Chapter 6 assessment Flashcards
Does the endocrine system have non-specific manifestations? What are the examples? (3)
Yes, it often has non-specific manifestations. Examples: Fatigue, altered mood, sleep pattern
Why is a detailed health history important?
Lack of clear manifestations makes patient health history useful
What is the function of the thyroid gland? (4)
- Major function is production, storage and release of thyroxine (T4 inactive) and triiodothyronine (T3 active)
- Growth
- Heart rate
- Metabolism
Explain the process the release of T3 in the thyroid gland (negative feedback loop)
Hypothalamus releases TRH, stimulating the anterior pituitary gland which then releases TSH, stimulating the thyroid which releases T4 (inactive) –> T3 (active)
What are the thyroid disorders on a scale? List from Hyperthyroid to Hypothyroidism
Thyroid storm (thyroid crisis), Hyperthyroidism, Euthyroid, Hypothyroidism, Myxedema Coma
What to assess during a thyroid gland assessment? (4)
- Check if thyroid is palpable
- Symmetry
- Tenderness
- Goitre
What are the hyperthyroidism symptoms? Think “FAST” (11)
- Heart beat is rapid and strong, tachycardia
- Nervous, insomnia, rapid thoughts/speech, restless, agitated, rapid speech
- Weak
- Increased temp. (burning lots of calories)
- Weight loss (high metabolic rate)
- Menstrual irregularities/infertility
What happens in the GI while having hyperthyroidism? (4)
- Increase in secretion
- Increase in peristalsis
- Diarrhea
- Hyperactive bowel sounds
How is hyperthyroidism diagnosed? (3)
- History and physical exam
- Blood test for TSH, T4, and if needed T3
- RAIU (radioactive iodine uptake test)
Hyperthyroidism: What would you expect to see for these blood tests if the problem is with the thyroid?
Low TSH and High T4
Hyperthyroidism: What if the problem is in the pituitary or hypothalamus?
High TSH and High T4
If the patient takes a RAIU (radioactive iodine uptake test) and tested positive what does he have?
Grave’s disease
What is the treatment of Hyperthyroidism? (5)
- Methimazole “antithyroid drug”
- B-adrenergic blocker (propranolol often used)
- Radioactive iodine (RAI)
- Surgical - removes significant part of thyroid gland
- Nutritional therapy - high calorie preventing hunger and tissue breakdown, avoid caffeine, highly seasoned food, high fibre foods to decrease abdominal pain
What is HYPOthyroidism and what percentage of the population does it affect?
- Insufficient thyroid hormone - most often autoimmune “Hashimoto’s Thyroiditis”
- 2%
What are the symptoms of hypothyroidism? Think SLOW (9)
- Vital signs change (Low temp. low HR, low CO, low RR)
- Goitre
- Fatigue
- Lethargy
- Constipation
- Weight gain
- Cold intolerance
- Susceptibility to infection
- Mental changes (slowing of thought, memory loss
When does a patient who has hypothyroidism experience symptoms?
Patient must have had thyroidectomy or antithyroid therapy to notice symptoms. Otherwise, it takes months to years for patient to notice.
How to diagnose hypothyroidism? (4)
- History and physical exam
- Blood test for TSH and T4
- May also look for TPO antibodies
- May have high cholesterol & triglycerides, anemia, increased creatine kinase
Hypothyroidism: Why should we look for TPO antibodies?
If TPO antibodies are present it is likely an autoimmune disease
Hypothyroidism: What would we expect to see for these blood tests if the problem is with the thyroid?
High TSH and Low T4
Hypothyroidism: What if the problem is in the pituitary or hypothalamus?
Low TSH and Low T4
Hypothyroidism: Why may a patient have increased creatine kinase?
Due to destruction of skeletal muscle
How is Hypothyroidism treated?(2)
- Pharmacotherapy: Levothyroxine (Synthroid)
2. Low calorie diet to promote weight loss
While on treatment for hypothyroidism what do we need to monitor for? (4)
- Signs of thyrotoxicosis
- A month to take effect
- Increase in insulin requirement
- Lifelong treatment
HYPERthyroid ongoing thyroid treatment: What do we assess for? (3)
- Ongoing symptoms
- Worsening symptoms - associated stressors
- Symptoms of hypothyroidism
HYPOthyroidism ongoing treatment: What do we assess for? (3)
- Ongoing symptoms
- Worsening symptoms
- Symptoms of hyperthyroidism
What do we check for health and physical exam relating to thyroid disorders for “history”? (6)
- “OPQRST” relating to current symptoms
- Review of systems - head to toe
- Reproductive/menstrual history
- Patient and family history - any auto immune diseases?
- Patient past health history - past surgery (thyroid)
- Meds - immigration from iodine-deficient area
What do we check for health and physical exam relating to thyroid disorders for “physical”? (2)
- Vital signs
- General head to toe - inspection, palpation, auscultation
- Head, neck, eyes
- Integumentary
- Respiratory
- Cardiovascular
- Abdominal
- Special assessment - thyroid gland
What does the medulla secrete?
Catecholamines
What does the cortex secrete?
Cortex secretes >50 steroid hormones, collectively known as “corticosteroids”, categorized as:
- Glucocorticoids - Cortisol
- Mineralocorticoids - Aldosterone
- Androgens
What controls the adrenal glands?
Controlled by the hypothalamus - anterior pituitary gland
How does the adrenal gland function?
Hypothalamus releases CRH, which stimulates the A. Pituitary gland which then releases ACTH, which then stimulates the adrenal cortex, which in turn releases corticosteroids, resulting in biologic effects
What is the function of glucocorticoids? (2)
- Maintaining blood glucose
2. Has anti-inflammatory action by suppressing immune system & supportive action to respond to stress
What is the function of Mineralocorticoids (aldosterone)?
- Essential for maintenance of fluid and electrolyte balance
What is the function of androgens? (2)
- Produced and secreted in small but significant amounts
2. Stimulate public and axillary hair growth and sex drive in females
What dose amount is Physiological and Pharmacologic?
Physiological is LOW dose
Pharmacologic is HIGH dose
What is Cushing’s syndrome?
High levels of circulating corticosteroids
What causes Cushing’s syndrome to happen? (2)
- Most common - iatrogenic administration of exogenous corticosteroid in large doses for long periods of time
- 85% of endogenous cause for Cushing’s syndrome is a ACTH secreting tumour in pituitary (Cushing’s disease)
What are the Cushing’s manifestations for Androgen? (3)
- Thinning of hair
- Acne
- Increased body and facial hair
What are the manifestations of Cushing’s for Glucocorticoids? (10)
- Buffalo hump
- Supraclavicular fat pad
- Thin extremities with muscle atrophy
- Thin skin and subcutaneous tissue
- Moon face
- Weight gain
- Pendulous abdomen
- Ecchymosis resulting from easy bruising
- Purple striae
- Slow wound healing
What is the manifestations of Cushing’s for Mineralocorticoids? (2)
- BP
2. Weight gain
How is Cushing’s diagnosed? (2)
- 24 Hour urine free cortisol - Cortisol release follows a circadian rhythm so this will catch it at different times of day (very hard to do, if one time gets thrown, you will have to do it again (repeat again next day)
- CT or MRI of pituitary and/or adrenals for tumour localization
What is the treatment for Cushing’s? (2) What should never be done r/t treatment? (1)
- If due to corticosteroid use (most common) –> Gradually taper off or switch to alternate-day regimen
- If tumour is culprit, surgical removal of gland or tumour
- NEVER discontinue corticosteroids abruptly
Cushing’s Syndrome: Nursing assessment (6)
Monitor:
- Vital signs (Increase BP, increase HR, hypertension - mineral)
- Daily weight (mineral or gluco)
- Blood glucose (gluco)
- Signs and symptoms of infection - redness, fever, may be minimal (look for high WBC)
- Signs and symptoms of thromboembolic phenomena - increase risk of clotting
- Emotional support
What is the cause of Addison’s disease (auto-immune)? Primary and secondary cause of adrenal insufficiency?
Adrenal gland is not working and lack of endogenous corticosteroids
Primary: Auto-immune (Addison), tuberculosis, CMV, adrenal tumour
Secondary: Pituitary disease, administration of exogenous corticosteroids
What are the primary manifestations of Addison’s? (4)
- Weakness
- Fatigue
- Weight loss
- Anorexia
What are the manifestations of Addison’s? (Non-primary (6)
- Insidious onset, progressive
- Skin hyperpigmentation (high ACTH)
- Reduced Aldosterone: N&V, hypotension, diarrhea (water not retained), hyponatremia, dehydration, hyperkalemia, metabolic acidosis
4 Reduced Cortisol: Decrease blood sugar between meals, weakness & fatigue, decrease in tolerance to stress - Irritability
- Depression
What is the complication for Addison’s during crisis (acute adrenal insufficiency)? (10)
- Life threatening
- Hypotension
- Tachycardia
- Dehydration
- Hyponatremia
- Hyperkalemia
- Hypoglycaemia
- Fever
- Weakness
- Confusion - ALL lead to shock and circulatory collapse
Addison’s is triggered by what? (4)
- Stress
- Sudden corticosteroid withdrawal
- Adrenal surgery
- Sudden pituitary gland destruction
What are the GI manifestations of Addison’s? (3)
- Nausea & vomiting
- Diarrhea
- Abdominal pain
What is the treatment for Addison’s? (3)
- Shock management
- Agressive hypo-cortisone replacement
- Increased salt in diet (due to hyponatremia)
Serum cortisol - What would you expect to find?
Cortisol level is low
- How is Addison’s diagnosed (4)? 2. If the rest result is low cortisol persisting, where would the problem be located? 3. If the test result is a rise in cortisol, where would the problem be located?
- ACTH stimulation test, EKG (related to arrhythmias), CT and MRI
- Adrenal gland
- Brain
What are abnormal Addison’s lab results? (6)
- Hyperkalemia - Not excreted
- Hyponatremia - Excreted due to aldosterone
- Hypoglycaemia - Low glucocorticoids
- Anemia - Lack of B12 due to low intrinsic factor
- Increased BUN - indicates kidney injury - Kidney needs certain blood pressure, hypotension cause low blood in kidney
- Low urine cortisol and aldosterone
What is the dosage for minor stress, major stress and rule for Addison’s treatment?
- Double dose - minor stress
- Triple dose - major stress
- 3X3 Rule - patient 3x dose for 3 days in terms of stress
* *If unsure take higher dose
* *Patient knows in long term
Addison’s: Nursing Implementation (2)
- Frequent assessments
2. Medications: glucocorticoids, mineralocorticoids
What are the two extremes of ADH Dysfunction (posterior pituitary)?
- Syndrome of inappropriate ADH (SIADH) - too much
2. Diabetes Insipidus (DI) - lack of ADH secretion
What is the pathology of SIADH?
Recall: ADH release despite low or normal serum osmolality
- Increased antidiuretic hormone
- Increase water reabsorption in renal tubules
- Increased intravascular fluid volume
- Dilutional hyponatremia and decreased serum osmolality
* Changes in sodium due to dilution (low sodium)
- What are the manifestations of SIADH? 2. What are the symptom related to decrease in Na+ (3)?
- Fluid retention
2A. Muscle cramps, twitching and weakness
2B. Vomiting, abdominal cramping, anorexia
2C. Lethargy, confusion, headache, seizure, coma
*Unique to low sodium
*Compare and contrast sodium symptoms
- How is SIADH diagnosed? 2. What are the other two lab results?
- Simultaneous measurements of serum and urine osmolality
1A. Serum osmolality - decreased, dilute blood
1B. Urine osmolality - increased, very concentrated urine even tho we have high water
2A. Decreased serum Na+ - dilution effect
2B. Decreased Hgb and Hct - Because of dilution effect
SIADH: What should a nurse monitor for? (4)
- Sudden weight gain (fluid retention) - Fluid retention
- Urine with increased concentration
- Change in LOC - associated with low Na+
- Vital signs
What is Diabetes Insipidus (3)?
- Decreased production or secretion ADH (or lack of renal response to ADH) = inability to conserve water
- Peeing a lot
- High sodium due to low water
What are the 3 types of Diabetes Insipidus?
- Central (neurogenic) - interference with ADH synthesis or release
- Nephrogenic - inadequate renal response to ADH
- Primary (psychogenic) - Excessive water intake
What is the pathophysiology of Diabetes Insipidus?
Decreased antidiuretic hormone –> Decreased water reabsorbtion in renal tubules –> Decreased intravascular fluid volume –> Increased serum osmolality (hypernatremia) OR Excessive urine output
Diabetes Insipidus: What are the Manifestations? (8)
- Dying of “thirst”
- Polydipsia (thirsty)
- Abrupt polyuria
- Fatigue
- Constipation - Low water
- Weight loss
- Dehydration
- Decreased LOC, seizures, shock, coma - Hypernatremia
How is Diabetes Insipidus diagnosed? (3)
- History and physical exam - may help determine origin
- Labs: - Urine osmolality/specific gravity - low, extremely diluted
- Serum osmolality - high (or high-normal if
compensating well with oral intake, very
concentrated) - Water deprivation test - stop giving for 8-10 hrs and ADH given, if no change in urine, problem is kidney
How is diabetes insipidus treated? (3)
- Treat primary cause if possible
- Central DI
2A. Acute, hypotonic IV saline to replace urine output
2B. Vasopressin (ADH) - hormone replacement d/t lack of ADH - Nephrogenic DI
3A. Dietary measures (low sodium, <3g daily)
3B. Thiazide diuretics - slows the GFR so theres more, time for kidneys to absorb water
Diabetes Insipidus(vasopressin) Nursing Considerations Monitor (3), Assessment & Client teaching (6)
Monitor: Input/output, daily weights, vital signs (dehydration signs)
Assess:
- Weight gain
- headache
- restlessness
- signs of hyponatremia
- signs of water intoxication
- Will need decreased dose
- increasing dilute urine - will need an increased dose
Clinical manifestations may be
System wide
What is needed for synthesis of thyroid hormones
Iodine
