nsg 246 test 2

Thyroid gland

*Located:* anterior neck, below cricoid cartilage, either side of the trachea *Not visible:* on inspection *Can be palpated when:* swallowing. go behind them and tell them to swallow. *Follicular:* *Secretes:* T3 (triiodothyronine) and T4 (thyroxine) *Regulates:* basal metabolism *Parafollicular:* *Secretes:* calcitonin (thyrocalcitonin) *Regulates:* calcium and phosphate

adrenal medullary

*Produces:* Catecholamines- Dopamine, Epinephrine--strongest; 10x stronger than norepi, Norepinephrine *Hypofunction:* is not life-threatening because this isn't the only organ that produces them. nervous system also secretes. *Hyperfunction:* can cause problems, most severe is HTN (WORRIED ABOUT HYPERTENSIVE CRISIS).

parathyroid

*2- 6 small glands located:* close to, embedded in, or attached to the posterior surface of the thyroid *Chief cells secrete:* PTH - parathyroid hormone *Parathyroid Hormone:* Regulates Calcium and Phosphorous *NORMAL PARATHYROID* *Bone:* primary storage site of calcium. Promotes Resorption - (TEARS DOWN BONE. Calcium and Phosphorous released from the bone into the serum) (decrease osteoblastic and increase osteoclastic activity *Kidney:* Activates Vit. D, Reabsorbs Calcium ,Excretes Phosphorus *GI:* Increases the absorption of Calcium and Phosphorous via activated Vit D. *calcium metabolism regulation:* Vitamin D - promotes all three. Calcitonin - opposite, decreases calcium in body. Parathyroid hormone. Calcium feedback. *Calcium and phosphorous from parathyroid:* INCREASES calcium in body, decreased phosphorous bc kidney excretes. *If calcium is low in body:* parathyroid hormone stimulated to have more.

vulvovaginitis

*what is it:* Inflammation of lower genital tract resulting from imbalance of hormones and flora in vagina and vulva *Characterized by:* itching, change in vaginal discharge, odor, or lesions *Treatment focuses on:* the causative agent for infection

care of pt with breast mass

*Decreasing the risk for:* metastasis *tx:* Surgical management. Radiation therapy. Drug therapy. Chemotherapy. Hormonal therapy. Stem cell transplantation *pt education:* Affected arm: NO B/P cuffs, needle sticks, constrictive clothing, watches, or jewelry. Wear compression garment if prescribed. Keep skin clean & nails clean & trimmed. Avoid exposure to extreme heat or cold. Use sun screen & insect repellant. Follow guidelines for exercise. Social support, Reach for Recovery, Canoe rowing group (also good arm exercise)

aging related to endocrine system

*ADH:* decreased. urine more dilute and may not concentrate when fluid intake is low. pt at greater risk for dehydration. assess more frequently. offer fluids q2 hours while awake unless fluid restriction. *Estrogen:* decreased ovarian production. bone density decreases. skin is thinner, drier and at greater risk for injury. perineal and vaginal tissues become drier, and risk for cystitis increases. teach pt to engage in regular exercise and weight bearing activity. avoid pulling or dragging pt. use minimal tape on skin. use skin moisturizers. perform peri care at least twice daily. promote use of lubricants for sexually active women. *Glucose tolerance:* decreased. elevated glucose, slow wound healing, frequent yeast infections, polydipsia, polyuria. weight becomes greater. *metabolism:* decreased. less tolerance for cold. appetite decreased. hr and bp decreased. can be difficult to distinguish from hypothyroidism. check for additional ss

uterine leiomyomas

*Also called:* fibroids or myomas *Excessive local growth of:* smooth muscle cells *Can be:* Symptomatic versus asymptomatic *Cause (pathology):* Unknown. Estrogen dependent *History:Predisposing:*Age, Genetics, African-American, Nulliparous, Obese *SS:* *Abnormal menstrual bleeding. Up to 30%:* Heavier, prolonged periods that can cause anemia. Painful periods. Spotting before or after periods. Bleeding between periods *Pelvic pain & pressure:* Abdomen, pelvis, or low back. During sexual intercourse. Bloating & feelings of abdominal pressure *Urinary problems:* Frequency. Incontinence *Other symptoms:* Difficulty or pain with bowel movements. Infertility. Problems with pregnancy, such as placental malpositions or abruption & premature labor, malpresentations. Miscarriage *DX:* Symptoms. Bimanual exam. Ultrasound *Treatment goal:* is reduce symptoms, size *Nursing goals would include:* management of symptoms, explanation of procedures, & post procedure care *Most common:* Hysterectomy. Myomectomy. Uterine artery embolization *MEDS:* *Drug:*Low dose mifepristone (progestin antagonist) *Action:* Decrease flow or use continuous to stop flow *Drug:* Danazol (androgenic), & gonadatropin-releasing hormone (GnRH) like Luprolide *Action:* Decrease size & slow growth. Reversible menopause

mammography

*American College of Obstetricians and Gynecologists recommends annual screening mammography for women age:* 40 and over *What is it:* Soft tissue X-ray of the breast. No injection of contrast medium. Can detect lesions earlier than by using palpation *Monthly self-breast examination (BSE) is:* less emphasized as a screening tool than in the past *Recommended to:* increase breast self-awareness

standards of practice

*Assessment:*The registered nurse collects pertinent data and information relative to the healthcare consumer's health or the situation *Diagnosis:*The registered nurse analyzes assessment data to determine actual or potential diagnosis, problems, and issues *Outcomes identification:*The registered nurse identifies outcomes for a plan individualized to the healthcare consumer or the situation *Planning:*The registered nurse develops a plan that prescribes strategies to attain expected, measurable outcomes. *Implementation:*The registered nurse implements the identified plan *Coordination of care:*The registered nurse coordinates care delivery. Health teaching and health promotion. the registered nurse employs strategies to promote health and a safe environment *Evaluation:*The registered nurse evaluates progress toward attainment of goals and outcomes *Ethics:*The registered nurse practice ethically *Culturally congruent practice:*The registered nurse practices in a manner that is congruent with cultural diversity and inclusion principles *Communication:*The registered nurse communicates effectively in all areas of practice *Collaboration:*The registered nurse collaborates with the healthcare consumer and other key stakeholders in the conduct of nursing practice *Leadership:*The registered nurse leads the professional practice setting and the profession *Education:*The registered nurse seeks knowledge and competence that reflects current nursing practice and promotes futuristic thinking *Evidence-based practice and research:*The registered nurse integrates evidence and research findings into practice *Quality of practice:*The registered nurse contributes to quality nursing practice *Professional practice evaluation:*The registered nurse evaluates one's own and other's nursing practice *Resource utilization:*The registered nurse utilizes appropriate resources to plan, provide, and sustain evidence-based nursing services that are safe, effective, and fiscally responsible *Environmental health:*The registered nurse practices in an environmentally safe and healthy manner.

ductal etasia

*Benign breast problem of women:* approaching menopause *ss:* Hard mass; irregular borders, tender. Greenish-brown nipple discharge, enlarged axillary nodes, redness and edema over mass *Management:* May improve without treatment. Reduce anxiety regarding threat of breast cancer. Warm compresses. Antibiotics. May require surgical removal

gynecomastia

*Benign condition of:* breast enlargement in men *Can be result of:* primary cancer (for example, lung or testicular cancer) *Other causes:* Drugs. Aging. Obesity. Underlying disease causing estrogen excess. Androgen deficiency

vulvar vestibulitis or vulvodynia

*Benign condition:* of vulva *What is it?* Local irritation & inflammation of vestibule *Symptoms:* Burning & itching. Severe pain with vaginal penetration. Sometimes dysuria & urinary frequency *Cause:* unknown - chronic infections, trauma *Diagnosis:* symptoms, q tip test, neg biopsy *Nursing diagnoses should address:* pain control, sexual dysfunction *Interventions:* Introital lubricants. Low oxalate diet. Topical anesthetics. Use of tricyclic antidepressants. Antifungals. *Medical treatment:* local interferon injections, surgery

POLYPS

*Benign or malignant?* Benign *Most common:* cervix or in uterus *Endometrial polyps:* common cause of bleeding. *Diagnosis:* visualize, U/S, hysteroscopy *Treatment is:* removal. Depends on site *Vaginally-* grasp & twist *Sometimes endometrial biopsy:* will not only diagnose, but remove *Other:* Dilation & curettage (d/c) *ANYTHING THAT IS REMOVED:* MUST GO TO PATHOLOGY!

Symptoms due to pressure (tumor in pituitary)

*C/O:* diplopia, temporal headaches, changes in peripheral vision.

hyperparathyroidism

*Calcium:* hyper. can be deposited in soft tissue (kidney stones, skin - waxy, pallor) *Mental:* Fatigue, lethargy, Psychological distress *Bone:* fractures, deformities, osteoporosis, because taking calcium out of bone. *GI:* anorexia, N/V, constipation, wt. loss, PUD) *If Ca >12 mg/dl:* Normal is 8.5-10.5. confusion, psychosis, eventually coma and death *Magnesium:* high (nl is 1.3-2.1) *Causes:* benign adenoma. Other causes include neck trauma, radiation, Vit D deficiency, chronic renal failure *Lab tests:* High Serum PTH. High Serum calcium and Low serum phosphate levels. *Radiography:* Kidney stones. Calcium deposits. Bone fractures or cysts *interventions:* Hypercalcemia is main problem. Hydrate to flush out calcium (watch I&O), ambulate. Furosemide causes excretion of Calcium. Cardiac monitoring. Monitor Calcium levels - don't want a sudden drop. Vitamin D deficiency (stimulates all). Safety-Falls Precautions. Lift with sheets, do not pull. *Meds:* calcimimetics, oral phosphates and calcitonin.

problems with adrenal cortex: hyperfunction

*Can oversecrete:* just one or all adrenal hormones Hypercortisolism-Cushing's syndrome; all 3 of adrenal hormones. autoimmune. Hyperaldosteronism- Conn's syndrome Hyperandrogenism

psychological considerations

*Deep, psychological meaning attached to:* sexual & reproductive organs *Consider:* impact on body image & sexuality, self image, libido *During exams:* patient's comfort level *Unable to cooperate, unexplained or disproportional discomfort?* consider past history sexual abuse

pheochromocytoma

*Catecholamine-producing tumor:* in adrenal medulla or the abdomen) *Releases:* epinephrine and NE(norepinephrine) *Mimics stimulation of:* sympathetic nervous system (fight or flight) *Main risk is:* Hypertensive episodes or crisis. HA, chest pain, diaphoresis, palpitations (sinus tachycardia), flushing, apprehension, N/V, *Avoid:* manipulation of the tumor (abdominal pressure, constipation-GIVE stoolsofteners, palpating, surgery) - cause HTN *dx:* *Diagnostic tests of urine:* Vanillylmandelic acid testing *Plasma catecholamine levels-*will be high *High:* Hyperglycemia, hypercalcemia , erythrocytosis *Imaging:* Used only after identified with lab *tx:* *Surgery:* to remove adrenal gland(s)-adrenalectomy. *Preoperatively:* Prevent HTN crisis (diet, activity, environment). Hydrate to prevent post-op hypotension. Meds to stabilize BP *Postop care:*Adrenalectomy *If tumor is inoperable:* Treat for HTN. Respond poorly to chemo or radiation

ovarian cysts

*Cause?* Depends on type *Form:* during the menstrual cycle. "egg gone wrong" *Risks:* Drugs used to cause ovulation, such as Clomid® or Serophene® *Two types:*follicular & corpus luteum *Usually:* resolve on their own *SS:* Abdominal pressure or bloating. Abnormal bleeding: spotting, early or delayed menses. Problems passing urine completely. Weight gain. Nausea or vomiting. Breast tenderness *Pain:* *Caused by:* Mechanical friction. May rupture or leak *Presents as:* Sharp, knife-like, then dull (if rupture). Dull ache in abdomen, lower back & thighs to severe pain. Constant or with sex, menses *Danger:* Twist & cause pain or necrosis: need to go to Emergency if pain lasts more than one hour! *Diagnosed by:* Symptoms. Bimanual. Labs - include pregnancy test. History-relation to menstrual cycle. Ultrasound. MRI or CT scans are not good *Treated by:* Watchful waiting. NSAIDS. Hormones like OCs *Surgery:* Laparoscopic vs Laparotomy. Oophorectomy *Prevention:* stop ovulation

Goiter

*Causes:* Hyperthyroidism. Hypothyroidism. Thyroid cancer *What is it?* Enlarged Thyroid Gland *The gland enlarges to meet the demand for increased thyroid hormones:*adolescence, pregnancy, and menopause *Assessment:* Lab tests usually remain normal (euthyroid). Symptoms are related to the pressure the enlarging gland causes on the neck structures. More common in females-body image is a problem. *Can be triggered by:* Lack of iodine in diet. Drugs - propylthiouracil (PTU), lithium, phenylbutazone, iodides *Can progress:* Secretes too much hormone and starts to have hyperthyroid. *TX:* Hormone replacement - Rest the gland. T4 - Levothyroxine. T3 - Liothyronine

hypercortisolism (cushings)

*Causes:* Pituitary Cushing's disease - ACTH over-secretes - adrenal hyperplasia. Adrenal Cushing's disease - adenoma. Cushing's Syndrome - results of drugs. Disrupted sleep. primary would be oversecretion from adrenal gland. *Manifestations:* *Blood sugar:* Altered CHO metabolism. Hyperglycemia. *Cardiac:* htn, petechiae, bruising, dependent edema. *Fat redistribution:* buffalo hump, moon face. trunkal obesity. weight gain. Muscle wasting, muscle weakness from depletion of protein-risk for falls. *Skin:* Degradation of collagen - striae,. Capillary fragility - bruising, thin skin, non-healing wounds. inc pigmentation. *Bone density:* pulling calcium out of bone. loss - osteoporosis, fractures. *Na and water:* retention - hypertension *if high acth:* Hyperpigmentation; bronze skin. if adrenal problem, wouldn't have this. *GI:* Increased GI distress. increased gastric secretions *Mental status changes:*Irritability. Depression. Crying/laughing inappropriately. Difficulty concentrating. Fatigue, sleep disturbances. Severe psychiatric disturbances (Schizophrenia). *Immune system:* Compromised immune system/Infections. Signs of infections may not be seen (fever, purulent exudate, redness). Reduced protection of the inflammatory and immune responses *Increased androgen:* Hirsutism. Clitoral hypertrophy. Acne. Menstrual irregularities, amenorrhea, infertility, decreased libido. impotence. gynecomastia *ACTH - producing pituitary tumor:* H/A, polyuria, nocturia, visual problems or galactorrhea. *lab dx:* *High:* Serum cortisol (midnight), glucose, sodium *Saliva cortisol:* greater than 2ng/ml. usually done at midnight because should be lower at that time, but if it's high you would have too much at that time. *24 hour Urine:* elevated 17 - hydroxycorticosteroids, 17 - ketosteroids, calcium, potassium, glucose *ACTH serum levels:* elevated if Pituitary Cushings. *Low:* Serum lymphocyte count, calcium, potassium-see metabolic alkalosis. *Definitive tests are the dexamethasone suppression tests:* In the normal regulation, the presence of dexamethasone causes suppression of free cortisol and the urinary metabolites (17 hydroxycorticosteroids). In Cushing's, these will be elevated in the overnight or 3 day screening test *Interventions for testing:* Explain tests (esp urine collection). Be sure client avoids medications for 2 days before and has had no stressful procedures or therapy (will > cortisol) *tx:* *Nursing interventions:* *Fluid:*Watch fluid overload - VS (BP), I & O, Wt. gain or loss, neck veins, lungs, dependent edema *Watch electrolytes:* Potassium, Sodium *Nutrition:*Fluid and sodium restrictions (vary), Teach to read labels. High calorie (from all major food groups)-having trouble getting nutrition you need because youre breaking down protein. increased calcium/Vit D for bones. (Watch for hyperglycemia). Avoid caffeine and alcohol for the gastric acid content. *interventions for injury:* Lift Sheets, Fall Precautions. Clean, dry skin, moisturizers. Watch for bleeding. Pressure areas (edema). ROM exercises *GI Bleeding:* H2-receptors. antacids (neutralizing acids). gastric proton pump (prevent formation of production of acid). Avoid caffeine, alcohol, smoking, fasting, NSAIDS, aspirin *Risk for Infection:* may have problems with reduced inflammation and the immune response ongoing (replacement) or weeks (after surgery). Assess every four hours for infection (immunosuppressed patient may not have the usual fever/pus). Increased temperature of 1degree F is significant. Check labs CBC with WBC. Precautions, Wash hands. *Need to have:* alert bracelet on.

What is your role in testing

*Check with the lab:* for specifics. Ice, preservatives, correct container, timing. *24 hour Urine collection:* starts after client empties bladder and ends with emptying anything left in the bladder at the end time, preservatives, dark containers, cold-need to be on ice. if preservative, teach pt to avoid splashing bc some can make urine caustic. *A lot of times for endocrine purposes:* need something to preserve *CNA:* teach them to be careful with urine, any drops spilled needs to start over. *If you are drawing blood from an IV:* clear the line

lichen sclerosis

*Chronic, most common:* 40-50 yo *Benign but has slight increased risk for:* squamous cell carcinoma *Sometimes associated with:* autoimmune diseases *Symptoms:* chronic itching & burning *Diagnosis:*symptoms. White papules & plaques. Labia minora eventually disappear, clitoral hood & labia may fuse *Needs to be:* biopsied *Nursing diagnoses should address:* symptom control & sexual discomfort *Interventions:* High dose topical steroids (Prolonged use can thin tissues). Comfort measures. lubricants

menopause

*Climacteric or Perimenopause:* Begins with decline in hormones. Ends with menopause *Menopause:* *Natural:* 1 year after cessation of menses (avg. 51.4 yrs; range 30-60) *Artificial:* external means. Surgical or radiation damage to ovaries. Some medications *Symptoms related to:* loss of estrogen & progesterone *SS:* Menses change. Anovulatory = Irregular intervals & amounts, then cease. Vasomotor instability = hot flashes. Sexual organs shrink in size. Mucosa thins & dries = dysparunia, UTIs. Muscular support weakens. Sleep disturbances, Dizzy spells, Palpitations, Weakness, Weight gain *Therapies:* Hormone replacement. Estrogen. Estrogen + Progesterone. Phytoestrogens. Lifestyle changes. SSRIs. Vaginal lubricants. Kegels. Complementary therapies. Osteoporosis prevention/treatment

pap smear

*Cytologic study to detect:* precancerous and cancerous cells within a female's cervix *Schedule:* between patient's menstrual periods *Teach patient:* not to douche, use vaginal medications or deodorants, or have intercourse for 24 hours prior

Growth hormone deficiency

*Decreased GH:* cell, tissue and bone growth *Children":* dwarfism, short stature *Adults:* fragile bones (osteoporosis), decreased bone density, increased fractures. Decreased muscle strength. Increased cholesterol levels (caused by increased fatty acid intake) *Interventions:* Remove the cause, if possible. Replace the hormone/hormones. Treat Symptoms (give GH if child not growing). Safety to avoid bone fractures. Counseling. Nutrition changes. Exercise. Use lift sheets to move the adults. *Replacing GH:* *In children:* GH secreted in pulses during sleep, short half life. Somatropin and Somatrem are recombinant human GH. SQ nightly. Watch their height for effectiveness. *Teaching:* teach family or maybe pt how to give. rotate sites, measuring it up. Have them demonstrate back to you. *In adults:*Can be given oral.

Gonadotropins (hypo)

*Decreased gonadotropins:* *Males:* testicular failure with delayed onset of puberty and infertility, decreased male sexual characteristics (facial hair) and libido, decreased ejaculate volume. reduced muscle mass. loss of bone density. decreased body hair. impotence (ED). *Females:* ovarian failure with amenorrhea and infertility, anovulation, decreased estrogen, decreased female sexual characteristics (pubic hair, axillary hair) and libido, dyspareunia (painful intercourse). Osteoporosis. *FSH/LH deficiency replacements:* *Women:* Estrogen/ Progesterone (Contraindicated in some breast cancers) *Men:* Testosterone (Contraindicated in elevated PSA levels - suspect prostate enlargement/cancer) *Supplements:* lifelong. Looking for secondary sexual characteristics (axillary hair, beard, etc). May adjust. Bone density will improve, increased libido, increase muscular strength with tx.

hypothyroidism: myxedema

*Decreased:* metabolism *Glycosaminoglycans-*Metabolites (protein and sugar) buildup. Cellular edema caused by the buildup of mucous/water. (Non-pitting edema forms everywhere). *ss:* Coarse features. Edema around eyes and face. Blank expression. Thick tongue. Slow muscle movement. Husky voice (larynx)

evidenced based practice

*Definition:* Practice in which nurses make clinical decisions using the best available research and other evidence that is reflected in approved policies, procedures and clinical guidelines (clinical expertise) in a particular healthcare agency. *Includes the patient's:* values and preferences to make a decision about care. *Knowledge:* *Differentiate:* clinical opinion from research and evidence *Policies/procedures:* What references are cited? *Must respect the patient's:* preferences, values, beliefs *Accuracy:* Source is updated, comprehensive *Reasonableness-* objective, consistent with other's worldwide views *Support-* Find at least two other sources that support it *Seek current evidence:* to determine best practice and care decisions *Participate in* best practice studies *Attitude:* *Spirit of:* inquiry. Not just we have always done it this way, or this is what I learned in school, or it is easier to do it this way

quality improvement

*Definition:* Use of data/evidence based practice to monitor care outcomes and develop solutions to change and improve care *Why are nurses involved?*Nurses must be engaged. (All nurses) *It is our professional responsibility:* to improve care and keep the patient safe *Define the problem:* -*Monitor, collect data, look for potential causes:* Research, compare to others *Develop a strategy/plan/outcomes:* Carry out the plan *Collect data:* Did the plan work? Did it meet the outcome? Any changes needed? *Barriers:* Cost, unwillingness to Change, not recognizing the need to change. No workarounds instead of solutions *Participate in a "root cause analysis":* Define the problem. Collect the data. What are the factors causing the problem? Why is this happening? Change: prevent from happening again

Non invasive breast cancers

*Ductal carcinoma in situ (DCIS):* localized, non-invasive. If left untreated, it may progress. Confined to duct - not cancer yet, but can spread. Usually found on mammogram *Lobular carcinoma in situ (LCIS):* located in the lobules which produce milk. This type will also spread if left untreated. Usually not seen on mammogram. Become invasive

assessing

*Dysfunctions:* excess or deficiency of a specific hormone or a defect at it's receptor site. *Hormonal changes:* Slow (usually slow) or Abrupt and Life threatening. *Risk factors:* Age, Female/Male, Past/Current Medications, GI disturbances, Change in Weight, History of growth and development difficulties, Energy level changes, Elimination, Sexual/Reproductive *Physical assessment head to toe:* palpate thyroid and gonads. Breasts, Genitalia. Auscultate for dysrhythmias *Diagnostic evaluations:* *Blood/Urine/Saliva tests:* determine direct levels, antibodies, or effect of the hormone (like insulin on glucose). Hormones excreted through kidneys, so looking for overproduction. blood samples drawn for catecholamines must be placed on ice and taken to lab immediately. *Venous Sampling:* taking sample directly from circulation coming out of particular target. *Radioimmunoassay:* labeled hormone compete for binding sites and bound and unbound are measured *Urine tests:* measure hormone or end products excreted by kidneys (24 hour urines) *Other:* CT, MRI, x-ray, US, angiography, stimulation and suppression tests.

endometriosis

*Endometrial tissue:* implantation outside the uterine cavity *Common sites:* ovaries, fallopian tubes and the tissue lining your pelvis. *Most common symptom:* Pain is the most common symptom, peaking just before menstrual flow *Treatment focuses on:* Reduction of pain. Restoration of sexual function. Decrease in anxiety. Education. Prevention of self-concept disturbance related to infertility *Med:* Orilissa

selected common gynecologic conditions

*Endometriosis:* is an often painful disorder in which tissue that normally lines the inside of your uterus — the endometrium — grows outside your uterus. Endometriosis most commonly involves your ovaries, fallopian tubes and the tissue lining your pelvis. *Fibroids:* noncancerous growths of the uterus that often appear during childbearing years. Also called leiomyomas *Ovarian cysts:* noncancerous growths on the ovaries may be painful, fluid filled sac from corpus luteum. *Vulvodynia:* chronic vulvar pain without an identifiable cause. Vulvar vestibulitis syndrome is pain in the vestibule. ... Often a burning sensation, this type of vulvar pain comes on only after touch or pressure, such as during intercourse. *Lichen sclerosis:*uncommon condition that creates patchy, white skin that's thinner than normal. can affect skin anywhere on your body. But it most often involves skin of the vulva, foreskin of the penis or skin around the anus. *Risks:* Anyone can get lichen sclerosus but postmenopausal women have a high risk. *TX:* Sometimes lichen sclerosus improves on its own, and you won't need any treatment. If you do need treatment, your doctor can suggest options to return a more normal appearance to your skin and decrease the tendency for scarring.

thyroid functions-t3 and t4

*Fetal development:* neural and skeletal systems *Control:* metabolic rate of all cells *Promotes pituitary secretion of:* GH and gonadotropins *Regulates metabolism:* protein, carbohydrate and fat *Regulates body heat production:* > heat production *Cardiac:* maintains rate, force, output *Red blood cell:* Increase red blood cell production *Respiratory:* Increased respiratory rate and drive. Increased Oxygen consumption *Bones:* Increase bone formation and decrease bone resorption. *insulin:* Act as insulin antagonists *In the cell:* T4 converts to T3 *Impaired by:* Stress, Starvation, Radiopaque dyes, Beta blockers, amiodarone, corticosteroids, PTU *Increased by:* Cold temperatures. Stress

fibrocystic breast condition-benign.

*Fibrocystic changes of breast may involve:* lobules, ducts, stromal tissues *Common in:* premenopausal women between 20 and 50 years of age *Thought to be caused by:* imbalance in normal estrogen-to-progesterone ratio *Symptoms:* Breast pain, tender lumps, swelling (often before menstrual period), aggravated by caffeine. *Two main features are:* fibrosis and cysts *Variance of:* normal *No findings have associated FCD:* with cancer *Interventions:* NSAIDS, reassurance. Analgesics. Limit salt intake before menses. Wear supportive bra at all times. Ice or heat may help. Reduce or eliminate caffeine, dairy product. Needle aspiration may be necessary. Oral contraceptives or selective estrogen receptor modulators may be prescribed

fistula/ diverticulum

*Fistula:*rare. urine flows directly through an abnormal tract into the vagina. *Diverticulum:* very rare. urine collects in a pouch within the urethra then expels at random

Suppression tests

*Give the hormone:* and then measure to see if the negative feedback mechanisms are intact *Negative feedback isn't working if:* the hypothalamus or pituitary continue to make the stimulating hormones when there is enough of that hormone in circulation *Ex.:* Give Dexamethasone should decrease ACTH, in turn decrease cortisol *Used:* determining which gland has the problem

Stimulation tests

*Give the hormone:* that is usually produced by the hypothalamus, pituitary or other (Insulin) and see if the specific endocrine gland reacts by producing it's hormone *If the endocrine gland does produce the hormone:* the problem is not in the gland but in the hypothalamus or pituitary gland *If the endocrine gland doesn't respond:* the problem is in that specific gland *EX:* Insulin normally increases GH and ACTH - Checking the response. *Why stimulation test?* You know specifically what gland is not working. Usually use for hypo condition.

assessment: noticing reproductive

*Health habits—*e.g., nutrition history. Alcohol, tobacco, drug use *Females:* last Pap, self-exams *Males:* last prostate exam and PSA test *blood studies:* Cytologic vaginal cultures. Human papilloma virus (HPV) test. Hormone levels. Serologic testing. Prostate-specific antigen (PSA) if > 4.0, recommend a prostate biopsy

labs for goiter/hyperthyroidism

*High:*Serum T3 (triiodothyronine). Serum T4 (thyroxine). TSH (In secondary/tertiary hyperthyroidism) *Low:* TSH (Graves') (Primary) *What to test first:* Test the TSH first - then can differentiate. *Antibodies-* *TSI (thyroid stimulating Immunoglobulin test):* Increased in Graves disease. *Thyrotropin receptor antibodies (TSH-Rab):* high titers indicate Graves' disease *Diagnostic exams:* US *Radioactive Iodine uptake (RAIU) (I - 123):* measures how much iodine the thyroid gland can collect. Given PO, no radiation precautions needed, but not with pregnancy. (over 35% uptake). Be sure no Iodine meds. X1wk or tests X4wks prior to scan. diagnostic. goes out through urine quickly. *Needle Biopsy/CT:* Guides needle placement for biopsy. determine cancer. *EKG -* tachycardia, atrial fib, P & T wave changes

What causes the gland to release the hormone

*Hormonal (Endocrine):* a hormone from one endocrine gland controlling another endocrine gland. (Ex. -hypothalmic hormones stimulate the anterior pituitary to release hormones, which cause other glands to release hormones) *Humoral (Chemical):* serum chemical factors/ion/nutrients stimulate the gland to release a hormone to bring them back to normal (Ex. Blood sugar could say we need to release insulin, calcium levels affect parathyroid activity) *Neural:* nerve fibers stimulate the release of the hormone *hormones Controlled by:* hypothalamus

What secretes what

*Hypothalamus secretes to stimulate anterior pituitary:* TRH (thyrotropin releasing hormone), gonadotropin releasing hormone (gnrh), growth releasing hormone (ghrh), growth inhibiting hormone (ghih, somatostatin), prolactin inhibiting hormone (pih), melanocyte inhibiting hormone (mih), corticotropin releasing hormone (crh). *ANTERIOR PITUITARY:* *thyrotropin releasing hormone:* secreted from anterior pituitary to stimulate thyroid stimulating hormone *GnRH:* secreted from anterior pituitary to stimulate Luteinizing hormone and follicle stimulating hormone *GhRH and GhIH:* secreted from anterior pituitary to stimulate growth hormone *PIH:* secreted from anterior pituitary to stimulate prolactin releasing hormone *MIH:* secreted from anterior pituitary to stimulate melanocyte stimulating hormone *CRH:* secreted from anterior pituitary to stimulate adrenocorticotropic hormone (acth)

invasive breast cancers

*Infiltrating ductal carcinoma:* Fibrosis develops around the cancer. Peau d'orange. Palpable lump - irregular, poorly defined, Dimpling of skin *Inflammatory breast cancer (IBC):* Diffuse erythema. Peau d'orange. Often harder to successfully treat. Most malignant- Poor prognosis. Invades lymph system

patient centered care

*Knowledge:* *Who is in full control?* The patient *Effective communication:* ask patients their preference. Involve family and patient in care. *Be aware and apply care considering:* cultural & Spiritual beliefs, values, preferences. Genetic/Genomic Considerations *Skills:* *Communicate the patient's values, preferences, needs:* to other healthcare providers *The white board:* Person caring for you, daily goals/scheduled treatments. Family communication questions. Be careful with HIPAA. *Attitude:* Recognize your own personal attitude *Support the care of those:* who are different from yourself

teamwork and interprofessional collaboration

*Knowledge:* Function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care *Treat family and patient:* as team members *Intervene when:* care is compromised *Skills (effective communication and team functioning)* Interprofessional rounds. Coordinate the care (Nurse job). Know the roles of the other team members. Be the patient advocate. Taking orders, repeating them back. ISBAR. *ISBAR:* *introduction-*identify yourself *situation-*state purpose (if urgent, say so), *background:*tell the story (current problem) *assessment-*state what you think is going on *recommendation-*state request. *"CUS":* C="I am concerned" ; u= "I am uncomfortable" s="I think this a safety issue". *Value the experience and perspective of:* other team members *Recognize your own:* strengths and limitations as a team member. Take constructive feedback and learn from it

delegation

*LPN CANNOT DO:* picc line, port, central line infusions. new admit. cant give certain meds. cant blood transfuse. can't discharge *Meds not given:* iv heparin. IG. iv benadryl, iv bp meds, iv pepcid, iv ativan, iv reglan, iv protonix *CAN DO:* reinforce teaching. can dressing change. can monitor blood transfusion.

issues of breasts size in women

*Large-breasted women:* Clothing difficulty. Backaches. Fungal infections under the breast *Small-breasted women:* Breast augmentation may be elected to increase or improve size, shape, or symmetry. Implantation of saline-filled or silicon prostheses

mineralcorticoids

*Life-sustaining-main hormone:* ALDOSTERONE *Maintains:* extracellular fluid volume *Causes kidneys to:* conserve water and Na and to excrete K *Stimulated by:* Serum K ion concentration increase (stimulate to get rid of k). ACTH from the anterior pituitary (rapid rise and rapid fall). decreased sodium and water volume (Angiotensin II produced by the renin-angiotensin)

Thymus

*Located in:* the mediastinum. *Central Gland:* of the Lymphatic System *Increases:* during puberty, gradually shrinks as we age *Produces:* Thymosin *Develops:* T-cells within the thymus, which in turn migrate to the lymph nodes and spleen

pineal body (gland)

*Located:* Center of the Brain *Believed to secrete:* Melatonin-for sleep *Production:* Usually high production during the night and low during the day.

adrenals

*Located:* on top of each kidney. Highly vascular *2 layers function independently:*Cortex outer, 90%. Medulla- inner. *Adrenal cortex:* Cells are divided into 3 layers that secrete different hormones (Synthesized in the adrenal cortex from cholesterol). Mineralcorticoids (salt). Glucocorticoids (sugar). Sex hormones (adrenal androgens/estrogens) *Dysfunctions:* *Inadequate secretion of:* adrenocorticotropic hormone (ACTH) from the pituitary *Dysfunction of the:* hypothalamic-pituitary control mechanism *Primary:* Direct dysfunction of adrenal gland tissue

diagnostic/labs for hypothyroidism

*Low:* Serum T4 (thyroxine). T3RU (T3 resin uptake) (Scan). TSH (In secondary/tertiary hypothyroidism) *High:* TSH (In primary disease) Measure this first *what to measure first:*Measure TSH first. *Thyrotropin-releasing Hormone Stimulation Test:* delayed or poor response of TSH (secondary hypothyroidism - pituitary failure). Elevated in primary hypothyroidism (thyroid gland failure) *Thyroid suppression tests:* No change *Thyroid Stimulation Hormone Stimulation test:* differentiates primary from secondary. No response in primary. Normal response in secondary

hypoparathyroidism

*Main cause:* Iatrogenic is main cause (surgical removal of parathyroid or thyroid) *Autoimmune:* Can be the cause. Sometimes associated with other autoimmune diseases (adrenal insufficiency, hypothyroidism, diabetes mellitus) *Magnesium:* Hypomagnesemia. *Effect is:* HYPOCALCEMIA *dx:* *Chronic Hypocalcemia may result in:* bone loss, tooth enamel and root loss, cataracts *Lab tests:* Serum Ca (low), PTH (low), Magnesium (low), Vitamin D deficiency, phosphate (high) Imaging *Hypoparathyroidism Associated with Chronic Health Conditions:* Increased Mortality. Cataracts, epilepsy, cardiovascular disease, cerebrovascular disease, infection, mental illness, renal failure

glucocorticoids

*Main hormone:* Cortisol *NORMAL CORTISOL:* *Maintains:* blood glucose through control of carbohydrate, protein and fat metabolism *What does it do:* Anti-inflammatory, Decreases Cellular Immunity, polycythemia. Maintains behavior and cognitive functions (emotional stability, mood, sleep) *Other physiological processes:* *excitability of:* myocardium *Action:* catecholamine action *bone:* inhibits formation *gastric acid:* stimulates secretions; concerned about GI bleeding. *promote distribution of:* fat *serum Calcium:* decreased

What does endocrine system do

*Maintains:* Homeostasis *Coordinates:* M/F Reproductive system *Development of:* the Fetus *Stimulation of:* Growth and Development during childhood and adolescence. *How do hormones act?* Binding to the SPECIFIC receptor sites on the surface of the target cell *Binding causes:* the tissue to change its activity

malignant cancer dx

*Mammography:* calcifications *Physical exam:* Palpable lump, usually painless. Most common in upper, outer quadrant. Non-mobile. Dimpling of skin. Recent change in size of breast or nipple inversion. Axillary, supraclavicular or chest lymph node nodules (indicates metastasis) *If biopsy indicates malignancy:* additional testing is done *Sentinel node biopsy:* radioactive dye injected to identify node. If it is negative, no metastasis *Hormone receptor status =*which hormone stimulates tumor growth. identifies which cancers will respond to hormone therapy *Estrogen + :* will continue to respond to estrogen. Postmenopausal. Will respond best to hormone therapy *Estrogen -:*: premenopausal *Also will determine:* Progesterone + or - *HER-2/neu marker =:* effectiveness of chemo *Oncoprotein:* protein linked to tumor cells *High levels =* poor prognosis *Helps to determine:* chemo agent *Possibly:* BRCA-1 & BRCA-2 genetic testing *If +, may offer:* bilateral mastectomy & oophrectomy. Still not 100% preventative *After diagnosis:* Stage of cancer: based on Tumor size, Lymph node involvement, ? metastasis, Sentinel node biopsy (arm pit)

hysterectomy

*May be performed:* abdominally, vaginally, laparoscopically, or with robot assistance *Is indicated for:* multiple gynecologic problems *Psychosocial assessment:* is essential. Quality of life. Fear. Anxiety. Significance of loss of uterus for patient and partner *Postoperative care focuses on:* management of vaginal bleeding, incision intactness, urinary output, and pain management

problems with adrenal cortex: hypofunction

*May be:* primary or secondary insufficiency *Primary:* Most common primary cause is an autoimmune disease (Addison's Disease) *Secondary causes:* Pituitary does not produce ACTH. Sudden withdrawal from long term glucocorticoid therapy (abrupt stopping of meds)-Withdraw gradually *Assessment:* *Deficiency of glucocorticoids:* *Blood sugar:* hypoglycemia. the liver and muscle glycogens are depleted as the body tries to convert protein to glucose (gluconeogenesis). Sweating , headaches, tachycardia, tremors *BP:* postural hypotension. *Glomerular filtration rate and gastric acid secretion:* Both decreased. Reduced urea nitrogen (breakdown of protein) excretion leads to anorexia and weight loss *Na & water are:* excreted leading to hyponatremia and dehydration. Dizziness, confusion, neuromuscular irritability, tachycardia, postural hypotension and syncope *K is:* retained (hyperkalemia). This causes hydrogen ions to be retained and leads to metabolic acidosis. Cardiac arrhythmias. *Psychosocial:* Lethargic, Depressed, Confused (? person, place, time), Psychotic, Wide mood swings *Deficiency of androgen ("male" hormones):* Loss of body, axillary and pubic hair *The deficiency of adrenal cortex hormones results in an increase in:* ACTH. *ACTH also stimulates melanocytes:* Skin may look bronzed. Finger, knee, elbow creases may darken. Scars, mucous membranes (esp mouth) darken. Areas of vitiligo (patches of skin losing pigment) may appear

meds for hyperthyroidism

*Methimazole:*Blocks hormone production. not a cure but can stop as much as possible. *Response may be delayed due to:* stored hormones. *Adverse Effects:* Fever, rash, urticaria (hives-occurs first 6 weeks of therapy), arthralgia. *Serious:* agranulocytosis, hepatitis, lupus-like syndrome (Not during pregnancy- birth defects) *Propylthiouricil:* Blocks hormone production *Caution:* Liver Disease/Failure (use less often). Decreased immune response - avoid crowds. May take first trimester of pregnancy. *adjuvant therapies:* *Iodide (potassium iodide - SSKI):* Sudden increase in available iodide rapidly blocks release - short-term reaction. Can be used for thyroid storm for quick effect. Caution - it interferes with uptake of radioactive iodide *Beta blockers:* Control cardiovascular effects *Radioactive iodine 131:* *type:* Oral (Rapidly absorbed) *Taken up by follicular cells:* resulting in necrosis and destruction. *50 - 75% will be:* euthyroid in 6-8wks. Maximum benefit 3-6 months. *Side Effect:* Hypothyroidism (90% in 1st yr/100% of all thyroid gland is destroyed) *Caution-* no pregnancy/breast feeding. Radiation precautions *Safety Precautions - Unsealed Radioactive Isotope - 2 weeks:* *Urine:*Use toilet not used by others for 2 weeks. Sit to urinate - avoid splashing. Flush the toilet three times after each use. If splash, clean with paper tissues/towels, bag and return to the hospital in sealed bag. Do not use gel-filled briefs. *Laxatives:* Take a laxative on second and the third days to excrete the contaminated stool faster. *Clothing:* Wear only machine washable clothing. Wash these separate from others in household. Run the washing machine full cycle again empty. *Avoid close contact with:* pregnant women, infants, and young children for first week (at least 3 feet away from them, limit exposure to no more than 1 hour daily). *Saliva contamination:* Do not share toothbrush or toothpaste tubes. Use disposable tissues, flush down toilet or keep in plastic bag and return to hospital. Use disposable utensils, plates and cups. Select foods that can be eaten completely (Avoid such as apple leaving core, meat with bones) *SX:* *Total (All):* Must replace thyroid hormones and parathyroid. *Bilateral subtotal thyroidectomy:* Removes all but a small portion of the gland. 12-80% hypothyroidism ( need thyroid replacement). 5% recurrence of hyperthyroidism. May need parathyroid hormone replacement *Post Operative Care:*Alignment of the neck, avoid neck extension, semi - fowler. Assess for Laryngeal nerve damage Q2hours-spasms, hoarseness, weak voice. Watch especially for hypocalcemia, tetany. Check VS frequently (slight inc in temp could indicate impending thyroid crisis), watch for hemorrhage - dressing, tubes. Watch for respiratory distress, swelling from hemorrhage or surgery - stridor, (Keep tracheostomy kit available). Watch for thyroid storm

Urinary incontinence

*Mixed incontinence:* Stress & Urge *Overflow incontinence:* Small amounts of leakage happen frequently *Caused by:* obstruction or inability of bladder to contract *Warning:* can occur if F/C not draining! (Bladder spasms) *Functional Incontinence:*inability to reach the restroom in time because of physical conditions (e.g., arthritis). Implications for geriatrics *NOT due to:* pelvic muscle or floor disorder *Purewick:* may be used instead of F/C, less chance of UTI

cervical cancer

*Most cases caused by:* certain types of HPV *HPV vaccine:* available for girls and young women (ages 9-26) gardasil and cervarix *Treatment for HPV is usually:* cryosurgery *Incidence & mortality decreased due to:* Pap test *At risk:* Exposure to HPV. Unprotected intercourse. Early sexual debut (before 18). Multiple partners or partner with multiples. Previous HPV infections (genital warts, etc.) or other STIs. Smoking. HIV or other immunocompromised states. Previous history of abnormal Pap with HPV *ASSESSMENT:* *May be:* asymptomatic *Classic symptom is:* painless vaginal bleeding (especially between periods, or after intercourse or douching) *other ss:* Unexplained weight loss, dysuria, pelvic pain, hematuria, rectal bleeding, chest pain may be reported *Diagnostic assessment:* Pap. HPV-typing DNA test of cervical sample. Coloposcopy. Endometrial curettage *Prevention:* safer sex (condoms). Gardasil vaccine-Girls & boys 9-26 years old, can start as early as 9 years old. *If HPV positive:* Colposcopy & Endocervical Curettege (ECC) *ECC is:* like Pap but samples entire endocervical canal to determine how high the lesion extends *Colposcopy visualizes:* abnormal cells to do a definitive biopsy *TX:* *Goal is to:* remove the abnormal cells *Method depends on:* the extent of the lesion *May be done:* in office *Nursing care:* patient education. Premedicate with NSAIDS. May have bleeding or dark discharge after procedure. Pelvic rest for 2-6 weeks after procedure

BREAST CANCER

*Most common sites of metastasis are:* bones, liver, lung, and brain *etiology:* Increased age. Family history. Early menarche, nulliparity, late menopause. Lack of breastfeeding. Postmenopausal obesity. Use of postmenopausal HRT. Alcohol consumption. Mutations in BRCA1 and BRCA2 *Screening mammogram for women ages:* 40 and older yearly *Clinical breast examination by health professional at least every:* 3 years for women 20-40 years old *assessment:* *History:* Risk factors. Breast mass. Health maintenance practices (smoke, oc). OBGYN history. Alcohol use *Physical assessment:* Location, shape, size, consistency, mobility of mass. Skin changes. Lymph nodes. pinch area to see any dimpling. far back behind armpit. *Diagnostic assessment:* *Laboratory assessment:* Pathologic study of breast mass tissue and lymph nodes. Liver enzymes, serum calcium, alkaline phosphatase *Imaging assessment:* mammography. Tomosynthesis. Ultrasonography. MRI. Chest x-ray, CT for metastasis *Interpreting:* *Decreasing the risk for metastasis:* *Nonsurgical management:* Complementary and integrative health. aromatherapy, social therapy, meditation, bucket list. *Surgical management:* Preoperative care. Operative procedures. Postoperative care *Adjuvant therapy:*Radiation, chemotherapy, or combination. Drug therapy. Stem cell transplantation *Self-management education:* Post-surgical care. Avoidance of lymphedema-no bp on side of mastectomy. Measures to meet psychosocial needs.

ENDOMETRIAL (UTERINE) CANCER

*Most common type:* Adenocarcinoma *Main symptom:* Postmenopausal bleeding *Diagnostic assessment:* CA-125 tumor marker. Transvaginal ultrasound. Endometrial biopsy

fibroadenoma

*Most common:* benign tumor in women during reproductive years. *Mass of:* connective tissue unattached to surrounding breast tissue *Hyperplastic tissue:* Rarely cancer *Occurs during:* normal development. Most common 20 - 40 year old *Symptoms:* oval, Well-defined edges, rubbery, mobile. May be non-tender. No nipple discharge *Aggravated by:* estrogen, progesterone, lactation & pregnancy *Interventions:* Watchful waiting

synthesis of thyroid hormone

*Must have:* iodine and protein. *Iodine:* (Forms T3 or T4). salt products usually have iodine in it. *Protein intake (Forms thyroglobulin):* T3 & T4 stay bound to thyroglobulin in the thyroid gland. One of only few hormones that are stored

Over active bladder

*Nursing Interventions: teach:*Dietary changes. Kegel's & Urge Control technique. *TX:* Percutaneous nerve stimulation *Medications:* oxybutynin (ditropan), tolterodine (Detrol), Anticholinergics so also effect other organs. Common side effects are constipation,dry mouth, can cause urinary retention.

BARTHOLINS CYST

*Obstruction of:* the duct of the Bartholin gland *Bartholin gland:* is blocked *Fills:* with fluid *Frequently is:* gonorrhea *Can be:* extremely painful or asymptomatic *Moderate/severe:* antibiotics, warm soaks *Recurrent:* surgery *Caused by:* infection, thickened mucus near ductal opening, or trauma (lacerations) *May need:* simply incision and drainage (I&D)

Adrenal Insufficiency (Addison's Disease)

*Onset may be gradual:* about 90% of the gland's functions have been lost when symptoms appear *Onset may be acute:* this is LIFE THREATENING. Addisonian crisis. Usually response to stressor like surgery, trauma, or severe infection *ss:* bronze pigmentation of skin. changes in distribution of body hair. weakness. weight loss. postural hypotension. hypoglycemia. fatigue. joint/muscle pain. anorexia. n/v. abd pain. constipation or diarrhea. salt craving. vitilligo. hyperpigmentation. anemia. *adrenal (addison's) crisis:* profound fatigue. dehydration. dec bp. renal shut down. dec serum na, inc serum k. *dx:* *Low:*serum sodium. serum glucose (may be normal if a certain diet). serum cortisol. urine steroids (17-hydroxycorticosteroids, 17-ketosteroid)-24 hour urine. *High:* potassium. calcium. BUN and bicarbonate *Stimulation Test:* ACTH should stimulate increase of cortisol in serum and urine-if it doesn't it is an adrenal gland problem *meds:*Completely corrected by lifelong replacement therapy *Glucocorticoid:* hydrocortisone, Prednisone. Dose 2/3 in AM and 1/3 in PM to mimic normal rhythm of adrenal gland release *Mineralcoricoid:* Fludrocortisone. may cause increase in bp. May need to adjust dosages to compensate for Na loss in sweat, illness, etc *Addison disease usually present with features of both:* glucocorticoid and mineralocorticoid deficiency. *interventions:* Assess for hypovolemia-I&O, daily wts-best indicator, thirst, dry mucous membranes, listening to lungs to make sure not overloaded. Monitor cardiovascular-VS, character of pulse (thready?) K levels. Encourage fluid, Na intake, no skipped meals. Be alert to postural hypotension *Teaching:* Stress taking meds regularly - abrupt cessation could trigger Addisonian crisis. Pt should do daily wts, report > or edema, easy bruising. Teach to alter dose for emotional or physical stress. Teach SQ injections in case of illness-if you haven't taken med in 24 hours need to contact hcp or go ahead and come in. Should wear Medic Alert bracelet. take meds with food.

tx for hyperparathyroidism: sx

*Parathyroidectomy:* Surgical removal of parathyroid glands ,If hyperplasia - may leave ½ of one gland *Preop:* Ca levels are decreased to near normal before surgery. *Teaching:* standard, also possible vocal cord damage, edema in the area (AIRWAY, TALKING), lifelong meds(calcium replacement) *Post op:* Respiratory distress is main concern from swelling of neck - monitor and be prepared. VS, I&O, dressing, neck support, assess voice changes. monitor bleeding, infection. *interventions:* *Monitor for calcium:* Hypocalcemia *How to monitor for it:* Tingling, twitching, tetany. Ca levels q 4h. Trousseau's sign-Inflate cuff above systolic for 3-4 min and palm will spasm in palmar flexion. Chvostek's sign-Tap below and anterior to ear and that side of face will twitch. Altered consciousness. *If all removed:* lifelong Calcium and Vitamin D

screening tests

*Pelvic Exam:* Pap Smear. Bimanual exam *Osteoporosis/osteopenia:* Dexascan *diagnostic tests:* CBC. Pregnancy test. Transvaginal ultrasound

osteoporosis

*Prevention/Treatment:* Weight bearing exercise. Calcium 1200mg/day. Vitamin D 800-1000IU/day. Estrogen - no longer an approved preventive *meds:* Bisphosphonates (Alendronate - Fosamax, Ibandronate - Boniva, Zoledronic acid - Reclast) Raloxifene (Evista) Calcitonin Parathyroid hormone

hyperaldosteronism

*Primary:* Conn's syndrome *Secondary:* hypersecretion Usually from renal hypoxia or thiazide diuretics. ACTH *Risk factors:* 3x more in women. 30-60yo *What happens? Too much of a good thing!* *Na and fluid:* retention. hypernatremia. HTN. HA, visual changes.stroke and renal damage. *K:* excretion. hypokalemia. Cardiac arrhythmias. Weakness, fatigue. Paresthesia. Metabolic alkalosis *With primary aldosteronism:* you may not see edema due to spontaneous natriuresis and diuresis (aldosterone escape) *Laboratory Exams:* *High:* Serum Na. Aldosterone. Blood pH. Aldosterone levels in urine *Low:* Serum K. Plasma renin *Imaging:* for tumors *interventions:* *Surgery:* adrenalectomy *Medications:* *spironolactone:* K sparing diuretic and aldosterone antagonist - control HTN and hypokalemia *Supplements:*Potassium supplements *If no surgery:* normalize the hypokalemia and HTN *Remember, if you remove both adrenal glands:* you have to treat for hypocortisolism and hypoaldosteronism

prolactin hyperpituitaryism

*Prolactinomas:* pituitary tumor secretes prolactin (Most common) *Symptoms:* *Women:* Galactorrhea (milk), Amenorrhea, Infertility, Hirsutism (is excessive body hair in men and women on parts of the body where hair is normally absent or minimal). decreased gonadotropin. increased body fat. *Men:* hypogonadism, erectile dysfunction, possible galactorrhea. decreased gonadotropin. increased body fat. *Treatments:* Dopamine agonists: cabergoline, bromocriptine (constipation). promote dopamine. dopamine decreases prolactin. Cause orthostatic hypotension. *Prolactin should be produced:* after birth.

tx for cushings

*Radiation therapy:* (if caused by pituitary adenomas) *Surgery:*Depends on cause *If pituitary:* transsphenoidal surgery *If adrenal:* adrenalectomy (partial or complete). Laparoscopic, lateral flank or abdominal. *Pre op adrenalectomy:* *Nursing interventions:*Monitor K, Na, Chloride, glucose. Dysrhythmias. Protect from infection and bone fractures. Safety from falls. High calorie, high protein diet. Glucocorticoid drugs will be given pre op and during surgery. *Post op interventions:* Shock-insufficient glucocorticoid replacement. Skin breakdown. Pathological fractures. GI bleeding. *Discharge teaching:* decrease infection. safety at home. record weight. adherence to med schedule-don't stop abruptly, for the rest of their life, take on time. *Remember, if you remove both adrenal glands:* you now need to treat for hypocortisolism

myxedema coma

*Rare:* but very high mortality *Sign/Symptoms:* Change in mental status, Hypotension, Hyponatremia, Hypothermia, Hypoglycemia, Respiratory failure, Cardiogenic Shock, Death *Who's at risk:* Anyone with hypothyroidism is at risk. Severe stressors, Inadequate treatment or sudden withdrawal of drugs, Opiates *Myxedema coma is a severe form of hypothyroidism that most commonly occurs with:* undiagnosed or untreated hypothyroidism who are subjected to an external stress. *Can lead to:* organ damage, shock, death. *Prevention:* assess pt with hypothyroidism at least every 8 hrs for changes that indicate inc severity. *tx:* Maintain airway. Replace fluids - IV. Thyroid hormone - IV, Glucocorticoids. Check temp & BP hourly. Warm blankets. Monitor mental status . Turn every 2 hours. Aspiration Precautions

tx for malignant cancer

*Reconstructive surgery:*May be done at time of mastectomy or at a later time. Tissue expanders with permanent saline implants. Tissue from back (LAT) or abdomen (TRAM). Prosthesis *adjunctive therapy:* Radiation, chemotherapy, hormone & immuno therapy *Radiation:* kill stray cells. Daily for 6 weeks. Wait 3 weeks after lumpectomy for healing. Targeted or partial breast irradiation. Bid for 5 days. Criteria include large enough breasts. Catheter in place *se:* Fatigue. Anorexia. Skin changes - "sun-burn". Breast changes - inflammation, edema, heaviness, swelling *Nursing care:*teach to protect catheter, skin care, look for infection *chemo:*Kills rapidly growing cells. Given in cycles over 3-6 months *Not specific:* Kills hair, mouth, GI tract, bone marrow *Very aggressive chemo will:* destroy all bone marrow & then replace with marrow or stem cell transplant *HORMONE THERAPY:* *If ER+:* estrogen makes it grow, so give a drug that Blocks the estrogen from entering the cells. Tamoxifen - risk of uterine cancer & blood clots. Raloxifene - less risk. These are sometimes given prophylactically. Aromatase inhibitors - Anastrozole. Only for post menopausal with ER+ *SE:* Hot flashes. Bone pain. Fatigue. Nausea. Cough. Dyspnea. Headache *IMMUNOTHERAPY:* Herceptin. Also thought to boost immune system *Side effects:* Cardiac toxicity. Vascular thrombosis. Hepatic failure. Fever, chills. N&V. Pain with 1st infusio

glucocorticoid regulation

*Release of ACTH and CRH is affected by:*Serum concentration of cortisol (feedback) *Low cortisol-* inc CRH, inc ACTH, inc secretion of cortisol from adrenal cortex. *If cortisol elevated:* Opposite *Circadian rhythm:* Release peaks in AM (2/3) and is lowest 12 hrs before and after peak (1/3) *Stress:* Causes increased release of cortisol

breast cancer in men

*Risk factors:* Family history (M or F) of breast cancer. BRCA 1/2 mutation. Diabetes. Gynecomastia (taking estrogen for prostate cancer). Testicular disorders. Obesity. *Usually presents as:* hard, painless, subareolar mass *Treatment is:* the same as that for women at similar stage of disease

sex hormones

*Small amounts of:* androgens and estrogens are secreted by the adrenal cortex in both sexes *Females:* main sources of androgen, the way they get it

posterior pituitary

*Stores the hormones:* secreted by the hypothalamus and releases them when needed *Oxytocin:* *Target:* uterus and mammary glands *Action:* stimulates uterine contractions and ejection of breast milk *Antidiuretic hormone (ADH) or VASOPRESSIN:* *Target:* kidney *Action:* promotes water reabsorption

Pituitary problems

*Symptoms are:* usually gradual/selective *Panhypopituitarism:* is rare. Problem with all hormones. *Primary dysfunction:*Problem from within the pituitary *Secondary dysfunction:* Problems in the hypothalamus that change pituitary function *Other:* Exogenous drugs

fistulas

*What is it?* Tracts or opening between a genital organ & another organ *Vesicovaginal -*bladder to vagina. uncontrolled urine leakage *Urethrovaginal -* urethra to vagina. uncontrolled urine leakage *Rectovaginal:* rectum to vagina. uncontrolled fecal leakage & flatus *Causes:* surgery, trauma or radiation *Tx:* Surgery is only remedy *ASSESSMENT: NOTICING:* *Key symptom is:* often heavy vaginal bleeding *Ask:* how many pads/tampons are used daily *Assess:* pelvic pressure, elimination patterns, abdomen size, dyspareunia, infertility

Hormones controlled by

*What part of the brain:* hypothalamus. *Hypothalamus:* link between nervous system and endocrine system. Either posterior pituitary, or anterior through blood stream. *Negative feedback:* Most common. *Positive feedback:* Increase in one hormone causes release of another *Anything that affects brain:* can affect hypothalamus. neuro problem can turn into endocrine/hormone problem.

Growth hormone hyperpituitarism

*Symptoms of:* GH *Before puberty:* Gigantism *After puberty:* Acromegaly - too much GH. after puberty (Uncommon) *blood sugar:* Hyperglycemia. GH is an insulin antagonist *dx:* inc serum somatotropin (GH). XR, MRI, Physical exam. oral glucose challenge test-level doesn't decrease, glucose should lower growth hormone (suppression test). *Complications:* inc icp, enlarged tumor, inc blood sugar. *Clinical manifestations:* enlarged pituitary gland, headache, visual disturbances, slanting forehead, coarse facial features, portruding jaw, inc BP, inc CHF, menstrual changes, sleep apnea, hypertrophy of soft tissue (such as tongue, skin, lips, and visceral organs). enlargement of small bones in hands and feet. Arthralgia and backache, enlarged joints. Overactive sebaceous/sweat glands. Weakness, muscular atrophy. Watch for respiratory problems. increase in head size. barrel shaped chest. enlarged heart, lungs, liver. *Problem with acromegaly:* usually not determined till it's too late and changes can't be reversed. *TX:* *Outcomes:* Return to normal hormonal levels or near normal. Reduce headaches and visual disturbances. Prevent complications. Reverse as many body changes as possible *Interventions for acromegaly:* Psychological support. meds *Surgery:* hypophysectomy. Relieves HA, sexual effects may reverse. Doesn't regress body changes, visual problems or visceral enlargement. Counseling. *Drug therapy:* *Dopamine agonists:* bromocriptine, carbergoline (inhibits the release of GH). *Bromocriptine:* seek medical care immediately if chest pain, dizziness, or watery nasal discharge occurs because of the possibility of serious side effects, including cardiac dysrhythmias, coronary artery spasms, and csf leakage.

vulvar cancer

*Symptoms:* Persistent vulvar itching. Chronic vulvar inflammation. Skin changes like lichen sclerosis, atypical moles. Flat or raised, may be rough, may be lump. Can vary in color from brown to white, gray or red *In older women -*burning, pain, chronic ulcerations or bleeding *Screening & diagnosis:* Annual vulvar exams. Biopsy of suspicious lesion. Punch biopsy in office *Therapeutic Management:* Laser surgery. Cryosurgery. Electrosurgical incision. Radical vulvectomy *Nursing Management:* Education-healthy lifestyle behaviors, preventive measures. Communication. Information & support

Regulators

*TSH (anterior pituitary):* Negative feedback - Decreased T3 & T4 levels, increaseTSH and stimulates the thyroid to release more hormone *Cold and stress:* The hypothalamus is stimulated to produce TRH which then stimulates the anterior pituitary to release TSH

Emergency disaster

*Tags:* *Black:* deceased. injured people who are beyond scope of medical assistance. persons are tagged deceased only if they are not breathing and attempts to resuscitate have been unsuccessful. *Red:* immediate. injured people who can be assisted or their health aided by adv medical care immediately or within 1 hr of onset. airway, severe bleed to head, hypovolemic shock. *Yellow:* delayed. injured people who can be assisted after immediate people are cared for first. medically stable but require medical assistance. open fractures, open wounds, loss of consciousness. *Green:* minor. can be assisted after red and yellow have been attended to. won't need care for at least several hours and can usually walk with assistance (usually consisting of bandages and first aid). contusions, lacerations, back pain, neck pain. no ellusion to SCI. *Who does triage?* emt. paramedics. dr, nurses. *ANTHRAX:* *Precautions:* standard isolation. no person to person contact *SS:* *GI:* fever 3-5 days. chills. severe abd pain. abd distension. hematemesis. diarrhea. hoarseness. sore throat. swollen neck or neck glands. red face. red eyes. HA *Inhalation:* dry harsh cough. fatigue. low grade fever. mild chest pain. then pt feels better in 2-4 days, but gets worse...diaphoresis. dyspnea. hematemesis. stridor. high fever. hypotension. mediastinitis. pleural effusion. septic shock. *Cutaneous:* exposed itching skin. papular lesions. vesicle lesions. eschar. edema. ulceraton. sloughing. if untreated, it may spread to lymph nodes and bloodstream. *Management:* vaccine available. ciprofloxacin, doxycycline. oral for 6 months twice a day. *DISASTER:* *How many days of supplies should be in preparedness kit?* 3 *How often should you replace?* every 6 mo *How many do you prepare for?* 1 gallon of water per person per day. *Pets:* food and water for 3 days. id, leashes,pic of pet, vet info. *What do you need?* water filter. dehydrated food. batteries. sleeping bag. clothing. trash bags. *TYPES OF DEBRIEFING:* *Critical stress debriefing:* analyzing patients reactions to disaster including ptsd *Administrative review:* analyze hospital response to event. what went right/wrong.

Anterior pituitary hormones

*Thyroid-stimulating hormone (TSH):* *Target:* thyroid *Action:* stimulates synthesis and release of thyroid hormone *Adrenocorticotropic hormone (ACTH):* *Target:* adrenal cortex *Action:* stimulates synthesis and release of corticosteroids and adrenocortical growth *Luteinizing hormone (LH) or Interstitial Cell (Leydig cell) Stimulating hormone (ICSH):* *Target:* ovary and testes *Action:* stimulates ovulation and progesterone secretion-stimulates testosterone secretion *Follicle stimulating hormone(FSH):* *Target:* ovary and testes *Action:* stimulates estrogen secretion and follicle maturation-stimulates spermatogenesis *Prolactin (PRL):* *Target:* mammary glands *Action:* stimulates breast milk production *Growth hormone (GH):* *Target:* bone and soft tissue *Action:* promotes growth through lipolysis, protein anabolism, and insulin antagonism *Melanocyte stimulating hormone (MSH):* *Target:* melanocytes *Action:* promotes pigmentation

abnormal uterine bleeding

*Treat the cause:* Meds as appropriate. Hormone therapy *Progesterone:* oral, Depo, Nexplanon or Mirena. Oral contraceptives, patch or ring. NSAIDs *only non-hormonal FDA approved drug for excessive menstrual bleeding:* Lysteda *Menorrhagia:* heavy bleeding *Oligomenorrhea -* infrequent periods > 35 days *Metrorrhagia -* between *Menometrorrhagia:* prolonged or excessive irregular bleeding *Polymenorrhea:* menstrual cycle shorter than 21 days *The treatment includes:* medication and surgical procedures.

tx for hyperthyroidism

*Treatment depends on:* What caused it. Severity. Other conditions present. Rare for deaths to occur unless untreated *Medical:* Decrease the effect of thyroid hormone (Cardiac). Decrease thyroid hormone secretion *Monitor -* VS - Every 4 hours. Tachycardia, dysrhythmias, palpitations, chest pain. if you're having increased hr you need to try to calm them down (first thing). Temperature even one degree Fahrenheit increase. Dyspnea, vertigo. *Administer/Teach drug therapy:* Main treatment is Beta-blockers that decrease the BP and slow the heart rate. They do not affect the level of thyroid hormone: propranolol, atenolol, metoprolol *Nutrition:* Increase calories, proteins and carbohydrates *stimulation:* Reduce stimulation (especially if Increased Temp). Rest, quiet, postpone nonessential care, limit visitors, close the door to the room *Promote comfort (heat intolerance):*change linen with diaphoresis, ice water at bedside, room temp. cooling blankets. *Eyes:* Use artificial tears. Wear dark glasses - photophobia. Wear eye patch if needed. Short term steroid therapy (Prednisone) to decrease swelling behind the eye. Diuretic therapy to decrease edema around the eye *Medical tx:* Anti-thyroid drugs. Radioactive iodine. Surgery

levothyroxine for hypothyroidism

*Tx. Goals:* resolution of symptoms, Normalization of TSH, avoid overtreatment. *Start with:* just T4. Only add T3 if unable to normalize with T4. *Pregnancy:* Only T4, T3 - developing fetus neuro system is impermeable to T3. *If ischemic heart disease, elderly:* start slow. *Change every:* 6-8 weeks until the TSH is in target range. *How to take:* life long. take on empty stomach. *if hr below 60:* do not give. can cause bradycardia. *Starting a too high dose or inc dose too rapidly can cause:* severe htn, heart failure, MI

toxic shock syndrome

*Usually results from:* menstruation and tampon use; can be fatal *Bacteria:* Staphylococcus aureus *Develops:* within 5 days after onset of menstruation *SS:* Fever, rash, myalgia, sore throat, edema, hypotension *Treatment focuses on:* removal of infection source

Pituitary

*Where is it?* by hypothalamus, located in base of brain. *Anterior:*secretes tropic hormones that stimulate other glands. Receives hormones from hypothalamus thru bloodstream. *Posterior:* stores hormones secreted by the hypothalamus. Receives from hypothalamus thru nervous system. *How is it assessed?* Can be seen on x-ray. Looking at size of glands. *If changes are suspected or seen on x-ray:* F/U with CT or MRI *Angiogram:* for malformation or aneurysm-assessing circulation/vascular *Blood tests:* specific for the problem. *Anterior-what does it control?* GROWTH. METABOLIC ACTIVITY. SEXUAL DEVELOPMENT

ovarian cancer

*Vague:* abdominal and GI symptoms *Treatment usually involves:* surgery and chemotherapy *Malignancy of:* ovary *Disordered growth in response to:* excessive estrogen *NON MODIFIABLE RISK FACTORS:* *Hormone exposure:* Increased age (mean age is 56, between 55 & 75 years). Early menarche or late menopause. Infertility *History of:* breast, bladder or colon cancer *Heredity:* 1st degree relative with disease. BRCA -1 & BRCA-2 mutations. autosomal dominant *MODIFIABLE RISK FACTORS:*Lifetime ovarian activity & exposure to hormones. Null parity or over 30 at time of 1st pregnancy. High fat diet. Obesity. Hormone replacement > 10 years *SS:* Vague. Bloating. > abdominal size. Difficulty eating, early satiety. Abdominal or pelvic pain. Urinary symptoms - urgency &/or frequency, incontinence. Unexplained vaginal bleeding *Diagnosis:* ca 125. transvaginal us. *No:* screening protocol yet *Usually a late diagnosis:* because symptoms are so vague *CA-125:* Blood test. Biologic tumor marker associated with ovarian cancer. Not specific - also present with other tumors. Can even be present with fibroids or endometriosis. Not present in all ovarian tumors. Works best to judge therapy response (if present before therapy) *For dx and staging:* Laparotomy or laparoscope *Staging determines treatment & survival rates:* *I -* limited to ovaries ( 5 yr survival) *II -* one or both ovaries with pelvic extension *III:* spread to lymph nodes & other structures in abdomen *IV:* spread to distant sites *Usually Stage:* III or IV before diagnosis *Treatment:* Surgical removal of any cancer that can be seen & removing all reproductive organs, the omentum, & sampling lymph nodes *Surgical Debulking -* above plus any tumors in peritoneal area *Adjunctive:* radiation & chemo *Prognosis:* Poor

tx for hypoparathyroidism

*Watch for:* Hypocalcemia *Hypocalcemia:* *if acute/severe:* Give IV calcium (10%) solution of Calcium chloride or calcium gluconate over 10 - 15 minutes. *Chronic:* oral calcium. *Vitamin D deficiency:* (Activated Vitamin D) calcitriol; Chronic - 50,000 to 400,000 units of ergocalciferol daily, in divided doses. *Hypomagnesium:* 50% magnesium sulfate in 2 ml. doses either IV *Oral Calcium salts:* gastrointestinal side effects and hypercalciuria-related complications. *Thiazide diuretics:* they reduce urinary calcium excretion. *Diet high in:* Ca but low in phosphorus (avoid dairy because of phosphorus- milk, yogurt and processed cheeses). *Need to wear:* Medic Alert Bracelet

hypopituitaryism: anterior

*What are the signs?* Lack of the hormone's effect on the body. Affect whatever is below it. *Causes:* head trauma. child abuse. tumors (most common). carotid aneurysm. sheehans syndrome. shock or severe hypotension. sx. radiation. anorexia. malnutrition. familial. tb. syphilis *interventions:*Remove the cause, if possible. Replace the hormone/hormones. Treat Symptoms. Counseling, including genetic. *Replace the deficient hormone:* *FSH/LH deficiency:* estrogen/progesterone/testosterone *GHRH deficiency:* hGH in children *TSH deficiency:* thyroxine *ACTH deficiency:* Cortisol *Prolactin:* None *Vasopressin:* DDAVP

BENIGN NEOPLASMS

*What are they?* Ovarian Cysts. Uterine leiomyoma (fibroids or myomas) *Uterine leiomyoma:* May not need treatment if asymptomatic. Nonsurgical management. Surgical management

thyroid cancers

*What is it:* Painless lump. 4 distinct types *tx:*Radioactive Iodine treatments.Surgical removal *Post op:* take suppressive doses of thyroid hormone. If still has RAI uptake after 3 months, ablative RAI. Chemotherapy if metastasis *Papillary carcinoma:* Most common type. Slow growing. Spreads to lymph nodes. Most often in women under 40years old. Prognosis good if confined to gland *Follicular carcinoma:* Over 50 years old. Spreads to blood vessels, bone and lung. Can adhere to other structures in neck causing problems. Prognosis fair - depends on metastasis *Medullary carcinoma:* Over 50 years old. Often part of a familial endocrine disorder. Metastasizes through lymph nodes *Anaplastic carcinoma:* Extremely aggressive. Most die in 1 yr

thyroid storm

*What is it:* Uncontrolled hyperthyroidism. Life threatening. *Caused by:* stress, surgery. stress on body. can also be caused by palpating the thyroid too hard; stimulates a sudden release of thyroid hormones. *SS:* Fever/tachycardia. Systolic hypertension. Abdominal pain,N/V, diarrhea. Agitation/anxiety/tremors, restless/confused/psychotic. Seizures/coma *TX:* Maintain airway patency. Providing adequate ventilation. Reducing fever. Stabilizing hemodynamic status. Suppress thyroid hormones

graves disease

*What is it:* hyperthyroidism, autoimmune. *Risk factors:* More common in women, 20-40yo *Autoimmune disease:* Antibodies attach to the TSH receptor site on the thyroid tissue - produces overproduction of the thyroid hormone and increased size *SS:* All of the symptoms of hyperthyroidism + ophthalmopathy-Exophthalmos (bulging eyes), proptosis- edema and > fatty tissue in eyes. steroids or maybe surgery to decrease edema. Goiters (may or may not see). Pretibial Edema

Diabetes insipidus

*What is it?* ADH deficiency *Undersecretion of:* ADH or Inability of the kidneys to respond to ADH *Without ADH:* the water is excreted as urine (large volumes) *Causes:* *Nephrogenic diabetes insipidus:* Hereditary. Kidney can't respond (level of hormone is normal) *Primary diabetes insipidus:* Defect in the hypothalamus or pituitary *Secondary diabetes insipidus:* Tumors, head trauma, infections, surgical removal of the gland (hypophysectomy), metastatic cancer from breast or lung, brain hemorrhage *Drug-related diabetes insipidus:* Known offenders - lithium, Interfere with kidney's response *ss:* Thirst/polyuria. Hemoconcentration. Hypotension. Dry mucous membranes. Ataxia. Hyperthermia. Poor turgor. Tachycardia. Decreased LOC. Irritability. Lethargy *DX:* *Urine tests:* Dilute, specific gravity <1.005 (low) (nl is 1.005-1.030) *Hypo-osmolar:* 50-200mOsm/kg *24 hour urine:* exceeds 4L (could have up to 16L) *Interventions:* *Teach:* Hydrate, Daily Weights. Recognize symptoms of dehydration *Drug therapy:* Vasopressin-desmopressin acetate (DDAVP) *Watch:* Headache/Acute Confusion - H2O toxicity

early gonadotropins: precocious puberty

*What is it?* Abnormally early development of sexual maturity. *Usually marked by:* early breast development and ovulation in girls before 8 years of age and the production of mature sperm in boys before age 10 years. *Psychological:* they look different, embarrassed.

HYPOthyroidism

*What is it?* Decreased metabolism *Causes:* Cell damage. lack of ingestion of iodide or tyrosine *Etiology:* *Radioactive Iodine Treatment/Surgery:* Treatment for hyperthyroidism *Medications:* Lithium, high doses of iodine, amiodarone (Cardarone,Pacerone) *Postpartum Thyroiditis:* After hyper. *Autoimmune -Hashimoto's Thyroiditis:* Most common thyroid disease. more common in women. Inherited. Autoantibodies destroy the thyroid gland. May be undetected, progresses with goiter, dysphagia *Endemic goiter:* Not ingesting enough iodide or tyrosine *ss:* *ASSESS FOR:* *Skin:* Cool, pale, dry, scaly, yellowish. Coarse, dry, brittle hair. Loss of eyebrow hair. hick, brittle nails. \Poor wound healing, easy to bruise. could have goiter. myxedema. facial and eyelid edema. receding hairline. hirsutism . *Lungs:* Hypoventilation, pleural effusions. Dyspnea. co2 retention. need to do quad cough. *Cardiovascular:* Bradycardia/Dysrhythmias. Decreased activity tolerance. Hypotension. enlarged heart. *Metabolic:* Decreased causing myxedema. Cold intolerance. < body temp (Less than 97 degrees F). hypoglycemia *Musculoskeletal:* Aches. Delayed contraction, relaxation. thick tongue-slow speech. weakness. *Neurological:* Impaired memory, inattentive, lethargy, confusion, slow or slurred speech. Paresthesias. < DTRs. Depression, apathy, paranoia, withdrawal. fatigue. hearing loss. dull, blank expression. *GI:* Constipation, abdominal distention. Wt gain despite anorexia *Urinary:* dec uo *Reproductive:* Anovulation, changes in menses. Impotence. <libido *Main reason they seek tx:* weight gain, depression, lethargy. *Nursing interventions:* *Respiratory Failure:* Assess O2 Sats (want to be above 90), Oxygen. Adventitious breath sounds. Watch with sedation (need less drug). assesss loc, indicator if they don't have enough o2. *Cardiac Failure:* Watch for shock, teach patient about notification of chest pain/discomfort, Caution when initiate thyroid hormone replacement drugs. we want greater than 60. don't want edema or arrythmias. *Disturbed Thought Process:* Orient, safe environment, support family.

Hyperpituitaryism: anterior

*What is it?* Oversecretion *Cause is usually:* tumors or hyperplasia. *Most commonly:* Somatotropic cells - GH Lactotropic cells - PRL Corticotropic cells - ACTH *Most common cause of hyperpituitarism:* Pituitary adenoma; Benign. *Assessment:* MRI (Best), skull x-rays

cervical polyp

*What is it?* Pedunculated tumors that arise from the mucosa that extends through the opening of the cervical os *May be:* asymptomatic *If symptomatic:* Bleeding, leukorrhea *Usually removed:* during an office visit via clamp and cauterization

siadh

*aka:* Schwartz-Bartter syndrome *Occurs when:* ADH (vasopressin) is secreted even when plasma osmolarity is low or normal. (Feedback mechanism isn't working) *Malignancies and cancer therapy:* some tumors (ie oat cell of lung, pancreatic CA, leukemia) can produce ADH *Transient causes like:* trauma, pituitary surgery, pulmonary disorders (infectious, asthma, CF), medications (general anesthesia, opiates, tricyclic antidepressants, ecstasy, diuretics) *SS:* Water retention w/o edemA , Decreased DTR, Hypothermia, Weight Gain, Hyponatremia (dilutional hyponatremia-because theres so much extra fluid, it makes the sodium look lower), Tachycardia, Loss of appetite, Decreased LOC, Irritability, Lethargy *Initial symptoms are due to water retention:* GI - N&V, loss of appetite. Weight gain. Tachycardia from fluid overload. Hypothermia from CNS disturbance *Level of consciousness:* lethargy, irritability, headaches, disorientation, hostility, sluggish DTRs, seizures, coma *Water retention is primary development:* *Dilutional hyponatremia:* < 135mEq/L: the Na would be normal but there is too much water *Because the glomerular filtration rate is increased:* renin and aldosterone are inhibited so the body actually excretes more Na, makes hyponatremia worse *Plasma volume:* > plasma volume *Extracellular fluid:* > (without edema) *DX:* History *Serum:* Decreased Sodium. Increased plasma volume *Urinalysis:* < urine production. > urine osmolarity. > urine sodium levels > specific gravity *Radioimmunoassay of ADH:* ADH should be low if plasma osmolarity is normal or decreased *Interventions:* Restrict fluid. Nursing measures to help with discomfort. I&O, Daily Weights. Monitor neuro status (Flow Sheets), safety *IV fluids:* Hypertonic IV saline

ethics

*autonomy:* patients right to self determination without outside control. freedom to make choices and decisions about ones own care. *beneficence:* duty to actively do good for patients. *nonmaleficence:* duty to prevent or avoid doing harm, whether intentional or unintentional. *fidelity:* duty to be faithful to commitments. *Justice:* duty to treat all patients fairly regardless of age, SES, or other variable. *Veracity:* duty to tell the truth.

intraductal papilloma

*benign or malignant:* benign *Mass is rarely:* palpable *Wart - like growth in:*mammary ducts, usually near nipple *Most common:* 30-50 year old *Symptoms:* Spontaneous nipple discharge - serous, yellow, watery, may even be serosanguinous. No mass. *Interventions:* R/O breast CA. Remove

Calcitonin

*bone resorption:*inhibits which lowers the Ca serum levels *Works opposite the:* ParaThyroid Hormone. *Decreases absorption of:* Calcium from the GI. *Enhances:* excretion by the kidneys. *REGULATION:* *If serum Ca levels are low:* calcitonin is suppressed (bone breaks down) *If serum Ca levels are high:* calcitonin is increased (bone is conserved) *Other times it is increased:*regnancy, high-calcium diet, increased gastrin - result is less bone breakdown

breast cancer in young women

*strong risk factor:* Genetic predisposition, women who havent had kids before 30. *Often younger women have:* more aggressive forms of the disease-cells divide faster. *Screening:* can be less effective *Encourage women with symptoms:*to seek evaluation without delay.

HYPOPHYSECTOMY

*endoscopic transnasal:*minimally invasive. no incision. *Transshpenoidal:* Nasal packing. "Moustache dressing". Incision. taking pituitary out. *Post op care:* *Checking:* Neuro status-monitor hourly for first 24 hours, then every 4 (assess for meningitis, infection, LOC, orientaion, vision, CSF leak). Fluid balance (be alert for diabetes insipidus). Assess for c/o HA (inc ICP). *Monitor for CSF leak:* increased swallowing, post nasal drip-looking for light yellow color on edges, check for halo, glucose. *Oral care:* Frequent mouth care-No toothbrushes, Can floss/mouthwash. *No "activity that increases intracranial pressure:* Bending, coughing, blowing nose, sneezing, Straining with stool (stool softeners, fiber, increased fluids), Lifting. *HOB:* UP. *deep breathing:* but no cough (increase bleeding and opening that area). *Sense of smell:* may be altered or diminished and may experience incision numbness for 3-4 months. *Advise client to report any problems with:* excessive voiding (diabetes insipidus) or return of any symptoms of hyperpituitarism. *May need other hormone replacement:*Gonadotropin: Ask about libido, other sexual aspects. Thyroid Hormone. ACTH. Watch for hypoglycemia.

safety

*knowledge:* Keep the patient and healthcare providers free from harm and minimize errors in care. *Safety Culture:* how are my actions affecting safety risk? Where could an error occur? How to prevent harm? *Sentinel event reporting:* Sentinel- unexpected occurrence that may result in death or a serious adverse patient outcome *Why are we concerned:* Poor communication. Lack of clinical judgement, attentiveness, patient monitoring. Error in medication administration. Lack of professional accountability, patient advocacy. Lack of mandatory reporting *Identify patients:* correctly *Improve staff:* communication *Use medicines/alarms:* safely *Prevent:* infection *Identify:* patient safety risks *Prevent mistakes:* in surgery *Skills:* *One minute:* safety check. *Safe:* handoffs/report *Give information to Patients for:* advocate for self *Two patient:* identifiers *Medication:* reconciliation *High alert:* medication/look alike/sound alike *SX:* Time outs/huddles. Correct surgery/correct site *Nonverbal requires:* confirmation *Use:* checklist *Culture of safety vs. culture of blame: fairness algorithm:* Did they intend to cause harm? Are they impaired, drunk? Did they do something that was unsafe? Could 2 or 3 peers make the same mistake in similar circumstances? Do they have a history of similar problems? Negligence, intentional *individual accountability:* Most errors are committed by good, hardworking people who try to do the right thing.Everyone does their job *Blame:* negative results - focus on the individual, punitive, reactive *No punishment unless:* deliberate and willful

informatics and technology

*knowledge:* The use information and technology to communicate, manage knowledge, mitigate error, and support decision making Related to all other competencies Spirit of Inquiry - seek evidenced based practice, current practice, resources *Includes:* Recording - health records. Safety Alerts. Smart Devices. NCLEX-RN *Skills:* patients can access their medical records online. charting is done through computer systems/EHR. medication bar code scanning/point of care reference information. Smart IV pumps. HIPAA. Mobile Devices - Precautions to secure client information *Data:* labs, diagnostic studies

malignant breast disorders

*non modifiable risk factors:* Gender (female). Aging (>50 years old). Family history. 1st degree relative: mother, sister, daughter grandmother, or aunt. Genetic mutations (BRCA-1 & BRCA-2 genes). Personal history Ovarian or colon cancer, Breast cancer (3-4X risk for recurrence). Exposure to chest radiation, Mammograms. Especially between ages 10-30yrs. Nulliparous or 1st child after 30yo—increases # of menstrual cycles. Postmenopausal use of estrogens & progestins. Increased breast density *Modifiable:* Alcohol use-boosts estrogen in blood stream Obesity- fat cells produce & store estrogen, so more fat cells create higher estrogen levels Sedentary lifestyle & lack of physical exercise - body fat houses estrogen Smoking —exposure to carcinogenic agents found in cigarettes Low levels Vit D

prolapse

*what is it:* descent of pelvic organ *Lack of support by:* vagina & ligaments *Types:* Cystocele. Rectocele. Uterine *In cystocele:* the urinary bladder is displaced downward, causing bulging of the anterior vaginal wall. *In rectocele:* the rectum is displaced, causing bulging of the posterior vaginal wall. *ASSESSMENT: NOTICING:* *Uterine prolapse—*may report painful intercourse, backache, pelvic pressure *Rectocele—*constipation, hemorrhoids, fecal impaction, rectal fullness. *Diagnostic testing:* Cystography. Bladder ultrasound. Urine culture and sensitivity. Radiographic imaging of urinary anatomy, voiding

dysfunctional uterine bleeding

*what is it?* Excessive and frequent bleeding *Treatment focuses on:* Prevention or treatment of anemia. Control of bleeding via nonsurgical or surgical methods

HYPERthyroidism

*what is it?* Excessive thyroid hormone secretion from the thyroid gland *Permanent or temporary:* depending on the cause *Causes:* *Graves' Disease (toxic diffuse goiter) -* autoimmune disease (Most Common) *Postpartum thyroiditis:* 5-10% after birth, *Excessive Iodine ingestion:* medications (amiodorone), x-ray dyes *Exogenous:* overmedication with thyroid replacements - *ss:* *Later signs:* Confusion and delirium, irregular heart rhythms and heart failure - later signs. *State of hypermetabolism:* *Cardiac:* increased rate and stroke volume. Palpitations, HTN(systolic) - widened pulse pressure, chest pain, tachycardia. Atrial fib, P and T wave changes *Metabolism:* *protein:* increased breakdown. negative nitrogen balance. *glucose:*hyperglycemia. *Fat metabolism increases:*wt loss despite increased appetite and intake. *Heat intolerance:* increased likely to perspire *GI:*Wt loss, diarrhea *Lungs:*SOA, rapid, shallow respirations, decreased vital capacity, not expanding lungs the way they shou.d. finger clubbing. *Skin:*Diaphoresis, smooth, warm, moist, silky body hair but thins at scalp. Pruritis. Separation of the nail from the nail bed. Hyperpigmented, thickened plaques with "orange peel appearance". low grade fever. facial flushing. localized edema. *Musculoskeletal:* Weakness, muscle wasting, trembling hands. may or may not have goiter. *Neurologic:* *Vision:* blurred or diplopia, photophobia, increased tears, Lid lag (looking up but lid not follow), Globe lag (looking down but lid is up), eye fatigue, stare (See Graves' Disease for other symptoms). *DTR:* Hyperactive Deep Tendon Reflexes, tremors *Sleep:* Insomnia, fatigue *Mental:* Restless, decreased attention span *Emotional:* Irritable, emotionally labile, manic behavior, depression *Reproductive:* Dev before puberty - delayed sexual dev in women. After puberty - irreg menses and infertility, increased miscarriages. Both sexes have > increased libido. Gynecomastia. amenhorrhea. *Most common symptoms:* weight loss, nervousness, heat intolerance, goiter.

cyst

*what is it?* Fluid filled sac *Must evaluate:* usually benign *Symptoms:* Tender, mobile, size may fluctuate with hormones, may resolve *Interventions:* Watchful waiting. Drainage. Removal

galactorrhea benign

*what is it?* Nipple discharge not associated with breastfeeding *No alarm if:* Bilateral. More than one duct. Milky to brownish *Can be a:* Side Effect of many medications *Clear or bloody is:* ominous

options for high risk women

Close surveillance Annual mammography and clinical breast examination Annual breast MRI screening Prophylactic mastectomy Prophylactic oophorectomy Anti-estrogen chemopreventive drugs