Class Day I Flashcards
1
Q
What is Cushing’s?
A
- Hypercortisolism
- Caused by an over secretion of the hormones the adrenal cortex produces
- Can be the result of a tumor in the pituitary gland resulting in release of the hormone ACTH
2
Q
what hormones are made by the adrenal cortex?
A
- Mineralocorticoids: aldosterone increases sodium reabsorption and causes potassium excretion in the kidney
- Glucocorticoids: cortisol affects glucose, protein, and fat metabolism; the body’s response to stress; and the body’s immune function
- Sex Hormone: androgens and estrogens
3
Q
risk factors for Cushing’s
A
- women ages 20-40 yo
- endogenous causes of inc cortisol
- adrenal hyperplasia
- adrenocortical carcinoma
- pituitary carcinoma secreting ACTH
- exogenous causes of inc cortisol
- organ transplant
- chemo
- autoimmune dz
- asthma
- allergies
4
Q
Cushing’s: expected findings
A
- weakness , fatigue, sleep disturbances
- Back and joint pain
- fluid retention: JVD, SOC, crackles, tachypnea, HTN, edema
- Altered emotional state
- Decreased libido
- Evidence of decreased immune function and decreased inflammatory response
- Thin, fragile skin
- Bruising and petechiae
- Hypertension
- Tachycardia
- Gastric ulcers due to over secretion of hydrochloric acid
- Weight gain and increased appetite
- Irregular menses
- Dependent edema
- Fractures (osteoporosis)
- Bone pain and fractures with an increased risk for falls
- Muscle wasting
- Frequent infections, poor wound healing
- Hirsutism
- Acne
- Red cheeks
- Striae
- Clitoral hypertrophy
- Thinning, balding hair
- Hyperglycemia
- Emotional liability
5
Q
Cushing’s: Lab Tests
A
- Elevated plasma cortisol levels: in the absence of acute illness or stress indicate cushing’s dz. Urine contains elevated levels of free cortisol
- Plasma ACTH levels: hypersecretion of ACTH by anterior pituitary, disorders of the adrenal cortex or medication therapy results in decreased ACTH levels
- Salivary cortisol: elevations confirm the diagnosis of Cushings dz
- Potassium and calcium: decreased
- Glucose: increased
- Sodium: increased
- Lymphocytes: decreased
- Dexamethasone suppression tests: usually done through 24 hr urine collection
6
Q
Cushing’s: Diagnostic Procedures
A
- X-ray, MRI, CT identify lesions of the pituitary, adrenal glands, lungs, GI tract, and pancreas
- Radiological imaging determines the source of adrenal insufficiency
7
Q
what occurs with potassium and calcium in Cushing’s? why?
A
- decreased due to an increase in aldosterone which causes water and sodium retention and potassium excretion
8
Q
what will we see with WBCs and RBCs in Cushing’s?
A
- WBCs: inc (leukocytosis)
- RBCs: inc (polycythemia)
9
Q
what are the three medications used for Cushing’s?
A
- Ketoconazole
- Mitotane
- Hydrocortisone
10
Q
Ketoconazole for Cushing’s
A
- Corticosteroid inhibition
- Antifungal agent that inhibits adrenal corticosteroid synthesis in high doses
- Supplements radiation or surgery
- Monitor liver enzymes
- Monitor fluids and electrolytes for clients who have gastric effects
- Can cause N/V, dizziness
- Only temporary relief - cannot stop taking meds
11
Q
Mitotane for Cushing’s
A
- Produces selective destruction of adrenocortical cells
- Treats inoperable adrenal carcinoma
- Monitor for indications of shock, renal damage, and hepatotoxicity and orthostatic hypotension
- Purpose is to reduce the size of the tumor
- Need lifelong replacement with glucocorticoids
12
Q
Hydrocortisone for Cushing’s
A
- For replacement therapy who have adrenocortical insufficiency
- Monitor potassium and glucose
- Measure daily weight
- Monitor BP, HR, manifestations of infections
- pt needs to carry emergency ID about corticosteroid use
- Report black or tarry stools
- Need diet high in calcium and vit D
13
Q
what therapeutic procedures can be used to help with Cushing’s?
A
- chemotherapy
- radiation therapy
- hypophysectomy
- adrenalectomy
14
Q
explain adrenalectomy for Cushing’s
A
- Surgical removal of the adrenal gland (can be unilateral or bilateral)
- Provide glucocorticoid and hormone replacement
- will want to give IV hydrocortisone to prevent problems in surgery, then the pt will need lifelong replacement
- Monitor for adrenal crisis
- Monitor bleeding, fluids, electrolytes, bowel sounds
- bleeding–>distention
15
Q
what are the 4 complications possible with Cushing’s?
A
- perforated viscera/ulceration
- bone frxs due to hypocalcemia
- infection due to immunosuppression
- adrenal crisis
16
Q
explain perforated viscera/ulceration as a complication of Cushing’s
A
- Decreases production of protective mucus in the lining of the stomach due to an increase in cortisol
- Monitor for evidence of GI bleed
- Need antiulcer medications
17
Q
explain bone frxs due to hypocalcemia as a complication of Cushing’s
A
- Caution when moving pt
- Provide assistance when the client is ambulating
- Encourage diet high in calcium and vit D
18
Q
explain infection as a complication of Cushing’s
A
- Occur due to elevated glucocorticoid levels which often cause immunosuppression
- Monitor subtle indications of infections
- Minimize exposure to infectious organisms
19
Q
explain adrenal crisis as a complication of Cushing’s
A
- Sudden drop in corticosteroids is due to sudden tumor removal; stress of illness, trauma, surgery, or dehydration or abrupt withdrawal of steroids
- Taper medication
- Might need more medication for times of stress
20
Q
discharge teaching for a client with Cushing’s
A
- explain how to take glucocorticoid replacement medication: 2/3 in the morning and 1/3 in the afternoon (to mimic normal cortisol)
- do not d/c abruptly
- teach them that they will have to increase dosage when under stress
- monitor for signs of immunosuppression
- monitor weight
- monitor glucose
21
Q
What is Addison’s?
A
- Adrenocortical insufficiency caused by damage or dysfunction of the adrenal cortex
22
Q
Addison’s: Risk factors
A
- Primary causes
- Idiopathic autoimmune dysfunction
- TB
- Histoplasmosis
- Adrenalectomy
- Cancer
- Radiation therapy of the abdomen
- Secondary
- Steroid withdrawal
- Hypophysectomy
- Pituitary neoplasm
- High dose radiation of pituitary gland or entire brain
- Acute insufficiency
- Sepsis
- Trauma
- Stress: can be emotional or physical
- Adrenal hemorrhage
- Steroid withdrawal
23
Q
Addison’s: expected findings
A
- late sign: bronze are to arms, legs, and face
- Weight loss
- Craving for salt
- Hyperpigmentation
- Weakness and fatigue
- Nausea and vomiting
- Abdominal pain
- Constipation or diarrhea
- Dizziness with orthostatic hypotension: can occur if BP drops and/or pulse elevates
- Severe hypotension
- Dehydration
- Hyponatremia
- Hyperkalemia
- Hypoglycemia
- Hypercalcemia
- Manifestations of chronic addison’s dz develop slowly
- Manifestations of acute adrenal insufficiency develop rapidly
24
Q
Addison’s: Lab Tests
A
- Serum electrolytes: increased K, decreased Na, increase Ca
- BUN and Cr: increase
- Serum glucose: normal to decreased
- Serum cortisol: decreased
- ACTH stimulation test: plasma cortisol remain same or decrease
25
Addison's: Diagnostic Procedures
* ECG: assess for ECG changes or dysrhythmias assoc with electrolyte imbalance
* Xray, CT, MRI: determine source of adrenal insufficiency such as a tumor or adrenal atrophy
26
what are the medications used for Addison's?
* hydrocortisone/prednisone
* fludrocortison
27
explain hydrocortisone use for Addison's
* Adrenocortical replacement for adrenal insufficiency and as anti-inflammatory
* this is a replacement for mineralocorticoids and glucocorticoids
* Monitor BP, weights, electrolytes
* Increase dose during stress
* Do not abruptly stop
28
explain fludrocortisone use for Addison's
* Replacement in adrenal insufficiency
* Monitor weight, BP and electrolytes
* HTN potential SE
29
what are the complications of Addison's?
* acute adrenal insufficiency
* hypoglycemia
* hyperkalemia/hyponatremia
30
explain acute adrenal insufficiency as a complication of Addison's
* When an acute drop in adrenocorticoids due to sudden discontinuation of glucocorticoid meds or when induced by severe trauma, infection, stress
* Insulin and dextrose to move potassium into cells
* Admin calcium to counteract the effects of hyperkalemia
* Monitor electrolytes
31
explain hypoglycemia as a complication of Addison's
* Insufficient glucocorticoid causes increase in insulin sensitivity, and decreased glycogen → hypoglycemia
* Monitor glucose
* Need to have carbohydrate snacks easily accessible
32
explain hyperkalemia/hyponatremia as a complication of Addison's
* Decrease in aldosterone levels can cause an increased excretion of sodium and decreased excretion of potassium
* Monitor electrolytes and ECG
* Take meds as directed
33
discharge teaching for Addison's
* explain how to take glucocorticoid replacement medication: 2/3 in the morning and 1/3 in the afternoon (to mimic normal cortisol)
* do not d/c abruptly
* teach them that they will have to increase dosage when under stress
* monitor for signs of immunosuppression
* monitor weight
* monitor glucose
* teach them S/S of Cushing's which she could develop from the use of the glucocorticoids
* should wear a medic alert ID
* should carry an emergency kit with IM hydrocortisone
34
what is hypothyroidism?
Inadequate amount of T3 and T4 causing a decrease in metabolic rate that affects all body systems
35
Hypothyroidism: Risk Factors
* F 30-60 y/o are affected 7-10 times more than M
* Mild is usually undiagnosed
* Use of certain meds - lithium and amiodarone
* Inadequate intake of iodine
* Radiation therapy to head or neck
36
Hypothyroidism: expected findings
* Usually vague and carried findings that develop slowly over time
* fatigue/ lethargy
* Irritability
* Intolerance to cold
* Constipation
* Weight gain without an increase in caloric intake
* Pale skin
* Thick, brittle fingernails
* Depression and apathy
* Periorbital edema
* Joint or muscle pain
* Bradycardia, hypotension, dysrhythmias
* Slow thought processes and speech
* Hypoventilation, pleural effusion
* Thickening of the skin
* Thinning of hair on the eyebrows
* Dry, flaky skin
* Swelling in face, hands, and feet
* Decreased acuity of taste and smell
* Hoarse, raspy speech
* Abnormal menstrual cycle
* Decreased libido
* goiter
37
Hypothyroidism: Lab Tests
* T3: decreased
* Serum TSH: increased with primary hypothyroidism, decreased or within the expected reference range in secondary hypothyroidism
* Free Thyroxine index and T4 levels: decreased
* T3 resin uptake: decreased
* Thyrotropin receptor antibodies: no response
* Serum cholesterol: increased
38
Hypothyroidism: Diagnostic Procedures
* thyroid scan
* Radioisotope scan and intake: clients who have hypothyroidism have a low uptake of the iodine preparation
* ECG: sinus bradycardia, dysrhythmias
39
how to treat hypothyroidism
* Levothyroxine
* Thyroid hormone replacement therapy
* monitor HR before you give it to make sure it is not overly therapeutic
* Increases effects of warfarin and can increase the need for insulin and digoxin
* 4 hr apart from cimetidine, lansoprazole, Sucralfate, and colestipol
* Meds can accelerate metabolism: phenytoin, carbamazepine, rifampin, sertraline, and phenobarbital
* Dosage increase every 2-3 weeks
* will need lab tests to monitor thyroid H levels
* Do not stop taking the medication
40
what is a complication of hypothyroidism?
* Myxedema coma:
* S/S: stuporous, non responsive, ventilatory support needed, bradycardia, hypothermia, dec O2 sats, hypoTN, dec Na and glucose
* life threatening condition when hypothyroidism is untreated or when a stressor affects a client
* ensure patent airway, continuous ECG, monitor ABGs
* continuously monitor the pt's temperature and I/O
* will have to administer IV levothyroxine
41
hypothyroidism: nursing considerations
* monitor A&O status b/c if dec, it is a sign of myxedema
* keep them warm
* monitor V/S: HR, BP, temp
* put them on telemetry to monitor HR
* monitor edema, bowel sounds
* inc fluids, movement, and fiber
42
hypothyroidism: discharge teaching
* take levothyroxine 30-40 min before eating, on an empty stomach
* teach S/S of hypo and hyperthyroid
* f/u is vital: need labs Q2-3 weeks to adjust meds
* start low and slow with levothyroxine so you don't cause hyperthyroid
43
what are the hormones the thyroid produces?
* Thyroid produces T3, T4 and calcitonin
* T3 and T4 secreted from anterior pituitary through negative feedback
* Calcitonin inhibits mobilization of calcium from bone and reduces blood calcium levels
44
what is hyperthyroidism?
* clinical syndrome caused by excessive circulating thyroid hormone. This exaggerates normal body functions and produces a hypermetabolic state
45
hyperthyroidism: risk factors
* Graves’ disease is the most common cause
* Autoimmune antibodies result in hypersecretion of thyroid hormones
* Autosomal recessive trait passed in females
* Toxic nodular goiter, a less common form of hyperthyroidism is caused by overproduction of thyroid hormone due to nodules
* Exogenous hyperthyroidism is caused by excessive dosages of thyroid hormones
46
hyperthyroidism: expected findings
* Nervousness, irritability, hyperactivity, emotional lability, decreased attention span, cries or laughs without cause, change in mental or emotional status
* Weakness, easy fatigability, exercise intolerance
* Muscle weakness
* Heat intolerance
* Weight change (usually loss) and increased appetite
* Insomnia and interrupted sleep
* Frequent stools and diarrhea
* Menstrual irregularities and decreased fertility
* Libido initially increased in both M and F, followed by a decrease as the condition progresses
* Warm, sweaty, flushed skin with velvety-smooth texture
* Hair thins, and develops a fine, soft, silky texture
* tremor , hyperkinesia, Hyperreflexia
* Exophthalmos (Graves only) due to edema in the extraocular muscles and increased fatty tissue behind the eye
* Blurred or double vision and tiring of eyes due to pressure on the optic nerve
* Photophobia
* Excessive tearing and bloodshot appearance of eyes
* Pretibial myxedema: dry, waxy smelling of frontal surfaces of lower legs that resembles benign tumors (graves only)
* Vision changes
* Hair thinning and loss
* Goiter
* Bruit over thyroid gland
* Elevated systolic blood pressure and widened pulse pressure
* Tachycardia, palpitations and dysrhythmias
* Dyspnea
* More subtle in older adults
47
hyperthyroidism: lab tests
* Serum TSH test: decreased in the presence of Graves dz → can be elevated in secondary and tertiary hyperthyroidism
* Free T4 index, T4 (total) T3: elevated in the presence of disease
* Thyroid - stimulating immunoglobulins: elevated in graves’ disease, normal in other hyperthyroidisms
* Thyrotropin Receptor antibodies: elevation most indicative of Graves dz
48
hyperthyroidism: diagnostic procedures
* Ultrasound: used to produce images of the thyroid gland and surrounding tissue
* Electrocardiogram: used to evaluate the effects of excessive thyroid hormone on the heart. ECG changes include Afib, and changes to the P and T waves
* Radioactive iodine uptake
49
radioactive iodine uptake test for hyperthyroidism
* gold standard for diagnosing hyperthyroidism
* clarifies size and function of gland
* contraindicated in pregnant women
* will have to give every female a pregnancy test
* must assess iodine or shellfish allergy
* elevated uptake is indicative of hyperthyroidism
50
what are the classes of medications used for hyperthyroidism?
* thionamides
* beta adrenergic blockers
* iodine solutions
51
explain thionamides use in treating hyperthyroidism
* Methimazole and propylthiouracil inhibit production of thyroid hormone
* Used to treat graves’ dz as an adjunct to radioactive iodine therapy
* take 1-2 weeks to become therapeutic
* Monitor for manifestations of hypothyroidism
* Monitor CBC for leukopenia or thrombocytopenia
* Monitor for indications of hepatotoxicity
* Take meds with meals
* Report jaundice
52
explain beta blockers use in treating hyperthyroidism
* Propranolol, atenolol, and metoprolol treat sympathetic nervous system effects
* Counteract the effects of increased thyroid hormones but do not alter levels
* Monitor BP, HR, ECG
* Monitor for hypoglycemia in clients who have DM
* Pt needs to check pulse prior to taking the medication
53
explain iodine solutions use in treating hyperthyroidism
* Nonradioactive 5% elemental iodine in 10% potassium iodine that inhibits the release of thyroid hormone
* will inhibit T3 and T4 release
* often used to prepare someone for a thyroidectomy
* Short term use only
* 1hr after an antithyroid med
* Contraindicated in pregnancy
54
what are the therapeutic procedures used to treat hyperthyroidism?
* radioactive iodine therapy
* thyroidectomy
55
explain radioactive iodine therapy as a tx for hyperthyroidism
* tx of choice
* Destroys some of the hormone producing cells
* Degree of destruction varies
* Contraindicated in pregnancy
* must take a pregnancy test prior to procedure
* Monitor for hypothyroidism manifestations
* Effects may not be effective for 6-8 weeks
* so will need to be on methimazole or PTU while waiting for it to become effective
* Continue to take meds as directed
* Stay away from pregnant women and children
56
explain thyroidectomy as tx for hyperthyroidism
* often performed when: thyroid storm emergency, thyroid cancer, large goiter causing airway obstruction
* Surgical removal of part or all of thyroid gland
* Incision in the neck with possible drainage
* Received propylthiouracil or methimazole 4 to 6 weeks before surgery
* High protein - high carbohydrate diet preop
* Receives iodine for 10-14 days preop to reduce the glands size and prevent excessive bleeding
57
what are postop considerations with a thyroidectomy?
* Semi-fowlers
* Monitor vital signs q15 until stable
* Assist with deep breathing
* Check surgical dressing for excessive bleeding
* Monitor for parathyroid damage
* risk for hypocalcemia
* can lead to laryngospasm--monitor for stridor
* would have to administer IV calcium gluconate to make up for low calcium
* can cause a hoarse voice: if that lasts for more than 5-10 days, then look for laryngeal N damage
58
what are possible complications of hyperthyroidism?
* hemorrhage at incision site
* thyroid storm
* hypothyroidism
* airway obstruction
* nerve damage
* hypocalcemia and tetany
59
explain hemorrhage as a complication of hyperthyroidism/thyroidectomy
* Due to loosened surgical tie or excessive coughing or movement
* Avoid neck flexion and extension
* Show client how to change position with support of the neck
60
explain thyroid storm
* Results from a sudden surge of large amounts of thyroid hormones into the bloodstream, causing an even greater increase in body metabolism
* Medical emergency
* may need to go in and do a thyroidectomy
* Maintain airway
* Aspirin is contraindicated
61
explain airway obstruction as a complication of hyperthyroidism/thyroidectomy
* Hemorrhage, tracheal collapse, tracheal mucus accumulation, laryngeal edema, and vocal cord paralysis can cause respiratory obstruction with sudden stridor and restlessness
* Tracheostomy tray should be kept near pt
* High fowlers
