - Ensure IV access, crash cart at bedside - Cardiac monitor, pulse ox, BP cuff in place - Oxygen set up - MD orders regarding holding Digoxin - Anesthesiology at bedside if not intubated - Sedate pt (e.g. Versed) - Reassess patient post procedure

Nursing Management - Ventricular Fibrillation (VF)

If not treated patient will expire *Assess your patient* Begin CPR immediately (ACLS protocols) Rapid defibrillation and drug therapy epi and vasopressin

Nursing Management - *Sinus Bradycardia*

If patient symptomatic: - Assessment of medications - *Atropine - anticholinergic, counteracts rest and digest - TEST!* increases HR. - Possible pacemaker Nutritional information: increase daily fiber, water intake -> reduce risk of constipation

Nursing Management - *Sinus Tachycardia*

If symptomatic: - Assess pain management - IV fluids - Correct the etiology Medications -> if unable to correct cause Beta blockers, calcium channel blockers

Implantable Cardioverter - Defibrillator (ICD)

Implantable device to help patients with symptomatic VT and high risk for life-threatening dysrhythmias Bradycardia backup pacing Dual chamber system threaded through subclavian vein to the endocardium Dual chamber allows for cardioversion/pacing for atrial tachydysrhythmias

Nursing Dx for Dysrhythmias

Ineffective tissue perfusion r/t interruption of arterial flow Decreased cardiac output r/t altered electrical conduction Activity intolerance r/t decreased cardiac output Anxiety/fear r/t threat of death, change in health status Ineffective health maintenance r/t deficient knowledge regarding self-care with disease

*Postoperative Care* for hyperthyroidism and thyroid surgery?

Maintain patent airway Oxygen, suction equipment, tracheostomy tray in patient's room Monitor for laryngeal stridor IV calcium readily available Postoperative complications include hypothyroidism; damage to or inadvertent removal of parathyroid glands, causing hypoparathyroidism and hypocalcemia; hemorrhage; injury to the recurrent or superior laryngeal nerve; thyrotoxic crisis; and infection. Recurrent laryngeal nerve damage leads to vocal cord paralysis. If both cords are paralyzed, spastic airway obstruction will occur, necessitating an immediate tracheostomy. Although not common, airway obstruction after thyroid surgery is an emergency situation. Oxygen, suction equipment, and a tracheostomy tray should be readily available in the patient's room. Respiration may also become difficult because of excess swelling of the neck tissues, hemorrhage, and hematoma formation. Laryngeal stridor (harsh, vibratory sound) may occur during inspiration and expiration as a result of edema of the laryngeal nerve. Laryngeal stridor may also be related to tetany, which occurs if the parathyroid glands are removed or damaged during surgery, leading to hypocalcemia. To treat tetany, IV calcium salts (e.g., calcium gluconate, calcium gluceptate) should be available.

Thyrotoxicosis - manifestations

Manifestations Tachycardia, heart failure Shock Hyperthermia Restlessness, irritability Seizures Abdominal pain, vomiting, diarrhea Delirium, coma Treat by reducing circulating hormones Supportive therapy Manage respiratory distress Reduce fever Replace fluids Eliminate or manage initiating stressor In thyrotoxicosis, all the symptoms of hyperthyroidism are prominent and severe. Manifestations include severe tachycardia, heart failure, shock, hyperthermia (up to 105.3º F [40.7º C]), restlessness, irritability, seizures, abdominal pain, vomiting, diarrhea, delirium, and coma). Treatment is aimed at reducing circulating thyroid hormone levels and the clinical manifestations with appropriate drug therapy. Supportive therapy is directed at managing respiratory distress, fever reduction, fluid replacement, and elimination or management of the initiating stressor(s). Individuals who have hyperthyroidism are usually treated in an outpatient setting. However, patients who develop acute thyrotoxicosis (thyroid storm) or those who undergo thyroidectomy require hospitalization and acute care. Acute thyrotoxicosis is a systemic syndrome that necessitates aggressive treatment, often in an intensive care unit. Administer medications (previously discussed) that block thyroid hormone production and the sympathetic nervous system. Provide supportive therapy to the patient. This includes monitoring for cardiac dysrhythmias and decompensation, ensuring adequate oxygenation, and administering IV fluids to replace fluid and electrolyte losses. This is especially important in a patient who experiences fluid losses as a result of vomiting and diarrhea. Ensuring adequate rest may be a challenge because of the patient's irritability and restlessness. Provide a calm, quiet room because increased metabolism and sensitivity of the sympathetic nervous system causes sleep disturbances. Other interventions may include placing the patient in a cool room away from very ill patients and noisy, high-traffic areas. Use light bed coverings and changing the linen frequently if the patient is diaphoretic. Encourage and assist with exercise involving large muscle groups (tremors can interfere with small-muscle coordination) to allow the release of nervous tension and restlessness. It is important to establish a supportive, trusting relationship to help the patient who is irritable, restless, and anxious to cope.

Patient Presentation - A. fib

May be asymptomatic if rate controlled (ventricle <100 bpm) *Palpitations - most common* Fatigue Exercise tolerance decreased Syncope (if underlying stenosis or PE) *Irregular pulse*

Measuring HR

Measured from a 6 sec EKG strip Four methods - Number of QRS complexes in 1 minute - Number of small boxes between 1 R-R interval and divide into 1500 - Number of large boxes between 1 R-R interval and divide into 300 - *Count the R-R intervals in a 6 sec strip and multiply by 10 (most commonly used in practice)*

PR Interval

Measured from beginning of P wave to start of QRS complex Represents impulse conduction from SA to AV node *Measures 0.12-0.20 sec*

QT Interval (FYI)

Measured from the beginning of the Q wave to the end of the T wave Represents total amount of time it takes the ventricles to depolarize and repolarize Usually measures < 0.40 sec (adjusted for patient specific factors such as HR, age, gender)

2nd Degree Type II AVB

Mobitz II More advanced and severe than Type I PR interval remains consistent and QRS complex is dropped without warning Regular or irregular

Ambulatory and Home Care: Discharge Teaching - hyperthyroidism

Monitor hormone balance periodically Decrease caloric intake Adequate but not excessive iodine intake Regular exercise Avoid ↑ environmental temperature Regular follow-up care Complete thyroidectomy The patient and family need to be aware that thyroid hormone balance should be monitored periodically. Most patients experience a period of relative hypothyroidism soon after surgery because of the substantial reduction in the size of the thyroid. However, the remaining tissue usually hypertrophies over time and recovers the capacity to produce hormones. The administration of thyroid hormone is avoided because the use of exogenous hormone inhibits pituitary production of TSH and delays or prevents the restoration of normal gland function and tissue regeneration. To prevent weight gain, caloric intake must be reduced substantially below the amount that was required before surgery. Adequate iodine is necessary to promote thyroid function, but excesses can inhibit the thyroid gland. Seafood once or twice a week or normal use of iodized salt should provide sufficient iodine intake. Encourage regular exercise to stimulate the thyroid gland. Teach the patient to avoid high environmental temperatures because they inhibit thyroid regeneration. Regular follow-up care is necessary. The patient should be seen by the health care provider biweekly for a month and then at least semiannually to assess thyroid function. If a complete thyroidectomy has been performed, instruct the patient about the need for lifelong thyroid hormone replacement. Teach the patient the signs and symptoms of progressive thyroid failure and to seek medical care if these develop. Hypothyroidism is relatively easy to manage with oral administration of thyroid replacement.

Etiology & Risk Factors - SVT

Overexertion Stress CAD Hypoxia Fever Cor pulmonale Digoxin toxicity Rheumatic heart disease Caffeine Tobacco

Postoperative Care and assessment for hyperthyroidism and a thyroidectomy?

Monitor vital signs and calcium levels Signs of hypocalcemia Difficulty speaking and hoarseness Trousseau's and Chvostek's signs http://www.youtube.com/watch?v=kvmwsTU0InQ Analgesics Ambulation Psychosocial support Monitor vital signs and calcium levels. Complete the initial assessment by checking for signs of tetany secondary to hypoparathyroidism (e.g., tingling in toes, fingers, around the mouth; muscular twitching; apprehension) and by evaluating difficulty in speaking and hoarseness. Monitor for Trousseau's sign and Chvostek's sign. Chvostek's sign is the twitching of the facial muscles in response to tapping over the area of the facial nerve. Trousseau's sign is carpopedal spasm caused by inflating the blood-pressure cuff to a level above systolic pressure for 3 minutes. Expect some hoarseness for 3 to 4 days after surgery because of edema. Control postoperative pain by giving medication. If postoperative recovery is uneventful, the patient is ambulated within hours after surgery, is permitted to take fluid as soon as tolerated, and eats a soft diet the day after surgery. The appearance of the incision may be distressing to the patient. Reassure the patient that the scar will fade in color and eventually look like a normal neck wrinkle. A scarf, jewelry, a high collar, or other covering can effectively camouflage the scar.

Nursing Management - blocks

Most likely cause is ischemia Place O2 Identify rhythm Obtain 12 lead Monitor freq VS Assess if hemodynamically stable If symptomatic: administer atropine, place pacer pads on pt and crash cart by room

Patient Example - Sinus Tachycardia

Mr. P is 56 years old with a hx of *COPD and hyperthyroidism* who was admitted with palpitations and shortness of breath. 12 lead confirms sinus tach HR 137 bpm. Mr. P's VS: T 99.4, HR 137, BP 115/67, RR 24, O2 82% on RA. Which action should the RN take next? hypoxia and decreased cardiac output 1. Prepare for cardioversion 2. Apply oxygen *3. Have pt cough and bare down (valsalva maneuver) lower HR* - do this first! 4. Check K, Mg, CBC

Sinus Rhythm

Normal sinus rhythm - Rate 60-100 - Regular - A P for every QRS and P waves upright - P-R interval 0.12 - 0.20 seconds and consistent, QRS 0.04 - 0.10 seconds SR NSR

Heart rate and rhythm

Not all patients on telemetry; must auscultate HR and rhythm Heart rate - Normal: 60-100 bpm Heart rhythm - Regular - Irregular

Patient Example - VT Mr. R is a 63 yo man with a hx of CHF, MI x2, CABG x4, HTN, and high cholesterol. The RN's tele alarm signals a high alert alarm and the rhythm is shown. The patient is alert, diaphoretic, and c/o palpitations. What should the RN do? (SELECT ALL THAT APPLY.) Notify the physician immediately. Check Mr. R's VS. Administer adenosine. Apply pacer pads.

Notify the physician immediately. Check Mr. R's VS. Apply pacer pads.

Nursing Care/Teaching: ICD

Often placed in Cath Lab under conscious sedation or with open heart surgery Patients often experience fear of recurrent dysrhythmias and an expectation of pain associated with ICD Fear of body image change Anxiety Know the type of ICD place, functions, activated If device fires, RN prepared to defib patient and alter pad/paddle placement accordingly Pre-op: - Informed consent - Provide patient information on device (how it works, what to expect) - Patient education on living with an ICD - F/U with provider - Continued use of antidysrhythmics - What to do if device fires - Support groups Immediately post-op - Arm immobilizer - Possible bed rest - Frequent VS - Monitor via telemetry - EKG in am - Possible labs: Basic, Mg Upon patient discharge - F/U with primary care provider - Signs/Sx of site infection - Incision care - Avoid heavy lifting (lead displacement) - Broken leads - Sensing of supraventricular tachydysrhythmias resulting in unneeded discharges - Avoid activities that may cause direct blows to ICD site - Avoid large magnets and electromagnetic fields (no MRIs) - Airline travel - Avoid lingering around antitheft devices in stores - Notifying EMS and care provider when ICD fires - Medical bracelet - Caregivers should learn CPR

List some more clinical Manifestations of *hyperthyroidism*

Ophthalmopathy Abnormal eye appearance or function Exophthalmos Increased fat deposits & fluid Eyeballs forced outward Nursing care Goiter Inspection Auscultation: bruits Another common finding is ophthalmopathy, a term used to describe abnormal eye appearance or function. A classic finding in Graves' disease is exophthalmos, a protrusion of the eyeballs from the orbits that is usually bilateral. Exophthalmos results from increased fat deposits and fluid (edema) in the orbital tissues and ocular muscles. The increased pressure forces the eyeballs outward. The upper lids are usually retracted and elevated, with the sclera visible above the iris. When the eyelids do not close completely, the exposed corneal surfaces become dry and irritated. Serious consequences, such as corneal ulcers and eventual loss of vision, can occur. The changes in the ocular muscles result in muscle weakness, causing diplopia. If exophthalmos is present, there is a potential for corneal injury related to irritation and dryness. The patient may have orbital pain. Nursing interventions to relieve eye discomfort and prevent corneal ulceration include applying artificial tears to soothe and moisten conjunctival membranes. Salt restriction may help reduce periorbital edema. Elevate the patient's head to promote fluid drainage from the periorbital area. The patient should sit upright as much as possible. Dark glasses reduce glare and prevent irritation from smoke, air currents, dust, and dirt. If the eyelids cannot be closed, they should be lightly taped shut for sleep. To maintain flexibility, teach the patient to exercise the intraocular muscles several times a day by turning the eyes in the complete range of motion. Good grooming can be helpful in reducing the loss of self-esteem that can result from an altered body image. If the exophthalmos is severe, treatment options include corticosteroids, radiation of retroorbital tissues, orbital decompression, and corrective lid or muscle surgery. Palpation of the thyroid gland may reveal a goiter. When the thyroid gland is excessively large, a goiter may be noted on inspection. Auscultation of the thyroid gland may reveal bruits, a reflection of increased blood supply.

Iodine Drugs used for *hyperthyroidism*?

Potassium iodine (SSKI) and Lugol's solution Inhibit synthesis of T3 and T4 and block their release into circulation Decreases vascularity of thyroid gland Maximal effect within 1 to 2 weeks Used before surgery and to treat crisis Iodine is available in the form of saturated solution of potassium iodine (SSKI) and Lugol's solution. The administration of iodine in large doses rapidly inhibits synthesis of T3 and T4 and blocks the release of these hormones into circulation. It also decreases the vascularity of the thyroid gland, making surgery safer and easier. The effect of iodine is usually maximal within 1 to 2 weeks. Because there is a reduction in the therapeutic effect, long-term iodine therapy is not effective in controlling hyperthyroidism. Iodine is used with other antithyroid drugs to prepare the patient for thyroidectomy or for treatment of thyrotoxic crisis.

Electrolytes: Potassium and Magnesium

Potassium replacement (patient dependent) - Hypokalemia < 3.5 mEq/L leads to PVCs, VT, VF - Replaced per physician order or institution's sliding scale - Nursing management: monitor EKG, monitor s/sx hypokalemia, dietary K+, K+ sparing diuretics, monitor patient's n/v - Hyperkalemia > 5.2mEq/L leads sine wave (very wide QRS - ST - T) - Administer kayexalate, calcium gluconate, insulin, or Na Bicarb Magnesium replacement - Hypomagnesaemia < 1.5 mEq/L leads to form of VT known as Torsades de pointes Administer IV Mg Sulfate Assess for neuromuscular irritability - *Hypermagnesaemia* > bradycardia, increased PRI, widened QRS, elevated T waves Administer *calcium gluconate* if prescribed

First degree AV Block

Prolonged conduction between atrium and ventricle PR interval > 0.20 seconds and consistent QRS complex and QT interval measurements not affected

Beta Blockers used with *hyperthyroidism*?

Propranolol Suppresses tachycardia and other symptoms of Graves' disease from the beta-adrenergic blockade; in thyrotoxic crisis, give immediately unless pt. has asthma or CHF β-Adrenergic blockers are used for symptomatic relief of thyrotoxicosis. These drugs block the effects of sympathetic nervous stimulation, thereby decreasing tachycardia, nervousness, irritability, and tremors. Propranolol (Inderal) is usually administered with other antithyroid agents. Atenolol (Tenormin) is the preferred β-adrenergic blocker for use in hyperthyroid patients with asthma or heart disease.

What are the Antithyroid Drugs used for *hyperthyroidism*?

Propylthiouracil (PTU) Blocks synthesis of thyroid hormones Methimazole—Similar to PTU Drugs used in the treatment of hyperthyroidism include antithyroid drugs, iodine, and β-adrenergic blockers. These drugs are useful in the treatment of thyrotoxic states, but they are not considered curative. The first-line antithyroid drugs are propylthiouracil (PTU) and methimazole (Tapazole). These drugs inhibit the synthesis of thyroid hormones. Indications for the use of antithyroid drugs include Graves' disease in young patients, hyperthyroidism during pregnancy, and the need to achieve a euthyroid state before surgery or radiation therapy. PTU is generally given to patients who are in their first trimester of pregnancy, who have an adverse reaction to methimazole, or for whom a rapid reduction in symptoms is required. PTU is also considered first line in thyrotoxic crisis as it also blocks the peripheral conversion of T4 to T3. The advantage of PTU is that it achieves the therapeutic goal of a euthyroid state more quickly, but it must be taken three times per day. In contrast, methimazole is given in a single daily dose. Although there is individual variation, improvement usually begins 1 to 2 weeks after the start of drug therapy. Good results are usually seen within 4 to 8 weeks. Therapy is usually continued for 6 to 15 months to allow for spontaneous remission, which occurs in 20% to 40% of patients. Emphasize to the patient the importance of adherence to the drug regimen. Abrupt discontinuation of drug therapy can result in a return of hyperthyroidism.

Sinus Dysrhythmias - *Sinus Bradycardia*

Rate <60 bpm Regular Normal and consistent PR interval and QRS complex A P for every QRS

Sinus Tachycardia

Rate > 100 < 150 bpm Regular Normal and consistent PR interval and QRS complex A P for every QRS

Supraventricular Tachycardia (SVT)

Rate > 150 bpm Regular P waves hidden in T waves Normal QRS complex measure If onset/ending abrupt - paroxysmal atrial tachycardia

Patient Example - asystole P.G. is a 59 yo female with an extensive cardiac hx, hypothyroidism, and diabetes. She was admitted for syncope and hypoxia with RA Sats of 87%. She has denied complaints all day and at shift change the RN notices the following rhythm. After running to the patient's room, the RN finds her ambulating to the bathroom. What is the RN's next action? Call a CODE Blue Monitor patient's vital signs Replace the telemetry electrodes Administer atropine

Replace the telemetry electrodes

QRS Complex

Represents depolarization of ventricle *Measures 0.04 - 0.12 sec or less* Measured from the beginning of the Q wave to the end of the S wave Q wave: first negative deflection R wave: first positive deflection S wave: negative deflection following R wave

T wave

Represents ventricular repolarization Typically positive deflection especially in lead II Inverted T wave may indicate ischemia and/or infarction

Terminology - pacemakers

Sensing- the generator is able to "see" the patient's intrinsic beat Firing- the generator delivers a pacing stimulus Inhibition- pacer senses patient's own heart beat and inhibits generator firing Triggering- pacer senses patient's missed beat and generates response Capture- the heart responds to the stimulus that generator delivered Fixed pacing- the generator sets an impulse at a fixed rate regardless of the patient's intrinsic rhythm Demand pacing- is able to inhibit impulse generation when the patient's intrinsic rhythm is adequate

Cardioversion vs Defibrillation: Synchronized Cardioversion

Shock delivered on the R wave of the QRS complex Synchronized button switched on and verify sensing of QRS complexes Used for hemodynamically unstable patients with: VT with pulse, SVT, AFib RVR, A flutter May also be a planned procedure in patients with stable dysrhythmias

ACLS: Defibrillation

Shockable rhythms: - VF - ventricular fibrillation - Pulseless VT - ventricular tachycardia

Etiology & Risk Factors - Ventricular Tachycardia (VT)

Significant electrolyte imbalance MI Cardiomyopathy CAD CNS disorders Drug toxicity Prolonged QT Freq PVCs Infections

Cardiac Dysrhythmias

Sinus Dysrhythmias Atrial Dysrhythmias Ventricular Dysrhythmias Asystole

Nursing Care - hypothyroidism

Skin care Vital signs, weight, I&O, edema Cardiovascular response to hormone Energy level The treatment goal for a patient with hypothyroidism is restoration of a euthyroid state as safely and rapidly as possible with hormone therapy. Use soap gently, and moisturize frequently to prevent skin breakdown. Frequent changes in patient positioning and a low-pressure mattress can also assist in maintaining skin integrity. Monitor the patient's progress by assessing vital signs, body weight, fluid intake and output, and visible edema. Cardiac assessment is especially important because the cardiovascular response to hormone therapy determines the medication regimen. Note energy level and mental alertness, which should increase within 2 to 14 days and continue to improve steadily to normal levels. The patient's neurologic status and free T4 levels are used to determine continuing treatment.

Etiology & Risk Factors - PVC

Stimulants Electrolyte imbalance Fever Infection Stress Exercise Gastric overload Acute MI Acidosis Cyclic antidepressants Heart disease

Etiology & Risk Factors - PAC

Stress Fatigue Caffeine Alcohol Tobacco CHF Electrolyte imbalance COPD Hypoxia Heart disease Myocardial ischemia or injury Digoxin toxicity

Surgery for *hyperthyroidism*?

Subtotal thyroidectomy Traditional approach Endoscopy now being done Thyroidectomy is indicated for individuals who (1) have a large goiter causing tracheal compression, (2) have been unresponsive to antithyroid therapy, or (3) have thyroid cancer. In addition, surgery may be done when an individual is not a candidate for RAI. One advantage that thyroidectomy has over RAI is a more rapid reduction in T3 and T4 levels. A subtotal thyroidectomy is often the preferred surgical procedure and involves the removal of a significant portion (90%) of the thyroid gland. Endoscopic thyroidectomy is a minimally invasive procedure. In this procedure, several small incisions are made, and an endoscope is inserted. Instruments are passed through the endoscope to remove thyroid tissue or nodules. Endoscopic thyroidectomy is an appropriate procedure for patients with small nodules (less than 3 cm) in whom there is no evidence of malignancy. Advantages of endoscopic thyroidectomy over open thyroidectomy include less scarring, less pain, and a faster return to normal activity.

ICD Indications

Sudden cardiac death survivor Spontaneous VT Syncope with VT/VF during EPS High risk life-threatening dysrhythmias

Defibrillation

Unsynchronized shock through the heart sufficient to depolarize myocardial cells and allow SA node to resume pacemaker role Used to terminate pulseless VT or VF Successful patient outcomes improved with rapid defib (within 2 minutes) Monophasic: energy delivered in 1 direction Biphasic: energy delivered in 2 directions

Temporary Pacemakers

Transvenous Lead(s) threaded through R atrium and R ventricle with external power source Epicardial Leads attached to epicardium and passed through chest wall Transcutaneous Pacer pads placed on skin and attached to power source with HR and voltage control

Cushing Syndrome : Collaborative Care

Treatment depends on cause Pituitary adenoma Surgical removal of tumor and/or radiation Adrenal tumors or hyperplasia Adrenalectomy Ectopic ACTH-secreting tumors Managed by treating primary neoplasm Goal of drug therapy is inhibition of adrenal function

Radioactive Iodine Therapy (RAI) with *hyperthyroidism*?

Treatment of choice in nonpregnant adults Damages or destroys thyroid tissue Delayed response of 2 to 3 months Given on outpatient basis Patient teaching Radioactive iodine (RAI) therapy is the treatment of choice for most nonpregnant adults. RAI damages or destroys thyroid tissue, thus limiting thyroid hormone secretion. RAI has a delayed response, and the maximum effect may not be seen for up to 3 months. For this reason, the patient is usually treated with antithyroid drugs and propranolol before and during the first 3 months after the initiation of RAI until the effects of irradiation become apparent. Although RAI is usually effective, there is a high incidence of posttreatment hypothyroidism (80% of adequately treated persons); thus the need for thyroid hormone therapy may be lifelong. RAI therapy is usually administered on an outpatient basis. A pregnancy test is done on all women who experience menstrual cycles before initiation of therapy. Instruct the patient that radiation thyroiditis and parotiditis are possible and may cause dryness and irritation of the mouth and throat. Relief may be obtained with frequent sips of water, ice chips, or the use of a salt-and-soda gargle three or four times per day. This gargle is made by dissolving 1 teaspoon of salt and 1 teaspoon of baking soda in 2 cups of warm water. The discomfort should subside in 3 to 4 days. A mixture of antacid (Mylanta or Maalox), diphenhydramine (Benadryl), and viscous lidocaine can be used to swish and spit, allowing for better patient comfort during eating. Patients are asked to follow some radiation precautions after treatment in order to limit radiation exposure to others. Instruct the patient receiving RAI on the importance of home precautions, including the following: Use private toilet facilities, if possible, and flush two to three times after each use. Separately launder towels, bed linens, and clothes daily at home. Do not prepare food for others that requires prolonged handling with bare hands. Avoid being close to pregnant women and children for 7 days. Because of the high frequency of hypothyroidism after RAI therapy, teach the patient and family about the symptoms of hypothyroidism and to seek medical help if these symptoms occur.

Assessment: Diagnostic Studies - hyperthyroidism

↓ TSH and ↑ free thyroxine (free T4) Total T3 and T4 Radioactive iodine uptake (RAIU) Differentiates Graves' disease from other forms of thyroiditis The two primary laboratory findings used to confirm the diagnosis of hyperthyroidism are decreased TSH levels and elevated free thyroxine (free T4) levels. Total T3 and T4 levels may also be assessed, but they are not as definitive. Total T3 and T4 determine both free and bound (to protein) hormone levels. The free hormone is the only biologically active form of these hormones. The RAIU test is used to differentiate Graves' disease from other forms of thyroiditis. The patient with Graves' disease will show a diffuse, homogeneous uptake of 35% to 95%, whereas the patient with thyroiditis will show an uptake of less than 2%. The person with a nodular goiter will have an uptake in the high normal range.