Endocrine/Thyroid, DM, adrenal dysfunction Flashcards
Normal process of Thyroid hormone release
1. Hypothalamus releases thyrotropin releasing hormone (TRH) to anterior pituitary 2.Anterior pituitary releases thyroid stimulating hormone (TSH) to thyroid gland 3.Thyroid secretes thyroid hormones
T3
Increases metabolic rate
T4
Increases cellular response to catecholamines
Thyrocalcitonin
Decreases breakdown of bone and
decreases reabsorption of calcium in the intestines and
kidneys (↓Ca++)
Causes of hypothyroidism
• Disorders of hypothalamus or anterior pituitary • Autoimmune disease – Hashimoto’s thyroiditis • Hyperthyroidism treatment – Thyroidectomy, radioactive iodine therapy
Causes of hyperthyroidism
• Autoimmune disease
̶ Graves’ disease
Clinical manifestations Hypothyroidism (mental status?, weight, GI, appetite, sensitivities, HR, skin)
-Sluggish mental & physical activity
- Weight gain
- Decreased GI motility
- Decreased appetite
- Cold sensitivity
- Bradycardia
- Coarse, dry (not fragile) skin
- Goiter
- Decreased fertility/menstrual
irregularities
Clinical manifestations Hyperthyroidism (mental status?, weight, GI, appetite, sensitivities, HR, skin)
-Tachycardia, hypertension • Nervousness, excitability • Increased gastric activity • Increased appetite • Weight loss • Heat intolerance • Insomnia • Decreased fertility/menstrual irregularities • Exophthalmos/goiter
Hypothyroid management Diagnosis labs
- Elevated TSH
* Decreased T3, T4
Treatment of hypothyroid
• Thyroid hormone replacement (levothyroxine)
Levothyroxine safety/drug metabolism
Safety – Drug metabolism
• Decreased metabolism of sedatives, hypnotics or narcotics
• Decrease dose or frequency
Hypothyroid nursing actions/interventions
- Administer medication in AM
- Be mindful of drug metabolism (i.e. narcotics and sedatives)
- Warming blankets
Complication of hypothyroidism:
Myxedema Coma
• Profound decrease in cellular metabolism
– Hypoventilation → Hypoxia and CO2 retention
– Fluid and electrolyte imbalance
– Hypothermia
– Decreased cardiac function → Bradycardia and hypotension
– Hypoglycemia
– Hyponatremia
Myxedema Coma treatment
• Treatment – Replace thyroid hormone, supportive care
Hyperthyroid Diagnosis
• Decreased TSH, Increased T3, T4
Hyperthyroid treatment
Treatment
• Symptom management (fluid replacement, beta blockers)
• Medical
– Propylthiouracil (PTU), methimazole (Tapazole), lithium carbonate (Lithonate)
• Radioactive iodine
• Surgical
– Total or subtotal thyroidectomy
Thyroidectomy Preoperative considerations
Antithyroid medications and/or beta blockers
• Potassium iodide
• Vitamin D and calcium
Thyroidectomy postoperative care
- Pain control
- Thyroid hormone supplementation
- Calcium management
What is a complication of thyroidectomy and why does this happen
Hypocalcemia – Complication of thyroidectomy
• Parathyroid damage during surgery
– Surgical damage, devascularization
• Appears within 48 hours, resolves within a few months
What is done to treat preThyroidectomy complication
Calcium given pre-procedure
► Calcium levels checked routinely post procedure and Ca
replaced
• May need exogenous calcitrol for Ca absorption if PTH levels are also
low
► S/s hypocalcemia
Hyperthyroid Assessment
Vital signs • Intake and output • Eyes and vision • Thyroid hormone levels • Seizures • Daily weight
Thyroid storm symptoms
Tachycardia, fever, systolic hypertension, abdominal pain, tremors,
changes in level of consciousness
Treatment of thyroid storm
Treatment
• Supportive care – i.e. Airway, pulse rate and blood pressure
management
• Fluid resuscitation
• Glucocorticoids
• Anti-thyroid meds once the pt’s symptoms stabilize
What is Diabetes insipidus
Decreased secretion of antidiuretic hormone (ADH) from
posterior pituitary r/t hypothalamus damage
Diabetes insipidus causes
30% idiopathic (usually autoimmune)
• 25% brain tumor
• 20% intracranial surgery
• 16% head trauma
What happens in the body to lead to DI
1. Decrease in ADH production 2. Collecting ducts in kidney less permeable to water 3. Excretion of large volumes of very dilute urine
Clinical symptoms of Diabetes insipidus
R/t extreme water loss • Polyuria, polydipsia, nocturia • Hemoconcentration – Elevated Na+ and hematocrit • Hypotension and tachycardia
Diagnosis of DI
Serum osmolality > urine osmolality
• Concentrated blood, dilute urine
H&H, BMP
MRI (determine cause)
What meds are given for management of DI
Hypotonic fluid (D5) • Glucose control
Gentle correction of hypernatremia
Desmopressin DDAVP
• Synthetic ADH
• Subcutaneous, intranasal, PO
Nursing interventions for DI
Maintain IV access
• Administer IVF and medications
• Provide mouth care
What are the adrenal glands important for?
Glucocorticoids (cortisol) Mineralocorticoids: Aldosterone Other hormones/NT Sex hormones: Androgens and estrogens Epi/Norepi
What is cortisol used for?
Carb, fat and protein metabolism; Suppression of immune response, control of stress response
What regulates mineral corticoids
RAAS system
Adrenal insufficiency (types)
Primary: destruction of adrenal gland can be due to autoimmune disorder or infection
Secondary: Decreased secretion of ACTH from anterior pit
Tertiary: dysfunction of hypothalamus
Adrenal hyperfunction
Cushings syndrome
S/s of adrenal insufficiency r/t cortisol
What is it associated with and when do they present
Addisons disease Present 90% is non functional Dec Cortisone/aldosterone C-Hypoglycemia C-weakness C-weight loss C-fatigue C-mental health s/s (dep)
S/s adrenal Hyper function r/t cortisol
Cushings C-Hyperglycemia C-Abnormal fat distribution C-High protein metabolism=dec muscle mass C-Increase susceptibility to infection (suppressed immune response) C-Thin, friable skin C-Mental health s/s Virilization in F
S/s of adrenal insufficiency r/t aldosterone.
A-Dehydration
A-Hypotension
A-Hyperkalemia
S/s of adrenal insufficiency not r/t cor or aldosterone.
Hyperpigmentation
Decreased pubic hair
S/s adrenal Hyper function r/t Aldosterone
A-Fluid retention HTN
A-Sodium retention
A-Hypokalemia
S/s of adrenal hyperfunction not r/t cor or aldosterone.
Virilization in F
Adrenal insufficiency, what is the greatest cause and what goes wrong
Addisons disease, nonspecific autoimmune destruction of adrenal gland.
or abrupt discontinuation of corticosteroids
Diagnosis of adrenal insufficiency
Cortisol levels -Drawn first thing in the AM (body produces more cortisol to help us wake up)
Less than 3mcg/dL=adrenal insufficiency
CT or MRI of adrenal gland
Shrinking of adrenal gland = autoimmune destruction
Enlarged gland= infectious process (inflammation)
Management of Adrenal insufficiency
Replace coritsol (hydrocortisone/dexamethasone)
IV fluids
Treat hyperkalemia
Assessments of Adrenal insufficiency (vitals)
Hypotension & tachycardia risk due to dehydration
Assessments of Adrenal insufficiency I&O
Fluid recussestation
lab Assessments of Adrenal insufficiency
Na, K, Glucose, Hct, cortisol
Nursing intervention of adrenal insufficiency
IV access, admin meds safety precautions (postural hypotension)
Adrenal crisis clinical manifestation
Hypotension unresponsive to fluid resuscitation or vasoactives (septic likely to present with this)
Treatment of Adrenal crisis
200-300 mg hydrocortisone IVP daily in divided doses
Taper once serum lactate has normalized
Hypercortisolism
excessive secretion of glucorticoids
Hyperaldosteronism
Excessive secretion of aldosterone
Causes of adrenal hyperfunction
70% caused by anterior pituitary tumor
15% causes by tumor of adrenal cortex
15% caused by ectopic tumors
Adrenal hyperfunction diagnosis
Lab values: Cortisol levels, electrolytes, glucose, dexamethasone suppression test (Dexamethasone before bed, cortisol level drawn in AM, if high =Cushings)
Hyperaldosteronism medical management
Potassium sparing diuretic (spironolactone)
secretes NA+ and water while preserving K+
Hypercortisolism medical management
Ketoconazole, pasireotide
Decreases cortisol secretion
Surgery
Radiation
Adrenal hyperfunction what should nurse assess for
Vitals: HTN
Weight fat muscle distribution
I&O
Skin, wound healing (thin frible skin)
Adrenal hyperfunction what labs should nurse assess
Glucose potassium sodium
Adrenal hyperfunction what should nurse
Med mngment
HOB elevated
Meticulous skin care (extra thin)
Turn/reposition
