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Thyroid gland

• Produces 3 hormones (T3, T4, Calcitonin)
• Calcitonin decreases serum Ca+ levels by taking the calcium out of the blood and
pushing it back into the bone.
• You need iodine to make hormones. (This is dietary iodine)
• Thyroid hormone gives us energy

1

Hyperthyroid. S/S, dx

Graves' disease
a. S/S:
• Nervous
• Weight loss
• Sweaty/hot
• Exophthalmos
• Attention span decreased
• Appetite increased
• Irritable
• GI fast/diarrhea
• BP increased
• Thyroid enlarges
b. Dx:
• If you drew a serum T4 (thyroxine) level on this client would it be increased or decreased? Increased
• Thyroid scan
• Client must discontinue any iodine containing medication 1 week prior to
the thyroid scan.

2

Hyperthyroid treatment

1) Anti-thyroids: Propylthiouracil (PTU®), Methimazole (Tapazole®)
• Stops the thyroid from making thyroid hormone.
• It’s used preop to stun the thyroid.
• We want this client to become euthyroid

2) Iodine Compounds: Potassium Iodine (SSKI®), Strong Iodine Solution (Lugol’s solution®)
• decrease the size and the vascularity of the gland and decreases the risk for bleeding
• ALL endocrine glands are VERY VASCULAR!
• Give in milk or juice, and use straw. Why? Stains teeth
3) Beta Blockers: propranolol (Inderal®)
• Decreases myocardial contractility
• Could decrease cardiac output
• Decreases HR, BP
• decreses anxiety.
Testing strategy: Do not give beta blockers to asthmatics or diabetics.
4) Radioactive Iodine 1 (dose)
• Given PO (liquid or tablet form)
**Rule out pregnancy first**
• Destroys thyroid cells→hypothyroidism which is expected.
• Follow radioactive precautions.
Stay away from babies for 24 hours.
Don’t kiss anyone for 24 hours.
• Watch for thyroid storm (thyrotoxicosis and thyrotoxic crisis). It is hyperthyroidism multiplied by 100.
Could be rebound effect post-radioactive iodine
5) Surgery: thyroidectomy (partial/complete)
• Post op:
Teach how to support neck.
Put personal items close to them to protect suture line
• Positioning: HOB? Elevate to decrease edema
• Check for bleeding where? Behind neck for pooling
• Nutrition (pre & post op) needs more calories.
• Assess for recurrent laryngeal nerve damage by listening for hoarseness and weak voice.
• Could lead to vocal cord paralysis, if there is paralysis of both cords airway obstruction will occur requiring immediate trach.
• Teach to report any c/o pressure.
• Trach set at bedside
1) Swelling
2) Recurrent laryngeal nerve damage (vocal cord paralysis)
3) Hypocalcemia
Assess for parathyroid removal. How? S/S of hypocalcemia (rigid muscle, seizure, spasms)

Eye care is important for a client with hyperthyroidism. If the client can’t close their eyelids, hypoallergenic tape may be applied to close lids (to help prevent injury or irritation). Dark glasses may be worn if photosensitivity is present. Artificial tears are used to prevent drying of the eyes.
Treatment of hyperthyroidism DOES NOT correct any eye or vision problems.

3

Hypothyroid

2. Hypothyroid (Myxedema):
a. S/S:
• No energy
• When this is present at birth it’s called cretinism (very dangerous, can
lead to slowed mental and physical development if undetected).
• Fatigue
• GI slow
• Weight up
• Cold
• Speech slow, slurred
• No expression
You may be taking care of a totally immobile client
b. Tx:
• Levothyroxine (Synthroid®), Thyroglobulin (Proloid®), Liothyronine (Cytomel®)
• meds forever?
• What will happen to their energy level when they start taking these meds? Increase.
c. People with hypothyroidism tend to have CAD

4

Parathyroid

• The parathyroids secrete PTH which makes you pull calcium from the bone and place it in the blood. Therefore, the serum calcium level goes up.
• If you have too much parathormone in your body the serum calcium level will be high.
• If you do not have any parathormone in your body the serum calcium level will be low.

5

Hyperparathyroidism

Hypercalcemia. Hypophosphatemia

a. S/S:
• Too much PTH
• Serum calcium is HIGH. Serum phos is LOW.
• Other S/S sedated
b. Tx:
• Partial parathyroidectomy – when you take out 2 of your parathyroids.... PTH secretion decreases.
• What are you going to monitor post op? Hypocalcemia. Will not be sedated and have tight rigid muscles.

6

Hypoparathyroidism

Hypocalcemia, hyperphosphatemia
a. S/S:
Not enough PTH
Serum calcium is low. Serum phos is high. Other S/S: not sedated
b. Tx:
• IV calcium
• Phosphorus binding drugs. Renegal, oscal

7

Adrenal medulla problem

• Pheochromocytoma
Benign tumors that secrete epi and norepi in boluses
a. S/S:
• BP? Increases
• HR and Pulse? Increases
• Flushing/diaphoretic
b. Dx:
• VMA (vanillylmandelic acid) test: a 24 hour urine specimen is done and you are looking for increased levels of epi and norepinephrine (also called catecholamines). Tell them to stay calm cuz stress (anxiety, smoke, running) causes release. Do not use vanilla for 1 week.

With a 24 hour urine you should throw out the first voiding and save the last voiding.
c. Tx:
• Surgery to remove rumors

8

Adrenal cortex glucocorticoids

• Change your mood.
Example: insomnia, depressed, psychotic, euphoric
• Alter defense mechanisms Immunosuppressed
High risk for infection
• Breakdown fat and proteins
• Inhibit insulin
Hyperglycemic
Do blood glucose monitoring

9

Adrenal cortex mineralocorticoids

Aldosterone
• Make you retain Na & h2o
• Make you lose K+
• Too Much Aldosterone.
Fluid volume excess
Serum Potassium: low
• Not Enough Aldosterone. Fluid volume deficit
Serum Potassium: high

10

Steroids other names

Adrenocorticotropin hormones (ACTH) are made in the pituitary and they stimulate cortisol to be made. Cortisol is a hormone of the adrenal cortex.
So no matter what “fancy” word the NCLEX® Lady uses...you will still get the same result...think “steroids”.☺
↑ACTH = ↑Cortisol level
Too many steroids = Hypercortisolism (just another word).

11

Addison's disease

Adrenal cortex problem
a) Pathophysiology:
• They do not have enough glucocorticoids, mineralocorticoids, or sex hormones.
• Aldosterone (mineralocorticoids)
• Normally, aldosterone makes us retain Na and h2O and lose K+......Now we don’t have enough (insufficient) so we will lose na and H2O and retain K+.
• The serum K+ will be high.
b) S/S:
• Initially, the majority of the S/S are a result of the hyperkalemia.
Beginning with muscle twitching, then proceeds to weakness, then flaccid paralysis.
Other S/S:
• Anorexia/nausea
• Hyperpigmentation-bronzing color of the skin and mucous
membranes
• Decreased bowel sounds
• GI upset
• White patchy area of depigmented skin (vitiligo)
• Hypotension
• Decrease Na, increased K+ and hypoglycemia.

c) Tx:
Combat shock (losing Na and h2o)
Increase sodium in their diet
Processed fruit juice/broth (has lots of sodium) I & O and daily weight
If this client is losing Na and water their BP will probably be low
They will probably be losing weight
Nursing DX: Fluid Volume deficit
Will be placed on the mineralocorticoid drug Fludrocortisone (Florinef®). It’s aldosterone.
DAILY WEIGHTS are very important in adjusting their medication.
Rule: When on a medicine where weight has to be monitored daily, keep the weight within 2-3 lbs (+ or -) of their normal weight. Fluid retention=heart problems

12

Addisonian crisis

Addisonian Crisis = severe hypotension and vascular collapse

Never stop steroids immediately, they need to wean off of them

13

Cushings disease

Adrenal cortex problem

a) S/S:
These clients have too many glucocorticoids, mineralocorticoids, and sex hormones.

Too many glucocorticoids
Growth arrest
Thin extremities/skin (lipolysis)
Increased risk of infection
Hyperglycemia
Psychosis to depression
Moon faced (fat redistribution or fluid retention)
Truncal obesity (fat redistribution; lipogenesis)
Buffalo hump (fat redistribution)

Too many sex hormones
Oily skin/acne
Women with male traits
Poor sex drive (libido)

Too many mineralocorticoids
High BP
CHF
Weight gain
Fluid Volume excess

• Since the client has too much mineralocorticoid (aldosterone), the serum K+ will be low.
• If you did a 24 hour urine on this client the cortisol levels would be high.
b) Tx:
• Adrenalectomy (unilateral or bilateral)
*If both are removed→ lifetime replacement
• Quiet environment. (Can't handle stress)
• Diet pre-treatment?
High K+ low Na High Protein high Ca
• Avoid infection.
• What might appear in their urine? Glucose and ketones (not protein)

14

Type 1 diabetes

70-110mg/dL

a. Type 1:
• They have little or no insulin.
• Usually diagnosed in childhood
• Causes: Auto-immune response (Type 1A) or Idiopathic (Type 1B)
• First sign may be DKA.
• Appears abruptly, despite years of beta cell destruction.
1) Pathophysiology:
You have to have insulin to carry glucose out of the vascular space into the cell...since there is no insulin, the glucose just builds up in the vascular space, the blood becomes hypertonic and pulls fluid into the vascular space...the kidneys filter excess glucose and fluids (polyuria and polydipsia) the cells are starving so they start breaking down protein and fat for energy (polyphagia)...when you break down fat you get ketones (acids)...Now have metabolic acidosis. Lungs will compensate by blowing off co2 and kussmauls

2) S/S:
• Polyuria. Think shock first
• Polydipsia
• Polyphagia

3) TX:
• No orals
• They have to have insulin.

15

Type two diabetes
NIDDM

1) Pathophysiology:
• These clients don’t have enough insulin or the insulin they have is no good.
• These clients are usually obese.
• They can’t make enough insulin to keep up with the glucose load the client is taking in.
• This type of diabetes is not abrupt as Type I.
• It’s usually found by accident; or the client keeps coming back to the physician for things like a wound that won’t heal, repeated vaginal infections, etc.
• Individuals with Type 2 diabetes should be evaluated for metabolic syndrome (Syndrome X).
The features of Metabolic Syndrome include:
• insulin resistance,
• obesity, (waist circumference > 40 inches)
• increased triglycerides,
• decreased HDL,
• increased BP,
• and CAD.
2) Tx:
• Start with diet and exercise, then add oral agents, then some clients take insulin.

16

Metabolic syndrome/syndrome X

The features of Metabolic Syndrome include:
• insulin resistance,
• obesity, (waist circumference > 40 inches)
• increased triglycerides,
• decreased HDL,
• increased BP,
• and CAD.

17

Gestational diabetes

• Resembles Type 2
• Mom needs 2-3x more insulin than normal.
• Screen all moms at 24-26 weeks gestation.
• If mom has risk factors for Gestational Diabetes, screen at ________ prenatal visit.
• Complication to baby:
Increased birth weight and hypoglycemia

18

Diabetes
diet and exercise

Extreme blood sugar > vascular damage
a. Diet:
• Majority of calories should come from: complex carbohydrates, then fats, and lastly protein. Limit protein to 10-20%.
Diabetics tend to have renal disease.
• Why are diabetics prone to CAD? Sugar destroys vessels just like fat.
• High fiber diet (keeps blood sugar steady; client may have to decrease insulin)
High fiber slows down glucose absorption in the intestines, therefore, eliminating the sharp rise/fall in blood sugar.
b. Exercise:
• Wait until blood sugar normalizes to begin exercise.
• What should the client do pre-exercise to prevent hypoglycemia? Eat something
• Exercise when blood sugar is at its highest
• Exercise same time and amount daily.

19

Diabetes
Medications

• How do oral hypoglycemic agents work? Stimulate the pancreas to make insulin.
*Note: not all oral hypoglycemic agents stimulate the pancreas to make insulin.
Despite whether they stimulate the pancreas, all oral hypoglycemic work to decrease the amount of circulating glucose.
Only give to Type II
Common Oral Anti-Diabetic Agents: Glipizide (Glucotrol®), Metformin (Glucophage®), Pioglitazone (Actos®), Sitagliptin (Januvia®)

How is the insulin dose determined?
It is based on body weight. The average adult dose of insulin is 0.4-1 units/kg/day.
The insulin dose is adjusted until the blood sugar is normal and until there is no more glucose or ketones in urine.
Reg (clear)....NPH (cloudy)
Lantus is also clear and is considered a long acting insulin.
What is the only type of insulin you can give IV? Regular
The most common method of daily dosing insulin is basal bolus dosing.
• The total daily dose of insulin with the Basal/Bolus method is a combination of a long acting/lantus insulin, and a rapid acting/novolog insulin.
The long-acting insulin is given once a day.
The rapid-acting insulin is given throughout the day before meals in divided doses, and it covers the food eaten at meals.
• Snacks are not required with Basal/Bolus insulin dosing, but clients still must eat when dosing with a rapid-acting insulin. So, have food available.
• Clients should eat when insulin is at its peak
• When insulin is at its peak, the blood sugar is at its? Lowest
• Always monitor a client on insulin for Hypoglycemia.
• When drawing up Regular and NPH insulin together, which one do you draw up first? Regular

20

Diabetic education

• Glycosylated Hemoglobin (HbA1c): blood test; gives an average of what your blood sugar has been over the past 3 months. Ideal goal is 4 to 6%.
• What happens to your blood sugar when you are sick or stressed? Increases
The normal pancreas can handle these fluctuations. An increase in the blood sugar when sick or stressed is a normal reaction to help us fight the illness/stressor.
• Rotation of sites (Rotate within an area first)
• Aspirate? No

**Illness = DKA**

21

Hypoglycemic episodes

Defined as <70
What are the S/S of hypoglycemia?
Cold, clammy, confused, shaky, headache, nausea, increased heart rate
If hypoglycemic, what should the client do? Eat simple sugar
Glucose absorption is delayed in foods with lots of fat
Once the blood sugar is up, what should they do? Eat a complex carb and protein
You enter a diabetic client’s room and they are unconscious ... treat this client like he is hypo

D50W (hard to push; and if you have a choice you need a large bore IV)
Injectable glucagon (GlucaGen®) (used when there is no IV access; given IM)
For prevention teach the client to:
Eat, Give insulin regularly, eat snacks,monitor levels

22

Diabetic ketoacidosis

1) Pathophysiology:
• Anything that increases blood sugar can throw a client into DKA (illness, infection, skipping insulin).
• DKA may be the first sign of diabetes.
• Have all the usual S/S of Type 1 diabetes
• Patho: Absent or inadequate insulin→ blood sugar goes sky high→
Polyuria, Polydipsia, Polyphagia→ Fat breakdown (metabolic acidosis) → Kussmaul’s respirations (trying to blow off CO2 to compensate for the metabolic acidosis). Also, as the client becomes more acidotic the LOC goes down.
2) Tx:
• Find the cause. (Illness, skipping insulin)
• Hourly blood sugar and K+ levels
• IV insulin
Insulin decreases glucose & K+ by driving
them out of the vascular space into the cell.
• ECG
• Hourly outputs
• ABGs
• IVFs→ Start with NS...then when the blood sugar gets down to about 300 switch to D5W to prevent throwing the client into hypoglycemia. Often you have an IV in each arm with fluid going into both arms
• Anticipate that the physician will want to add K+ to the IV solution at some point.

23

Hyperosmolar hyperglycemic non-ketosis coma
HHNK OR HHNC

• Looks like DKA, but NO Acidosis
• Making just enough insulin so they are not breaking down body fat. No fat breakdown....no ketones
No ketones...no acidosis
• NO Kussmauls' respirations
DKA and HHNK (HHS) are both hyperosmolar states caused by _____________ and _______________, but there is no ______________ with HHNK (HHS).

**In the NCLEX® world: Type 1→ DKA Type 2→ HHNK (HHS)**

24

Diabetic vascular problems

VascularProblems:Macro-vascularandMicro-vascular
• Will develop poor circulation everywhere due to vessel damage (sugar irritates the vessel lining; accumulation of sugar will decrease the size of the vessel lumen therefore decreasing blood flow)
1) Diabetic retinopathy > blindness
2) Nephropathy. Kidneys

25

Diabetic neuropathy

1) Sexual problems: impotence/decreased sensation
2) Foot/leg problems: pain/paresthesia/numbness Review Diabetic Foot Care
3) Neurogenic bladder: the bladder does not empty properly...the bladder may empty spontaneously, called incontinence, or it may not empty at all, and this is called retention.
4) Gastroparesis: stomach emptying is delayed so there is an increased risk for aspiration.

Increased risk for infection.