Endocrine System

When the cause of hypoglycemia is organic and the effects mild, treatment usually consists of which of the following interventions?

A higher intake of protein and a reduction in carbohydrate intake will usually relieve hypoglycemic symptoms as long as they are organic in origin and the effects mild. - A higher intake of protein - A lower intake of carbohydrates

In caring for a hospitalized patient taking an oral diabetic medication for type 2 diabetes, what does the nurse anticipate for this patient as a result of taking a corticosteroid such as prednisone (Deltasone)?

Commonly used medications that can induce diabetes in some people include corticosteroids (prednisone), thiazides, phenytoin (Dilantin), and atypical antipsychotics (e.g., clozapine [Clozaril]). Diabetes caused by medical conditions or medications can resolve when the underlying condition is treated or the medication discontinued. (Drugs that can alter blood glucose levels are listed in Table 49-8.

What information doses the nurse expect to include when tacking a patient with diabetes type 2 about glyburide (Micronase, DiaBeta, Glynase)?

Concurrent use of disulfiram may cause a reaction within a simultaneous use of alcohol. - Side effects include epigastric fullness, heartburn, and nausea. Erythema, photosensitivity, hypoglycemia, and skin eruptions. Serious Possible side effects include agranulocytosi, hemolytic anemia, thrombocytopenia, and cholecstatic jaundice. - Weight gain - The primary action of sulfonylureas is to increase insulin production form the pancreas. Therefore hypoglycemia is the major side effect with sulfonylureas.

In caring for the patient post-parathyroidectomy, what nursing action does the nurse expect to take if the patient develops tingling around the lips and a posive Trousseau's sign?

Confirm that a tracheostomy set, suction and O2 are available at bedside. Notify the healthcare provider immediately of hypocalcemia. - IV calcium may be given, IV calcium gluconate or gluceptate should be readily available for patients following parathyroidectomy in the event that acute tetany occurs.

In reviewing results of a patient's glycosylated hemoglobin (HbA1C), what information is the nurse able to determine?

All patients with diabetes should have regular assessments of A1C done to monitor success of treatment and to make changes in treatment modalities. People with diabetes who can maintain near-normal A1C levels over time have a greatly reduced risk for the development of retinopathy, nephropathy, and neuropathy. For people with diabetes, the ideal A1C goal is ≤7.0% according to the ADA. (Lewis 1223) - Indicates the amount of glucose linked to hemoglobin. Measures degree of glucose control during previous 2-3 mo. Reference interval 4%-6% - Inform patient that fasting is not necessary and that blood sample will be drawn. Observe venipuncture site for bleeding or hematoma formation. (Lewis 1216)

Hyperglycemia

An absolute or relative deficiency of insulin.

Storage of Insulin

As a protein, insulin requires special storage considerations. Heat and freezing alter the insulin molecule. Insulin vials that the patient is currently using may be left at room temperature for up to 4 weeks unless the room temperature is higher than 86° F (30° C) or below freezing (less than 32° F [0° C]). Prolonged exposure to direct sunlight should be avoided. Extra insulin should be stored in the refrigerator. The same principles apply for a patient who is traveling. Insulin can be stored in a thermos or cooler to keep it cool (not frozen) if the patient is traveling in hot climates. Prefilled syringes are stable for up to 1 week when stored in the refrigerator. This may be beneficial to patients who are sight impaired or who lack the manual dexterity to fill their own syringes at home. In these cases family members, friends, and caregivers may prefill syringes on a periodic basis. Syringes prefilled with a cloudy solution should be stored in a vertical position with the needle pointed up to avoid clumping of suspended insulin binders in the needle. Likewise, commercially prepared mixtures may be prefilled and stored for later use. Some insulin combinations are not appropriate for prefilling and storage because the mixture can alter the onset, action, and/or peak times of either of the types. Pharmacy references should be consulted as needed when mixing and prefilling different types of insulin. Prefilled syringes should be gently rolled between the palms before injection to warm the refrigerated insulin and to resuspend the particles. (Lewis 1226)

Grave's disease (toxic diffuse goiter)

Autoimmune in nature. Antibodies (TSH-Ab) bind to TSH receptors and keep them activated, increasing the size of the gland and increasing the production of thyroid hormones.

Steriods: Systemic

Dexamethosone (Decadron) Hydrocortisone (Solucortef) Prednisone (Deltasone) Side effects - Depression, hypertension, anorexia, nausea, bruising Nursing Considerations - give orally w/ meals to avoid GI irritation - Causes hyperglycemia-monitor glucose levels closely especially if diabetic - Decreases immune response and WBC count: assess closely for signs of infection - Monitor these labs closely - Assess for signs of adrenal insufficiency that can cause hypotension, weight loss, weakness, N&V, confusion, peripheral edema - Monitor I&O and daily weights for these reasons

Appropriate nursing diagnosis for patient with hyperthyroidism: Hair loss and vitiligo

Disturbed body image related to change in body appearance

What data does the nurse plan to monitor closely in the patient receiving rosliglitazone (Avandia)? (Note: use of Avandia has been largely discontinued.

BP, HR, edema - Increased risk of myocardial infarction and stroke. - Do not use in patients with heart failure

Administration of Insulin

Because insulin is inactivated by gastric juices, it cannot be taken orally. Routine doses of insulin are usually administered by subcutaneous injection, although intravenous (IV) administration of regular insulin can be done when immediate onset of action is desired. Inhaled insulin (Exubera) was made available in 2005. It was a rapid-acting, dry powder form of insulin that was inhaled through the mouth into the lungs before eating. It was removed from the market in 2007 because it failed to gain the acceptance of patients and physicians. Inhaled insulin continues to be studied and other drug companies are working on approval of this method of administration of insulin. (Lewis 1226)

What teaching does the nurse anticipate for patient with hyperthyroidism who is being treated with radioactive iodine (RAI)?

Because of the high frequency of hypothyroidism after RAI therapy, teach the patient and family about the symptoms of hypothyroidism and instruct to seek medical help if these symptoms occur. - Instruct the patient that radiation thyroiditis and parotididis 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. p. 1266

Diagnosis of Hypothyroidism

Blood test: - TSH, this is the most important and sensitive test for hypothyroidism. it measures how much of the thyroid hormone T4 the thyroid gland is being asked to make. An abnormally hight TSH means hypothyroidism - T4 test

What questions will the nurse ask when obtaining a health history for a patient undergoing an oral glucose tolerance test?

Ensure that tests are not done on patients who are malnourished, confined to bed for over 3 days, or severely stressed. Instruct patient to refrain from smoking and caffeine and to fast (except water) for 8-12 hr before test. Ensure that patient's diet 3 days before test includes 150-300 g of carbohydrate with intake of at least 1500 cal/day. Screen for estrogens, phenytoin (Dilantin), and corticosteroids, and check for hypokalemia, which may impair glucose tolerance. (Lewis 1216)

During admission assessment, what nursing behavior is most appropriate with regard to palpation and assessment of a patient's thyroid glands?

In a normal person the thyroid is often not palpable. If palpable, it usually feels smooth, with a firm consistency and is not tender with gentle pressure. Nodules, enlargement, asymmetry, or hardness is abnormal; refer the patient for further evaluation.

In caring for a hospitalized patient taking an oral diabetic medication for type 2 diabetes, what does the nurse anticipate for this patient as a result of taking a corticosteroid such as prednisone (Deltasone)?

It can induce diabetes in some people include corticosteroids (prednisone , thiazides,

Thyroid Hormone: Systemic

Levothyroxine (Synthroid) Side effects - Usually seen only when excessive doses cause hyperthyroid symptoms Nursing Considerations - give on empty stomach in the morning - assess apical pulse and BP prior to giving periodically - monitor thyroid function tests (T3-T4-TSH)

Thyroid gland

Located in the anterior part of the neck - Controls the rate of body metabolism and growth and produces thyroxine (T4), triiodothyronine (T3), and thyrocalcitionin.

Parathyroid glands

Located on the thyroid gland - Control calcium and phosphorus metabolism; produce parathyroid hormone

Pancreas

Located posteriorly to the stomach - Influences carbohydrate metabolism, indirectly influences fat and protein metabolism and produces insulin and glucagon.

What is the most likely nursing action for the patient diagnosed with primary hyperparathyroidism who has developed elevated serum calcium levels?

Monitor I&O to evaluate fluid status. Encourage mobility to promote bone calcification. Surgery to remove all or partial parathyroid glands. Continued ambulation and the avoidance of immobility are critical aspects of management. Dietary measures also include maintenance of a high fluid intake and a moderate calcium intake.

A patient with hypothyroidism is treated with levothyroxin (Synthroid). When teaching the patient about the therapy the nurse.

Provides written instruction for all information related to the medication therapy. Rationale: Because of metal sluggishness, inattentiveness, and memory loss that occur with hypothyroidism is important to provide written instruction and repeat information when teaching the patient.

Alpha-Glucosidase Inhibitors (Acarbose and miglitol):

Should be taken with the first bite of a meal because these agents work by blunting an increased blood sugar level after a meal.

Sulfonylureas (glyburide): Action, side effects and contraindications

Sulfonylureas stimulate insulin secretion form the beta cells of the pancreas. In turn, the insulin carries glucose out of the blood and into the tissues, cells, and organs, where it is needed. - The most common side effects of sulfonylureas include epigastric fullness, heartburn and nausea. Patients may also experience erythema, photosensitivity, hypoglycemia, and skin eruptions. Serious thromobocytopenia, and cholestatic jaundice. - Concurrent use of disulfiram may cause a (antabuse) like reaction with the simultaneous use of alcohol.

In hyperthyroidism T3, T4 and TSH are:

T3 and T4 are increased and TSH is decreased

In hypothyroidism T3, T4, and TSH are:

T3 and T4 decreased and TSH is increased

How is hypothyroidism treated?

T4 replacement - only complications is taking too little or too much.

In completing an admission assessment for the patient diagnosed with Cushing syndrome, what signs and symptoms does the nurse expect to find?

Weight gain, the most common feature, results from the accumulation of adipose tissue in the trunk, face, and cervical spine area. - Hyperglycemia because of glucose intolerance

A 72 year old woman is diagnosed with diabetes. The nurse recognizes that management of diabetes in the older adult a. does not require as tight glucose control as in younger diabetics. b. is usually not treated unless the patient becomes severely hyperglycemic. c. does not include treatment with insulin because of limited dexterity and vision. d. usually requires that a younger family member be responsible for care of the patient.

a. does not require as tight glucose control as in younger diabetics. Rationale: Because the clinical manifestations of long-term complications of diabetes take 10 to 20 years to develop, and because tight glucose control in the older patient is associated with an increased frequency of hypoglycemia, the goals for glycemic control are not as rigid as in the younger population.

Causes of primary hypothyroidism in adults include

autoimmune-induced atrophy of the thyroid gland. Rationale: Both Graves' disease and Hashimoto's thyroidiits are autoimmune disorders that eventually destroy the thyroid gland, leading to primary hypothyroidism.

Postoperative Care Following Subtotal Thyroidectomy: Which assessment finding would indicate the possible onset of thyroid storm? a. Numbness and tingling in both arms. b. Tachycardia, fever and altered mental state. c. Pain and a hoarse voice. d. Respiratory stridor.

b. Tachycardia, fever, and altered mental state.

Goals of nutritional therapy for the patient with ape 2 diabetes include maintenance of a. ideal body weight b. normal serum glucose and lipid levels c. a special diabetic diet using dietetic foods. d. Five small meals per day with a bedtime snack

b. normal serum glucose and lipid levels Rationale: Maintenance of as near-normal blood glucose levels as possible and achievement of optimal serum lipid levels with dietary modifications are believed to be the most important factors in preventing both short and long term complications of diabetes.

Postoperative Care Following Subtotal Thyroidectomy: Which assessment is most important for the nurse to complete after checking vitals? a. measure urinary output b. Observe neck dressing c. Palpate pedal pulses d. obtain oxygen satruration

b. observe neck dressing

Priority Decision: The nurse is assessing a newly admitted diabetic patient. Which of these observations should be addressed as a priority by the nurse? a. Bilateral numbness of both hands. b. Stage II pressure ulcer on the right heel c. Rapid respirations with deep inspiration d. Areas of lumps an dents on the abdomen

c. Rapid respirations with deep inspirations Rationale: Rapid deep respirations are symptoms of diabetic ketoacidosis (DKA). Stage II ulcers and bilateral numbness are chronic complications of diabetes. The lumps and dents on the abdomen indicate a need to teach the patient about site rotation.

Which nursing intervention is appropriate for a patient receiving Radioactive Iodine Therapy RAI? a. Assess for respiratory stridor. b. Monitor the patient's voice for hoarseness. c. Instruct the patient to avoid hyperextension of the neck. d. encourage the patient to drink plenty of fluids.

d. Encourage the patin tot drink plenty of fluids.

Diagnostic testing in the patient with Graves' disease will reveal an

decreased TSH level.

When replacement therapy is started for a patient with long-standing hypothyroidism, its is most important for the nurse to monitor the patient for

dysrhythmias Rationale: Myocardial oxygen consumption is increased, and the resultant oxygen demand may cause angina, cardiac dysrhythmias, and heart failure.

When the patient with parathyroid disease experiences symptoms of hypocalcemia, a measure that can be used to raise serum calcium levels temporarily is to

have a patient rebreathe in a paper bag. Rationale: Rebreathing in a paper bag promotes carbon dioxide retention in the blood, which lowers pH and creates an acidosis.

Hemorrhage is always a possible complication of surgery. It is a particular concern after thyroidectomy because:

hematomma formation can externally compress the airway. - airway obstruction can cause respiratory distress. - after surgery bleeding would likely be visible on the patient's anterior neck dressing. - Check posteriorly for bleeding.

An appropriate nursing intervention for the patient with hyperparathyroidism is to

increase fluid intake to 3000 to 4000 mL daily. Rationale: A high fluid intake is indicated in hyperparathyroidism to dilute the hypercalcemia and flush the kidneys so that calcium stone formation is reduced.

What lab values will the nurse monitor closely in the patient receiving metformin (Glucophage)?

increased BUN, Patient w/ impaired Renal function should not be given metformin p. 1230

Clinical manifestations of hyperthyroidism occur as a result of

increased metabolic rate and tissue sensitivity to the sympathetic nervous system.

Thyrotoxicosis

is a condition of excess thyroid hormones. (hyper function of the thyroid gland.

Thyroid-stimulating hormone (TSH)

is secreted from the anterior pituitary gland and regulates the secretion of thyroid hormones.

Carbohydrate counting is a:

meal planning technique that individuals with diabetes use to keep track of the amount of carbohydrates they eat with each meal and per day. With this method they set a limit for their maximum amount. The amount of total carbohydrates per day depends on age, weight, activity level, and medications that they take. - Instruct patient on the foods that contain carbohydrates and the appropriate serving size. Each serving of carbohydrates is 15g. They usually start with 45 to 60 g of carbohydrate at a meal. Teach the person with diabetes to read food labels as the is is very important with carbohydrate counting. - My plate and my pyramid guide.

Calcitonin

one of the three hormones secreted by the thyroid gland, helps regulate serum calcium levels.

Thyroxine (T4)

one of three hormones secreted by the thyroid gland, is responsible for a number of functions, including maintenance of metabolic rate and normal metabolism, normal growth and development and protein, fat and carbohydrate catabolism.

The day after surgery the patient has a positive Chvostek's sign which suggests hypocalcemia. Which nursing action should be implemented immediately? a. Set the defibrillator for 200 joules. b. Place Ms. Pool in a shock position. c. Confirm that a tracheostomy set , suction, and O2 are available at bedside. d. Reduce Ms. Pool's IV rate to a Keep Open rate of 20 ml/hour.

c. confirm that a tracheostomy set, suction and O2 are available at bedside.

A patient with hypoparathyroidism result in form surgical treatment of hyperparthyroidism is preparing for discharge. The nurse teaches the patin that

calcium supplements with Vitamin D can effectively maintain calcium balance. Rationale: The hypocalcemia that results from parathyroid hormone (PTH) deficiency is controlled with calcium and vitamin D supplementation and possible oral phosphate binders.

What should the nurse teach a patient about propylthiouracil (PTU)? a. "Call the clinic if symptoms do not subside within 24 hours." b. "You will continue taking this medication the rest of your life" c. "Drink this medication with water or fruit juice" d. "Report the onset of a sore throat or fever to the health care provider."

d. "Report the onset of a sore throat or fever to the health care provider"

In the patient newly diagnosed with Addison's disease, what teaching is appropriate for the nurse to offer?

1. Names, dosages, and actions of drugs 2. Symptoms of overdosage and under dosage 3. Conditions requiring increased medication (trauma, infection, surgery, emotional crisis) 4. Course of action to take relative to changes in medication - Increase in dose of corticosteroid - Administration of large dose of corticosteroid intramuscularly, including demonstration and return demonstration - Consultation with health care provider 5. Prevention of infection and need for prompt and vigorous treatment of existing infections. 6. Need for lifelong replacement therapy 7. Need for lifelong medical supervision 8. Need for medical identification device.

Functions of Endocrine Glands

- Maintenance and regulation of vital functions - Response to stress and injury - Growth and development - Energy metabolism - Reproduction - Fluid, electrolyte, and acid-base balance

Critical Monitoring: Thyrotoxicosis/Thyroid Strom: These manifestations should be monitored in a client who is thought at risk for thyroid storm:

- Anxiety, short attention span irritability - Hyperreflexia - Increased temperature (as high as 106 degrees) - Systolic hypertension - Dyspnea - Augmentation of other disorders, such as atrial fibrillation, heart failure, angina pectoris (chest pain), paranoia, and anxiety

Causes of Hypothyroidism?

- Autoimmune disease (Hashimoto's thyroiditis and atrophic thyroiditis - Surgical removal of part or all of the thyroid gland. Some people with nodules, cancer or Grave's disease need to have part or all of their thyroid removed. - Radiation treatment. Some people with Grave's disease, nodular goiter, or thyroid cancer are treated with radioactive iodine. - Congenital hypothyroidism (hypothyroidism that a baby is born with - Thyroiditis - medicines. aminodarone, lithium, interferon alpha, and interleukin 2 can prevent the thyroid gland form being able to make hormone normally. - Too much or too little iodine - Damage to the pituitary gland. - Rare disorders that infiltrate the thyroid.

Nursing Diagnosis for a patient with a hypothyroid and it's etiology with signs and symptoms that support the diagnosis.

- Disturbed sleep pattern related to depression and altered metabolism as evidence by excessive sleeping as manifested by no relief of somnolence and altered sleep stages. - Imbalanced nutrition: more than body requirements related to calorie intake greater than need; as evidenced by weight gain as manifested by weight gain and slow metabolism. - Disturbed thought processes related to slowed metabolism; as evidenced by personality changes as manifested by forgetfulness and memory loss. - Activity intolerance related to decreased metabolic rate and mucin deposits in joints; as evidenced by fatigue,as manifested by weakness and muscular aches and pains.

Antidiabetic drugs occasionally contribute to episodes of hypoglycemia, regardless of how well educated the patient is about diabetes mellitus. The nurse would teach the patient to watch out for which of the following hypoglycemia symptoms?

- Confusion - Diaphoresis - Decreased blood glucose readings on fingerstick - Irritability - Seizures - Tremors

Critical Monitoring: IV Calcium infusion

- Dilute to reduce vein irritation and venospasm - Administer into a large central or deep vein. - Confirm latency of the IV prior to administration. - Monitor vital signs and serum calcium levels - Observe for hyperchloremic acidosis if calcium carbonate is administered. - Observe fro extravasation. Necrosis and sloughing may occur. - Inject 1 % procaine hydrochloride and hyaluronidase using a 25 to 27 gauge needle if extravasation occurs to reduce vasospasm.

Hyperthyroidism: Graves Disease Clinical manifestations

- Exophthalamos - Tachycardia and palpitations - Diarrhea and weight loss - Anxiety and fatigue

Symptoms of Hypothyroidism?

- Feeling cold - tire more easily - dry skin - forgetful and depressed - constipation - The only way to know you have hypothyroidism is with a blood test for TSH.

Describe an appropriate general teaching plan for the patient newly diagnosed with type 2 diabetes?

- Include an introduction about the pancreas and the islets of Langerhans. - Describe how insulin is made and what affects its production. - Discuss the relationship of insulin and glucose. - Discuss the importance of regular exercise on the management of blood glucose, improvement of cardiovascular function, and general health. - Stress the importance of a well-balanced diet as part of diabetes management plan. - Explain the impact of carbohydrates on the glycemic index and blood glucose levels. - Ensure that the patient understands the proper use of insulin (see Table 49-5) and oral agents. - Account for a patient's physical limitations or inability for self- medication. - Discuss all side effects and safety issues regarding medication. You should include the following essential instructions for diabetes management. Yes, and to add a bit regarding hyperglycemia management, it's important to provide teaching that includes a) the information that diet and exercise may be sufficient to control blood glucose for some individuals; b) that regular followup A1C (glycosylated hemoglobin testing) will need to be done to confirm the treatment regimen is working, or to change the regimen if numbers remain high; c) med teaching, such as for sulfonylureas--glipizide (Glucotrol,) and glyburide (Micronase, Glynase, Diabeta) which stimulate the beta cells of the pancreas to release more insulin...or biguanides including Metformin (glucophage) which lower blood glucose levels by decreasing the amount of glucose provided by the liver; d) even when diet and exercise have brought about weight loss, it's important to check blood sugar for A1C because it's possible to lose weight and STILL have a high A1C; e) it's important to check the patient's BUN before administering Metformin because Metformin is contraindicated in patients with kidney failure, and also Metformin should be discontinued before a coronary arteriogram and not used again until 48 hours after contrast media has been administered (to avoid lactic acidosis, a form of metabolic acidosis-- respiratory and metabolic acidosis and alkalosis are NPIV topics). For hypoglycemia management, what will you teach?

Emergency Care of the client during thyroid storm:

- Maintain a patent airway and adequate ventilation. - Give antithyroid drugs as prescribed: propyithiouracil (PTU, Propyl-Thyracil), 300 to 900 mg daily; ;methimazole (Tapazole), up to 60 mg daily. - Administer sodium iodide solution, 2 g IV daily as prescribed. - Give propranolol (Inderal, Detensol) - Give glucocorticoids as prescribed: - Monitor continually for cardiac dysrhythmias. - Monitor vital signs every 30 minutes. - Provide comfort measures, including a cooling blanket. - Give nonslicylate antipyretics as prescribed. - Correct dehydration with normal saline infusions. - Give aspirin or other antipyretic. - Apply cooling blanket or ice packs to reduce fever.

What particular considerations is the nurse aware of when providing care for a patient who has just returned to the unit post-thyroidectomy?

- Possible Hemorrhage and fluid and electrolyte disturbance. - Mild or severe tetany - Monitor intake and output - Assess calcium, potassium, phosphate, and magnesium keels frequently, as well as Chvostek's and Trousseau's - Encourage mobility to promote bone calcification.

Oral Antidiabetic Medications

- Sulfonylureas (glyburide) - Biguanides (metformin) - Thiazolidinedisone (rosiglitazone) - Medglitinides (repaglinide and nateglinide) - Alpha-Glucosidase Inhibitors (Acarbose and miglitol)

Meglitinides (repaglinide and nateglinide): action, indication

- They stimulate the release of insulin form pancreatic beta cells. - They may be used in the treatment of type 2 diabetes because: Some patients simply respond better to these drugs and achieve better glycemic control.

Thiazolidinedione (rosiglitazone): contraindication

- may cause moderate weight gain and edema as a result of fluid retention. - not recommended for patients with heart failure

What action(s) does the nurse anticipate while caring fora patient who is several hours post-surgery for a subtotal thyroidectiony, if the patient develops laryngeal stridor and a cramp in the right hand?

...

What is the most likely nursing action for the patient diagnosed with primary hyperparathyroidism who has developed elevated serum calcium levels?

...

What lab values will the nurse monitor closely in the patin receiving metformin (Glucophage)?

...

What questions will the nurse ask when obtaining a health history for a patient undergoing an oral glucose tolerance test?

...

Appropriate nursing diagnosis for patient with hyperthyroidism: Exhaustion and dyspnea

Activity intolerance related to fatigue and dyspnea

Diabetes mellitus

Chronic disorder of impaired carbohydrate, protein, and lipid metabolism caused by a deficiency of insulin Type 2 Diabetes Mellitus is a relative lack of insulin or resistance to the action of insulin; usually, insulin is sufficient to stabilize fat and protein metabolism but not carbohydrate metabolism. - Can lead to chronic health problems and early death as a result of complications that occur in the large and small blood vessels in tissues and organs. - Macro-vascular complication include coronary artery disease, cardiomyopathy, hypertension, cerebrovascular disease, and peripheral vascular disease. - Microvascular complications include retinopathy, nephropathy, and neuropathy. - Infection is also a concern because of reduced healing ability. - Male erectile dysfunction can also occur as a result of the disease.

The Dos and Don'ts of Diabetes management

DO - Monitor your blood glucose at home and record results in a log. - Take your insulin or OA as prescribed. - Obtain A1C blood test every 3-6 months as an indicator of your long-term blood glucose control. - Know the symptoms of a hypoglycemia and hyperglycemia - carry some form of glucose at all times so you can treat hypoglycemia quickly - Instruct family members in the use of glucagon administration in the case of emergencies due to hypoglycemia. - Learn how exercise and food affect your blood glucose levels. - Begin an exercise program after approval form health care provider. - Have an individualized meal plan created by a dietitian. - Follow your diet, eating regular meals at regular times. - Choose foods low in saturated and trans fat. - Learn your cholesterol level. - Obtain an annual eye examination by an ophthalmologist. - Obtain annual urine testing for protein. - Examine your feet at home. - Wear comfortable, well-fitting shoes to help prevent foot injury. Brak in new shoes gradually. - Always care identification that says you have diabetes. - Have other medical problems treated, especially high blood pressure and high cholesterol. - Quit cigarette smoking. DO NOT - skip doses of your insulin, especially when you are sick - Run out of insulin - Ignore the symptoms of hypoglycemia and hyperglycemia. - Forget that exercise will lower your blood glucose level. - Drink excessive amounts of alcohol because this may lead to unpredictable low blood glucose reactions. - Enroll in a fad diet. - Drink regular soda or lots of fruit juice. - Smoke cigarettes or use nicotine products. - Apply hot or cold directly to your feet. - Go barefoot - Put oil or lotion between your toes. ** you should be prepared to work with dietitians as part of an interdisciplinary diabetes care team.

Biguanides (metformin): Action, therapeutic effects and side effects

Decreases the production of glucose in the liver and increasing the sensitivity of peripheral tissues to insulin. - decreases hepatic production of glucose - decreases intestinal absorption of glucose. - increases insulin sensitivity. - Metformin may be used with a sulfonylurea to more effectively control the blood glucose level. - Rare but potentially fatal side effect: Lactic acidosis has a 50% mortality rate. - Abdominal bloating, cramping, nausea, and diarrhea are common side effects of a biguanide such as metformin but are not ordinarily fatal. - Metformin can leave a metallic taste in the mouth, alt hough this effect is rare.

Addison's Disease: Collaborative Care

Hydrocortisone - most commonly used as replacement therapy Glucocorticoid dosage must be increased during times of stress to prevent addisonian crisis.

Combination Therapy

For those who do not want to use more than one or two injections per day, two different insulin types can be mixed in the same syringe. Although this may be more appealing to the patient, it may not achieve the kind of blood glucose control that can be achieved with basal-bolus therapy. Short- or rapid-acting insulin is often mixed with intermediate-acting insulin to provide both mealtime and basal coverage without having to administer two separate injections. Patients may mix the two types of insulin themselves or may use a commercially premixed formula (see Table 49-3). These offer convenience to patients and are especially helpful to those who lack the visual, manual, or cognitive skills to mix insulin themselves. However, the convenience of these formulas sacrifices the potential for optimal blood glucose control, because there is less opportunity for flexible dosing based on need. Patients may also use other types of insulin in combination (i.e., long-acting and rapid-acting insulin), but these combinations must be administered as separate injections. (Lewis 1226)

What information does the nurse expect to provide when tacking a patient with type 2 diabetes about glipizide (Glucotrol)? How about metformin (Glucophage)?

Glipizide Stimulates release of insulin from pancreatic islets.; Side effects: weight gain, hypoglycemia Metformin decreases the rate of hepatic glucose production; augments glucose uptake by tissues, especially muscles; side effect: Diarrhea, lactic acidosis. - Needs to be held 1-2 days before IV contrast media given and for 48 hr after - Metformin may be used in combination with sulfonylurea to more effectively control the blood glucose level because they work throughout different mechanisms.

Exophthalmos may occur in:

Graves' disease

Two most common forms of hyperthyroidism are:

Graves' disease and toxic nodular goiters.

Problems with Insulin Therapy

Hypoglycemia, allergic reactions, lipodystrophy, and the Somogyi effect are problems associated with insulin therapy. Hypoglycemia is discussed in detail later in this chapter. (Guidelines for assessing patients treated with insulin are presented in Table 49-6.) Allergic Reactions Local inflammatory reactions to insulin may occur, such as itching, erythema, and burning around the injection site. Local reactions may be self-limiting within 1 to 3 months or may improve with a low dose of antihistamine. A true insulin allergy is rare. It is manifested by a systemic response with urticaria and possibly anaphylactic shock. Zinc or protamine used as preservatives in the insulin and the latex or rubber stoppers on the vials have been implicated in insulin reactions Lipodystrophy Lipodystrophy (atrophy of subcutaneous tissue) may occur if the same injection sites are used frequently. As previously mentioned, the use of human insulin has reduced the risk for lipodystrophy. Hypertrophy, a thickening of the subcutaneous tissue, eventually regresses if the patient does not use the site for at least 6 months. The use of hypertrophied sites may result in erratic insulin absorption. (Lewis 1228) Somogyi Effect and Dawn Phenomenon The Somogyi effect is a rebound effect in which an overdose of insulin induces hypoglycemia. Usually occurring during the hours of sleep, the Somogyi effect produces a decline in blood glucose level in response to too much insulin. Counterregulatory hormones are released, stimulating lipolysis, gluconeogenesis, and glycogenolysis, which in turn produce rebound hyperglycemia and ketosis. The danger of this effect is that when blood glucose levels are measured in the morning, hyperglycemia is apparent and the patient (or the health care professional) may increase the insulin dose. The Somogyi effect is associated with the occurrence of undetected hypoglycemia during sleep, although it can happen at any time. The patient may report headaches on awakening and may recall having night sweats or nightmares. If the Somogyi effect is suspected as a cause for early morning high blood glucose, the patient may be advised to check blood glucose levels between 2:00 and 4:00 am to determine if hypoglycemia is present at that time. If it is, the insulin dosage affecting the early morning blood glucose is reduced. The dawn phenomenon is characterized by hyperglycemia that is present on awakening in the morning due to the release of counterregulatory hormones in the predawn hours. It has been suggested that growth hormone and cortisol are possible factors in this occurrence. The dawn phenomenon affects the majority of people with diabetes and tends to be most severe when growth hormone is at its peak in adolescence and young adulthood. (Lewis 1228)

In obtaining a patient's general health history, what assessment data would indicate a need for further assessment of a patient's thyroid function?

Hypothyroidism - Changes in skin texture, thick, cold, dry skin - Changes in hair distribution - Puffiness, myxedema, preorbital edema, masklike affect - Goiter - Dysrhythmias, tachycardia, atrial fibrillation - Altered glucose levels: weight gain - Lethargy: state of mental sluggishness or somnolence - Constipation - Cold insensitivity - generalized edema - Seizure Hyperthyroidism - changes in skin texture, warm smooth, moist skin - hair loss - Exophthalmos - Goiter - Chest pain, dysrhythmias: tachycardia, atrial fibrillation - Hypertension - weight loss - Hyperreflexia - heat intolerance

What is Hypothyroidism?

Hypothyroidism is an under active thyroid gland. Hypothyroidism means that the thyroid gland can't make enough thyroid hormone to keep the body running normally. People are hypothyroid if they have too little thyroid hormone in the blood. Common causes are autoimmune disease. Surgical removal of the thyroid and radiation treatment. - No cure, treated for life - Non-compliance can be life threatening myxedema coma

Symptoms of Hyperthyroidism?

If there is too much thyroid hormone, every function of the body tends to speed up. - Nervousness, irritability, increased perspiration, heart racing, hand tremors, anxiety, difficulty sleeping, thinning of your skin, fine brittle hair and weakness in your muscles- especially in the upper arms and thighs. - You may have frequent bowel movements, but not diarrhea - You may lose weight despite a good appetite and, for women, menstrual flow may lighten and menstrual periods may occur less often. - initially have a lot of energy. However, as hyperthyroidism continues, the body tends to break down, so being tired is very common. ** At first the symptoms symptoms may be mistaken for simple nervousness due to stress. - In Graves' disease, which is the most common form of hyperthyroidism, the eyes may look enlarged because the upper lids are elevated. Sometimes, one or both eyes may bulge. Some patients have swelling of the front of the neck from an enlarged thyroid gland (a goiter)

Appropriate nursing diagnosis for patient with hyperthyroidism: Weight loss and hunger

Imbalanced nutrition: less than body requirements related to hyper-metabolism

Long- or Intermediate-Acting (Basal) Background Insulin

In addition to mealtime insulin, people with type 1 diabetes must also use a long-acting basal or intermediate-acting (background) insulin to control blood glucose levels in between meals and overnight. Without 24-hour background insulin, people with type 1 diabetes are more prone to developing diabetic ketoacidosis. Many people with type 2 diabetes who use mealtime insulin injections or oral medications also require basal insulin to adequately control blood glucose levels. Insulin glargine (Lantus) and detemir (Levemir) are long-acting insulins that are released steadily and continuously, and for most people do not have a peak of action (see Fig. 49-3). They are used for once-daily subcutaneous administration. (Detemir can be given twice daily.) Because they lack peak action time, the risk for hypoglycemia from these insulins is greatly reduced. Glargine and detemir must not be diluted or mixed with any other insulin or solution.5 Intermediate-acting insulin NPH is also used as a basal insulin that has a duration of 10 to 16 hours. The disadvantage is that it has a peak at 4 to 10 hours, which can result in hypoglycemia. It is the only basal insulin that can be mixed with the short- and rapid-acting insulins. NPH is a cloudy insulin that must be gently agitated before administration. (Lewis 1225-1226)

What are the special nursing considerations in caring for the older adult diagnosed with hypothyroidism, who will be taking levothyroxine (Synthroid)? What would be a general teaching plan for a 35 year old patient receiving this medication?

In the older adult patient and the person with compromised cardiac status, a smaller initial dose is recommended because the usual dose may increase myocardial oxygen demand. The increased oxygen demand may cause angina and cardiac dysrhythmias. - Any chest pain experienced by a patient starting thyroid replacement should be reported immediately and an ECG and serum cardiac enzyme test must be performed. - In a patient without side effects, the dose is increased at 4-6 week intervals. it is important that the patient take replacement medication regularly. Lifelong thyroid replacement therapy is usually required.

Adrenal gland

One adrenal gland is on top of each kidney. - Regulates sodium and electrolyte balance; affects carbohydrate, fat, and protein metabolism; influences the development of sexual characteristics; and sustains the fight -or flight response. Adrenal Cortex - The cortex is the outer shell of the adrenal gland. - The codex synthesizes glucocorticoids and mineralocorticoids and secretes small amounts of sex hormones (androgens, estrogens; Adrenal Medulla - The medulla is the inner core of the adrenal gland. - The medulla works as part of the sympathetic nervous system and produces epinephrine and norepinephrine.

What causes Hyperthyroidism?

Overproduction of thyroid hormone by the entire thyroid gland. This condition is also known as Graves' disease - antibodies in the blood that turn on the thyroid and cause it to grow and secrete too much thyroid hormone. - tends to run in families and occurs more often in young women - One or more nodules or lumps in the thyroid that may gradually grow and increase their activity so that the total output of thyroid hormone into the blood is greater than normal. This condition is known as toxic nodular or multi-nodular goiter. - Peo;e may temporarily have symptoms of hyperthyroidism if they have a condition called thyroiditis. ** This condition is caused by a problem with the immune system or a viral infection that causes the gland to leak stored thyroid hormone. - Also caused by taking too much thyroid hormone in tablet form.

What particular considerations is the nurse aware of when providing care for a patient who has just returned to the unit post-adrenalectomey?

Patients may have a nasogastric tube, a urinary catheter, IV therapy, central venous pressure monitoring and leg sequential compression devices to prevent emboli. - Surgery on the adrenal glands poses risks beyond those of other type of operations. Because these glands are highly vascular, the risk of hemorrhage is increased. - BP, fluid balance, and electrolyte levels tend to be unstable because of hormone fluctuations. - High doses of corticosteroids are administer intravenously during surgery and for several days afterward to ensure adequate responses to the stress of the procedure. - Report any rapid or significant changes in BP, respirations, or heart rate. - Morning urine samples for cortisol measurement to evaluate the effectiveness of surgery. - You must constantly be alert for signs of corticosteroid balance. - patient will remain on best rest until BP stabilizes

A patient has a diagnosis of Diabetes type 2 and has been taking oral medication for several years. Attempts to control blood glucose levels through oral agents and lifestyle changes have been unsuccessful. He is aware that his healthcare provider will make changes to his treatment protocol. What teaching might the nurse expect to provide to this patient regarding types of insulin, insulin regimens, mealtime insulin, basal insulin, combination therapy, storage, administration, and potential problems with insulin therapy?

People with type 2 diabetes may also need up to four injections per day to adequately control their blood glucose levels if diet, exercise, and/or OAs are not controlling glucose levels. - NPH can be given once a day at bedtime - Long-acting (glargine (lantus) can be give in the morning or at night and will last for 24 hours and there is a less chance of hypoglycemia.

In perparing a patient for a glucose tolerance test, the nurse is aware that what medication(s) can affect blood glucose results?

Phenytoin (Dilantin), and corticosteroids Commonly used medications that can induce diabetes in some people include corticosteroids (prednisone), thiazides, phenytoin (Dilantin), and atypical antipsychotics (e.g. clozapine [Clozaril])

Pituitary Hyperthyroidism

Pituitary adenoma resulting in excessive TSH secretion.

Hypothalamus

Portion of the diencephalon of the brain, forming the floor and part of the lateral wall of the third ventricle - Activates, controls, and integrates the peripheral autonomic nervous system, endocrine processes, and many somatic functions, such as body temperature, sleep, and appetite.

In caring for the patient with a goiter and possible hypothyroidism, what is the most appropriate way to complete a physical assessment, and what are some interventions that the nurse anticipates?

Questions about weight gain, mental changes, fatigue, slowed and slurred speech, cold intolerance, skin changes such as increased dryness or thickening, constipation, and dyspnea. Question the patient about the recent introduction of iodine containing medications. Assess the patient for bradycardia; distended abdomen; dry thick, cold skin; thick, brittle nails; paresthesias; and muscular aches and pains. p. 1271 Acute Interventions: - 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 replacement therapy and all other medications intravenously because paralytic ileum may be present in myxedema coma. Monitor the core temperature because hypothermia often occurs in myxedema coma. - 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 the hormone determines the medication regimen. Note energy level and mental alertness. These should increase within 2 to 14 days and continue to rise steadily to normal levels. p. 1271

Negative-Feedback loop

Regulates hormone secretion by the hypothalamus and pituitary gland - Increased amounts of target gland hormones in the blood stream decrease secretion of the same hormone and other hormones that stimulate its release.

Appropriate nursing diagnosis for patient with hyperthyroidism: Exophthalmos

Risk for injury: corneal ulceration related to inability to close eyelids

In the older patient diagnosed with hypothyroidism, what medication class. if prescribed to the patient, would cause the nurse particular concern and a need to consult with the healthcare provider before administering?

Sedatives - Older adults who are diagnosed with hypothyroidism should avoid sedatives. If they must be used, suggest that the lowest dose be used. Family members should closely monitor mental status, level of consciousness, and respirations. p. 1271

Manifestations of Hypothyroidism:

Skin - Cool, pale or yellowish, dry, coarse, scaly skin - Thick, brittle nails - Dry, coarse, brittle hair - Decreased hair growth, with loss of eyebrow hair - Poor wound healing Pulmonary - Hypoventilation - Pleural effusion - Dyspnea Cardiovascular - Bradycardia - Dysrhythmias - Enlarged heart - Decreased activity tolerance - Hypotension Metabolic - decreased basal metabolic rate - decreased body temperature - Cold intolerance Neurologic - slowing of intellectual functions - Lethargy or somnolence - Confusion - Hearing loss - Numbness and tingling) of the extremities - Decreased tendon reflexes Psychological/Emotional - Apathy - Depression - Paranoia - Withdrawal Gastrointestinal - Anorexia - Weight gain - Constipation - ABD distention Reproductive - Changes in menses - Anovulation - decreased libido - Impotence (Men) other - Periorbital edema - Facial puffiness - nonpitting edema or the lands and feet - hoarseness - Goiter - Thick tongue - Increased sensitivity to opioids and tranquilizers - Weakness, fatigue - decreased urine output - Anemia - Easy bruising - Iron deficiency - Folate deficiency - Vitamin B12 deficiency

Addison's Disease Clinical manifestations:

Skin hyper pigmentation seen primarily in - areas exposed to sun - pressure points - over joints - in skin creases, especially palmar creases

Addison's Disease: Diagnostic studies

Subnormal levels of cortisol levels fail to rise over balsa levels with ACTH stimulation test - latter indicates primary adrenal disease - Positive response to ACTH stimulation - indicates functioning adrenal gland

In the patient admitted for tetany, what specific lab value(s) does the nurse plan to monitor, in addition to general monitoring of lab results?

Sudden decreases in calcium concentration cause tetany Decreased PTH levels and increased serum phosphate levels.

What action(s) does the nurse anticipate while caring for a patient who is several hours post-surgery for a subtotal thyroidectomy, if the patient develops laryngeal stridor and a cramp in the right hand?

The hypocalcemia is causing the muscle tetany in the hand (positive Trousseau's sign) and laryngeal stridor. There's a high risk of damage to the parathyroid glands during a subtotal thyroidectomy, leading to hypocalcemia. Tetany is an uncomfortable result, and stridor can be a life-threatening result of hypocalcemia. As mentioned in posts here, the stridor will be treated ASAP with IV calcium gluconate. Hopefully, the calcium gluconate infusion will prevent respiratory emergency and the need for endotracheal intubation. p. 1269

Pituitary gland

The master gland; located at the base of the brain - Influenced by the hypothalamus; directly affects the function of the other endocrine glands - Promotes growth of body tissue, influences water absorption by the kidney, and controls sexual development and function.

Triiodothyronine (T3)

The most active of three hormones secreted by the thyroid gland, is responsible for a number of functions, including maintenance of metabolic rate and normal metabolism, normal growth and development, and protein, fat and carbohydrate catabolism.

In the patient displaying signs and symptoms of hypothyroidism, which lab values does the nurse plan to monitor, to determine if the condition is caused by malfunction of the anterior pituitary gland, or the thyroid gland?

The most common and reliable laboratory test for thyroid function are TSH and free T4. These valises, correlated with symptoms gathered form the history and physical examination, confirm the diagnosis. 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. An increase in TSH after TRH injection suggest hypothalamic dysfunction, whereas no change suggests anterior pituitary dysfunction. The presence of thyroid peroxidase antibodies suggests an autoimmune origin of the problem. Other abnormal laboratory findings are elevated cholestesterol and triglycerides, anemia, and increased creatine kinase.

Ovaries and testes

The ovaries are located in the pelvic cavity and produce estrogen and progesterone. - Testes are located in the scrotum, control the development of the secondary sex characteristics, and produce testosterone.

In planning teaching for the patient with hypothyroidism who has been admitted with myxedema coma, what considerations will the nurse take into account?

The patient who develops myxedema coma requires acute nursing care, often in a n intensive care setting. - Mechanical respiratory support and cardiac monitoring are frequently necessary. - Administer thyroid hormone replacement therapy and all other medications intravenously because paralytic ileum may be present in myxedema coma. Monitor the core temperature because hypothermia often occurs in myxedema coma. - 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 the hormone determines; the medication regimen. Not energy level and metal alertness.These should increase within 2 to 14 days and continue to rise steadily to normal levels. - It is important to provide written instructions, repeat the information often, and assess the patient's comprehension level. p1271

For the patient with hypoparathyroidism, what patient teaching is appropriate?

The patient with hypoparathyroidism needs instruction in the management of long-term drug therapy and nutrition. PTH replacement is not a recommended drug therapy because of the expense and the need for parenteral administration. - Oral calcium supplements of at least 1.5 to 3 g/day in divided doses are usually prescribed. Vitamin D is used in chronic and resistant hypocalcemia to enhance intestinal calcium absorption. - Preferred preparations are dihydrotachysterol (Hytakerol) and 1,25-dihydroxycholecalciferol (calcitriol (rocaltro). These drugs raise calcium levels rapidly and are quickly metabolized. Rapid metabolism is desired because vitamin D is a fat soluble vitamin and toxicity can cause irreversible renal impairment. - A calcium meal plan includes foods such as dark green vegetable, soybeans, and tofu. The the patient that foods congaing oxalic acid (spinach, rhubarb), physic acid (bran, whole grains), and phosphorus reduce calcium absorption. Instruct the patient about the need for lifelong treatment and follow up car including the monitoring of calcium levels three of four times a year.

What is Hyperthyroidism?

The term hyperthyroidism refers to any condition in which there is too much thyroid hormone produced in the body. In other words, the thyroid gland is overactive. Another term that you might hear for this problem is thyrotoxicosis, which refers to high thyroid hormone levels in the blood stream, irrespective of their source.

Mealtime Insulin (Bolus)

To control postmeal blood glucose levels, the timing of rapid- and short-acting insulin in relation to meals is crucial. Rapid-acting synthetic insulin analogs, which include lispro (Humalog), aspart (NovoLog), and glulisine (Apidra), have an onset of action of approximately 15 minutes and should be injected 0 to 15 minutes before the meal. The rapid-acting analogs most closely mimic natural insulin secretion in response to a meal. Short-acting regular insulin has an onset of action of 30 to 60 minutes and should be injected 30 to 45 minutes before a meal to ensure that the onset of action coincides with meal absorption. Because timing an injection 30 to 45 minutes before a meal is difficult for people to incorporate into their lifestyles, the rapid-acting insulins are often preferred by people who take insulin with meals.5 (Lewis 1225)

During the admission assessment, what nursing behavior is most appropriate with regard to palpation and assessment of a patient's thyroid glands?

When inspecting the thyroid gland, observe it first in the normal position (preferably with side lighting), then with the neck in slight extension, and then as the patient swallows some water. The trachea should be midline and the neck should appear symmetric. Any unusual bulging over the thyroid area should be noted. If there is no noticeable enlargement of the thyroid gland, palpation can be done. (Because palpation can trigger the release of thyroid hormones, defer palpation in the patient with a visibly enlarged thyroid gland.) When an enlarged thyroid (Lewis 1210) Lewis, Sharon. Medical-Surgical Nursing (with Media), 8th Edition. Mosby, 112010. VitalBook file. Thyroid palpation requires considerable practice, as well as validation by a more experienced examiner. Water should always be available for the patient to swallow as part of this examination. There are two acceptable approaches to thyroid palpation: anterior or posterior. p. 1210

In offering teaching to a patient, what information will the nurse provide about the diagnosis "prediabetes"?

You are in a good position to recognize patients who are at risk for diabetes and those with prediabetes. Therefore you need to educate patients about risk factors and encourage them to have their glucose levels tested. If action is taken to manage blood glucose, patients with prediabetes can delay or prevent the development of type 2 diabetes. Maintaining a healthy weight, exercising regularly, and eating a healthy diet have all been found to reduce the risk of developing diabetes in people with prediabetes. (Lewis 1221) - 100 mg/dL but less than 126 mg/dL (7.0 mmol/L),

In the patient with diabetes type 2 who has developed peripheral neuropahty and peripheral artery disease, what information will the nurse use in patient teaching?

You should include the following instructions when teaching the patient and / or caregiver about diabetic foot care. 1. Wash feet daily with mild soap and warm water. First test water temperature with hands. 2. Pat feet dry gently, especially between toes. 3. Examine feet daily for cuts, blisters, swelling, and red tender areas. Do not depend on feeling sores. If eyesight is poor, have others inspect feet. 4. Use lanolin on feet to prevent skin form drying and cracking. Do not apply between toes. 5. Use mild foot powder on sweaty feet. 6. Do not use commercial remedies to remove calluses or corns. 7. Cleanse cuts with warm water and mild soap, covering with clean dressing. Do not use iodine, rubbing alcohol, or strong adhesive. 8. Report skin infections or non healing sores to health care provider immediately. 9. Cut toenails evenly with rounded contour of toes. Do not cut down corners. The best time to trim nails is after a shower or bath. 10. Separtate overlapping toes with cotton or lamb's wool. 11. Avoid open-toe, open heel, an high-heel shoes. Leather shoes are preferred to plastic ones. Wear slippers with soles. Do not go barefoot. Shake out shoes before putting on. 12. Wear clean, absorbent (cotton or wool) socks or stockings that have not been mended. Colored socks must be colorfast. 13. Do not wear clothing that leaves impressions, hindering circulation 14. Do not use hot water bottles or heating pads to warm feet. Wear socks for warmth. 15. Guard against frostbite. 16. Exercise feet daily either by walking or by flexing and extending feet in suspended position. Avoid prolonged sitting, standing, and crossing of legs.

Two days following a self-managed hypoglycemic episode at home, the patient tells the nurse that his blood glucose levels since the episode have been between 80-90 mg/dL. The best response by the nurse is. a. "That is a good range for your glucose levels" b. "You should call your health care provider because you need to have your insulin increased." c. "That level is too low in view of your recent hypoglycemia, and you should increase your food intake" d. "You should only take half your insulin dosage for the next few days to get your glucose level back to normal"

a. "That is a good range for your glucose levels" Rationale: Blood glucose levels of 80 to 90 mg/dL (4.45-5 mmol/L) are within the normal range and are desired in the patient with diabetes, even following a recent hypoglycemic episode.

In nutritional management of all types of diabetes, it is important for the patient to a. eat regular meals at regular times b. restrict calories to promote moderate weight loss. c. eliminate sucrose and other simple sugars form the diet. d. limit saturated fat intake to 30% of dietary calorie intake.

a. eat regular meals at regular times. Rationale: The body requires food at regularly spaced intervals throughout the day and omission or delay of meals can result in hypoglycemia, especially for the patient taking insulin or oral hypoglycemic agents.

To prevent hyperglycemia or hypoglycemia with exercise, the nurse teaches the patient using glucose-lowing agents that exercise should be undertaken. a. only after a 10- to 15-g carbohydrate snack is eaten. b. about 1 hour after eating, when blood glucose levels are rising. c. when glucose monitoring reveals that the blood glucose is in the normal range d. when blood glucose levels are high because exercise always has a hypoglycemic effect.

b. about 1 hour after eating, when blood glucose levels are rising. Rationale: During exercise, a diabetic person needs both adequate glucose to prevent exercise induced hypoglycemia and adequate insulin because e counterregulatory hormones are produced during the stress of exercise and may cause hyperglycemia.

What is the action of propranolol (Inderal) to Ms. Pool? a. Decreases the size of the thyroid gland. b. blocks the production of thyroid hormone. c. Reduces symptoms such as palpitations and nervousness. d. decreases the blood flow to the thyroid gland.

c. Reduces symptoms such as palpitations and nervousness.

Following the teaching of foot care to a diabetic patient, the nurse determines that additional instruction is needed when the patient says. a. "I should wash my feet daily with soap and warm water" b. "I should always wear shoes to protect my feet form injury" c. "If my feet are cold, I should wear socks instead of using a heating pad" d. "I'll know if I have sores or lesions on my feet because they will be painful."

d. "I'll know if I have sores or lesions on my feet because they will be painful" Rationale: Complete or partial loss of sensitivity of the feet is common with peripheral neuropathy of diabetes, and diabetics may suffer foot injury and ulceration without ever having pain. Feet must be inspected during daily care for any cuts, blisters, swelling, or reddened areas.

A patient with Graves' disease asks the nurse what caused the disorder. The best response by the ruse is, a. The cause of Graves' disease is not know, although it is thought to be genetic" b. "It is usually associated with goiter formation from an iodine deficiency over a long period of time" c. "Antibodies develop against thyroid tissue and destroy it, causing a deficiency of thyroid hormone" d. "In genetically susceptible persons, antibodies are formed that cause excessive thyroid hormone secretion'

d. "in genetically susceptible persons, antibodies are formed that cause excessive thyroid hormone secretion" Rationale: In Graves' disease, antibodies to the TSH receptor are domed, attach to the receptors, and stimulate the thyroid gland to release triiodothyronine (T3), thyroxine (T4), or both, creating hyperthyroidism. The disease is not directly genetic, but individuals appear to have a genetic susceptibility to the develop autoimmune antibodies.

Which of the following patients would a nurse plant to teach how to prevent or delay the development of diabetes? a. A 62 year old obese whit e man. b. An obese 50 year old Hispanic Woman. c. A child whose father has type 1 diabetes. d. A 34 year old woman whose parents both have type 2 diabetes.

d. A 34 year old woman whose parents both have type 2 diabetes Rationale: Type 2 diabetes has a strong genetic influence, and offspring of parents who both have type 2 diabetes have increased chance of developing it.

Before the procedure, the patient should be informed of which possible long-term side effect of Radioactive Iodine Therapy RAI? a. Thyroiditis. b. Thyroid nodules c. Thyroid storm d. Hypothyroidism

d. Hypothyroidism