Exam 4 - Study Material (liver)

Question 1

What are the functions of the liver?

Answer 1

• —Storage of nutrients
• —Breakdown of erythrocytes
• —Bile formation & secretion
• —Synthesis of plasma proteins; cholesterol
• —Immunity – Kupffer cells
• —Conversion of ammonia into urea
• —Inactivation - various substances (ammonia, toxins, steroids, other hormones)

Question 2

What are some changes to the liver with aging?

Answer 2

• —Decrease in size, weight
• —Decreased portal blood flow
• —Decreased metabolism of some medications
• —Increased prevalence of gallstones
• —Atypical presentation of biliary tract disorders
• —Liver function test values remain unchanged

Question 3

How is hepatitis A transmitted and what are the manifestations of hepatitis A?

Question 4

How would you diagnose a patient with hepatitis A?

Answer 4

• —Gold standard: clinical picture & Serum IgM anti-HAV
  
  • —+ at onset
  • —Peaks during acute/early convalescence
  • —Positive - 4-6 months
• —Serum IgG anti-HAV:
  
  • —Early convalescence
  • —Detectable for decades

Question 5

What are the risk factors for hepatitis B?

Question 6

What are the manifestations of heptitis B? (viral)

Answer 6

• 70% are subclinical – asymptomatic
• Flu like symptoms
  *

Question 7

How would you diagnose a patient with heptitis B?

Answer 7

• —HBsAg – Hallmark serologic marker of HBV:
  
  • —1-10 weeks after acute exposure
  • —Detectable up to 6 months
• —Anti-HBs (hepatitis B surface antibody):
  
  • —Appears – life-time immunity—
• —If “window period” (no HBsAg or Anti-HBs) – may be diagnosed by detecting IgM antibodies against HB core antigens

Question 8

What are some risk factors for heptitis C?

Answer 8

• **—Most common blood-borne infection **
• —Most asymptomatic; not detected
• —Incubation period 60-160 days
• —IV drug users; blood transfusions
• —HIV infection
• —High-risk sexual behavior
• —Hemodialysis
• —Occupational exposure
• —Perinatal transmission—

Question 9

What are the manifestations of a heptitis C infection?

Answer 9

—elevated liver function tests, perhaps jaundice

Question 10

How would you diagnose a patient with hepitis C?

Answer 10

• —Anti-HCV antibodies
• —Acute:
  
  • —If HCV-RNA with detectable replicating virus – needs Rx
  • —If HCV-RNA not detectable & no replications – no Rx
• —Immunosuppressed; hemodialysis
  
  • —HCV RNA test even if anti-HCV negative

Question 11

What are some characteristics of Hepatitis D?

Question 12

What drugs can cause drug/toxin induced hepatitis?

Answer 12

• —Acetominophen
• —Some - Anesthetic agents; antidepressants; antibiotics, anti-metabolities

Question 13

What are the acute and later symptoms of drug/toxin induced hepatitis?

Answer 13

• —Acute: abrupt; chills, fever, rash, pruritis, anorexia, nausea, fatigue, anorexia, abdominal discomfort, headache
• —Later: jaundice, dark urine, hepatomegely

Question 14

What are the acute clinical manifestations of hepatitis?

Answer 14

• —Hepatomegaly; splenomegaly
• —Lymphadenopathy
• —Jaundice
• —Dark urine; light/clay-colored stools (because of lack of bile)
• —Pruritus (itching –> scratching)

Question 15

How would you treat drug/toxin induced hepatitis?

Answer 15

—Rx: stop drug! S&S may slowly diminish; may need liver transplant.

Question 16

Describe the convalescent phase associated with hepatitis A

Answer 16

• —Major complaints: malaise, fatigue, hepatomegaly
• —Almost all cases of HVA resolve
  
  • —Acute illness – 2-3 weeks
  • —Lab recovery -9 weeks
• —Complications – rare:
  
  • —Fulminant hepatic failure
  • —Chronic hepatitis
  • —Cirrhosis of the liver
  • Hepatocellular carcinoma

Question 17

How would you manage patients with hepatitis A?

Answer 17

• —Bed rest & nutritious diet – then progressive ambulation
  
  • —Small frequent feedings
  • —Low-fat option, high protein; adequate fluids
• —For those with more severe hepatitis infections – enteral feedings may need to be considered
• —No alcohol for at least 6 months following recovery
• —Serial liver function studies monitors recovery
• —Medications – avoid those that affect liver function

Question 18

What medications will be given to a patient with hepatitis B?

Answer 18

• —Not all respond to current therapeutic regimens
• —A-interferon
• —Antiviral agents
  
  • —Lamivudine (Epivir)
  • —Adefovir ( Hepsera)

Question 19

How would you prevent hepatitis A transmission?

Answer 19

• —Good hygiene, hand washing & sanitation
• —Vaccination for travel to foreign countries with high incidence
• —Hepatitis A vaccine
• —Immune globulin (IG) if contact

Question 20

How would you prevent transmission of hepatitis B?

Answer 20

• —Standard precautions/infection control measures
• —Screening of blood products
• —Immunization:
  
  • —Series – 3 injections – 0,1 & 6 months
  • —Hepatitis B immune globulin (HBIG)

Question 21

How would you prevent hepatitis C?

Answer 21

• —No vaccine available
• —Screening - blood products
• —Prevention - needle sticks
• —Reduce infection spread
• —Avoid high risk behaviors
• —Use barrier precautions when in contact with blood or body fluids

Question 22

What would you teach a patient with hepatitis A,B, or C?

Answer 22

• —Hepatitis A & B
  
  • —Education – re infection
  • —Vaccinations available
  • —Hygiene practices
• —Hepatitis C
  
  • —Education – re infection
  • —Infection control measures
  • —Modification of high risk behaviors
  • —Treatment protocols

Question 23

What is cirrhosis?

Answer 23

—Chronic disorder; normal hepatocytes replaced with diffuse hepatic fibrosis (Scarring of the liver)

Question 24

What can cause cirrhosis?

Answer 24

• —Chronic alcohol consumption
• —Hepatitis – C & B
• —Primary biliary
• —Non-alcoholic fatty liver
• —Environmental factors; exposure to chemicals
• —Predisposition regardless of alcohol intake or diet
• —Alpha 1-antitryptsen deficiency (it maintains surfactant)
• —Repeated episodes of heart failure (congestion and backing up of blood)
• —Autoimmune
• —Cause may not be known

Question 25

What are the clinical manifestations of cirrhosis?

Answer 25

* —**Asymptomatic for long periods** * —Systemic – fever, weakness, fever, weight loss * —GI disturbances * —Abdominal pain * —Amenorrhea * —Erectile dysfunction; gynecomastia * —**Portal hypertension →hepatomegaly; splenomegaly → developing ascites** * —Infection; spontaneous bacterial peritonitis * —Vitamin deficiencies * —Jaundice * —Hematologic * —Skin lesions * —Encephalopathy - subclinical * —Anemia * —Malnutrition * —Hematologic * —Neurologic changes * —Hepatic encephalopathy * —Day-night reversal; asterixis; tremor * —Delirium, drowsiness, coma * —Asterixis * —Fetor hepaticus -- must smell from all of the urea

Question 26

What would be used to diagnose a patient with cirrhosis?

Answer 26

* —CBC; serum electrolytes * —Serum albumin * —Liver function tests * —Prothrombin times * —Stool for occult blood * —Esophagogastroduodenoscopy (EGD) * —Liver biopsy * —Liver scan * —Liver ultrasound * —Angiography

Question 27

How would you manage a patient with cirrhosis?

Answer 27

* —Rest – depends upon stage & S&S * —Nutrition * —Skin care * —Reduce risks for injury * —Monitor for bleeding * —B complex, folate acid; ferrous sulfate * —Vitamins – especially K * **—Avoid: alcohol, aspirin, NSAIDs, acetaminophen** * **—For ascites – Na+ restricted to 400-800 mg/day** * **—If poor response to Na+ restriction** * **—Spironolactone (Aldoctone) spares K+ & Furosemide (Lasix) wastes K+** * May restrict protein initially * —Re-introduce protein; daily 1.2 gm/kg/day * —Small frequent meals - high carbohydrate, low Na+ & protein; bedtime snack * —**Medications: lactulose (helps get rid of ammonia and fluid); oral antibiotics** * —Discontinue sedatives, analgesics, tranquilizers * Monitor for complications & infections.

Question 28

What are some complications with cirrhosis?

Answer 28

* **—Upper GI bleed** * —Infections * —Hypokalemia * —Azotemia * —Drug side effects * —Too high protein ingestion * —Constipation

Question 29

What are some characteristics of variceal hemorrhage?

Answer 29

* —1/3 of persons with varicies * —1st bleeding episode – mortality of 30-50% * —Manifestations: * —Hematemesis * —Melena * —Hypovolemic shock * —Avoid alcohol, aspirin, irritating foods * —Report chronic coughing & URIs for Rx * Rx - endocsopic sclerotherapy or banding

Question 30

How would you manage a patient with variceal hemorrhage?

Answer 30

* —Needs intensive care setting * —Hemodynamic support * —Balloon tamponade * —NG tube & gastric decompression * —02, IV fluids, electrolytes, volume expanders * —Blood; blood products * —Medications: * —Somatostatin (Octretide) – preferred, causes vasoconstriction of the splenic vessels * —Vasopressin * —Monitor: * —Hemodynamic function * —Patient condition; associated symptoms * —Treatments including tube care & GI suction * —Oral care; I & O * —Implement measures to reduce anxiety & agitation * —Quiet calm environment; reassurance * —Education & support – family & pt.

Question 31

What are the clinical manifestations of a Hepatocellular Carcinoma?

Answer 31

* —May be asymptomatic * —Abdominal pain * —Anorexia, weight loss * —Weakness/malaise * —Anemia * —Jaundice * —Enlarged; irregular liver * —Cirrhosis symptoms * —Hepatomegaly * —Abdominal bruits * —Ascites * —Splenomegaly * —Weight loss; muscle wasting * —Fever * —Chronic liver disease signs

Question 32

What are some riskfactors for cholelithiasis?

Answer 32

* **—High:** * —Multiparous women \> age 40 * —Obesity * —Native Americans * —**Others: ** * —Estrogen therapy * —Diabetes mellitus * —Cirrhosis, hemolysis * —Infections of biliary tract * **—Rapid weight loss; frequent weight changes**

Question 33

What are the manifestations of a choleliathiasis (gall stones)? -- uncomplicated

Answer 33

* —Most asymptomatic * —If symptomatic: * —**Pain following fatty meal – ½ hr. – 6 hrs.** * —N/V; diaphoresis * —_Not_ exacerbated by movement; squatting, bowel movements or passage of flatus * —Several attacks before seeking medical attention * May have refered pain in the shoulder

Question 34

What are they atypical syptoms of cholelithiasis?

Answer 34

* —Chest pain * —Nonspecific abdominal pain * —Belching, fullness after meals; early satiety * —Abdominal distention/bloating * —Epigastric or retrosternal burning * —N/V without biliary colic

Question 35

What are the manifestations of a complicated cholelithiasis

Question 36

What causes cholecystitis?

Answer 36

—Causes: * —With obstruction; without obstruction (acalculous cholecystitis) * —Bacterial --\> ecoili * —Neoplasms * —Anesthesia * —Opioids * —Inflammation * —Extensive fibrotic tissue * — * —

Question 37

What are the manifestations of choleystitis?

Answer 37

* —Fatty food ingestion 1 hr. + before initial pain onset * —Nausea/vomiting; diaphoresis * —Fever, tachycardia * —RUQ abdominal tenderness * —**Possible + Murphy’s sign** * —Guarding; rebound * —Jaundice (25%) * —May resolve in 7-10 days without treatment * —Possible complications

Question 38

What are some diagnostic tests done for choloecystitis?

Answer 38

* —CBC; WBC with differential * —Liver function tests; total bilirubin * —Serum amylase – they want to rule out any pancreatitis

Question 39

How would you manage a patient with cholelithiasis?

Answer 39

—Diet - ↓ fat, ↑protein, ↑carbohyrates —Medical dissolution therapy * —Ursodeoxycholic acid (UDCA) * —Ursodiol (actigall) * —Chenodeoxycholic acid (CDCA or Chenix) —Other dissolving options: * —Methyl tertiary terbutyl ether (MTBE) * —Oral drugs - bile salts —Nonsurgical removal: * —Endoscopic sphincterotomy ( ERCP) — * Intracorporal – mechanical shock waves Extracorporal shock wave lithotripsy (ESWl) — Surgical removal:

Question 40

What are some nursing interventios for patients with biliary disorders?

Answer 40

* —Assess and manage pain * —Oral care – especially if N/V * —Interventions for pruritis * —Personal hygiene as needed * —Intake & output * —Monitor for hemorrhage * —Assess; monitor for infection * —Assess – signs of obstruction

Question 41

What are some nursing interventions for post-op care with biliary disorders?

Answer 41

* —Low Fowler’s position * —NG tube to suction; IV fluids; I & O * —NPO; then soft, low-fat, high carbohydrate diet * —Maintain skin integrity; assess & promote biliary drainage if T-tube in place. * —Analgesics for pain; assess pain relief * —Encourage coughing & deep breathing * —Progressive ambulation * —Monitor & evaluate potential complications

Question 42

What causes acute pancreatits?

Answer 42

**Major causes:—** * **Gallstone - ~45%** * —Chronic alcohol abuse - ~30% * —Hyper-triglycerides – 3rd most common cause 1000mg/dl + Other causes: * —Endoscopic retrograde cholangiopancreatography (ERCP) * —Trauma * —Postoperative * —Drugs —Sphincter of Oddi dysfunction

Question 43

How is a patient diagnosed with acute pancreatitis?

Answer 43

**—Diagnostic criteria - ≥ 2 of the following:** * —Typical abdominal pain * —Amylase/lipase \> 3x UL * —Confirmatory findings on US/CT imaging

Question 44

What are the clinical manifestations of acute pancreatitis?

Answer 44

* —Onset - abrupt * —Pain * —Systemic: Fever, tachycardia, hypotension, pallor, diaphoresis, N&V, weakness * —Abdomen – tender, most often no guarding, rigidity or rebound; distention, no bowel sounds * —Anxious— * —Looks acutely ill; may sit with trunk flexed & knees flexed * —N/V; diaphoresis; fever * —Hypotension; shock * —Abdominal wall discoloration – Gray Turner’s; Cullen’s sign * —Diminished or absent bowel sounds * —Dyspnea; hypoxia * —Jaundice * —Renal failure * —Confusion &/or agitation

Question 45

What are some laboratory diagnostic tests for acute pancreatitis?

Answer 45

* —CBC with differential; * —Electrolytes * —Ca++ * —Lipids, BUN, Sr. Creatinine, LFTS * —Prothrombin; other coagulation tests * **—Serum amylase (20-110 U/L)** * **—Serum lipase (0-160 U/L)** * —Blood glucose * —Arterial Pa02 – hypoxemia

Question 46

How would you manage a patient with acute pancreatitis?

Answer 46

* —Fluid replacement; electrolytes -- use calloids * —Frequent hemodynamic monitoring * —Analgesia with parenteral opioids * —**Maintain/monitor urine output \>0.5cc/kg/h** * **—Bedrest**, NPO, frequent oral care; skin care * —I & O * —Position – for comfort & respiratory effort * —Manage & stabilize metabolic complications * —Monitor for possible complications

Question 47

What kind of nutrition plan will a patient with acute pancreatitis be on?

Answer 47

* —NPO – initially; begin PO intake when no pain, no N/V, + bowel sounds, pt. hungry * —Bland - small, frequent feedings – ↑ protein; ↑ carbohydrate, ↓fat – solid preferred if at all possible. * —Supplemental fat soluble vitamins; nutritional drinks * —Nasograstric feedings if unable to take PO * **—No caffeine or alcohol**

Question 48

What are some medications used for acute pancreatitis?

Answer 48

* —Analgesia – morphine, dilaudid * —Antibiotics – only with infections * —Others medications tried – H2 blockers, glucagon, antacids, have not proven to be effective * —PPIs may still prescribed to prevent stress ulcers * —Most recently, NSAIDs via the rectal route has been proven to be most beneficial following ERCP

Question 49

What are the 2 types of chronic pancreatitis?

Answer 49

1. —Chronic obstructive pancreatitis 2. —Chronic calcifying pancreatitis/alcohol induced

Question 50

What are the clinical manifestations of chronic pancreatitis?

Answer 50

* —Two primary symptoms – abdominal pain & pancreatic insufficiency * —Abdominal pain * —Pancreatic insufficiency * —Malabsorption * —Pancreatic diabetes

Question 51

How would you manage a patient with chronic pancreatitis?

Answer 51

* —Prevent further attacks * —**No alcohol!** * —Pain relief * —Diet – bland, ↓ fat, ↑ carbohydrate; protein * —Endocrine insufficiency may result from islet cell destruction which leads to diabetes * —Periodic blood glucose assessments; insulin may be required * —**Exocrine insufficiency typically manifests as weight loss and steatorrhea** * —If steatorrhea present, a trypsinogen level \< 10 is diagnostic for chronic pancreatitis * —Manage with low-fat diet and pancreatic enzyme supplements (Pancrease, Creon) with meals & with a PPI

Question 52

What are the manifestations of a pseudocyst?

Answer 52

* —Most asymptomatic * —Abdominal pain, duodenal or biliary obstruction * —Vascular occlusion or fistula formation * Spontaneous infection with abscess formation

Question 53

How would you manage a patient with a psuedocyst?

Answer 53

* —If small – follow up one year until cyst becomes about 12 cms * —Drainage & stenting if indicated

Question 54

What are some disorders of the anterior pituitary gland?

Answer 54

* Disorders * Tumors are the most common cause of primary anterior pituitary disorders * Usually benign * Produce symptoms of hypersecretion of 1 or more hormones * #1 prolactin * #2 Growth hormone * Growing mass can produce neuro symptoms from increased ICP

Question 55

What are some disorders asssociated with the posterior pituitary gland?

Answer 55

* SIADH * Diabetes insipidus

Question 56

What are some clinical findings associated with pituitary tumors?

Answer 56

* Headache * hemianopia * loss of visual acuity * blindness due to pressure exerted on the dura and optic chiasm * Disorder of target organ (ie, cushing’s syndrome)

Question 57

What is hypopituitarism?

Answer 57

* Is a partial or complete loss of the anterior lobe’s function. * Affects the function of endocrine glands that are stimulated by anterior pituitary hormones. * Can be deficit of one hormone or all * Deficient in LH & FSH

Question 58

What causes hypopituitarism (anterior pituitary)?

Answer 58

**Primary:** * pituitary tumors * inadequate blood supply to the pituitary * infections or inflammatory diseases * sarcoidosis or amyloidosis * irradiation * surgical removal of pituituary tissue * Sheehan syndrome * autoimmune disease **Secondary:** * tumors of the hypothalamus surgical damage to pituitary * inflammatory diseases * **head injuries**

Question 59

What are the manifestations of a patient with hypopituitarism?

Answer 59

**Manifests two ways:** * Hyposecretion of the target organ * S/S of a growing pituitary tumor **•Headaches** **•Visual changes (either peripheral or central vision)** * Anosmia * Seizures

Question 60

What is hyperpituitarism (anterior) and what causes it?

Answer 60

* An oversecretion generally of prolactin or growth hormone. * Most commonly caused by a benign tumor such as adenoma * In adults - begins between ages 30-50 which is after the end plates of the bones have closed. * Bones become deformed rather than enlongated.

Question 61

What is prolactin hypersecetion?

Answer 61

* Prolactin Hypersecretion - most common endocrine abnormality caused by hypothalamus- pituitary disorders. * Most common cause are pituitary adenomas * Prolactin - necessary for lactation. * Causes: physiological, pathological, pharmacological

Question 62

What are the signs and symptoms of prolactin hypersecretion?

Answer 62

* galactorrhea * amenorrhea * decreased libido * erectile dysfunction

Question 63

What is the treament for hyperpituitarism?

Answer 63

* Surgery - outcomes based on size of tumor & basal prolactin level. * Medical tx * Bromocriptine or Cabergoline- dopamine agonist that stimulates dopamine receptors and affects both the hypothalamus and pituitary levels. Works by inhibiting PRL secretion by tumor.

Question 64

What is acromegaly?

Answer 64

* Occurs in pituitary gland produces excess growth hormone in the adult. * Occurs after the epiphyseal plates have closed. * First noticed in hands and feet (excessive growth of soft tissue) * **Gigantism in children**

Question 65

What are the signs and symptoms of acromegaly?

Answer 65

* Swelling of feet and hands * Facial features coarse as bones grow * increased perspiration * protruding jaw * voice deepens * enlarged lips, nose, & tongue * thickened ribs (barrel chest) * joint pain * Degenerative arthritis * enlarged heart * enlargement of other organs * Peripheral neuropathies * Proximal muscle weakness * **Snoring/ sleep apnea -- because of the growth of the tounge** * fatigue & weakness * headaches * loss of vision * irregular menstrual cycles * breast milk production in women * impotence in men

Question 66

What are the long term effects of acromegaly?

Answer 66

* Joint pain - leads to crippling degenerative arthritis * Heart enlarged and impaired - leads to failure * Tissue compresses on nerves - pain, loss of visual fields * Headaches

Question 67

How would you treat acromegaly?

Answer 67

* Surgery to remove the tumor - hypophysectomy **(1st line)** * Radiation * Drug therapy- octreotide (Sandostatin) – reduces GH levels * Given SC 3Xs weekly * Diet - may dev. DM or carbohydrate intolerance * CHF - salt restriction

Question 68

What is SIADH and what does it result in?

Answer 68

* Occurs despite normal or low plasma osmolarity * Results in fluid retention, serum hypoosmolality, dilutional hyponatremia, hypochloremia, concentrated urine with normal renal function

Question 69

What are the manifestations of SIADH?

Answer 69

* Decreased Na+ and Cl- levels * Muscle cramping, pain, weakness, risk for seizures * **Na+ (\< 120 mEq severe vomiting, abdominal cramps, muscle twitching seizures)** * Stimulation of thirst, DOE, fatigue * Decreased urine output and weight gain * Decreased plasma osmolality **– can lead to cerebral edema --\> increased ICP** * Diagnostic – sodium level, urine and serum osmolality, urine specific gravity (\> 1.005)

Question 70

What are the nursing interventions for patients iwth SIADH?

Answer 70

* Frequent vital signs, LOC * **Daily weights, assess heart & lungs** * **Assess S/S hyponatremia,** * **Seizure precautions** * Position HOB flat or \< 10degree elevation * **Frequent oral hygiene - because they are going to feel thirsty** * **Maintain fluid restriction (800-1000ml per day)**, strict I & O * If sodium is \< 120, they will give a hypertonic fluid

Question 71

What is diabetes insipidus and what causes it?

Answer 71

* DI is a syndrome of altered water balance in which ADH is deficient or there is a renal resistance to its effects. * **Caused primarily by inadequate secretion of ADH.** * Neurogenic or central DI * Nephrogenic or renal DI

Question 72

What causes central DI?

Answer 72

linfections of meninges, head injury, surgery of the Hypothalamus- pituitary, amyloidosis, TB

Question 73

What causes Nephrogenic DI?

Answer 73

**Physiologic:** * familia, sarcoma, multiple myeloma, SCD, CF, electrolye disturbances such as hypercalcemia or hypokalemia **Drugs:** * aminoglycosides, foscarnet, lithium, amphotericin B, cisplatinum, **demeclocycline (helps treat SIADH)**, rifampin

Question 74

What are the signs and symptoms of DI?

Question 75

What are some lab findings for DI?

Answer 75

Serum chemistry * Increased serum osmolality _\>_ 295 mOsm/kg * Increased serum sodium _\>_ 148 mEq/L Urinalysis * Decreased urine osmolality 50-100 mOsm/kg * Decreased urine sodium _\>_ 20 mEq/L * Specific gravity 1.005 * Urine volume - _\>_ 6 liters per day

Question 76

How would you manage a patient with DI?

Answer 76

* Correct underlying cause * Medications * Desmopressin (DDAVP) intranasally. * Aqueous vasopressin (Pitressin) SC or IM * short acting agent (4-6 hours) * Diabinese, **tegretol** can be tried * Nephrogenic DI – low-sodium diet, thiazide diuretics, indomethacin

Question 77

Describe fluid therapy for DI patients?

Answer 77

* Hypotonic saline such as 1/4 or 1/2 strength saline. * Titrated to hourly uop. * Titration may be 500 ml uop for 1 hour is replaced by 500 ml of IV fluid bolus the next hour.

Question 78

What 3 hormones does the thyroid secrete?

Answer 78

* Thyroxine (T4) - regulate cell metabolism & energy production, influence growth & development, & affect cell differentiation in the fetus. * Triiodothronine (T3) * Calcitonin - increases calcium deposits in bones, decrease serum calcium levels.

Question 79

What is hyperthyroidism and what causes it?

Answer 79

* An increased production and secretion of thyroid hormone from thyroid gland. * **Causes:** * Grave’s disease (most common, 60-90%) * Plummer’s disease (toxic multinodular goiter) * Thyroiditis

Question 80

What is grave's disease

Answer 80

* **Most common cause of hyperthyroidism** * Autoimmune disorder * Affects women more than men * **Characterized by:** * diffuse goiter * hyperthyroidism * infiltrative ophthalmopathy * infiltrative dermaopathy

Question 81

What is plummer's disease?

Answer 81

* Presents with multiple nodules and a milder form of hyperthyroidism * More common in persons over 40 yrs. * Not autoimmune

Question 82

What is thyroiditis and what causes it?

Answer 82

* inflammation of the thyroid gland. * Can lead to release of excess amounts of thyroid hormones *

Question 83

What are some characteristics of hyperthyroidism?

Answer 83

* Increased metabolic rate, heat production, O2, peripheral vasodilation * Altered CHO, protein, & fat metabolism * **Increased body temp., Intolerance to heat, Warm & moist skin, increased appetite, metabolic fatigue, weight loss, muscle weakness** * **Blood glucose elev, decreased triglycerides, and cholesterol, hepatic dysfunction, increased # of stools** * They will develop hyperglycemia * Diarrhea * Altered CV functioning - hypermetabolic and adrenergic state * Increased myocardial oxygen consumption, shortened systolic interval, increased cardiac output * Tachycardia, palpitations, increased blood pressure, dyspnea, angina, atrial fib, CHF * Nervousness, restlessness, decreased attention span, insomnia, emotional lability

Question 84

What are the clinical manifestations of hyperhyyroidism?

Answer 84

* Feeling nervous, irritable, & excitable * Increase appetite with progressive weight loss * Heat intolerance with frequent perspiration * Exophthalmos (bulging eyes) from decreased venous drainage * Enlarged thyroid or goiter * Dyspnea * Insomnia * Amenorrhea * Tachycardia (90-160 beats/min) * Increase in systolic BP

Question 85

What are the symptoms of thyrotoxicosis?

Answer 85

* nervousness, hyperexcitable, irritable, apprehensive * Palpitations * Heat intolerant - perspire freely * skin flushed continuously * fine tremor of hands * startled facial expression (exophthalmos)

Question 86

How can you diagnose a patient with hyperthyroidism?

Answer 86

* Decreased TSH levels (becuase the thyroid is producing too much) * **Elevated free T4 levels** * Radio active iodine to differentiate Graves disease from other forms of thyroiditis

Question 87

How do you treat patients with hyperthyroidism?

Answer 87

* **Anti-thyroid drugs - Propulthiouracil (PTU) or methimazole.** * Usually will control problem within a few weeks. * Radioactive iodine - most widely recommended permanent treatment of hyperthyroidism. * Acts relatively quickly * If they take this they will be on life long synthroid (**DON'T TAKE VITAMINS WITH THIS DRUG)** * Surgical removal * Symptom management - beta blockers

Question 88

What are some nursing diagnoses associated with hyperthyroidism?

Answer 88

* Altered nutrition RT exaggerated metabolic rate, excessive appetite, & increased GI activity * Avoid giving anything that can cause diarrhea * Avoid caffiene * * Ineffective coping RT irritability, hyperexcitability * Altered body temperature * Disturbance in self-esteem RT to changes in appearance, excessive appetite, & weight loss

Question 89

What is hypothyroidism and what causes it?

Answer 89

* A decrease in the secretion of thryoid hormone. * May be caused by an interference with thyroid hormone production or a reduction in thyroid mass.

Question 90

What is hashimoto's thyroiditis?

Answer 90

* An autoimmune process where the thyroid enlarges and becomes inefficient in converting iodine into thyroid hormone and compensates by enlarging. * TSH levels will be high * T4 levels low * Thyroid antibodies in 95% of patients

Question 91

What are the signs and symptoms of hypothyroidism?

Answer 91

* Fatigue * Weight gain * Anorexia * Intolerance to cold * Constipation * Dry skin & brittle nails * Swollen eyelids * Coarse, dry hair * Decreased libido * Memory loss * Irritability * Abnormal menstrual cycles

Question 92

What are some nursing diagnoses associated with hypothyroidism?

Answer 92

* Activity intolerance RT fatigue & depressed cognitive process * Altered body temperature * Constipation RT depressed GI function * Altered thought process RT depressed metabolism & altered CV and respiratory status

Question 93

How would you diagnose hypothyroidism and how would you treat it?

Answer 93

* §Primary – Increased TSH level * lDecreased free T4 level * lIncreased cholesterol, LDL, triglycerides * l * §Levothyroxine (synthroid) = DOC * lOlder patients – need to know their cardiac status

Question 94

What is hyperparathyroidism and what causes it?

Question 95

What are the signs and symptoms of hyperparathyroidism?

Answer 95

* muscle weakness * Loss of appetite * Fatigue * Constipation * Emotional disorders * Shortened attention span * Osteoporosis, fractures, kidney stones

Question 96

How would you diagnose hyperparathyroidism?

Answer 96

* Bone x-rays * Lab tests to measure calcium & parathyroid hormone levels

Question 97

How would you treat hyperparathyroidism?

Answer 97

* 1st priority - control elevated calcium levels --\> give bisphosphonates * Removal of gland * Low calcium diet

Question 98

What is hypoparathyroidism?

Answer 98

* Characterized by too little parathyroid hormone production * Leads to decreased levels of calcium (hypocalcemia) & increased levels of phosphorus (hyperphosphatemia) * Very rare condition * usually caused because of loss of active tissue following thyroid or parathyroid surgery.

Question 99

What are the signs and symptoms associated with hypoparathyroidism?

Answer 99

Clinical signs 2nd to hypocalcemia * neuromuscular excitability, irritability, & muscle cramping (tingling in hands, fingers, & around mouth; severe - tetany) Other symptoms * Nausea, vomiting, diarrhea, & abdominal cramping * Acute - can cause tetany (tonic spasms in the upper and lower extremities accompanied by pain)

Question 100

What is chovstek's sign?

Answer 100

* Elicited by tapping the patient’s face lightly over the facial nerve. * Facial muscle twitching indicates a positive finding. * Indicates hypocalcemia & occurs with hypomagnesia

Question 101

What is trousseau's sign?

Answer 101

* Elicited by grasping the patient’s wrist or inflating the blood pressure cuff on the upper arm to constrict the circulation for a few minutes. * Palmar flexion is a positive finding. * Indicative of hypocalcemia & hypomagnesia

Question 102

What are the treatments for hypoparathyroidism?

Answer 102

Treatment * Replacement of Calcium & vitamin D * Calcium supplementation of 1.5-3 g/day * Vitamin D – preferred preparations (Calcatrol) * Diet – high in Ca++ * lTofu, dark green vegetables, soybeans * **Acute tetany - calcium gluconate IVP**

Question 103

Describe the care for a hypophysectomy

Answer 103

* Transsphenoidal approach used * avoids disturbing the cranium * incision is performed in upper gum line * Pre-operative care * sinuses are cleansed and antibiotic spray applied * Cortisol given to tolerate stress * After gland removed - muscle graft from anterior thigh used to pack dura and prevent leakage of CSF. * Nasal packing inserted after incision closed * Mustache dressing applied

Question 104

Describe post op care for hypothysectomy

Answer 104

Neurological assessment * Assess for s/s of target gland deficiences * •**Diabetes insipidus (DI), Addison’s disease, hypothyroidism** * **Avoid coughing, sneezing, or blowing nose - CSF leak** * **•encourage deep breath instead** * Strict I & O * Oral hygiene * NO toothbrush for 2 weeks * •provide oral rinses and dental floss * **Assess for meningitis (HA, Inc. temp, nuchal rigidity)** * After packing removed- observe for rhinorrhea * Monitor nasal drip for glucose (\> 30 mg/dL) * Avoid bending at the waist * Prevent constipation * Elevate HOB (at least 30 degrees at all times) * Teach patient he may have anosmia for 3-4 months * Lifelong replacement of cortisol (if total) or vasopressin for DI.

Question 105

How would you care a patient having a thyroidectomy pre op?

Question 106

What are some nursing interventions post op for a patient with a thyroidectomy regarding ineffective breathing patterns?

Answer 106

* Assess respiratory status * Observe for bleeding * Record amount/type of wound drainage * Monitor proper functioning of drains * Monitor patient’s neck for enlarging mass * Assess cough, swallowing, and aspiration * Maintain tracheostomy tray readily available

Question 107

What is acute thyrotoxicosis and what causes it?

Answer 107

**It is severe manifestations of hyperthyroidism, with symptoms of:** * elevated temperature * increased tachycardia * onset of dysrhythmias * worsening tremors * worsening mental status * Abdominal pain * (Delirium) **Causes:** * Grave’s disease * nonadherence to prescribed therapy

Question 108

What is the primary focus with acute thyrotoxicosis?

Answer 108

**The Primary focus is fever (ie, 105 F) & cardiovascular changes:** **Maintain cardiac output:** * Monitor CV status q 1hr * Report changes such as tachycardia, dysrhythmias, s/s of CHF linitially see atrial fibrillation * Decrease cardiac workload by decreasing physical & emotional stressors. **Maintain normothermia:** * Monitor temperature q 1 hr. * use external cooling devices. * Maintain room temp in cool range. * **DO NOT give salicylates (aspirin). Only Tylenol.**

Question 109

What are some nursing interventions for acute thyrotoxicosis?

Answer 109

* Administer oral propylthiouracil (PTU) as ordered. * Administer iodine preps as ordered - maybe IV or PO. * Administer dexamethasone as ordered. * Administer propranolol as ordered. * Other supportive therapy: O2, cardiac glycosides, etc.

Question 110

What is a myxedema coma, and what are some problems that develop because of it?

Answer 110

**It is a severe form of hypothyroidism that leads to:** * Develop respiratory problems (usually cause of death) * function impaired by large tongue and sleep apnea * respiratory effort decreased by hypoxic & hypercapneic ventiatory drives and respiratory mm weakness. * Develop cardiac problems * cardiac output low because of bradycardia & low stroke volume; may develop CHF * Treatment: supportive * Administer L-thyroxine (thyroid hormone) IV

Question 111

What hormones does the adrenal cortex secrete?

Answer 111

* glucocorticoids (cortisol) * mineralcorticoids (aldosterone) * sex steroid hormones

Question 112

What hormones does the adrenal medulla secrete?

Answer 112

* NE Epinephrine

Question 113

What is addison's disease and what causes it?

Answer 113

**It is a disorder characterized by decreased:** * mineralocorticoids * glucocorticoids * androgen secretion **Autoimmune process responsible for 80% of all cases - results in atrophy of gland.** * 90% of adrenal cortex destroyed before see manifestations * Most significant deficiencies are cortisol & aldosterone

Question 114

What are some characteristics of addison's disease?

Answer 114

* Clinically rare disease * Seen in persons 30-50 years old * **More common in women**

Question 115

What are the manifestations of addison's disease?

Answer 115

**Hyperkalemia - K+ levels of more than 7 meq/L** * aldosterone deficiency affects the ability of the distal tubules of the nephrons to conserve Na+, therefore Na+ is lost, and K+ is retained. * Leads to arrhythmias and possibly cardiac arrest. **Hypotension, decreased cardiac output, tachycardia, decreased heart size:** * Na+ & water excreted - leads to- dehydration - which leads to - hypotension * Decreased heart size - microcardia diminished workload of heart. Can lead to circulatory collapse, shock and death. **Decrease in glucocorticoids:** * Metabolic disturbances - glucocorticoids have an “anti-insulin” effect. * Gluconeogenesis - decreases with resultant hypoglycemia & liver glycogen deficiency. * Client grows weak, exhausted, and suffers from anorexia, wt. Loss, and N/V * Decreased resistance to stress **Increased ACTH leads to Increased MSH:** * stimulates the epidermal melanocytes - which- increases skin pigmentation and mucus membranes * Have a tanned or bronze appearance * Mood changes - delusional thinking, difficulty with stress, lethargic, apathetic, depressed, forgetful, emotionally labile

Question 116

What are some nursing interventions for hypoaldosteronism?

Answer 116

* Vital signs frequently- monitor for * hypotension, tachycardia, tachypnea * Fluid volume deficit * watch uop and report \< 30cc/hr * fluid replacement

Question 117

How would you treat hypoaldosteronism?

Answer 117

**cortisol replacement- life long replacement** * Fludrocortisone (Florinef) - mineralocorticoid * promotes inc. reabsorption of Na+ and loss of K+, H2O, H+ from distal renal tubules

Question 118

What would you teach a patient with hypoaldosteronism regarding their medications?

Answer 118

* **Take daily glucocorticoid in divided doses (2/3 on awakening in AM & 1/3 late afternoon)** * take medication with snack or meal * increase dose as directed for increased physical stress * never skip a dose; if sick notify MD * always wear Medic-Alert bracelet * learn how to administer emergency IM injections of hydrocortiosone

Question 119

What is Adrenocortical hyperfunction (Cushing syndrome & Cushing disease)?

Answer 119

* Cushing syndrome occurs from chronic over exposure to excess cortisol. ↓ feedback inhibition by cortisol on CRH & ACTH secretion * Cushing disease occurs from over production of pituitary ACTH by a pituitary adenoma. * Can also be caused by hyperaldosteronism

Question 120

What are the effects of prolonged increases in Cortisol levels?

Answer 120

* ↓ feedback inhibition by cortisol on CRH & ACTH release which leads to low levels of ACTH which leads to adrenal cortex atrophy which leads to ↓ cortisol secriton * Loss of diurnal variation in cortisol secretion

Question 121

What are the clinical manifestations of Cushing syndrome/disease?

Answer 121

* Bone effects * Weight gain * Glucose intolerance * Protein wasting

Question 122

Describe the bone effects of cushing's disease/syndrome ## Footnote

Answer 122

* ↑ bone resorption * ↓ bone formation & ↓ Ca++ absorption (intestine) * ↑ renal Ca++ excretion (hypercalciuria → kidney stones) **All of these factors contribute to osteoporosis**

Question 123

Describe the effects of cushing's disease/syndrome on weight

Answer 123

Weight gain – fat deposition & transient Na+ & H2O retention (from mineralcorticoid effects of high cortisol)  Facial (moon face)  Cervical (buffalo hump)  Truncal (central obesity)

Question 124

Describe the glucose intolerance associated with cushing's disease/syndrome

Answer 124

* Cortisol-induced insulin resistance * ↑ gluconeogenesis & glycogen storage by liver

Question 125

Describe the protein wasting associated with cushing's disease/syndrome

Answer 125

Catabolic effects of high cortisol on peripheral tissues leads to muscle wasting

Question 126

What are the complications associated with cushings disease/syndrome?

Answer 126

* ↑ cortisol → ↑ vascular sensitivity to catecholamines → vasoconstriction/↑ BP * Metabolic syndrome (central obesity, hypertension, glucose intolerance, dyslipidemias) * Infections from immune system suppression * Altered mental status (irritability, depression, psychiatric disorders) from cortisol effects on hippocampal neurons * Hyperglycemia, glycosuria, hypokalemia, metabolic alkalosis

Question 127

Who is at risk for cushings disease / syndrome?

Answer 127

* Take glucocorticoids more often than once every other day * Have been taking glucocorticoids for longer than 3 weeks. * Use long acting meds. such as dexamethasone * Take parenteral preps of steroids * take doses above what is needed * Take doses after 4 pm

Question 128

How would you manage patients with cushing's syndrome?

Answer 128

* Fluid restriction Intake & output * Medications that interfere with ACTH production may be used for palliation. * If cause is a pituitary adenoma * use surgery (hypophysectomy) or radiation * If adrenal adenoma or carcinoma * adrenalectomy

Question 129

What are some nursing interventions for patient's with cushing syndrome?

Answer 129

* Decrease controllable stressors * Monitor physiological coping ability * Monitor VS q 2-4 h especially for HTN and Inc. HR * Monitor blood sugars **Control fluid volume excess** * Restrict fluids as prescribed; distribute fluids over 24 h.; use ice chips to prevent thirst. * Provide low sodium diet * Provide K+ supplement as required. * Monitor daily weight, I & O, daily labs (Na+, K+, pH). **Prevent falls & infection** * Temperature q 4h * assess mouth, lungs, skin, GU tract for s/s infection * Limit staff & visitors with s/s of URI * preventive measures - TCDB, oral hygiene q 2h, etc

Question 130

What causes Hyperaldosteronism?

Answer 130

* Adrenal tumor, excessive cortex stimulation (angiotensin II, ACTH, ↑ K+), mineralcorticoid excess, adrenal hyperplasia * Primary (adrenal cortex) * Secondary (extra-adrenal, e.g., ↑ renin release/activation of angiotensin II, diuretic use) * continuous excessive secretion of aldosterone leads to higher levels of angiotensin II * mechanical obstruction of renal vessels (renal stenosis) * renin-secreting tumors

Question 131

What are the manifestations of hyperaldosteronism?

Answer 131

* HTN, **hypokalemia, Hypernatermia** * ↑ Na+, * hypervolemia * metabolic syndrome (HTN, obesity, dyslipidemia, hyperglycemia), * metabolic alkalosis, * ↑ urinary K+, * No edema – Na+ excretion rate “reset”

Question 132

What are the clinical signs and symptoms of hyperaldosteronism?

Answer 132

* headache * fatigue * muscle weakness * nocturia * loss of stamina * Paresthesias may occur if K+ depletion * Dysrhythmias * Metabolic alkalosis (tetany)

Question 133

How would you manage patient's with hyperaldosteronism?

Answer 133

* surgery * adrenalectomy which may be unilateral or bilateral * Must get K+ in normal range * –give K+ sparing agent (spironolactone) * –drug is aldosterone antagonist to promote fluid balance * Low sodium diet * glucocorticoids replacement with surgery

Question 134

What is pheochromocytoma?

Answer 134

**Is a catecholamine-producing tumor that arises in chromaffin cells.** * Most common are unilateral & on right side. * Must benign; 10% malignant. * Accounts for 0.1% of HTN * Women, 40-60

Question 135

What effect does the tumor have with a patient with pheochromocytoma?

Answer 135

**Tumor synthesizes epinephrine & norepinephrine. Excessive catecholamines stimulate alpha & beta receptors and can have a wide range of adverse effects.** * Tachycardia * Peripheral vasodilation * Bronchodilation * Increased myocardial contractility * Glycogenolysis * Free fatty acid secretion

Question 136

What are the clinical manifestations of pheochromocytoma and how would you diagnosis it?

Answer 136

**Presents with:** * severe headaches * palpitations * profuse diaphoresis * flushing * apprehension or feeling of impending doom * Pain in the chest N/V Diagnosis: 24 hr urine collection of metanephrines -a byproduct of catecholamine metabolism – 95% pts. +

Question 137

How would you manage patients with pheochromocytoma?

Answer 137

§Management lSurgery is the treatment of choice. Postoperative care is like patient who undergoes an adrenalectomy. •Short-acting alpha-adrenergic blocking drug used to control HTN during surgery lPreoperative * Goals: adequate tissue perfusion, nutritional needs, comfort * Hypertension is the hallmark - take regular BP lying & sitting –avoid smoking, caffeine, do not change position quickly-effect BP –Alpha-adrenergic blocking drugs used to bring HTN under control before surgery