Endocrine 3 Flashcards
1
Q
Adrenal cortex steroid hormones
A
Glucocorticoids
Regulate metabolism and ↑ blood glucose
Critical to physiological stress response
Mineralocorticoids regulate
Sodium balance
Potassium balance
Androgen contributes to
Growth and development in both genders
Sexual activity in adult women
2
Q
Cushing’s Syndrome
A
- Caused by excess of corticosteroids, particularly glucocorticoids
Most common cause
- Administration of exogenous corticosteroids
- Adrenal tumours
- Usually lung and pancreas tumours
- Ectopic ACTH production is more common in men
3
Q
Cushing’s Syndrome Clinical Manifestations
A
B: Increase Blood Pressure
B: Decrease Bone formation
I: Inflammatory response
I: Decrease Immune response
G: Increase Gluconeogensis
Feminization in men, Masculization in women
- Related to excess corticosteroids
- Weight gain most common feature
- Trunk (centripetal obesity)
- Face (“moon face”)
- Cervical area
- Transient weight gain from sodium and water retention
- Hyperglycemia
- Glucose intolerance associated with cortisol-induced insulin resistance
- Increased gluconeogenesis by liver
- Protein wasting
- Catabolic effects of cortisol
- Leads to weakness, especially in extremities
- Protein loss in bones leads to osteoporosis, bone and back pain
- Loss of collagen
- Wound healing delayed
- Mood disturbances
- Insomnia
- Irrationality
- Psychosis
- Mineralocorticoid excess may cause hypertension secondary to fluid retention
- Adrenal androgen excess may cause
- Pronounced acne
- Virilization (growing hair) in women
- Feminization in men
- Seen more commonly in adrenal carcinomas
- Women: menstrual disorders and hirsutism
- Men: gynecomastia and impotence
- Purplish red striae on abdomen, breast, or buttocks (it looks like stretch marks)
4
Q
Cushing’s Syndrome Assessment
A
Patient medical history
- Pituitary tumour
- Adrenal, pancreatic, or pulmonary neoplasms
- GI bleeding
- Frequent infections
- Use of corticosteroids
- Weight gain
- Anorexia
- Polyuria
- Prolonged wound healing
- Weakness, fatigue
- Easy bruising
- Insomnia
- Headache, back, joint, bone, and rib pain
- Amenorrhea
- Impotence
- Mood disturbances, anxiety, psychosis, poor concentration
- Truncal obesity
- Buffalo hump
- Moon face
- Hirsutism of body and face
- Thinning of head hair
- Thin, friable skin
- Acne
- Petechiae
- Purpura
- Hyperpigmentation
- Purplish red striae on breasts, buttocks, and abdomen
- Edema of lower extremities
- Hypertension
- Muscle wasting
- Thin extremities
- Awkward gait
5
Q
Nursing Diagnosis and Goals
A
- Risk for infection
- Imbalanced nutrition
- Disturbed body image
- Impaired skin integrity
Goals
- Experience relief of symptoms
- Have no serious complications
- Maintain positive self-image
- Actively participate in therapeutic plan
6
Q
Nursing Implentation
A
- Health promotion****** test about priority teaching
- Identify patients at risk for Cushing’s syndrome.
- Long-term exogenous cortisol therapy is major risk factor.
-Teach patients about medication use and to monitor for side effects. **
Acute intervention
Assessment of
- Signs and symptoms of hormone and drug toxicity
- *-Complicating conditions**
>Cardiovascular disease
>Diabetes mellitus
>Infection
Monitor
- Vital signs
- Daily weight
- Glucose
- Infection
- Signs and symptoms of abnormal thromboembolic phenomena
Emotional support
- Patient may feel unattractive or unwanted.
- Nursing staff should remain sensitive to patient’s feeling and be respectful.
- Reassure patient that physical symptoms will resolve when hormone levels return to normal.
Preoperative care
- Patient should be in optimal physical condition.
- Control hypertension and hyperglycemia.
- Hypokalemia must be corrected with diet and potassium supplements.
- High-protein diet helps correct protein depletion.
- Teaching depends on surgical approach.
- Include information on postoperative care.
- Nasogastric tube
- Urinary catheter
- IV therapy
- Central venous pressure monitoring
- Leg compression devices
- Risk of hemorrhage is increased because of high vascularity of adrenal glands.
- Manipulation of glandular tissue may release hormones into circulation.
- BP, fluid balance, and electrolyte levels tend to be unstable because of hormone fluctuations.
- High doses of corticosteroids administered by IV during and several days after surgery
- Report any significant changes in
- BP
- Respiration
-Heart rate
7
Q
Post Op Care
A
- Monitor fluid intake and output to assess for imbalances.
- Critical period for circulatory instability ranges from 24 to 48 hours.
- Morning urine levels of cortisol are measured to evaluate the effectiveness of surgery. *** urine specific gravity
- Adrenal insufficiency develops if corticosteroid dosage is tapered rapidly
- Indications of hypocortisolism
- Vomiting
- Increased weakness
- Dehydration
- Hypotension
- Patient may complain of
- Painful joints
- Pruritus
- Peeling skin
- Severe emotional disturbances
- Bed rest until BP is stabilized after surgery – may collapse if pt gets up
- Meticulous care should be taken when accessing skin, circulation, or body cavities to avoid infection - because of issues with wound healing
- Normal inflammatory responses are suppressed.
- Ambulatory and home care
- Discharge instructions based on lack of endogenous corticosteroids
- Wear MedicAlert bracelet at all times
- Avoid exposure to stress, extremes of temperature, and infection
-Lifetime replacement therapy is required for many patients
8
Q
Expected Outcomes
A
Expected outcomes
- Experience no signs or symptoms of infection
- Attain weight appropriate for height
- Increase acceptance of appearance
- Maintain intact skin
9
Q
An IV hydrocortisone infusion is started before a patient is taken to surgery for a bilateral adrenalectomy. The nurse explains to the patient that this is done to:
A
- Prevent sodium and water retention after surgery
- Prevent clots from forming in the legs during recovery from surgery
- Provide substances to respond to stress after removal of the adrenal glands
- Stimulate the inflammatory response to promote wound healing
10
Q
Addison’s Disease
A
Hypofunction:
Primary insufficiency: Addison’s disease (the gland itself)
- Atrophy, destruction of adrenal gland by autoimmune response, gland destroyed by antibodies against pt’s own adrenal cortex, most common in white females
- Other causes: infarction, fungal infection (i.e. histoplasmosis) , AIDS, metastatic Ca, TB
- From metastasis from other sites: lungs, breast, GI
- Risk factor: taking glucocorticoids for prolonged time (>3 weeks with sudden stop)
- need to taper dose of steroids to stop if suddenly stop its very dangerous
11
Q
Addison’s Disease Clinical Manifestations
A
- Onset of Addison’s is insidious
- Progressive weakness, fatigue
- Hyperpigmentation of skin
- Weight loss, Listlessness
- Irritability
- Anorexia, N & V, diarrhea
- Postural Hypotension
- Vitiligo
12
Q
Addison’s Disease Diagnosis
A
Blood hormone levels:
- Low cortisol levels** made from adrenal cortex
- High plasma ACTH (adrenocorticotropic hormone, from anterior pituitary)
- ACTH stimulation test: cortisol levels fail to rise over basal levels
- They give ACTH and if the cortisol levels don’t rise therefore then its coming from your adrenals
- However if it is positive then its coming from your anterior pituitary
- **Serum electrolytes: ** low Na and high K * know difference
- Hypoglycemia when cortisol is low its not activating your metabolism
13
Q
Addisonian Crisis and Clinical Manifestions
A
- Pt with adrenal insufficiency are at risk for developing Addisonian Crisis:
- if client under stress: surgery, trauma, infection, dehydration, anorexia, fever
- sudden withdrawal of corticosteroid hormone (often when pt lacks knowledge of importance of replacement therapy)
S & S of addisonian crisis
Life threatening emergency
- Hypotension: may lead to shock
- Tachycardia
- Dehydration
- Hyponatremia
- Hyperkalemia
- Hypoglycemia
- Fever, weakness, confusion
14
Q
Addisonian Crisis Goals of treatment and Treatment
A
Goals of Treatment
- Need to correct fluid and electrolyte imbalance
- Close monitoring of serum electrolyte levels
- Correction of hypoglycemia with IV glucose solution
- Steroid replacement: Hydrocortisone 100mg IV bolus followed by 100mg Q8H for 24 hrs.
- Need to take corticosteroid replacement for life with caution
Treatment
- Shock management, VS
- High-dose hydrocortisone replacement
- Large volumes of 0.9 % saline solution
- IV 5% dextrose
- Assess for fluid volume deficit & elect imbalance q 30 min to 4 hrs X first 24 hrs
- Daily weights
- Protect from noise, light, & environmental extreme temperatures because pt cannot cope with stress
15
Q
Addison’s Disease: Ambulatory and home care teaching
A
- Establish baseline: vital signs, bp lying and standing
- Glucocorticoids usually in divided doses: 2/3 in morning & 1/3 in afternoon
- Mineralocorticoids: once a day, preferably in a.m.
- Dosage schedule reflects normal circadian rhythm
- Decreases side effects
