Module 2 Blueprint Flashcards
The adrenal gland is made up of what two structures
adrenal cortex and adrenal medulla
The adrenal cortex secretes
corticosteroids (cortisol) and alderosterone (mineralocorticoid)
How does aldosterone work?
promotes sodium and water reabsorption and potassium excretion
Aldosterone is regulated by the?
RAAS system and adrenocorticotropic hormone (ACTH)
How does the RAAS system work
renin is produced in kidneys from sodium or blood loss. renin coverts angiotensinogen into angiotensin 1, then angiotensin 2. Angiotensin II triggers the release of aldosterone. Aldosterone promotes reabsorption in the kidneys to raise plasma level
How does serum potassium level control aldosterone secretion
aldosterone is released when serum potassium is above normal. Aldosterone then enhances kidney excretion of potassium, correcting fluid and electrolyte imbalances
What does cortisol affect
stress responses, metabolism, helps catecholamine function, maintenance of heart cell excitability
Describe the release of cortisol (negative feedback loop)
low blood cortisol levels –> secretion of CRH by hypothalamus –> causes pituitary to release ACTH –> ACTH releases cortisol from adrenal cortex
The adrenal medulla secretes
catecholamines
What are catecholamines
epinephrine and norepinephrine
Activation of the sympathetic nervous stem produces this response
stress response (release of catecholamines causing fight or flight)
What are the gonads
male and female reproductive glands
What are the male gonads
testes
What are the female gonads
ovaries
Function of the gonads is dormant until
puberty
How do the gonads become activated
gonadotropic hormones released by the anterior pituitary cause external genitalia and glands to mature
The testes produce what hormone
testosteroen
The ovaries produce what hormone
estrogen and progesterone
What is the hypothalamic hypophyseal portal system?
hormones produced in the hypothalamus travel directly to the anterior pituitary
the function of the hypothalamus is to produce _______ hormones
regulatory
The pituitary gland is known as the?
master gland
What two hormones are produced in the hypothalamus, but stored in the posterior pituitary?
ADH and oxytocin
Hormones of the posterior pituitary
oxytocin and vasopressin (ADH)
Hormones of the anterior pituitary
ACTH, FSH, GH, LH, MSH (melanocyte stimulating hormone), PRL (prolactin), TSH
target tissues for ACTH
adrenal cortex (stimulates release of corticosteroids)
target tissues for FSH
ovary , testes (secretes estrogen and stimulates spermatogenesis)
target tissues for GH
bone and soft tissues (promotes growth)
target tissues for LH
ovary, testes (stimulates progesterone secretion and ovulation, stimulates testosterone secretion)
target tissues for MSH
melanocytes
target tissues for PRL
mammary glands (breast development and milk production)
Target tissues for TSH
thyroid
ADH controls?
fluid and electrolyte balance
What three hormones does the pancreas secrete
glucagon, insulin, somatostatin
What does glucagon do?
hormone that increases blood sugar levels as a part of glucose regulation
What does insulin do
lowers glucose by moving glucose into the cells
What does somatostatin do
inhibits the release of glucagon and insulin
What does the parathyroid gland secrete
parathyroid hormone (PTH)
PTH regulates calcium and phosphorus metabolism by acting on?
bones, kidneys, and GI tract
PTH and how it works in the bone
promotes resorption (release of calcium from the bone)
PTH and how it works in the kidneys q
allows calcium to be reabsorbed back into the tubules
PTH and how it works in the intestines
in the kidneys, PTH activates vitamin D which increases absorption of calcium and vitamin d in the intestines
PTH secretion ____ when calcium is high
decreases
PTH secretion ____ when calcium is low
increases
The thyroid gland secretes what hormones
T4 and T3
Control of metabolism (protein, fat, carbohydrate) occurs through which hormones
T3 and T4
Explain the hypothalamic-pituitary-thyroid gland axis negative feedback loop
hypothalamus secretes thyrotropin-releasing hormone (TRH). TRH triggers anterior pituitary to secrete thyroid stimulating hormone (TSH). TSH stimulates thyroid glands to release thyroid hormones
If t3 and t4 are high, TSH is
low
If T3 and T4 are low, TSH is
high
Dietary intake to produce thyroid hormones includes
iodine and protein
Calcitonin, released by the thyroid gland, does what
lowers serum calcium levels by reducing bone resorption
If calcium levels are high, calcitonin is
increased
If calcium levels are low, calcitonin is
decreased
Common sources of iodine
table salt, eggs, saltwater fish, seaweed, shellfish, cheese, milk, yogurt
Explain the feedback loop of insulin secretion
blood glucose levels high - insulin secreted - insulin moves glucose into cells - blood glucose levels lower
What is hypopituitarism
deficiency of one or more of the pituitary hormones
most common cause of hypopituitarism
pituitary tumor (tumor suppresses gland)
What is selective hypopituitarism
one pituitary hormone is deficient
What is panhypopituitarism
two or more pituitary hormones decreased
How does shock or severe hypotension cause hypopituitarism
reaction of blood flow to pituitary gland causes hypoxia, infarction, and reduced hormones
head trauma, brain surgery, brain infection, radiation, and AIDS can all be causes of
hypopituitarism
Symptoms of hypopituitarism caused by ACTH
low cortisol, hypoglycemia, anorexia, hyponatremia, lethargy, hypotension, headache, decreased axillary or pubic hair
Symptoms of hypopituitarism caused by FSH and LH
males: decreased body and facial hair, decreased bone density and muscle mass, decreased libido, impotence
Females: amenorrhea, breast atrophy, decreased axillary and pubic hair, low estrogen, loss of bone density, decreased libido
Symptoms of hypopituitarism caused by GH (adults)
decreased bone density, decreased muscle strength, pathologic fractures
Symptoms of hypopituitarism caused by GH in children
short stature
Symptoms of hypopituitarism caused by TSH
cold intolerance, weight gain, slow cognition, alopecia, decreased libido
Symptoms of hypopituitarism caused by vasopressin (ADH)
dehydration, increased urine, increased thirst, hypotension
What kind of therapy is required for patients that have hypopituitarism
life-long hormone replacement therapy (HRT)
What is dyspareunia, a symptom reported by women with hypopituitarism
painful intercourse
Neurologic symptoms of hypopituitarism, frequently caused by tumor growth include
changes in vision, headaches, diplopia (double vision), limited eye movement
Laboratory findings for hypopituitarism
decreased levels in blood, abnormal assessment findings
Decreased TSH, which causes hypopituitarism, is treated with?
levothyroxine
Decreased GH, which causes hypopituitarism, is treated with?
somatotropin
Men who have gonadotropin deficiency, caused by hypopituitarism is treated with?
testosterone
Women who have gonadotropin deficiency, which causes hypopituitarism, is treated with?
estrogen and progesterone
Can men with prostate cancer receive androgen therapy
NO
Women taking androgen therapy with estrogen are at increased risk of ?
hypertension, thrombosis (especially with nicotine use)
Safety considerations for clients with decreased GH:
decreased bone density can increase risk of fractures –> increased risk for falls
hyperpituitarism is most commonly caused by
adenoma
As an adenoma grows larger in the pituitary, those with hyperpituitarism can experience/
vision changes, headaches, increased ICP
Acromegaly occurs from overgrowth of what hormone?
GH
The onset of acromegaly is usually
gradual (easily missed until late stages)
Symptoms of acromegaly
enlarged face, hands, feet, coarse facial features, increased head size, protruding jaw, joint pain, vision changes, voice changes, thick lips, sleep apnea
During acromegaly, we can see hypertrophy of the soft tissue such as the
tongue, skin, and visceral organs
Complications from acromegaly can occur when these organs become enlarged
heart, liver, lungs
Symptoms of acromegaly in children result in
gigantism
Why can those with acromegaly experience voice changes
hypertrophy of vocal cords
With acromegaly, will blood glucose be high or low
high
Cushings disease, a type of hyperpituitarism, occurs from overgrowth of what hormone
ACTH
Excess ACTH stimulates the adrenal cortex, so we have excessive production of what hormones
corticosteroids, mineralosteroids, androgens (this leads to bushings)
Symptoms of Cushing’s syndrome (a type of hyperpituitarism)
elevated cortisol, moon face, buffalo hump, purple striae, truncal obesity, weight gain, hypertension, hyperglycemia
Hypersecretion of PRL, a type of hyperpituitarism, has symptoms such as
sexual dysfunction, menstrual changes , decreased libido, painful intercourse
What is a growth hormone suppression test used for
acromegaly
Describe the growth hormone suppression test
oral glucose is given. if GH levels do not fall below 5ng/mL we have a positive test.
X-rays may be used to assess hyperpituitarism because it can see
bone
CT/MRI may be used to assess hyperpituitarism because it can see
pituitary gland itself
What medications can be used to treat acromegaly
dopamine agonists, somatostatin analogs, growth hormone receptor blockers
What do dopamine agonists do?
inhibit growth hormone
What are the dopamine agonists?
bromocriptine mesylate, cabergoline
Adverse reactions of dopamine agonists
CP, dizziness, watery nasal drainage (CSF leak)
How does somatostatin analogs work
inhibit growth hormone
What are the somatostatin analogs?
ocreotide , lanreotide
What is the growth hormone receptor blocker
pegvisomant
Client education for dopamine agonists
notify provider immediately if CP, dizziness, or water nasal drainage occurs
Surgical management of hyperpituitarism includes
hypophysectomy (removal of tumor)
Pre-surgical education for hypophysectomy
-nasal packing may be present 2-3 days
-do not cough, brush teeth, sneeze, blow nose, or bend over after surgery
What can coughing, sneezing, blowing nose, or bending over cause after hypophysectomy
increased cranial pressure, increased risk of CSF leak
Operative procedure during hypophysectomy
transphenoidal approach or transnasal approach. General anesthesia. Nasal packing with transphenoidal and mustache dressing.
Post operative interventions for hypophysectomy
neurochecks q h first 24 h –> then q 4
-mental status, altered LOC, pupillary response
monitor I & O
teach to report increased swallowing
teach to report post nasal drip
encourage deep breathing q h
monitor infection/meningitis
good oral care (mw and floss)
decreased smell 3-4 months
Presence of glucose in nasal drainage may indicate
CSF
presence of yellow halo sign in nasal drainage will indicate
CSF
Increased swallowing my indicate
CSF
S/S of meningitis we should monitor for after hypophysectomy
headache, fever, muscle rigidity
Straining while having a bowel movement, after hypophysectomy, can increase risk for
ICP
How long should our patients avoid brushing teeth after hypophysectomy ?
2 weeks
Treatment for CSF leak
bedrest (unless surgery is indicated)
What medications are used to treat cushings syndrome
ketoconazole , mitotane
Client education for ketoconazole
relief is temporary (findings will return after medication stops), take with food, can cause nausea vomiting fatigue
Risk factors for acromegaly
adult, pituitary tumors
Risk factors for cushings
females ages 20-40
laboratory tests used for Cushing’s syndrome
blood cortisol levels (elevated), ACTH (elevated), salivary cortisol (elevated), glucose and sodium levels (elevated), potassium and calcium levels (decreased) WBC levels (decreased)
Nursing care for Cushing’s syndrome
monitor I&O, monitor signs of hypervolemia, maintain safety due to pathological fractures, monitor for infections
Cushings syndrome can cause suppression of?
immune system and inflammatory response
Cushings syndrome can cause osteoporosis, so it is important to monitor our patients for
osteoporosis and their safety (due to fall risk)
Because of the suppressed immune system, people with Cushings syndrome are at risk of
frequent infections, delayed wound healing
Causes of hyperthyroidism include
Graves’ disease, thyroiditis, toxic nodular goiter, exogenous hyperthyroidism, adenoma
What functions does the thyroid control in the adult
metabolism, tissue use of fats proteins and carbs, increased RBC, RR rate and drive
When TH is high TSH is
low
When TH is low TSH is
high
How does hyperthyroidism cause hypertension
increase cardiac output –> increase blood flow –> increase BP
What does primary hyperthyroidism mean
caused by the thyroid itself secreting too many hormones
Secondary hyperthyroidism is caused by
hypothalamus or pituitary gland secreting too much TSH
What is Grave’s disease
autoimmune disorder in which autoantibodies attack the thyroid causing increase in hormone production
What specific changes occurs with Grave’s disease
exopthalamus (abnormal protruding of eyes) and pretibial myxedema
What is pretibial myxedema
dry, waxy swelling of the lower legs
symptoms of hyperthyroidism
irritability, weakness, heat intolerance, weight loss, diaphoresis, increased appetite, diarrhea, thin silky hair, goiter (common with graves), bruit over thyroid gland, tachycardia, dyspnea, amenorrhea, increased systolic BP, bulging eyes
Changes in vision can occur with hyperthyroidism. What will these changes look like
blurry vision, double vision, eye fatigue, eyelid lag
Which lab value is the greatest indicator of graves disease
thyrotropin receptor antibodies
What should the nurse monitor for patients with hyperthyroidism
apical pulse, blood pressure, and temperature every four hour
Why is it vital to monitor and report temperature
can indicate patient is moving into thyroid storm (even one degree difference is bad)
We should instruct patients with hyperthyroidism to report symptoms such as
palpitations, dyspnea, vertigo, chest pain
Reducing stimulation is good for our clients with hyperthyroidism because it
promotes rest and reduces cardiac problems
what are ways we can reduce stimulation in our clients
rest, dim lights, limit, time in room, limit visitors, close door, turn off monitors
What are ways we can increase comfort for our clients with hyperthyroidism/ graves disease
ice water, cold showers, turning down thermostat
What drugs are used to treat hyperthyroidism
pheoinomides (methimazole, propylthiouracil) , radioactive iodine
How does methimazole and propylthiouracil work
inhibits TH by preventing iodine from binding to thyroid gland
Nursing implications for hyperthyroid drugs
-teach patients to avoid crowds/other risks of infeciton
-monitor weight and HR (hypothyroidism)
-methimazole should not be used during pregnancy
-propylthiouracil can cause liver toxicity
-monitor CBC
What drugs can be used for supportive care with hyperthyroidism
beta blockers (to reduce HR, palpitations)
Describe Lugol’s solution, a treatment for hyperthyroidism
short term treatment before surgery
-reduces blood flow to thyroid which reduces hormone production
Why do patients with hyperthyroidism require ultrasound
determines thyroid size and assesses any masses or nodules q
Why would a patient with hyperthyroidism require EKG
see dysrhythmias, palpitations, fibrillations
What is radioactive iodine therapy
-treatment for hyperthyroidism
-thyroid picks up the RAI and some of the cells producing TH are destroyed by radiation
How long can radioactive iodine therapy take to be fully effective
6-8 weeks
Education for patient receiving radioactive iodine therapy
sit to urinate, flush 2-3 times with lid closed, avoid pregnant women children and infants for at least a week , stay away 6 feet, do not share toothbrushes utensils etc
What is thyroid crisis
acute attack with severe hyperthyroid symptoms
Thyroid storm is usually triggered by
stress (like pregnancy, infection, DKA, trauma)
Why is it not best practice to palpate a goiter
can cause thyroid storm Q
Key symptoms of thyroid storm include
pyrexia, tachycardia, delirium, seizures, coma
Nursing implications for patient during a thyroid storm
-maintain patent airway
-iv fluids NS
-BB
-monitor for dysrhythmias
-monitor vital signs every 15-30 minutes
Even after a thyroidectomy, it is a safety priority to monitor temperature because
thyroid crisis can still occur
What is a subtotal thyroidectomy
removal of part of the thyroid , may not require supplemental therapy afterwards
What is a total thyroidectomy
complete removal of the thyroid, will require supplemental replacement
Prior to thyroidectomy, the client will need to follow what kind of diet
high carb and high protein
Presurgical nursing actions for thyroidectomy
-premedicate (propylthiouracil and methamazole 4 to 6 weeks before)
-premedicate (iodine 10-14 days before)
-notify the provider immediately if client does not follow med regimen
Pre-op education for client receiving thyroidectomy
support the neck when performing deep breathing, expect to have a neck incision covered with a dressing, hoarseness can occur, notify nurse of tingling of mouth or extremities occur
Postprecedure nursing actions for thyroidectomy
-semi-fowlers position with pillows
-monitor vs q 15 min till stable then q 30
- ask client to speak upon waking from anesthesia and q 2 hours after
-avoid neck extension
-deep breathing exercises q 30 min-1hr
-pain management
Client education for thyroidectomy
-support while coughing or changing positions
-do not manipulate surgical drain
-symptoms of hypothyroidism
-report incisional drainage, redness, or swelling (infection)
-s/s of thyroid storm
Complications of thyroidectomy
hemorrhage, thyroid storm, respiratory distress, hypocalcemia
Nursing actions for hemorrhaging after thyroidectomy
-inspect surgical incision especially at back of neck
-monitor for voice changes (blood can compress the trachea)
Why do we assess client’s ability to speak after thyroidectomy
can damage the laryngeal nerves
How can respiratory distress occur after thyroidectomy
swelling in neck will suppress trachea and cause poor gas exchange/ trouble swallowing
What assessment finding will alert the nurse our patient may be experiencing an obstruction following a thyroidectomy
stridor
What equipment should be kept at the bedside following a thyroidectomy
tracheostomy equipment
If a patient experiences tracheal collapse following thyroidectomy, will oxygen and sitting up help?
No, call rapid response
How could thyroidectomy cause hypocalcemia
if parathyroid gland is removed
What symptoms will our patient experience with hypocalcemia
tingling around mouth, extremities, toes, trousseau and Chvostek signs
What is hypothyroidism
decreased amounts of thyroid hormone
What is myxedema, a symptom of hypothyroidism
buildup of proteins and sugars in the cell that forms cellular edema
Myxedema can cause non pitting edema to occur in what areas
pretibial areas, top of the feet, hands, elbows, feet
What is myxedema coma
rare but serious complication of poor hypothyroidism with reduced cardiopulmonary and neurologic functioning
What is the pathophysiology of myxedema coma
decreased metabolism cause heart muscle to be flabby and chambers to increase. Cardiac output decreases perfusion, and gas exchange does not occur. The brain and other vital organs will go into organ failure
Primary cause of hypothyroidism
decreased thyroid tissue, decreased synthesis of TH
Secondary cause of hypothyroidism
hypothalamus or pituitary gland not producing TSH
Risks for hypothyrodiism
females 30-60 years old, use of certain medications (lithium and amiodarone) inadequate intake of iodine, radiation therapy to the neck and back
Symptoms of hypothyroidism
intolerance to cold, receding hairline, decreased activity tolerance, bradycardia, weight gain, confusion, poor wound healing, impaired memory, thick tongue, anorexia, constipation, dry skin, edema around eyes, face puffiness, body temp is hypothermic
What is Hashimoto thyroiditis
autoimmune disorder where antibodies attack thyroid and leads to hypothyroidism
Patients with hypothyroidism may experience symptoms to muscles such as
weakness, tingling, paresthesia
Cardiac and respiratory function are decreased in hypothyroidism, which can lead to
reduced gas exchange
How to improve gas exchange in patients with hypothyroidism
monitor oxygen saturation and auscultate breath sounds
How to improve cardiac output in patients with hypothyroidism
monitor BP (diastolic may be increased) , heart rate, and rhythm
What oral drug is given for hypothyroidism
levothyroxine
Why should we monitor chest pain for clients that have chronic hypothyroidism
it can lead to cardiovascular disease
Why should we take caution when using sedatives in patients with hypothyroidism
decreased metabolism can increase times of effects for these medications and cause respiratory distress
Why should we apply anti-embolism stockings to our patients with hypothyroidism
decreased cardiac output and edema can increase risk of DVT
Patient education for levothyroxine
take on empty stomach 30-60 minutes before breakfast, monitor for symptoms of hyperthyroidism
Nursing implications for clients with hypothyroidism
monitor respoiratory status, monitor cardiovascular changes, provide extra blankets, administer stool softeners, gradually increase client’s a activity level
What can increase the risk for myxedema coma
stress such as illness, surgery, use of sedatives/ opioids
Manifestations of myxedema coma
respiratory failure, hypotension, hypothermia, bradycardia, dysrhythmias, hyponatremia, hypoglycemia, coma
Treatment for myxedema coma
IV levothyroxine, IV fluids such as 0.9% sodium chloride
Nursing actions for myxedema coma
maintain airway patency, EKG monitoring, monitor mental status, initiate aspiration precautions
What is thyroiditis
group of conditions that cause inflammation of the thyroid gland
What is infectious thyroiditis
bacterial invasion of the thyroid gland
Symptoms of infectious thyroiditis
sudden pain, tenderness on one side of neck, malaise, fever
Subacute or granulomatous thyroiditis results from
infection of the thyroid gland after a cold or upper respiratory infection
Symptoms of subacute or granulomatous thyroiditis
neck pain, hard and enlarged thyroid on palpation
What is radiation thyroiditis
occurs 5-10 days after treatment with radio iodine
Palpation/trauma induced thyroiditis
occurs during physical examination, biopsy, neck surgery, trauma
Chronic autoimmune thyroiditis (hashimotos disease)
autoimmune
Symptoms of hashimotos thyroiditis
dysphagia and painless enlargement of the gland
What are the four main types of thyroid cancer
papillary, follicular, medullary, anaplastic
What is the initial sign of thyroid cancer
single painless lump or nodule
What is the most common type of thyroid cancer
papillary carcinoma
Cure for papillary carcinoma
partial or total thyroidectomy, if confined to the thyroid gland
papillary carcinoma occurs most often in
women around 50 years of age
Follicular carcinosi occurs most often in
adults between ages of 40 to 60 and in countries where iodine is not found easily in the diet
Follicular carcinoma can easily spread because it
invades the blood vessels
What is the result of follicular carcinoma after it spread
dyspnea and dysphagia
What thyroid cancer is commonly found in children and young adults
medullary carcinoma caused by endocrine neoplasia type 2
Anaplasatic carcinoma is a rapidly growing tumor that invades nearby tissues. Symptoms include
SOB, hoarseness, dysphagia
For most types of thyroid cancer, what is the treatment regiment of choice
Surgery (total or partial thyroidectomy) , followed by RAI (radioactive iodine) to help destroy remaining tissue
What treatment is used for anaplastic carcinoma
external beam radiation / chemotherapy and surgery (RAI is not used)
After treatment for thyroid cancer, the patient will most likely develop what condition
hypothyroidism
How do excessive PTH levels increase bone resorption (breaking down)
decreases osteblastic activity and increasing osteoclast activity
Primary hyperparathyroidism is caused by
parathyroid glands secreting too much hormone
Causes of secondary hyperparathyroidism include
vitamin D deficiency and and CKD
Symptoms of hyperparathyroidism
kidney stones, bone fractures, gI upset, (anorexia, weight loss, constipation, vomiting) , fatigue, lethargy, confusion
Laboratory values for someone with hyperparathyroidism
PTH increased , Calcium increased, Phosphorus decreased, magnesium increased
How can x-rays help with the treatment of hyperparathyroidism
show kidney stones, calcium deposits, and bone lesions
What does chronic hyperparathyroidism cause in our patients
loss of bone density
What is the drug therapy used for hyperparathyroidism
cinacalcet (calcimimetic)
What is required for our patients taking a calcimemetic for hyperparathyroidism
routine monitoring of calcium levels
what is the preferred treament for hyperparathyroidism q
surgery
Patient teaching for hyperparathyroidism
have regular exercise, adequate hydration, avoid lithium therapy, avoid prolonged bedrest, eat moderate amount of calcium and vitamin D
Patients with hyperparathyroidism are at risk of?
fractures
Parathyroidectomy pre and post surgical education
same as thyroidectomy
Is a parathyroidectomy curative?
Yes ; calcium levels should return to normal
Hypoparathyroidism occurs most often because of
postsurgical complication of thyroid or parathyroid glands
Symptoms of hypoparathyroidism
numbness and tingling around lips, mouth, hands and feet. (mild) Chvostek and Trousseau signs, contractions, tetany (severe)
Laboratory values of hypoparathyroidism
decreased PTH, decreased calcium, increased phosphorus, decreased magnesium
Treatment for severe and acute hypocalcemia
IV calcium gluconate
Treament for mild hypocalcemia
Oral vitamin D, calcitriol, calcium carbonate
Why is medication dosage so important with hypoparathyroidism
we need calcium level high enough there are no symptoms, but low enough it will not cause kidney stones
Patient teaching for hyperparathyroidism treatment
lifelong, wear medical alert bracelet
What foods should we teach our patient why hypoparathyroidism to eat in moderation
milk, yogurt, cheese, ice cream
Dietary recommendations for hyperthyroidism
avoid excessive iodine and tyrosine intake
Dietary recommendations for hypothyroidism
increase iodine and tyrosine intake (seafood, dairy, strawberries, cranberries, pineapple)
Dietary recommendations for hyperparathyroidism
avoid foods high in calcium and vitamin D
dietary recommendations for hypoparathyroidism
increase calcium intake (avoid high phosphorus foods) with leafy greens and vegatbles. Dairy products in moderation
Dietary recommendations for hypopituitarism
foods rich in minerals, iron, and iodine (whole grains, legumes, seafood, dairy, eggs, leafy greens)
Which type of diabetes is autoimmune
type 1
Why does diabetes type 1 occur
triggered by viral infection. this attacks the beta cells to where they no longer secrete insulin
What is the age of onset for type 1 diabetes
< 30 years
What are the symptoms of type 1 diabetes
abrupt onset, polyuria, polydipsia, polyphasic, weight loss
What type of diabetes has beta cell dysfunction and insulin resistance
type 2 diabetes
Is type 2 diabetes an autoimmune disorder?
no
What is the age of onset for type 2 diabetes
any age
What are the symptoms of type 2 diabetes
frequently none; thirst, fatigue, blurred vision, vascular or neural complications
60-80 percent of adults with type 2 diabetes will have this condition
metabolic syndrome
Risk factors for type 2 diabetes
family hx, African American, Hispanic, Pacific Islander, native American, high birth weight babies, gestational diabetes, PCOS
What body shape will those with metabolic syndrome
apple in men and pear in women
To qualify as metabolic syndrome, our patient must have _____ or more of the criteria
3
What four things are evaluated in metabolic syndrome
abdominal obesity, hyperglycemia, hypertension, hyperlipidemia
What is considered abdominal obesity (in metabolic syndrome)
waist circumference 40 inches in males and 35 in females
What is considered hyperglycemia in metabolic syndrome
fasting glucose > 100
What is considered hypertension in metabolic syndrome
systolic > 140 and diastolic > 90
What is considered hyperlipidemia in metabolic syndrome
triglycerides 150 or more
Those with metabolic syndrome have an increased risk of
CVD, stroke, heart attack
Neurologic symptoms of metabolic syndrome
fatigue and inability to focus
Integumentary symptoms of metabolic syndrome
browning of folds of skin around neck, armpits, etc
Sexual dysfunction symptoms found with metabolic syndrome
PCOS (females) and erectile dysfunction (males)
What is hemoglobin (A1C)
average glucose over the last 120 days (3 months)
What is the normal range for hemoglobin A1c
4-5.7 %
What is pre diabetes range for hemoglobin a1c
5.7-6.4%
What is the diabetes range for hemoglobin a1c
> 6.5%
What is a fasting glucose
level of glucose in the blood after someone has been fasting
Normal range for fasting glucose
74-100mg/dL
Prediabetes range for fasting glucose
100-125mg/dL
Diabetes range for fasting glucose
> 126 mg/dL
What is a glucose tolerance test mostly used to diagnose (what type of diabetes0
gestational
How to give glucose tolerance test
give glucose in cup and monitor blood sugar 2h after
Normal range for glucose tolerance test
< 140 mg/dL
Prediabetes range for glucose tolerance test
140-199mg/dL
Diabetes range for glucose tolerance test
> 200 mg/dL
Can type 1 diabetes be prevented?
no
For type 2 diabetes, what treatment strategies do we try first?
nutrition and exercise
Are nutrition plans individualized for management for diabetes or are they the same
individualized
For nutrition plans, diabetics should work with
registered dietitians
clients with diabetes should focus on Whole Foods and limit
empty calories (like soda and candy)
What kind of fats should clients with diabetes consume
avocado, nuts, olives, omega 3 fish
What kind of fats should a client with diabetes avoid
trans and saturated fats
How much fiber should clients with diabetes consume in a day
25 g
Patient teaching for increasing fiber
increase slowly to limit gi irritation, increase fiber and fluids
In a 24 hour period, how many alcoholic beverages can clients with diabetes consume?
1 (female) 2 (males)
1 beer is equivalent to __ oz
12
1 glass of wine is equivalent to ____ oz
5
What important teaching should we include for diabetic clients
how to read food labels, avoid sugary drinks
How can exercise improve diabetes
improves carb metabolism and increases insulin sensitivity
What should an exercise schedule look like for a diabetic
150 mins total a week , resistance training as well as cardio, ideally do not miss more than 2 days
Can our client exercise if ketones are present in the urine
no
If it has been over 1 hour since the patient has eaten, they may need this before exercise
snack
What must the glucose levels be in order to perform exercise
100-250
What patient teaching should we include regarding exercise and insulin
check glucose more frequently after exercise (first 24 h) and they may need decreased insulin doses
What kind of adjustments may need to be made for diabetic exercise
based on complications such as retinopathy and neuropathy
What adjustments may need to occur with exercise and retinopathy? why?
exercise should not include jarring/jumping ; risk of hemorrhage or retina detachment
Diabetic neuropathy and exercise
be mindful of activities that can cause falls
How often should people with diabetes inspect their feet?
daily
Should people with diabetes soak their feet?
No
What should people with diabetes wash their feet with
mild soap and warm water
Can people with diabetes use OTC remedies to remove calluses or corns
no
What kind of shoes should people with diabetes a void
open - toe and open-heel
What time should people with diabetes buy shoes? and why
in the evening to leave room for swelling
What is the target goal for blood sugar for diabetic patient that’s sick or hospitalized
140-180
When someone with diabetes is sick, how often should they monitor blood sugar
q 2-4 hours
What could diabetic clients eat while they’re sick
6-8 small meals with carbs (pudding, jello, soups)
If a diabetic client is sick and can’t eat, what should they drink
fluids with carbohydrates (sugary drinks like gatorade)
How many oz of fluid should a diabetic drink in an hour if they are sick
8-12 oz of sugar free non caffeinated liquid
If a diabetic client is sick and their blood sugar continues to rise, when should they notify their provider
consistent n/v, ketones in urine for 24+, hypoglycemia symptoms, BG 250+ after two doses/treatment, unable to tolerate liquids, illness lasts 2+ days, high fever 101.5
How often should diabetics check their urine for ketones while sick?
q 2-4 hours
When should diabetics monitor blood glucose
ACHS / PRN (before meals, at bedtime, as needed)
Step by step of taking blood glucose
- clean with alcohol 2. let dry 3. stick with glucometer 3. wipe away first drop 4. obtain glucose
patient education for blood glucose monitoring
how to take, when to take, pump education
What angle is an insulin injection given
90 unless very thin
what sites can be used for insulin administration
belly, bat wings, thigh, butt
Should insulin injection sites be rotated?
yes (do but different places in the same site)
What color is an insulin syringe
orange
what is u500
very concentrated and dangerous form of regular insulin (used for insulin resistance)
What color is u500 syringe
green
Can u500 be given IV
NO
How often does a cannula (part of insulin pump) have to be changed
2-3 days
What is the name of short insulin
regular
What is the onset of short acting insulin
0.5-1h
What is the peak of short acting insulin
1-5 h
What is the duration of short acting insulin
6-10 h
What insulins can be given IV
regular
What type of insulin is intermediate
NPH
What is the onset of intermediate insulin
1-2 h
What is the peak of intermediate insulin
4-14
What is the duration of intermediate insulin
14-24
What are the long acting insulins
glargine , determir
What is the onset of long acting insulin
1-4 h
What is the peak of long acting insulin
no peak
What is the duration of long acting insulin
12-24 h
To avoid hypoglycemia, it is important that patients eat their meals
before onset begins
client is prescribed regular insulin before meals. If they got their dose at 0715, what time should they receive their breakfast
0745
What is basal insulin dose
secreted throughout the days ; long-acting insulins
What is bolus insulin dose?
given with meals to mimic normal insulin production ; rapid and regular insulins
What must blood sugar be to classify as hypoglycemia
< 70
What can hypoglycemia be caused by
giving too much insulin, missed meal/not enough food, being NPO, gastroparesis, alcohol, kidney failure
If someone is NPO, how should the nurse manage their insulin doses
administer basal dose, hold bolus
Why do we still administer basal dose when someone is NPO
if you hold both, hyperglycemia will be much harder to manage the next day
Symptoms of hypoglycemia
weak, blurred vision, sweating, cool/clammy skin, tachycardia, tremors, palpitations, hunger, anxiety, decreased LOC
Treatment for hypoglycemia
BG < 70 = 15 CHO
BG < 50 = 30 CHO
What are examples of 15g carb snacks
glucose tab or gel (premeasured)
a half cup of fruit juice or regular soft drink (120 mL)
5 hard candies
4 cubes of sugar or 4 tsp of sugar
1 TBS (15mL) of honey
15 g carb snacks from ATI quiz
1 slice bead, 1/3 cup sugar free yogurt, 1 cup milk, 1/2 regular ice cream
If patient is unable to eat/ is passed out from hypoglycemia and does not have venous access, what do we administer
IM glucagon
If patient is unconscious from hypoglycemia/ unable to swallow and has IV access, what do we administer
IV dextrose
After we give glucagon IM, why is it important to roll patient onto their side
they will probably puke, get suction and turn on aspiration precautions
If glucose does not raise after 2 doses (15 minutes apart) , we should now
contact the provider
Symptoms of hyperglycemia
3 P’s, warm/ dry skin, Fruity breath if Kussmaul’s is present, stuporous/obtunded/coma
Treatment for hyperglycemia
insulin or oral diabetic meds
Nursing implications for hyperglycemia
encourage oral fluid intake of sugar free fluids, test urine for ketones
What blood sugar is considered to be hyperglycemic
> 180
What is DKA
serious complication of type 1 diabetes with uncontrolled hyperglycemia, metabolic acidosis, and presence of ketones
What is starvation metabolism
occurs in DKA when insulin can no longer keep up with the amount of sugar in blood ; results in ketones that the body can use for energy
The presence of ketones in DKA causes what?
metabolic acidosis
What two symptoms can identify metabolic acidosis
fruity breath ; Kussmauls respirations (increased breathing rate and depth)
S/S of diabetic ketoacidosis
3 p’s, Kussmaul resp, fruity breath, nausea/vomiting, abd. pain, dehydration, neurosymptoms
Blood glucose levels of DKA
> 300
Treatment for DKA
monitor VS q 15 min till stable, then q 4
s/s of dehydration with fluids
regular insulin continuous IV infusion
BS checks q 15 min
What are s/s of dehydration
AMS, dry mm, decreased BP, increased HR, being very thirsty
What is HHS
severe hyperglycemia present in type 2 diabetes
Symptoms of HHS
dehydration, neuro symptoms
Blood glucose levels of HHS
> 600
in both HHS and DKA, BUN and creatinine will be elevated because of
dehydration
DKA and HHS are more likely to occur during
times of stres s
PH level of DKA
< 7.35
PH level of HHS
> 7.4
HCO3 of DKA
< 15
HCO3 of HHS
> 20
treatment for HHS
same as DKA
What are the oral anti diabetic medications
metformin and sulfonylurea
What should we monitor while patient is on metformin
monitor GI effects, monitor lactic acidosis, kidney function
Metformin should be stopped _____ before contrast
24-48
When can metformin be taken after contrast dye
after confirmation of normal kidney function (can cause kidney failure)
Patient education while taking metformin
avoid alcohol, take vitamin B and folic acid, maintain hydration, gi effects (gas, NV, abd pain)
Why should metformin and sulfonylurea be taken with food s
avoid adverse effect of hypoglycemia
Why should we avoid alcohol on sulfonylurea
disulfiram like reaction
s/s of lactic acidosis
myalgia, sluggishness, somnolence, hyperventilation
Can diabetic patients use heating pads?
no because they may not be able to feel it
What is diabetic retinopathy
when blood vessels in eye change
Prevention of diabetic retinopathy
monitoring BG levels closely, proper diet and exercise
patient education for diabetic retinopathy
get yearly eye exam, hypoglycemia can cause temporary blurred vision, exercise should not include straining or lifting weight
Nursing implications for retinopathy
education, monitoring BG, if eyesight is bad be mindful of falls
What is diabetic neuropathy
nerve damage –> slow progressing (can also effect urinary tract, minimizes effects hypoglycemia, and heart function)
Prevention strategies of diabetic neuropathy
maintaining glucose level control, proper diet and exercise
Patient education for diabetic neuropathy
conduct annual exams by podiatrist, report numbness and tingling/joint problems/ difficulties with urinary tract elimination, typical HA symptoms may not be present, reduced awareness for hypoglycemia requires more frequent monitoring
Nursing actions for neuropathy
monitor activity tolerance and other cardiac indicators, administer meds to promote gastric motility, check for urinary retention, provide foot care
What is diabetic nephropathy
damage to kidneys from prolonged dehydration and elevated BG
Client education for diabetic nephorpathy
conduct yearly UA, BUN, creatinine, and micro albumin level
avoid soda, alcohol, acetaminophen and NSAIDS (high amounts)
consume 2-3 L day of fluid with artificial sweetener and water
report decrease in output to provider
Nursing actions for diabetic nephropathy
monitor hydration and kidney function
(I&O, creatinine level (1.005-1.030) Bun (10-20)
report and hourly output less than 30 mL / h
monitor blood pressure
