Exam #2: Adult Care
Secondary hyperparathyroidism
- Decrease in vitamin D - Chronic Renal Failure (both of these lead to hypocalcemia) Decrease in Vitamin D Increase in PTH Increase or normal amount of Calcium
Diagnosis of diabetes
- Elevated Hbg A1C AND - RBC only last for about 120 days so testing this shows the hemoglobin activity for the past 120 days. - Fasting Blood Glucose elevated OR - The pt comes in NPO, they drink this sugary drink, then they test BG an hour or two later - Elevated glucose tolerance OR - Elevated casual BG with symptoms
What are the characteristics of HHS?
- Gradual onset - Caused by stress or infection - Dehydrated, neuro symptoms - Glucose is > 600; this is about time, the symptom onset is really gradual. - Urine ketones are negative - pH > 7.4 - HCO3 > 20 - Elevated BUN/Cr
Causes of hypoglycemia
- Too much insulin - Insulin at wrong time - Not enough food - Alcohol - Gastroparesis - Kidney failure o Decrease insulin clearance through the kidneys, so the body holds onto insulin
Potential causes of hyperthyroidism
- tumor on the thyroid gland - exogenous hyperthyroidism
What causes Hypothyroidism?
1. Hashimoto's thyroiditis - autoimmune inflammation in the thyroid gland Antithyroid peroxidase antibodies and antithyroglobulin antibodies - Triggered by an infection somewhere else in the body which results in an altered immune response that happens in the thyroid gland 2. Iodine deficiency - essential for the production of thyroid hormone (added to food) 3. Treatment for hyperthyroidism a. Lithium b. Amiodarone can also can thyrotoxicosis
What is the mechanism of release for GH?
1. Hypothalamus secretes GH releasing hormone 2. This GHRH goes to the hypophyseal portal system (this is what links the hypothalamus to the ante pituitary) 3. Growth hormone is released
What causes acromegaly?
1. Pituitary adenoma (benign) which is a tumor of the somatotrophs They continuously make excess of GH which leads to excess insulin-like growth factor 1 2. Hypothalamic Tumors: release too much GH releasing hormone RARELY: multiple endocrine neoplasia type 1; "Wermer Syndrome"
What causes growth hormone to be limited?
1. Too much GH releasing hormone signals hypothalamus to stop 2. GH reaches liver, bone and muscle; somatomedins (small protein hormones) signal anterior pituitary to stop producing GH 3. GH and somatomedins signal hypothalamus to produce somatostatin (another hormone that signals to anterior pituitary to stop producing GH)
Tx of hypoglycemia
15-15 rule: check BG, then give 15g of CHO, then wait 15 minutes and check BG again - BG < 70 = 15 g CHO - BG < 50 = 30 g CHO - 15g of CHO ex: glucose tabs or glucose gel, a half cup of fruit juice or of regular soft drink, 8 oz of skim milk, 6 to 10 hard candies, 3 graham crackers, 1 tbsp of honey or syrup · If the patient is unconscious, then you will give the pt glucagon or dextrose
How does an insulin pump work?
24/7, continuously or in surges gives insulin
Physiology of the parathyroid hormone
4 parathyroid glands that include chief cells that respond to lowered levels of Calcium by releasing parathyroid hormone: - PTH increase blood calcium by increasing the absorption of calcium in the intestines - Reabsorption of calcium in the kidneys and decrease in secretion of calcium from the kidneys - Increase absorption of calcium in the osteoclasts
A nurse is caring for a client who is being evaluated for acromegaly. Which of the following manifestations should the nurse expect to find during assessment? SATA A. Loss of color discrimination B. Coarse facial features C. Enlarged distal extremities D. Hepatomegaly E. Moon face
A,B,C,D
What is Grave's disease?
An autoimmune disease of unknow etiology marked by diffused thyroid enlargement and excessive hormone secretion. 75% of hyperthyroidism cases.
A nurse is assessing a client who has hypoparathyroidism. Which of the following findings should the nurse expect? A. flaccid muscles B. Client report of numbness in his hands C. Negative Chvostek's sign D. Client report of anorexia
B. Client report of numbness in his hands
A nurse is reviewing the lab results for four clients. The nurse should recognize that which of the following clients has a manifestation of primary hyperparathyroidism? A. The client who has a decreased calcium level B. The client who has an increased magnesium level C. The client who has a decreased parathyroid hormone level D. The client who has an increased phosphorous level
B. The client who has an increased magnesium level
Type I DM
Beta cell destruction (they can't produce insulin), autoimmune, insulin dependent, idiopathic, genetic component, onset < 30 years, abrupt onset
Secondary symptoms of acromegaly
Carpal tunnel syndrome - increased pressure on nerves Diabetes mellitus - diabetogenic effects on GH CHF - enlarged heart Gastrointestinal cancers - colon polyps
A nurse is planning care for a client who is postoperative following a thyroidectomy. Which of the following interventions should the nurse include in the plan? A. instruct the client to deep breath every 4 hrs B. check the client's voice every 2 hrs C. place the head of the client's bed in the flat position D. Hyperextend the client's neck
Check the client's voice every 2 hr. The nurse should assess the client's voice every 2 hr to monitor for hoarseness, which is a manifestation of laryngeal nerve damage.
A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidectomy. The client reports a tingling sensation in the hands, the soles of the feet, and around the lips. For which of the following findings should the nurse assess the client? A. Chvostek's sign B. Babinksi's sign C. Brudzinski's sign D. Kernig's sign
Chvostek's sign
A nurse is assessing a client who has myxedema. Which of the following findings should the nurse expect? A. Diarrhea B. Facial edema C. Tachycardia D. Heat intolerance
Facial Edema
First line treatment for hyperthyroidism
First line is Carbmazole and METHIMAZOLE: normally successful, normal thyroid function after 4-8 weeks This is then titrated to maintain normal levels "titration block" OR used to block ALL PRODUCTION of thyroid hormone and replaced with LEVOTHYROXINE
A nurse is assessing a client who has hyperthyroidism. The nurse should expect the client to report which of the following manifestations? A. sensitivity to cold B. Constipation C. Frequent mood changes D. Weight gain of 4.5 kg (10lb) in 3 weeks
Frequent mood changes
Secondary hyperthyroidism T3, T4, TSH
From the pituitary gland, the TSH is high then the T3 and T4 is elevated as well
Diabetogenic
GH directly affects insulin resistance; the more GH the more insulin resistance so blood insulin levels increase. This is called diabetogenic because it is similar to what happens in the bodies of people with diabetes.
What is the main cause of hyperthyroidism?
Grave's Disease
Symptoms of acromegaly
Growth of bones of the hands, feet, and lower jaw; protrusion of the forehead; soft tissue swelling in hands, feet, face, and tongue, increased organ size; excessive sweating
A nurse is assessing a client who has thyrotoxicosis after taking too high of a level of levothyroxine. Which of the following manifestations should the nurse expect? A. drowsiness B. Bradycardia C. Dry skin D. Heat intolerance
Heat intolerance
Primary hyperparathyroidism
If the parathyroid gland were to have a tumor, the PTH would increase. - This would subsequently the absorption of calcium, in the intestines, reabsorption in the kidney, increase of absorption in the osteoclast, and increases the calcium causing hypercalcemia So, increase in PTH Increase in Calcium
Diabetes management - nutrition
Individualized, you can't prescribe the same diet for every patient - Registered dieticians need to create this plan - Carbohydrates - eat nutrient dense carbohydrates: fruits, vegetables, whole grains, legumes, beans - Fat/cholesterol - nutrient dense; avocados, olive oils, coconut oils - Fiber - this is the key to this whole diet plan, fiber (25-35g of fiber daily) · Fiber improves carb metabolism · Fiber lowers cholesterol (important for diabetic pts) - Alcohol - can cause delayed hypoglycemia · The liver produces glucose (gluconeogenesis), alcohol is metabolized in the liver, the liver focused on the metabolism of the alcohol and forgets about the glucose release. This is especially true if the pt is on medication because they have taken medication to lower the BG and then the liver doesn't secrete glucose, so they then become hypoglycemic
Treatment for Type I DM
Insulin
What does the pancreas do when we eat?
It gives us a bolus of insulin to regulate carbs and sugars
Medications for hypothyroidism
Levothyroxine (Synthroid)
Tertiary Hyperparathyroidism
Occurs when secondary is prolonged - The parathyroid glands will experience hyperplasia because they are overexerting themselves to compensate for the hypocalcemia - The glands will keep producing PTH because they glands are so used to producing PTH - Hypercalcemia occurs and then they have to remove parts of the glands to prevent the over production of PTH Increase in PTH, increase in Ca
Hypopituitarism
Pituitary adenoma (usually benign tumor)
Why do Type I Diabetics have polydipsia?
Polydipsia happens because they are dumping a lot of fluids to get rid of the glucose excess
Why do Type I Diabetics have polyphagia?
Polyphagia happens because the cells use glucose for food, but there is no insulin to push glucose to the cells so the cells will begin to starve. The pt will begin to lose weight because the cells have no food and will look for an alternative food source (fat).
Why do Type I Diabetics have polyuria?
Polyuria happens because blood glucose stays in the bloodstream. The body tries to get rid of the excess glucose through osmotic diuresis.
What are the indirect effects of GH on the liver, muscle, bones, and kidneys
Produces somatomedin C (insulin-like growth factor 1) Which promotes cellular metabolism, prevents cell death, helps cells divide and differentiate throughout the body
A patient that has hypothyroidism is at risk what condition? What action would you take to avoid those risks?
Risk for myxedema coma and respiratory failure - provide supplemental oxygen
Second line treatment for hyperthyroidism
Second line is Propylthiouracil: small risk for hepatic reactions, reactions CAN cause death
Characteristics of DKA
Sudden onset Causes: stress, infection, no insulin Kussmaul, nausea, abd pain, dehydration, neuro symptoms - Glucose >300 - Positive ketones - pH > 7.35 - HCO3 < 15 - BUN/Cr is elevated
Primary hyperthyroidism - T3, T4, TSH
T3 and T4 are elevated and TSH is low
A nurse in a clinic is reviewing the lab values of a client who has primary hypothyroidism. The nurse should anticipate an elevation of which of the following lab values? A. TSH B. Free T4 C. Serum T4 D. Serum T3
TSH
Labs for hyperthyroidism
TSH goes down because T3 and T4 are overproduced so the pituitary gland doesn't need to stimulate the thyroid gland with TSH. The pituitary gland isn't going to send the TSH to stimulate more T3 and T4
Teaching points for levothyroxine
Therapy is lifelong You can't take it with other medicines (empty stomach) Take in the morning at the same time every day Labs checked regularly
Why is neuropathy an important aspect that diabetic pts need to be aware of . . .
They can injure their feet and not know that they have injured their feet Foot injuries are the number one cause of diabetic related hospitalization (foot care is extremely important in these patients)
Type I DM characteristics
Thirst, hunger, increased urine output, weight loss (polyuria, polydipsia, polyphagia)
Treatment of acromegaly
Treatment depends on underlying cause. If it is adenoma: surgery and radiation therapy are the solutions plus medications Medications: somatostatin analogs (limit GH production)
Retinopathy
Vision loss (they need a yearly eye exam) - Control blood glucose (this is the only way to prevent retinopathy) Regular monitoring
Treatment for secondary hyperparathyroidism
Vitamin D supplement Transplant
What are we most worried about in a pt that is on a insulin drip for the treatment of DKA?
We are worried about potassium when the pt is on an insulin drip · Insulin pushes potassium into the cells · The patient will become hypokalemic · You will give them a potassium supplement o This patient is going to look like they are in respiratory distress, but they don't need oxygen, this is a compensatory mechanism to try and correct the metabolic acidosis
symptoms of hypothyroidism
Weight gain, fatigue, dry skin, fluid retention, amenorrhea, constipation (everything goes down except their weight). They are depressed, have low BP, flat affect, no appetite, sleep all the time
How does insulin work?
When insulin is released from the pancreas, it pushes glucose from the bloodstream into the cells. Once it gets into the cells, the cells use glucose for energy. The cells will store glucose so they have energy in between meals.
Metabolic Syndrome
abdominal obesity, hyperglycemia, HTN, Hyperlipidemia. If a person has any three of these, they are considered to have metabolic syndrome and also have an increased risk for DM and cardiovascular disease
Universal features of hyperthyroidism
anxiety, irritability, sweating, tachycardia, weight loss, fatigue, frequent loose stool, sexual dysfunction
What prescription should you request for a patient with exophthalmos?
artificial tears
Exopthalmos
bulging of the eyeball (inflammation and swelling in Grave's Disease)
Primary hypothyroidism
decrease in T3/4 and increase in TSH (the one you need to know)
Secondary hypothyroidism levels
decrease in TSH, T3 and T4
Grave's Disease features
diffuse goiter with no nodules, thyroid eye disease, pretibial myxedema
pretibial myxedema
dry, waxy swelling of the front surfaces of the lower legs; hyperthyroidism, specifically Grave's Disease
If a patient is experiencing thyroid storm, what two parameters should you monitor?
dysrhythmias and seizures
Acromegaly
excessive growth hormone in adults (somatotropin)
Type II diabetes risk factors
family HX; African American, Hispanic, pacific islander; high birth weight babies/gestational diabetes, PCOS (polycystic ovarian syndrome)
What are the key manifestations of thyroid storm?
fever, tachycardia, systolic HTN, abdominal pain, N/V, diarrhea, anxiety, restlessness, tremors, confusion, dysrhythmias, seizures
Toxic multinodular goiter features
goiter with firm nodules, above 50 years old, second most common cause of thyrotoxicosis
Hyperparathyroidism
high levels of parathyroid hormone
What is HHS?
hyperosmolar hyperglycemic state
What is gigantism?
hypersecretion of GH in children
Hypothyroidism
inadequate output of thyroid hormones by the thyroid gland Pituitary gland isn't producing TSH because of tumors, infections, Sheehan syndrome, or radiation
Uncontrolled Blood glucose can . . .
increase mortality, increased ICU admission, and increase in length of stay in hospitals (even in non-diabetic patients)
DKA tx
insulin (IV insulin - regular is the only you can give IV) and fluids
Diabetes management - exercise
lowers cholesterol, lowers BP (cardiovascular and weight bearing exercises), maintains healthy BG levels
Neuropathy
nerve damage in the periphery
Macrovascular disease associated with DM
o Cardiovascular disease o Cerebrovascular disease - Risk for strokes, coronary artery disease, MI, can result in loss of feeling because the vascular system is injured
Hypoglycemia characteristics
o Cool, clammy, sweaty skin o No dehydration o No change in respirations o Nervous, irritable, confusion, decrease LOC o Weak, blurred vision, tachycardia, palpitations o Glucose < 70 o Negative Ketones
Sick day management of diabetes
o Monitor BG more often; the body is under stress so cortisol will increase. Cortisol raises the BG. o Take medications and insulin as prescribed, just because they aren't eating doesn't meant their BG is going to go down. - They may need more insulin when they are sick, but they need to call their provider and not self-adjust their medications o Stay hydrated o Eat regularly - If unable to eat, consume liquids with carbs o Rest o Know when to call provider - N/V - High fever - BS continues to be high even with additional medication - If they have ketones in their urine (especially Type I) you can use a ketones testing kit
Hyperglycemia symptoms
o Warm, dry skin o Dehydration o Stuporous, obtunded, coma o Symptoms varies with DKA and HHS o Glucose > 250 mg/dL o DKA (Kussmaul respirations - fruity breath; this is a hyperventilation) - They are trying to balance the pH because they are in a metabolic acidosis - Positive ketones with DKA
Type II medications
oral/subcutaneous antidiabetic medications AND/OR insulin · Metformin, glycoside · If the pt is on three different medications and their A1C is still high, then they should be put on insulin · Type II diabetes can be reversed through diet, exercise, and weight loss
What is hyperthyroidism?
over production of thyroid hormone
Treatment of tertiary hyperparathyroidism
parathyroidectomy
What two features of hyperthyroidism are SPECIFIC to Grave's Disease?
pretibial edema and exophthalmos
radioactive iodine
radiation that is emitted destroys thyroid cells that then decreases thyroid hormone, but they can be left with hypothyroidism. Iodine is exclusively absorbed in the thyroid.
How to manage hypothyroidism
replace thyroid hormone with oral levothyroxine (synthetic T4 that metabolizing into T3)
beta cells of pancreas
secrete insulin
Solitary toxic thyroid nodule
single abnormal thyroid nodule, benign adenomas that produce excess thyroid hormone
How do you treat solitary toxic thyroid nodules?
surgical removal
Treatment for primary hyperparathyroidism
surgical removal of parathyroid tumor
What is exogenous hyperthyroidism?
taking too much levothyroxine
What parameters should you monitor for a person experiencing hyperthyroidism?
temperature and T3/T4 levels
hyperpituitarism
the excess secretion of growth hormone that causes acromegaly and gigantism
Most popular treatment for hyperthyroidism?
thyroidectomy
thyroid storm
thyrotoxic crisis, relatively rare, life-threatening condition caused by exaggerated hyperthyroidism
Plummer's Disease
toxic multinodular goiter, hyperthyroidism; causes hyperthyroidism because of nodules on the thyroid
De Quervain's Thyroiditis
viral infection that causes fever, neck pain and tenderness, dysphagia, hyperthyroidism
Secondary hyperthyroidism
when the thyroid is producing too much hormone by an increase in thyroid stimulating hormone in the pituitary
Primary hyperthyroidism
when the thyroid itself is acting improperly (this is the one we need to know)
Medications for acromegaly
• Dopamine agonists- bromocriptine mesylate, cabergoline • Somatostatin analogs - ocreotide, lanreotide • Growth hormone receptor blockers - pegvisomant
Medications for hyperthyroidism
• Thionamides - methimazole and PTU (propylthiouracil) • Lugol's solution
