PT 3 Endocrine, Diabetes Flashcards
Give a simple summary of how hormones work
Hormones work like a “lock and key” - where they can only fit into specific “key holes” on cells to get them to do things
What are 5 functions of the endocrine system
- Reproductive and CNS development in fetus
- Stimulating growth and development during childhood and adolescence
- Sexual reproduction
- Maintaining homeostasis
- Responding to emergency demands
What four specific mechanisms control hormone secretion
- Negative feedback
- Positive feedback
- Nervous system control
- Rhythms
How does negative feedback work
Works like a thermostat. Cold air activates the thermostat, but if it’s warm, the thermostat won’t turn on. Low calcium levels will stimulate the parathyroid gland to release PTH, which will then tell your bones to increase blood calcium levels. Then the increase in calcium levels will stop anymore release of PTH.
How does positive feedback work
A hormone will keep secreting unless something stops it (think about oxytocin and babies - you keep releasing oxytocin until you have your baby)
How does the nervous system control hormones
The nervous system can release hormones when there is pain, fear, sexual excitement or other stresses (like releasing epinephrine when there is a threat)
How does rhythm control hormones
Think about the circadian rhythm (24 hour clock) you will have certain hormones that will release at certain times of the day based on this rhythm (cortisol rises early in the day, then declines in the evening)
What are 6 consequences from impaired hormonal regulation
- Alterations in growth and development
- Alterations in cognition
- Alterations in metabolism
- Changes in growth
- Altered adaptive responses
- Changes in reproduction
How can aging effect the endocrine system 5
- Decreased production and secretion of hormones
- Altered metabolism and biologic activity
- Decreased responsiveness of target tissue to hormones
- Changes in circadian rhythms
- Comorbid conditions and medications that change the body’s response
How is the hypothalamus important for hormones
It’s usually the hypothalamus that will stimulate or inhibit the production and release of hormones from the pituitary
What hormones are released by the anterior pituitary 6
- Adrenocorticotropic hormone (ACTH) (fosters growth of adrenal cortex and stimulates corticosteroid secretion)
- Gonadotropic hormones (follicle-stimulating hormone (FSH) and luteinizing hormone (LH)) - stimulates sex hormone secretion, reproductive organ growth, reproductive processes
- Growth hormone
- Melanocyte0stimulating hormone (MSH) - increases melanin to make our skin darker
- Thyroid-stimulating hormone (TSH)
- Prolactin - stimulates milk production
What hormones are secreted from the posterior pituitary 2
- ADH
2. Oxytocin
What hormones are released from the thyroid 3
- Calcitonin - reduces calcium and phosphorus levels
- Thyroxine (T4) - turns into T3
- Triiodothyronine (T3) - regulates metabolism
What hormone is released from your parathyroid
- parathyroid hormone (PTH) - increases calcium and phosphorus levels
What 2 hormones are released from the adrenal medulla
Epinephrine and norepinephrine - enhances and prolongs effects of sympathetic nervous system “fight or flight”
What 3 hormones are released from the adrenal cortex
- Androgens and estradiol - promotes growth spurts, sex characteristics and libido
- Glucocorticoids - Promotes metabolism, anti-inflammatory
- Mineralocorticoids (aldosterone) - retains salt, loses potassium = water balance
What 5 hormones are released from the pancreas
- Amylin - decreases gastric motility, makes you feel full
- Glucagon - stimulates glycogenolysis and gluconeogenesis
- Insulin
- Pancreatic polypeptide - helps with metabolism of absorbed nutrients
- Somatostatin - inhibits insulin and glucagon secretion
What is the purpose of ADH and how does it work
The purpose is to regulate fluid volume - when our fluid volume is low (hypovolemia) the hypothalamus will stimulate the release of ADH from the posterior pituitary, so we stop getting rid of so much fluid in our urine
What do thyroxine (T4) and triiodothyronine (T3) do
They affect our metabolic rate, caloric requirements, O2 consumption, carbohydrate and lipid metabolism, growth and development, brain function and more….
What is the purpose of calcitonin, which is stimulated by the thyroid
Control calcium levels
What are catecholamines, and why are they important
These are our epinephrine, norepinephrine and dopamine that are essential for our “fight or flight” response
What do corticosteroids do
Effect glucose metabolism, anti-inflammatory and help maintain fluid and electrolyte balance
What does cortisol do 3
- Helps regulate blood glucose
- Helps maintain vascular integrity and fluid volume
- Decreases the inflammatory response
Why is aldosterone important
It helps maintain extracellular fluid volume by promoting the renal reabsorption of sodium and the excretion of potassium and hydrogen
When can a patient have a goiter
If they have hypothyroidism or hyperthyroidism
What should you be careful of when inspecting to see if a patient has a goiter
To not push too hard on the thyroid gland, because you could cause the sudden release of thyroid hormone in a patient who already has hyperthyroidism
What are some diagnostics that we can run on a patient
- Imaging (look at the organ)
- Labs
- Biopsy
What are some primary prevention techniques to avoid a hormonal imbalance 8
- Education
- Diet
- Exercise
- Weight control
- Injury avoidance
- Avoiding extreme temperatures
- Stress management
- Maintaining routine sleep and wake patterns
What is a hypophysectomy
Removes the pituitary gland
What is adrenalectomy
Remove the adrenal glands
What is a thyroidectomy
Remove the thyroid
What is a parathyroidectomy
Remove the parathyroid
What are 5 parathyroid/thyroid disorders that we will see
- Thyrotoxicosis (hyperthyroidism)
- Primary hypothyroidism
- Congenital hypothyroidism
- Hyperparathyroidism
- Hypoparathyroidism
What are 6 pituitary disorders that you might see
- Hypopituitarism
- Gigantism
- Acromegaly
- Dwarfism
- Diabetes insipidus
- SIADH
What are 4 adrenal disorders that you might see
- Cushing’s syndrome (hypercortisolism)
- Hyperaldosteronism
- Adrenal insufficiency (Addison’s disease)
- Pheochromocytoma
Where are the adrenal glands located
On top of each kidney
Who controls the adrenal glands
The anterior pituitary
What can adrenal insufficiency lead to
Addison’s disease
In Addison’s disease, what three things are reduced
- Mineralocorticoids (aldosterone)
- Glucocorticoids (cortisol)
- Androgens (testosterone)
(you have low steroids)
What is the difference between primary and secondary adrenal insufficiency
In primary, there is an actual problem with the adrenal gland and you’re unable to produce and secrete cortisol and aldosterone, whereas in secondary the problem is from the pituitary gland, where we are not getting enough stimulation (ACTH) from the pituitary (ACTH stimulates the adrenal gland to release cortisol and aldosterone)
What is Addison’s disease usually caused from
An autoimmune disorder
What are some clinical manifestations of Addison’s disease 9
- Anorexia
- Nausea
- Progressive weakness
- Fatigue
- Weight loss
- Increased ACTH causes bronze-colored skin (only in primary, not secondary)
- Orthostatic hypotension
- Irritability
- Abdominal pain
- Salt craving
What are 8 symptoms of an adrenal crisis
- Profound fatigue
- Dehydration
- Vascular collapse (decreased BP) - this can lead to shock
- Renal shut down
- Hyponatremia
- Hyperkalemia
- Dehydration
- Hypoglycemia
What can cause an adrenal (Addisonian) crisis 4
- Stress (from an infection, surgery, psychologic distress)
- Sudden withdrawal of corticosteroid hormone therapy
- Adrenal surgery
- Sudden pituitary gland destruction
Should we be worried if someone goes into an Addisonian crisis
Yes - it can be a life-threatening emergency
What diagnostic tests can you do for someone with Addison’s disease
- ACTH stimulation (injected with ACTH, little to no increase in cortisol levels and a high ACTH = Addison’s disease)
- CRH test if ACTH comes back abnormal (given CRH, high ACTH levels and no cortisol = Addison’s disease, no ACTH = secondary adrenal insufficiency)
When someone is having an Addisonian crisis, what can we do
- Correct fluid and electrolyte imbalances
- Give fluids
- Get daily wts, Is and Os
- Note any drugs that interact with corticosteroids
- Watch for signs of cushing syndrome
- Protect against extremes (we want to watch for things that can trigger stress) (light, noise, temp)
- Give high-dose hydrocortisone
How can we manage Addison’s desease
- Lifelong glucocorticoid replacement (hydrocortisone) (two thirds in morning, rest at night)
- Instead of glucocorticoid replacement, they may take mineralocorticoid (fludrocortisone) instead (once in the morning)
- Increase salt in diet
- Increase dose during times of stress
- Teach patient signs and symptoms of corticosteroid deficiency and excess
- Wear med alert bracelet
- Diet high in protein and carbs
What is serious to report to your HCP if you have Addison’s disease
Diarrhea or vomiting, because you will probably need electrolyte replacement right away
Why do we need to limit stress with Addison’s disease
Because the patient cannot make corticosteroids (cortisol), which helps a person respond to stress
Basically what is it called if you don’t have enough cortisol
Addison’s disease
What is it called if you have too much cortisol
Cushing’s syndrome
How do we treat Addisonian crisis
- High-dose hydrocortisone
- Large volumes of 0.9% saline and 5% dextrose (to help restore electrolyte imbalance and BP
Corticosteroids are good to treat a lot of diseases, however, they can often lead to many side effects, what are some of these side effects 7
- Slow wound healing
- Increase for infection
- Hypokalemia
- Hypertension
- Suppressed inflammatory response
- Hypocalcemia (can lead to osteoporosis)
- Glucose intolerance (monitor sugars - this drug can cause hyperglycemia)
Should you ever abruptly stop taking your corticosteroids
No - this can lead to Addisonian crisis and death
What is it called when you have too much corticosteroids, particularly glucocorticoids
Cushing syndrome
What is the typical cause of cushing’s syndrome
An ACTH secreting pituitary adenoma (growth or tumor on the pituitary) (cushing disease)
What are some other causes of cushing’s syndrome 3
- Administration of corticosteroids
- Adrenal tumors
- ACTH secretion by tumors in the lung or pancreas
What is weird about cancer and hormones
Cancer can actually secrete their own hormones, so they can mimic cortisol for example, which causes your body to continually make this hormone even when it is not needed
What are clinical manifestations of cushing’s syndrome
- Weight gain (fat in the trunk, face (“moon face”) and back (“buffalo hump”)
- Hyperglycemia
- Weakness
- Osteoporosis
- Back pain
- Skin becomes weaker, thinner and more easily bruised
- Purplish red striae (stretch marks on abdomen, breast and buttock)
- Women can get male characteristics, acne, hirsutism
- Males (gynecomastia) - women breasts
- Hypokalemia
- Hypernatremia
- High blood pressure
- Red cheeks
- Thin arms and legs
What are the 3 ways we begin to diagnosis cushing’s syndrome
By confirming increased cortisol levels
- Midnight or late night salivary cortisol
- Low-dose dexamethasone suppresion test
- 24 hour urine cortisol (higher than 100mcg/24hrs indicates cushing disease)
What would high or normal or low ACTH levels indicate
Cushing disease
What would low or undetectable ACTH levels indicate
Adrenal or medication cause
How would you use imaging to determine cushing’s syndrome
Use CT or MRI to detect a pituitary or adrenal tumor
What is seen in ectopic (abnormal place) ACTH syndrome and adrenal cancer
Hypokalemia and alkalosis
How do we normally treat cushing’s syndrome
We try to remove the tumor
What is lung or pancreas cancer called when they are secreting ACTH and causing cushing syndrome
We call them Ectopic ACTH secreting tumors
If a patient is a poor surgical candidate, then how do we treat
Medication, we want to suppress the secretion of cortisol from the adrenal gland. We can use ketoconazole or mitotane.
What if cushing syndrome is caused by prolonged corticosteroid use
Then we gradually want to taper the patient off the medication
As nurses, what should we be monitoring for patients with cushing syndrome
- Monitor VS, daily wts, glucose
- Assess for infection
- Assess for inflammation because signs and symptoms may be minimal for absent
- Monitor for thromboembolic events (chest pain, dyspnea, tachypnea)
- Help patient deal with the physical changes of the disease (reassure them that physical changes will resolve with treatment)
Why do we want to watch for blood clots with cushing syndrome
Because hypercoagulant ability has increased
What should be done preoperatively before surgery
- Control hypertension and hyperglycemia
- Correct hypokalemia with diet and potassium
- Increase protein in diet
What are some risks during surgery
- Because the adrenal glands are very vascular, there is a high risk of hemorrhage
- When you cut into the gland, you can release all of the hormones into the body, which could cause the patient to go into crisis (unstable BP, fluid and electrolyte imbalances)
What do you want to monitor after surgery
- Is, Os, vital signs and wts.
- Monitor for acute adrenal insufficiency (vomiting, weakness, dehydration and hypotension)
What patient teaching do we provide for someone with cushing’s syndrome
- Wear medical bracelet
- Avoid exposure to extreme temperatures, infection and stress
- Teach how to adjust medication and when to call the HCP (they’ll be on corticosteroid replacement therapy)
- You will be on lifetime replacement therapy (if they had a gland removed)
What is pheochromocytoma
Tumor in the adrenal medulla that results in an excess production of catecholamines (epinephrine, norepinephrine)
What are signs of pheochromocytoma
Severe hypertension, tachycardia, palpitations, headache, profuse sweating, unexplained chest pain (your fight or flight response is in overdrive)
What causes pheochromocytoma
- Direct pressure on the tumor
- Stress
- Drugs
- Genetics
What is the most common test for pheochromocytoma
24 hour urine test
What are you looking for in a 24 hour urine test
95% increase in fractionated metanephrines (catecholamine metabolites), fractionated catecholamiens and creatinine
What should you never do with someone who has pheochromocytoma
Palpate their abdomen - this can cause the sudden release of catecholamines and severe hypertension
How can we treat pheochromocytoma
Surgically remove the tumor (it that’s what causing it)
What do we use give to patients before surgery to help control their high blood pressure
Alpha and beta blockers
What is hyperaldosteronism known as
Conn’s disease
What is Conn’s disease and what does it cause in the body
It is excess aldosterone secretion, which causes sodium retention and potassium and hydrogen excretion
What are the hallmarks of Conn’s disease
Hypertension with hypokalemic alkalosis (low potassium)
What are the clinical manifestations of Conn’s disease
- The sodium retention causes hypernatremia, hypertension and headache
- Edema doesn’t occur, because the rate of sodium excretion also increases
- Potassium wasting leads to hypokalemia (weakness, fatigue, dysrhythmias, glucose intolerance, metabolic alkalosis, tetany)
Due to the excess sodium, what do we really want to monitor
BP
How do we diagnosis Conn’s disease
- Look at labs (aldosterone levels will be increased, as well as sodium, we will see a decrease in potassium and plasma renin)
- CT/MRI to detect an adenoma (benign tumor)
- If no tumor is not found, 18 hydroxycortisone level is measured overnight
How do we treat hyperaldosteronism
- Adrenalectomy to remove the adenoma
What will happen before surgery
- Given potassium sparing diuretics and antihypertensives (decrease sodium and save potassium) Spironoacton “actone”
- Oral potassium supplements
- Restricting sodium
What is the treatment for patients with bilateral adrenal hyperplasia
- Potassium sparing diuretics
- Calcium channel blockers to control BP
- Dexamethasone to decrease adrenal hyperplasia
What are we doing as nurses for someone with Conn’s disease
- Monitoring fluid and electrolyte balance
- Monitoring their BP frequently (at least every 4 hours)
- Teach signs and symptoms of hypokalemia and hypernatremia
What is a severe form of hypothyroidism
Myxedema coma
What is a severe form of hyperthyroidism
Thyrotoxicosis
What does euthyroid mean
Having a normal functioning thyroid gland
What are signs and symptoms of hypothyroidism
- Hair loss
- Tired
- Dry skin
- Constipation
- Intolerance to cold
- Facial and eyelid edema
- Thick tongue (slow speech)
- Brittle hair and nails
- Menstrual issues
- Bradycardia
- Weight gain
- Low temp
Who do we see diagnosed with hyperthyroidism more
Women ages 20-40
What happens in primary hypothyroidism
- Destruction of the thyroid gland (can be from an autoimmune disease (Hashimoto’s), surgery, radiation, drugs that block production, iodine deficiency)
- Defective hormone synthesis (genetic)
What happens in secondary hypothyroidism
Problem with hypothalamus or pituitary, where there is a decrease in TSH secretion
What is myxedma
From long-standing hypothyroidism, where there is an accumulation of hydrophilic mucopolysaccharides in the dermis and other tissues (skin will look dull and puffy)
What is myxedma coma
Where a patient will lose consciousness from having such low thyroid. It can be caused by an infection, drugs, exposure to cold or trauma. We will see subnormal temperatures, hypotension, hypoventilation and cardiovascular collapse . Treat with IV thyroid hormone
What are the TSH levels for primary and secondary hypothyroidism
Primary has high TSH levels.
Secondary has low TSH levels.
What would the presence of thyroid antibodies suggest in hypothyroidism
That the hypothyroidism is an autoimmune origin
What are other abnormal lab findings for hypothyroidism
- Anemia
- High cholesterol and triglycerides
- Increased creatinine kinase
Why do we give lose doses of levo initially
Because we don’t want to increase resting HR and BP
Who should we monitor closely on levo
People with CVD (cardiovascular disease), too high of a dose may cause angina and dysrhythmias
How long until levo takes effect
6-8 weeks
When do we increase doses of levo based on TSH levels
Every 4-6 weeks as needed
What are we assessing for patients on levo
- Chest pain
- Weight loss
- Nervousness
- Tremors
- Insomnia
(Basically things putting them in a hyperthyroid state)
If you are a diabetic with hypothyroidism, what should you be checking daily and why
Your blood glucose, because levo will return you back to your normal state, which usually requires a higher insulin amount
Should you switch brands of levo
No
What are risk factors for hypothyroidism
- Being a female
- White
- Advancing age
- Hx of autoimmune disease
- Down’s syndrome
- Family history
- Previous hyperthyroidism
- Previous radiation
- Treatment with iodine or antithyroid medication
- Thyroid surgery
What are we monitoring closely for a patient in a myxedma coma
- Mechanical respiration support (Have intubation kit in the room next to the patient because their RR is going to be so slowwwww)
- Cardiac monitoring
- IV thyroid hormone replacement
- Monitoring core temp
What is the number one cause of hyperthyroidism
Grave’s disease
Besides grave’s disease, what else can cause hyperthyroidism
- Toxic nodular goiter
- Thyroiditis
- Excess iodine intake
- Pituitary tumors
- Thyroid cancer
What is thyrotoxicosis
When you have high levels of T3 and/or T3 circulating (thyrotoxicosis and hyperthyroidism usually occur together)
For hyperthyroidism would you have high or low levels of TSH
Low levels (T3/T4 and TSH are always going to be opposite)
How would you define Grave’s disease
Thyroid enlargement and excess thyroid secretion. Autoimmune disease
What can cause Grave’s disease
- Lack of iodine
- Smoking
- Infection
- Stressful life event
How does Grave’s disease work
It creates antibodies to the TSH receptor, where they bind to the receptors and stimulate the release of T3 and/or T4
What is bad about Grave’s disease
It can actually destroy the thyroid gland
What are some signs and symptoms of hyperthyroidism
- Exophthalmos (protrusion of the eyeballs)
- Tachycardia
- Heat intolerance
- Enlarged thyroid
- Weight loss
- Diarrhea
- Finger clubbing
- Increased appetite
- Insomnia
- Tremors
- Irritable
What is thyrotoxicosis also known as
Thyroid storm or thyrotoxic crisis
What is happening in acute thyrotoxicosis
There are excess amounts of thyroid hormones being released into circulation
What usually causes thyrotoxicosis
Usually brought on by a stressor (infection, life-event, trauma, surgery)
What are the signs and symptoms of thyrotoxicosis
Hyperthyroid symptoms magnified
- Tachycardia
- Heart failure
- Elevated temp (as high as 106)
- Seizures
- Abdominal pain
- Vomiting
- Diarrhea
- Delirium
- Coma
- Agitation and confusion (usually the number one early indicator of thyrotoxicosis)
How can we test for hyperthyroidism
- Look for decreased TSH levels
- Increased FT 4 levels (free thyroxine)
- RAIU test to determine Grave’s disease (see how much iodine collects in the thyroid - Grave’s disease will have a higher uptake)
- Scan the thyroid
How can we treat hyperthyroidism
- Medications (antithyroid meds (methimazole, PTU (report fever/sore throat), SSKI, Beta Blockers, iodine, and Beta blockers)
- Radioactive iodine therapy
- Surgery
What antithyroid meds can we give
- Propylthiouracil (PTU)
- Methimazole (Tapazole)
What do these drugs do
Inhibit the synthesis of thyroid hormones
What drug works faster
PTU
However, what is the downside to PTU
You have to take it 3 times per day, where as you only need to take methimazole once daily
When will you see results for these drugs
4-8 weeks
Do you need to be on these drugs for life
No - you can stop taking them after your thyroid levels off
What do we give iodine for
Treatment of thyrotoxicosis (thyroid storm) or preparing the patient for a thyroidectomy
Is iodine good for long term
No - it’s therapeutic effect decreases over time
What are beta blockers good for
They are good to help decrease the systems like high HR, nervousness, irritability and tremors
What is the treatment of choice for most nonpregnant adults
Radioactive iodine therapy RAI
How does RAI work
RAI destroys the thyroid tissue, which limits the secretion of thyroid hormones. The effectiveness is usually not noticed until 3 months. Can cause a person to end up with hypothyroidism for life.
What is important to tell your patient receiving RAI
- To keep their distance from pregnant women and children for 7 days after therapy.
- Use a private bathroom
- Don’t share food or drinks
- Separate your laundry
What should we watch for post op after a thyroid surgery
- Monitor for hypothyroidism
- Hypocalcemia
- Hemorrhage
- Laryngeal nerve damage
- Thyrotoxicosis
- Infection
- Maintain a patent airway (semi-folwer position so you are not putting any tension on surgical site)
What should you monitor for someone with thyroid storm in the ICU
- Dysrhythmias
- Ensure adequate oxygen (airway may be obstructed due to the neck surgery)
- Fluid and electrolyte replacement
- Give tylenol for high temp
- Cooling blankets
- ROM exercises for eyes to keep things from getting stuck (may need to tape eyelids down)
- Wear dark sunglasses
How can you treat exophthalmos
Restrict salt to help with the edema
What is some good discharge teaching for someone who had a thyroidectomy
- Monitor hormone balance periodically
- Decrease caloric intake
- Adequate but not excessive amounts of iodine intake (seafood once-twice per week should be enough, or using a normal amount of iodized salt)
- Avoid high temp environments
What is thyroidits
Swelling or inflammation of the thyroid gland
After a thyroid surgery, will the gland regenerate
Yes, it will begin to make hormones again (don’t take extra hormones in the meantime, because it will delay or prevent the regeneration of the normal functions)
What is hypoparathyroidism
When you have abnormally low PTH levels
What can low PTH levels lead to
Low calcium and high phosphorus
What does the parathyroid do
It regulates calcium and phosphorous
What can cause hypoparathyroidism
- Neck surgery that removed or damaged the parathyroid gland
- Autoimmune disorder
- Low magnesium (you need magnesium to produce PTH)
- Radiation to the neck or face
What do the clinical manifestations of hypoparathyroidism look like
Basically what low calcium levels look like
- Numbness/tingling around mouth
- Stiff extremities
- Tonic spasms
- Lethargy
- Anxiety
- Personality changes
- Tetany (spasms)
How do we treat hypoparathyroidism
- Treat acute complications like tetany, by maintaining normal calcium levels
What should we do if a person has acute tetany after surgery
- Give IV calcium (but give it slowly)
- Use ECG to monitor heart when giving IV calcium due to risk of hypotension, dysrhythmias or cardiac arrest
- Digoxin can make a patient vulnerable to issues
What else can you do if a patient is having acute neuromuscular symptoms associated with hypocalcemia
Have them rebreathe CO2 out of a bag (this can lower pH, which causes your body to increase calcium levels)
What is hyperparathyroidism
Where you have too much PTH
What is happening in primary hyperparathyroidism
There is a benign tumor (adenoma) in the parathyroid gland, which causes an increase in calcium levels.
How can we treat primary hyperparathyroidism
Usually treated by surgery
What is happening in secondary hyperparathyroidism
From a condition outside of the parathyroid gland that is causing hypocalcemia, which then causes the release of PTH to compensate. It can be from vitamin D deficiencies, malabsorption, kidney disease and hyperphosphatemia
How can we treat secondary
By fixing the underlying problem
What are the clinical manifestations of hyperparathyroidism
- Osteoporosis (your body is being told by PTH to make more calcium, so it is taking calcium from your bones)
- Kidney stones (kidneys cannot reabsorb the excess calcium, so it makes stones)
- Polyuria
- Abdominal pain
- Tiring easily
- Weakness
- Depression
- Forgetfulness
- Bone/joint pain
- N/v
- Anorexia
What are the main complications from hyperparathyroidism
- Osteoporosis, which increases your risk of fractures
- Kidney stones
What are two indications of hypocalcemia
Positive trousseau’s
Chvostek’s signs
What is a good way to remember hyperparathyroidism
Think Stones, Bones, Moans and Groans
(you’ll have kidney stones, prone to fractures and bone pain, you’ll have abdominal moans (n, v, weight loss, constipation), psychic groans (irritability, confusion))
What is hypopituitarism
Decrease in one or more of the pituitary hormones
What two hormones are most impacted by hypopituitarism
GH and gonadotropins (LH, FSH)
What can cause hypopituitarism
Pituitary tumor or hypothalamus damage
What does hypopituitarism cause
Metabolic/sexual dysfunction
What are some manifestations of hypopituitarism
- Children with short stature
- Issues with reproduction
- Decrease in libido
- Delayed puberty
- ED
- Excessive urination and thirst
- Issues producing enough breast milk
- Decrease in sperm
- Decrease in pubic hair
- decrease in facial hair
- osteoporosis
What can be given to treat GH deficiency in adults
Somatropin (Genotropin, humatrope, Omnitrope) (recombinant human GH)
What will growth hormone do
- Increase energy
- Increase lean body mass
- Provide a sense of well-being
- Improve body image
What are some side effects to GH
- Fluid retention
- Swelling in hands and feet
- Myalgia (muscle aches and pain)
- Joint pain
- Headache
What are the treatments for hypopituitarism
Surgery or radiation followed by lifelong hormone therapy
How is surgery done on the pituitary gland
They go through your nose hypophysectomy
What is hyperpituitarism
Where you have too much hormones related to growth, reproduction and metabolism being excreted
What is the usual cause of hyperpituitarism
Usually a benign tumor
What is acromegaly
Caused by an overproduction of GH (form of hyperpituitarism)
What are the manifestations of acromegaly
Things on and in your face keep growing (overgrowth of bones in hands, feet, face), tongue enlargement, deepening voice, sleep apnea, thick, leathery, oily skin with acne, vison changes, headaches , diabetes.
How can we diagnosis hyperpituitarism
- Look at insulin-like growth factor 1 (IGF-1) levels
- Look at GH response to an oral glucose tolerance test
(we will see a rise in both of these levels) - We can also look at a CT/MRI
What is the treatment of choice for hyperpituitarism
Surgery (hypophysectomy)
What happens in a transsphenoidal hypphysectomy
The entire pituitary gland is removed through the nose - patient will need lifelong replacement therapy of the thyroid hormone, sex hormone and glucocorticoids
What is some good patient teaching for someone who just had a transsphenoidal hypophysectomy
- Rinse mouth with saline water
- No tooth brushing until incision heals
- Do not blow your nose
- Breath through your mouth
- Report asap any clear fluid or bright red fluid coming from the nose
What if clear drainage from the wound tests positive for glucose and proteins
Notify the HCP right away for a possible CSF leak - there could be an open connection from the brain somewhere, which would be bad. Puts the patient at risk for meningitis.
What is diabetes insipidus
Decrease or absence in ADH
What are clinical manifestations of DI
- Polyuria
- Nocturia
- Polydipsia (excessive thirst)
- Tachycardia
- Hypernatremia
- Hypotension
How can we diagnosis DI
- Low urine specific gravity (diluted urine)
- Look at electrolytes
- MRI of head
What are the patients at risk for with DI
Dehydration
What can be given to treat DI
- Desmopressin (DDAVP) (for central DI)
- Vasopressin
(these drugs work like ADH - so they will cause you to retain your fluids)
What else can help to treat DI
- Adequate hydration
- Maintain fluid/electrolyte balance
- Low sodium diet (helps decrease urine output)
What is syndrome of inappropriate antidiuretic hormone (SIADH)
Where there is an overproduction or release of ADH when it is not needed (causes you to retain water)
What can cause SIADH
Lung cancer
What are the manifestations of SIADH
- Low urine output
- Increased thirst
- Increased weight
- Hypertension
- Hyponatremia
- Tachycardia
What are early symptoms of SIADH
- Increased thirst
- Dyspnea on exertion
- Irritability
- Headache
- Mild hyponatremia
What are late symptoms of SIADH
- Vomiting
- Abdominal cramps
- Muscle twitching
- Cerebral edema
- Severe hyponatremia
How can we diagnosis SIADH
- Low serum sodium
- High urine specific gravity (means it is very concentrated urine - because you’re not peeing)
How can we treat SIADH
- Fluid restriction
- IV hypertonic saline solution may be given for severe hyponatremia (give slowly) (you can cause permanent damage to nerve cells if given too quickly)
- Electrolyte supplements
- Seizure precautions
- Keep HOB flat or no more than 10 degrees to enhance venous return and reduce the release of ADH
- Diuretics may be administered to increase urine output
What do both DI and SIADH have in common
Both present as excessive thirst
What is cretinism
Severe deficiency in the thyroid hormone in newborns, which causes physical deformities and learning disabilities
What is hypoaldosteronism
Body doesn’t produce enough aldosterone
What does this lead to
- Hyponatremia
- Hyperkalemia
- Metabolic acidosis
What can bromocriptine mesylate do
It can prevent the release of GH, which can help lower levels and treat acromegaly
What can prednisone be given for
It’s a steroid, so it can be given to treat Addison’s, where there are not enough steroids
What is a normal glucose range
74-106
What type of disorder is type 1
An autoimmune disorder
What is type 1 known as
Juvenile diabetes or insulin-dependent diabetes mellitus
What happens in type 1 diabetes
Your body creates antibodies to destroy insulin and/or the B cells creating the insulin, resulting in not enough production of insulin
What are the two causes of type 1 diabetes
- Related to human leukocyte antigens (HLAs) (you get a virus and the B cells are destroyed during that process)
- Idiopathic diabetes - not related to autoimmunity
(both are genetic)
When do we usually diagnosis someone with type 1
When they are close or are in actual ketoacidosis
What are the 3 classic signs of type 1
- Polydipsia (excessive thirst)
- Polyuria
- Polyphagia (excessive hunger)
Can type 1 be cured
No - you will require insulin for the rest of your life
What is exogenous insulin
An outside source of insulin
What is type 2 known as
Adult-onset diabetes or non-insulin dependent diabetes mellitus (NIDDM)
What is endogenous insulin
Self-made insulin
What is happening in type 2
- There could be a problem with your insulin receptor, where the insulin receptor is blocked, which makes it difficult for insulin to attach to the receptor (insulin resistance)
- The beta cells of your pancreas actually start to die out, because they are so overworked trying to make insulin
- Then your glucose is going crazy trying to release insulin to compensate
Is there a genetic link with type 2
Yes, if you have a first degree relative, then you are 10x more likely to develop it
What are adipokines, and what do they have to do with type 2
Adipokines are secreted by adipose tissue, and are thought to play a role in chronic inflammation, which can cause insulin resistance
What syndrome also increases your risk for type 2.
Metabolic syndrome (person has 3 of the following: increased glucose levels, abdominal obesity, high BP, high triglycerides, decreased levels of lipoproteins (HDLs)
What levels would indicate that someone has prediabetes
- Their impaired glucose tolerance (IGT) levels are 140-199 and their impaired fasting glucose (IFG) is 100-125.
(You can have both, but just meeting one of the above will mean that you are prediabetic)
Why is prediabetes bad
Because people can go undiagnosed for 6 and a half years without any symptoms, yet there could already be long term damage to heart and blood vessels
Explain a little bit about gestational diabetes
- Older women, women who are obese, or they have a family history of GDM are at a higher risk
- Sugars will return back to normal after birth, however, the woman is at a higher risk of developing type 2 later on
What medical conditions can cause type 2
- Cushing syndrome
- Hyperthyroidism
- Pancreatitis
- Cystic fibrosis
- Hemochromatosis
- Parenteral nutrition
What drugs can cause type 2
- Corticosteroids (prednisone)
- Thiazides
- Phenytoin (dilantin)
- Antipsychotics
What are the 5 ways that we can diagnosis diabetes
- An A1C of 6.5% or higher
- Fasting plasma glucose (FPG) of over 126
- A 2 hour plasma glucose level of 200 during an OGTT
- Random glucose level above 200
- Or by looking at the classic symptoms (polyuria, polydipsia, polyphagia)
What is A1C looking at
How much glucose is attached to red blood cells (since RBC live for about 3 months, this helps us to determine how high glucose levels have been for the last 3 months)
What is a goal for diabetics to have their A1C level at
7%
What insulin plan mimics our regular production of insulin
The basal-bolus plan
How does the basal-bolus plan work
You are getting a long-acting insulin (basal) and a rapid or short acting insulin multiple times a day (bolus)
Why is short-acting scarier than giving rapid
Because short-acting can have a longer duration, which can increase your risk of hypoglycemia
What is the only insulin that can be given via IV
Regular insulin
When checking glucose before giving insulin, where is our goal
Between 80-130
What are the rapid acting insulins
lispro (Humalog)
aspart (Novolog)
glulisine (Apidra)
What are the times for rapid acting
Onset: 10-30 min
Peak 30min-3hr
Duration 3-5hrs
What are the short acting insulins
Regular (Humalin R, Novolin R)
