Endocrine ConditionsCh 56 and 57 part 2

ADH excess

SIADH •Decreased serum osmolality •Hypertension •Tachycardia •Decreased electrolytes •Hyponatremia - decreased reflexes, confusion, muscle twitching, lethargy, apprehension, HA, cerebral edema, seizures, coma •Hypokalemia - decreased neuromuscular excitability, muscle weakness, loss of smooth muscle tone (bladder, GI), arrhythmias •Hypocalcemia - •Weight gain •Increased urine osmolality •Decreased urine output

A nurse review's a client's serum calcium level of 7.2 mg/dL (normal 9-11 mg/dL). Which assessment would the nurse most likely conduct? 1.Trousseau's sign 2.Homan's sign 3.Allen's sign 4.Babinski's sign

Trousseau's sign

Hyperpituitarism in the H-P-A axis

results in hyperadrenalism (high mineralocorticoids and glucocorticoids). If the high levels are due to adrenal hyperactivity, then it is Cushing's disease. Serum cortisol levels peak in morning and lasts approximately 12 hours.

SIADH

•Decreased electrolytes •Arrhythmia •Hypertension •Fluid imbalance (hypoosmolality) •Decreased urination •Weight gain •Dependent Edema •Pulmonary edema •Among others

Take actions for DI

•Do NOT restrict fluids •IV and oral fluids to equal that of output •Desmopressin -Multiple formulations are available; dosing is NOT interchangeable •Neuromuscular assessment (including cardiac) •Strict intake and output •Daily weights Labs •Serum osmolality •Urine osmolality •electrolytes Teach when to seek help •Weight gain >/= 2.2 lb •Persistent HA •Nausea/vomiting •Acute confusion

Hyperpituitarism - priorities

•Hormone excess -ACTH and TSH deficiencies are most life-threatening -Necessary for essential hormones and metabolism •Fluid and electrolyte balance •Glucose regulation •Cardiac perfusion (arrhythmias) •Impaired skin integrity - risk for infection or injury •Neurological regulation •Cellular regulation •Stress/coping •Immunity

Diabetes insipidus

•Increased electrolytes •Hypotension •Tachyarrhythmia •Fluid imbalance (hyperosmolality) •Polyuria •Weight loss •Among others

SIADH evaluating outcome

•Normalizing electrolytes •Urine output increase •Serum osmolality increase •Urine osmolality decrease •Urine specific gravity decrease •Weight loss

DI evaluating outcome

•Normalizing of electrolytes •Urine output decrease •Serum osmolality decrease •Urine osmolality increase •Urine specific gravity increase •Weight gain

primary Hyperadrenalism vs secondary hyperadrenalism

•Primary adrenal excess if ACTH are low but excess in mineralocorticoids and/or glucocorticoids = Cushing's disease •Secondary adrenal excess (Cushing syndrome = Cushingoid) •Exogenous steroids •Anterior pituitary gland releasing too much ACTH

•Primary adrenal insufficiency vs secondary

•Primary adrenal insufficiency if ACTH levels are high but deficient in mineralocorticoids and/or glucocorticoids = Addison disease •Secondary adrenal insufficiency -Abruptly stopping exogenous steroids -Anterior pituitary gland not releasing ACTH

Hyperpituitarism - Generate Solutions

•Restore fluid volume - should be decreasing & Monitor for fluid and electrolytes prior surgery •Administer medications to decrease cortisol production or block receptors -Mifepristone: blocks receptors (not for pregnant women) -Ketoconazole: inhibits production •Strict fluid intake and output - increased urine output (assess urine characteristics) •Daily weights - weight loss •Cardiac rhythm •Prevent infection and other potential injury •Dietary consult - may need to restrict fluid and sodium •Surgical management if hypophysectomy or adrenalectomy -Teach how to avoid infection (hand hygiene, staying away from crowds, masks, etc). -Gastric ulcers r/t stress - take meds (h2 blockers or PPI or antacids on a routine schedule) Limit ETOH and caffeine - increases the risk for ulcers No smoking - increases risk of ulcers and other problems No NSAIDs

Take actions for SIADH

•Restrict oral fluids •Demeclocycline (for mild SIADH) •Vasopressin receptor antagonists (severe SIADH) -Tolvaptan -conivaptan •Hypertonic IV solution (3% saline) •Neuromuscular assessment (including cardiac) •Strict intake and output •Daily weights •Diuretics (can worsen hyponatremia) •Labs •Serum osmolality •Urine osmolality •Electrolytes (slowly increase Na) •Teach when to seek help •Weight gain >/= 2.2 lb •Persistent HA •Nausea/vomiting •Acute confusion

Addisonian crises

- due to acute hypoadrenalism - occurs due to abrupt or sharply declined mineralocorticoids/glucocorticoids and severe fluid and electrolyte imbalances occur -Hyponatremia & Hyperkalemia -Severe dehydration (hypovolemia) -Severe hypotension -Tachyarrhythmia Emergency situation •More severe CM of chronic hypoadrenalism •See p. 1238 Best Practice for Patient Safety & Quality Care Emergency management of the patient with acute adrenal insufficiency •Hormone replacement (also helps with hyponatremia management) •Hyperkalemia management •Hypoglycemia management

Glucocorticoid (Cortisol) excess

-Hyperglycemia -Thinning of skin easy bruising (ecchymosis) -Decreased collagen (increased stretch marks) -Moon face -Truncal obesity -Muscle wasting (periphery) -Weight gain -Hirsutism -Frequent infection -Decreased energy -Mood instability -Arrhythmias

Mineralocorticoid (Aldosterone) excess symptons

-Hypernatremia - hyperreflexia, confusion, restlessness, pulmonary edema, seizures, coma -Hypokalemia - decreased neuromuscular excitability, loss of smooth muscle tone (bladder, GI), muscle weakness, arrhythmias -Metabolic alkalosis -Thirst/Dry mucous membranes - mainly sodium being kept -Hypertension -Bounding pulse

A client with a head injury develops syndrome of inappropriate antidiuretic hormone (SIADH). Which data would the nurse expect during assessment? Select all that apply. One, some, or all may be correct. 1.Decreased urine output 2.Elevated serum osmolality 3.Elevated urine specific gravity 4.Decreased serum osmolality 5.Decreased serum sodium

1.Decreased urine output 3.Elevated urine specific gravity 4.Decreased serum osmolality 5.Decreased serum sodium

A client with Addison disease presents to the emergency department with abdominal pain. While in the emergency room, the client experiences a decline in systolic blood pressure of 30 mm Hg, has a heart rate increase from 75 to 100 beats/minute, and develops confusion. Which action would the nurse implement? Select all that apply. One, some, or all may be correct. 1.Give prescribed hydrocortisone intravenously 2.Administer prescribed morphine intravenously every 2 hours for pain 3.Administer potassium 40 mEq orally as prescribed 4.Begin intravenous infusion of 5% dextrose in 0.9% sodium chloride 5.Administer promethazine every 4 hours as needed for nausea

1.Give prescribed hydrocortisone intravenously 4.Begin intravenous infusion of 5% dextrose in 0.9% sodium chloride

Which medication would the nurse anticipate administering for a client with diabetes insipidus? 1.Vasopressin 2.Furosemide 3.Insulin regular 4.10% dextrose

1.Vasopressin

Which nursing action is appropriate in the care of a client who is newly diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH)? Select all that apply. One, some, or all may be correct. 1.Weigh daily 2.Administer prescribed normal saline boluses 3.Restrict oral fluid intake 4.Restrict dietary sodium intake 5.Initiate seizure precaution 6.Measure intake and output

1.Weigh daily 3.Restrict oral fluid intake 5.Initiate seizure precaution 6.Measure intake and output

Which assessment finding best supports hypothesis of fluid volume deficiency? 1.Cool, clammy skin 2.Distended neck veins 3.Increased urine osmolality 4.Decreased serum sodium level

3.Increased urine osmolality

Which condition would the nurse consider the most common cause of hyperaldosteronism? 1.Excessive sodium intake 2.Pituitary adenoma 3.Deficient potassium intake 4.Adrenal adenoma

4.Adrenal adenoma An autonomous aldosterone-producing adenoma is the most common cause of hyperaldosteronism. Aldosterone secretion is independent of sodium and potassium intake as well as of pituitary stimulation.

ADH deficiency

Diabetes insipidus •Increased serum osmolality •Hypernatremia - hyperreflexia, confusion, restlessness, pulmonary edema, seizures, coma •Hyperkalemia - increased neuromuscular irritability (cramps, twitches), arrhythmias, tingling of lips and fingers, restlessness, GI distress •Hypercalcemia - muscle weakness, arrhythmias •Postural hypotension (orthostasis) •Tachycardia •Increased electrolytes •Weight loss •Decreased urine osmolality •Polyuria •Thirst •Among others

Hyperpituitarism - Evaluate Outcomes

Fluid and electrolytes returning to baseline •Increasing potassium and calcium •Decreasing sodium, glucose and cortisol •Remain free from injury and infection •Weight loss •Understanding of hormone replacement if surgery •Verbalizes CM of acute adrenal insufficiency

ACTH excess

Mineralocorticoid excess -Electrolyte imbalance -Metabolic acid-base imbalance -Fluid imbalance Glucocorticoid excess -hyperglycemia -Increased metabolism of carbohydrates, fats, proteins -Poor stress response -Decreased inflammatory response -Osteoporosis -Decreased overall immunity

Which assessment would alert the nurse that a client is experiencing hyperkalemia following a unilateral adrenalectomy? 1.Muscle weakness 2.Tremors 3.Diaphoresis 4.constipation

Muscle weakness

DI vs SIADH - Recognize Cues

Obtain history r/t electrolyte and fluid imbalances; medication changes; head injury; weight changes; urine output and its characteristics; pulmonary disorders (SIADH); cancer; Review labs - serum and urine; 24-hour urine collection (DI); strict intake and output; daily weights; skin turgor; etc. Electrolytes should not be adjusted too fast. Closely monitor for further electrolyte imbalances (Na, K, Ca, Mg). Assess for muscle twitching, cramping, cp, palpitations, confusion, irritability, restlessness Monitor pulmonary status (o2 sat, crackles, sob, wet cough)