Mark k lecture 7 Flashcards
what are the S/Sx of hypermetabolism?
o Weight loss
o HR up, BP up
o Hyperpersonality
o They have heat intolerance … Can tolerate cold because body
is like a furnace
o Exophthalmos (bulging eyes) … Think Susan Sarandon, or
Don Knotts
graves disease
Hyperthyroidism (run yourself into the grave)
3 was to treat hyperthyroidism
- Nuke it with radioactive iodine
The Pt must flush three times after urinating
Call hazmat team if urine is spilled on the floor
The Pt needs a private room in the first 24 hours
o Visitors restriction and in hospital and at home in first 24 hours - PTU (Propylthiouracil)
o PTU “Puts Thyroid Under”
o PTU’s primary use is for cancer—Monitor WBC b/c pt is immunosuppressed
3.Thyroidectomy
o Surgical removal of the thyroid is the
most common treatment
o To answer questions on the Board
correctly, pay attention whether it is a
Total, Sub (a.k.a. Partial)
thyroidectomy
o Total thyroidectomy needs lifelong
hormone replacement, and pt is risk
for hypocalcemia due to difficulty to
spare the parathyroid glands
What are the symptoms of hypocalcemia?
- Paresthesia, tetany, twitching, spasm, clonus, seizure, jitteriness, tremor (all UP!). also,
Chvostek and Trousseau signs
Treatment of Subthyroidectomy
- Do not need lifelong hormone replacement
- May need to supplement at first
- HOWEVER, they are at risk for thyroid storm
S/Sx of thyroid storm / treatment — A medical emergency
- Temps of 105 or above
o Get temp down, bring oxygen up
o Bring body temperature down using ice packs/cooling blankets *
o Oxygen per mask at 10L*
o Stay with patient * - High BP, stroke level — about 210/180
- Severe tachycardia 180 as high as 200
- Psychotically delirious
Self-limiting, no meds due to rebound effects either they die or they survive
Lowering body temperature in thyroid storm first vs best
- First step is ice pack
- Best step is cooling blanket
Postop Risks in total thyroidectomy and subtotal thyroidectomy
* First 12 hours
1.Top priority is airway, due to edema
2. Next is hemorrhage because it is an endocrine gland—very vascular
Postop Risks in total thyroidectomy and subtotal thyroidectomy Next 12 to 48 hours
It matters what kind of surgery you’ve had now
1.Total: big danger is tetany due to low calcium
TOTAL = TETANY … Can close off airway with an irreversible spasm
2. Subtotal: big danger is thyroid storm
SUBTOTAL = STORM (Severe)
Postop Risks in total thyroidectomy and subtotal thyroidectomy after 48 hours
risk is infection
Note: For any type of procedure, the risk of infection significantly increases after 72 hours
So, what are the S/Sx of hypomatabolism?
o Obesity
o HR down, BP down
o Personality: Flat, boring, dull
o They have cold intolerance … Can tolerate heat
o Academically challenged
Myxedema is the name
Myxedema
- This is when a pt with severe hypothyroidism presents with skin involvement
Myxedema coma
- Severe hypothyroidism leading to decreased mental status, hypothermia, and other symptoms
related to slowing of function in multiple organs - Medical emergency
Treatment of hypothyroidism
- Levothyroxine (Synthroid)
- Taken in the morning 30 minutes to 1 hour before breakfast
- Taken alone on an empty stomach with water
Can you sedate pts with hypothyroidism?
- They’re already super slow. They can go into a coma
A pt dx with hypothyroidism will be undergoing surgery the next morning. The physician ordered the
pt NPO at 12:00 am. Pt is on Synthroid and multivitamin pills. What should the nurse question?
- Clarify the NPO order for the Synthroid … Why?
o The pt needs the Syntroid medication to get through surgery. Otherwise, the condition
may potentiate the suppressing effects of the anesthesia during surgery
o Therefore, don’t hold thyroid pills unless explicitly orders
Interestingly, all adrenal cortex diseases either start with an
“A” or
a “C”
* Addison Disease (a.k.a. hypoadrenalism or adrenal
insufficiency), Cushing
Addison disease
- Under secretion of steroids (they are a time bomb!)
- S/Sx: pts are Hyperpigmented (very tan)
- They do NOT adapt to stress
What is the purpose of the stress response in an individual?
- To maintain
o A normal blood pressure to perfuse the brain and other organs
o An adequate level of glucose to feed the body
What could happen if these pts can’t adapt to stress?
Under stress, pts with Addisson disease will go into shock and
have an hypoglycemic episode (Addisonian crisis)
Treatment of Addison
- Give steroids
- Glucocorticoids drugs that end in -SONE
o Prednisone
o Methylprednisone - “In Addison, you ADD-a-SONE”
Cushing’s Syndrome
Increased adrenal hormones
All the S/Sx of Cushing’s are the S/E of Steroid
medications
- Draw picture of a little man
- Give man a MOON FACE
- Give him a beard—hirsutism
- Draw a big body—truncal or central obesity
- Arms and legs are skinny—muscle atrophy
- Bump on front—gynecomastia (big breast)
- Bump on back—buffalo hump
- Fill him full of water (he is retaining Na+ and water)
He is losing K+ out the back - Give him some striae—stretch marks
- Most important one of all—high serum glucose
o Do Accu-Checks q6h. They look like diabetics - Easy bruising—put bruises all over him
- Make him say something in a speech balloon …
“I’M MAD, BECAUSE I HAVE AN
INFECTION”
o Grouchy (“Roid rage”)
o Immunosuppressed
A pt comes in with an acute exacerbation of COPD. The pt is being treated with Solu-Medrol
(methylprednilosone) IV push q8 hours to reduce the inflammation in the airway. What nursing action
needs to be taken while the pt is on the medication?
- Do an Accu-Checks q6 hours
- Since pt is on steroid, his condition is similar to diabetes even though he is not diabetics
Treatment for Cushings
- Adrenalectomy
- What happens with a bilateral adrenalectomy?
o Now pt has Addison disease
o Now give steroids (ending in SONE) to treat.
o Pt will start looking like Cushman (Cushinoid-like)
o It takes about a year or so—after a lot of titration—for the pt to start looking normal
considerations for toy selection
No small parts when a child is under 4
No metal toys when oxygen is in use (sparks)
Age appropriate toys 0 to 6 months
Sensorimotor. Best toy is a musical mobile (Best choice)
Toy should be large but soft (2nd best choice)
Age appropriate toys 6 to 9 months
Object permanence. Best toy teach them to Cover/Uncover
This is to teach them that the object is still there even if they
can’t see it
Examples are: Jack-in-the-Box and Peek-a-Boo
Toy should be large but firm
Worse toy after 6 months is the Musical Mobile because of
the risk of strangulation
Age appropriate toys 9 to 12 months
Vocalization. Best toys are speaking or verbal toys
Good list of toys are: Tickle me Elmo, Woody Cowboy, See and Say-
Barnyard Friends, Talking books
For purposeful play, the infant should be at least 9 months or older
* These words mean purposeful play: build, sort, stack, make, and
construct
* Baby in womb for 9 months, another 9 months for purposeful play
Age appropriate toys 1 to 3 years—
Work on Gross Motor skills, which is running, jumping
Best toys for this age group are Push/Pull toys
Examples are: Lawn mowers, Wagon, dog with floppy feet
They can paint (They use the hand to paint)
They are characterized Parallel Play
Age-appropriate toys 3 to 6 years—
Preschoolers
* 3 to 6 years— Work on fine motor skills
Therefore, preschoolers have finger dexterity; hence, can
write, draw, use colored pencils, scissors
Work on balance—Dance, ice skates, tricycles, tumbling
They are characterized by Cooperative Play
* Need to cooperate in Preschool (= Pretend)
* You’d be the sheriff, I’ll be robber …
Highly imaginative
Age-appropriate 7 to 11 years—
School age
* 7 to 11 years— Concrete
Characterized by the “3 Cs”
1. Creative—Give them blank paper to draw, they like to get involved …
Toys: Legos, Transformers
2. Collective—Baseball cards, Webkinz, Barbies, Beanie Babies
3. Competitive—Winner/losers
Age-appropriate 12 to 18 years—
Peer group association
Allow adolescents to be in each other’s
rooms unless one of them has been/is
1.Recently post-op for <12 hrs
2.Immunosuppressed
3.Contagious
Lamina
the vertebral spinous process (bumpy bones along backbone)
Laminectomy
the removal of the vertebral spinous process
Why perform a laminectomy?
- To relieve nerve root compression … In other words, cutting away the bony prominence gives
the nerve more room
What the S/Sx of nerve root compression?
- Pain
- Paresthesia (tingly)
- Paresis (muscle weakness)
There are 3 different locations where
laminectomy is performed
1.Cervical
2.Thoracic
3.Lumbar
What is the most important pre-op
assessment for cervical?
o Cervical innervates the diaphragm and the arms
o First, assess for breathing
o Next, check functions of arms/hands
Post-op complication for cervical laminectomy
o Watch for pneumonia
What is most important pre-op for thoracic?
o Thoracic innervates gut/abdominal muscles … Assess cough and bowels (cannot cough
when you cannot contract abs)
Post-op complication thoracic laminectomy
o Pneumonia and paralytic ileus
What is most important pre-op for lumbar?
o Lumbar innervates Bladder and legs … Assess for urinary retention or last time pt
voided or is the bladder empty
o Next best answer is to evaluate leg functions
Post-op complication lumbar laminectomy
Post-op complication
o Urinary retention and Leg problems
* Lumbar = Legs, Urinary retention
Postop Laminectomy
- Number 1 answer for postop laminectomy, including spinal surgery, is log roll
- Better pick log roll
Mobilizing pt after laminectomy or spinal surgery
- Do not dangle these pts—have them seat at the edge of the bed
- They should go from supine to walking as soon as possible
- Can they sit on bed long enough to overcome orthostatic hypotension?
o Yes, but not for 10 to 15 minutes - Do not allow pt to sit for more than 30 minutes
- So, what post-op order would you question for a laminectomy?
So, what post-op order would you question for a laminectomy?
o Up in chair for 1 hour TID
* These pts may
o Walk, stand, lie down without restriction
o Sitting is bad
You are caring for a pt with a lumbar oligodendrogliocytoma. What is the #1 problem?
a. Airway
b.Ileus
c. Cardiac arrhythmia
d. Urinary retention
Who cares what oligodendrogliocytoma is. The lesion is in the lumbar spine. Therefore, we
should assess for urinary retention, then for leg problems
* If the question instead mentions lumbar abscess or lumbar surgery, lumbar ependymoma, the
answer would be the same
Laminectomy with fusion
- This involves taking a bone graft from (1) the iliac crest and (2) the spine
- Bone from your hip is taken and put it in place so no bone-to-bone
Discharge Teaching?
There are 4 temporary restrictions and 3 permanent
- Temporary restrictions … (6 weeks)
1. Do not sit for >30 minutes
2.Lie flat, log roll for 6 weeks
3. Don’t drive for 6 weeks
4. Don’t lift more than 5 lbs for 6 weeks (gallon of milk) Permanent restrictions - Permanent restrictions
1.Laminectomy patients will never be allowed to lift by bending at waist (use knees)
2.Cervical laminectomy should never be allowed to lift anything over the head
3. No horseback riding, off trail biking, jerky amusement park rides, etc. …
