w4 notes Flashcards
ADH patho:
Patho
1. When there is an ___crease in plasma osmolality or ___crease in blood volume
2. ADH is released from _________ (AND thirst is increased)
3. ______ is excreted within the body (AND the body’s thirst mechanism prompts them to consume fluids)
4. the kidneys _______ the fluid so the water is retained within the body
- retaining pure water = ___crease in plasma volume and ___crease in plasma osmolality
5. the blood volume ___creases, and when normal blood _________ is achieved = ADH release is stopped (AND thirst mechanism stops)
(this is another example of ________ feedback cycle)
Patho
1. When there is an increase in plasma osmolality (concentrated blood) or decrease in blood volume (concentrated blood)
2. ADH is released from posterior pituitary (AND thirst is increased)
3. water is excreted within the body (AND the body’s thirst mechanism prompts them to consume fluids)
4. the kidneys reabsorb the fluid so the water is retained within the body
- retaining pure water = increase in plasma volume and decrease in plasma osmolality (blood concentration)
5. the blood volume increases, when normal blood osmolality is achieved = ADH release is stopped (AND thirst mechanism stops)
(this is another example of negative feedback cycle)
hyperthyroidism = overactive thyroid
TSH =
T4 =
T3 =
Caused by
- ______________ – most common, autoimmune
- toxic multi-_________ goiter
hyperthyroidism
overactive thyroid
TSH low
T4 low
T3 high
Caused by
- grave’s disease – most common, autoimmune
- toxic multi-nodular goiter
Teaching DM pt: what to do when sick
- notify provider when you are _____
- monitor BS more frequently
- keep taking meds
- prevent dehydration
- meet __________ needs – food, Gatorade, Pedialyte
- rest
- call provider when:
- ______ in urine
- BS >250
- Fever >101.5 and not _______
- Feeling confused, ______ breathing
- Persistent n/v/d
- Cant tolerate liquids
- Illness lasting longer than ___ days
Teaching DM pt: what to do when sick
- notify provider when you are sick
- monitor BS more frequently
- keep taking meds
- prevent dehydration
- meet carbohydrate needs – food, Gatorade, Pedialyte
- rest
- call provider when:
- ketones in urine
- BS >250
- Fever >101.5 and not responding to Tylenol
- Feeling confused, rapid breathing
- Persistent n/v/d
- Cant tolerate liquids
- Illness lasting longer than 2 days
Adrenal (cortex):
- responds to _______
- regulates ____
- adrenal gland sits on _______
- Adrenal ________ – 3 S’s
- Glucocorticoids - Cortisol (steroids)
- Mineralocorticoids – aldosterone (salt)
- Sex steroids – testosterone (sex)
- Adrenal ________
- Epinephrine
- Norepinephrine
Adrenal (cortex) Disorders
- responds to stress
- regulates Na
- adrenal gland sits on kidney
- Adrenal cortex (covers) – 3 S’s
- Glucocorticoids - Cortisol (steroids)
- Mineralocorticoids – aldosterone (salt)
- Sex steroids – testosterone (sex)
- Adrenal medulla (middle)
- Epinephrine
- Norepinephrine
Major regulator of water supply in body
(2)
- ADH
- thirst mechanism
Pituitary studies: _________ test
- used to differentiate the cause/the why behind diabetes insipidus
- Neurogenic – head trauma
- Nephrogenic – kidney issue
- Psychogenic – psychological issue
how does it work?
- stimulates ______ by administering ______
- monitor urine output, specific gravity, and serum osmolality every 1-2 hours during test (reaction to ADH)
Pituitary studies: water deprivation test
- used to differentiate the cause/the why behind diabetes insipidus
- Neurogenic – head trauma
- Nephrogenic – kidney issue
- Psychogenic – psychological issue
- stimulates ADH by administering ADH/vasopressin
- monitor urine output, specific gravity, and serum osmolality every 1-2 hours during test (reaction to ADH)
Hyp____glycemia
- sweating
- blurry vision
- dizzy
- anxiety
- hunger
- irritability
- shakiness
- tachycardia
-h/a
- weakness, fatigue
Hyp___glycemia
s/s – weak, fatigue, blurry vision, h/a, n/v/d
hypo BS < 70
hyper
cushings syndrome/disease treatment:
- depends on cause
- If ________ tumor = adrenalectomy
- If ectopic ACTH-secreting tumor = removal of _______
- Drug therapy to suppress ______
- If prolonged ________ = gradual d/c of drugs, reduction of dose, conversion of alternate-day regimen
teaching diet – ___creased protein and potassium, ___creased calories and sodium
cushings syndrome/disease treatment:
- depends on cause
- If adrenal tumor = adrenalectomy
- If ectopic ACTH-secreting tumor = removal of tumor
- Drug therapy to suppress cortisol
- If prolonged steroids = gradual d/c of drugs, reduction of dose, conversion of alternate-day regimen
teaching diet – increased protein and potassium, decreased calories and sodium
addisons Treatment
- hormone replacement therapy
- Hydrocortisone (daily) – exogenous ________
- 2/3 dose AM/PM?
- 1/3 dose AM/PM?
- Fludrocortisone (daily) – exogenous ________
- Salt additives for heat/humidity
- ___creased doses when stress
- Frequent vs
- stress free environment – low noise, light, temp
Treatment
- hormone replacement therapy
- Hydrocortisone (daily) – exogenous cortisol
- 2/3 dose AM – naturally higher cortisol in body upon wakening
- 1/3 dose PM
- Fludrocortisone (daily) – exogenous aldosterone
- Salt additives for heat/humidity
- Increased doses when stress
- Frequent vs
- stress free environment – low noise, light, temp
Cushing’s disease/syndrome = too much 3 S’s/cortisol
- Glucocorticoids - _______ (steroids)
- Mineralocorticoids – _________ (salt)
- Sex steroids – testosterone (sex)
(syndrome = collection of _____)
Common cause
- PO systemic __________
Cushing’s disease/syndrome
too much 3 S’s/cortisol
- Glucocorticoids - Cortisol (steroids)
- Mineralocorticoids – aldosterone (salt)
- Sex steroids – testosterone (sex)
(syndrome = collection of s/s)
Common cause
- PO systemic steroids long term
DI
s/s
- 3 P’s?
- high or low urine specific gravity?
- high or low urine osmolality?
- high or low serum osmolality?
- hyp___natremia
- fatigue from nocturia
- weakness from Na imbalance
s/s
- Polydipsia (r/t high serum osmolality)
- polyuria – 5-20 L/day
- (not polyphagia)
- Urine low specific gravity (not concentrated, diluted urine)
- low urine osmolality (not concentrated urine b/c it is very diluted with fluid that the kidneys are excreting)
- high serum osmolality (concentrated blood b/c there is no water in the body, the kidneys are excreting everything)
- hypernatremia (pure water loss in kidney, sodium is concentrated)
- fatigue from nocturia
- weakness from Na imbalance
Hypoglycemia Treatment
- check BS
- rule of 15
- conscious and able to swallow:
- 15g simple carbs – ______ or ______, avoid ______
- unconscious/unable to swallow:
- IM ______
- IV ______
- check BS again in 15 mins
- if > 70 = eat regular meal
- if < 70 = repeat rule of 15 until > 70
Hypoglycemia Treatment
- check BS
- rule of 15
- conscious and able to swallow:
- 15g simple carbs – 4 oz juice or regular soda, avoid sugars w/ fat like candy bar b/c delayed absorption
- unconscious/unable to swallow:
- IM glucagon
- IV D50
- check BS again in 15 mins
- if > 70 = eat regular meal
- if < 70 = repeat rule of 15 until > 70
Insulin deficit and F/E balance
1. increased serum glucose levels
2. __creased plasma oncotic pressure
3. fluid shifts ______ cells and _______ intravascular (to fix the pressure/concentration issue)
4. cells swell or shrink ?
Insulin deficit and F/E balance
1. increased serum glucose levels
2. increased plasma oncotic pressure (r/t balance/concentration of blood sugar in blood vessels)
3. fluid shifts out of cells and into intravascular (to fix the pressure/concentration issue)
4. intracellular dehydration, cells are dehydrated and shrink
TSH low
T4 low
T3 high
TSH high
T4 low
T3 low
hyper
hypo
hypothyroidism = underactive thyroid
TSH ____
T4 _____
T3 _____
Caused by
(1)
hypothyroidism
underactive thyroid
TSH high
T4 low
T3 low
Caused by
- Hashimoto’s thyroiditis
T___ s/s
- younger people – most common
- abrupt
- not common in DM cases
- no endogenous insulin production – must have insulin replacement
- 3 p’s = excessive thirst (polydipsia), excessive hunger (polyphagia), excessive urination (polyuria)
- Weight loss
- fatigue
- weakness
- recurrent infections
- prolonged wound healing
- pruritis
- vision changes
- paresthesia
- CV symptoms
T___ s/s
- adults with risk factors
- can be undx for years b/c s/s not as evident
- insulin resistant – PO/SQ meds, maybe insulin replacement
- fatigue
- increased thirst and urination
- recurrent infections and slow wound healing
- vision changes
- pruritus (itching)
- symptoms of neuropathy like paresthesias or weakness
- overweight w/ unexpected weight loss
T1 s/s
- younger people – most common
- abrupt
- not common in DM cases
- no endogenous insulin production – must have insulin replacement
- 3 p’s = excessive thirst (polydipsia), excessive hunger (polyphagia), excessive urination (polyuria)
- Weight loss
- fatigue
- weakness
- recurrent infections
- prolonged wound healing
- pruritis
- vision changes
- paresthesia
- CV symptoms
T2 s/s
- adults with risk factors
- can be undx for years b/c s/s not as evident
- insulin resistant – PO/SQ meds, maybe insulin replacement
- fatigue
- increased thirst and urination
- recurrent infections and slow wound healing
- vision changes
- pruritus (itching)
- symptoms of neuropathy like paresthesias or weakness
- overweight w/ unexpected weight loss
Pharmacotherapy for SIADH or DI?
- Desmopressin/DDAVP
DI
Desmopressin/DDAVP is a synthetic form of vasopressin/ADH for replacement (DI has a lack of ADH)
Goiter = ________
can be caused by
- hyperthyroid (toxic)
- hypothyroid
- thyroiditis
- benign thyroid nodules
- malignancy
- _______ deficiency
- iodine is necessary for synthesis of _______
- only the thyroid gland can uptake _______
- most iodine needs are met through _____
- (4)
- iodine deficiency is an issue in ______, and not an issue in _____
Toxic goiter – goiter with hyp___thyroidism
________ goiter – goiter with normal thyroid levels, d/t autoimmune problems
Goiter
Enlarged thyroid gland
can be caused by
- hyperthyroid (toxic)
- hypothyroid
- thyroiditis
- benign thyroid nodules
- malignancy
- iodine deficiency
- iodine is necessary for synthesis of thyroid hormones,
- only the thyroid gland can uptake iodine,
- most iodine is consumed through diet
- (yogurt, milk, eggs, and iodinized salt),
- issue in some parts of the world, not an issue in US
Toxic goiter – goiter with hyperthyroidism
Non-toxic goiter – goiter with normal thyroid levels, d/t autoimmune problems
Pancreatic disorders
diabetes mellitus
T___
- autoimmune
- immune system attacks and destroys insulin producing beta cells in the pancreas
- without beta cells body can’t make insulin = hyperglycemia
T____
- body’s cells wear out and become resistant to the effects of insulin = hyperglycemia
T1
T2
- A hypertonic solution/medium has a _______ osmolality/concentration of solutes compared to normal body fluids or cells.
- A hypotonic solution/medium has a ________ osmolality/concentration of solutes compared to normal body fluids or cells.
- When a hypertonic solution is administered IV, it causes water to move ______ the cells by osmosis to equalize the osmolality between the intracellular and extracellular compartments.
- When a hypotonic solution is administered IV, it causes water to move ______ the cells by osmosis to equalize the osmolality between the intracellular and extracellular compartments.
- Hypertonic solutions are useful in treating conditions like hyp___natremia
- Hypotonic solutions are useful in treating conditions like hyp___natremia
A hypertonic solution/medium has a higher osmolality/concentration of solutes compared to normal body fluids or cells.
A hypotonic solution/medium has a lower osmolality/concentration of solutes compared to normal body fluids or cells.
- When a hypertonic solution is administered IV, it causes water to move out of the cells by osmosis to equalize the osmolality between the intracellular and extracellular compartments.
- When a hypotonic solution is administered IV, it causes water to move into the cells by osmosis to equalize the osmolality between the intracellular and extracellular compartments.
- Hypertonic solutions are useful in treating conditions like hyponatremia
- Hypotonic solutions are useful in treating conditions like hypernatremia
ADH
Regulator of __________
- loss of pure water r/t ADH will not effect _________
Increase in ADH = ___crease in water retention
___crease in blood volume
___crease in BP
Regulator of pure water supply
- loss of pure water r/t ADH will not effect POTASSIUM
(will not cause hypokalemia)
Increase in ADH = Increase in water retention
Increase in blood volume
Increase in BP
hyperthyroidism s/s:
- ___creased HR
- 4 heart things?
- __creased RR
- breathing?
- ___creased appetite and thirst
- weight _____
- __creased peristalsis
- diarrhea or constipation?
- memory lapses, short attention span
- warm/cold?, dry/moist?, smooth skin
- hair amount?
- ________ erythema
- hair texture?
- diaphoresis
- hyper or depigmentation of skin
- goiter?
- bruit over ________
- _________ - abnormal protrusion/bulging of the eyeballs from the eye sockets
metabolism is turned up
- increased HR, murmurs, dysrhythmias, palpitations, angina
- increased RR,
- DOE
- increased appetite and thirst
- weight loss
- increased peristalsis,
- diarrhea
- memory lapses, short attention span
- warm, moist, smooth skin
- hair loss
- palmar erythema (red palm)
- fine silky hair
- diaphoresis
- vitiligo (autoimmune, depigmentation of skin)
- goiter
- bruit over thyroid gland – d/t increased vascularity
- exophthalmos - abnormal protrusion/bulging of the eyeballs from the eye sockets
ADH disorders:
________ = too much ADH (holding onto water)
_______ = not enough ADH (losing water like crazy)
Adrenal cortex disorders:
__________ = not enough 3 S’s/cortisol
- Glucocorticoids - Cortisol (steroids)
- Mineralocorticoids – aldosterone (salt)
- Sex steroids – testosterone (sex)
__________ = too much 3 S’s/cortisol
- Glucocorticoids - Cortisol (steroids)
- Mineralocorticoids – aldosterone (salt)
- Sex steroids – testosterone (sex)
Adrenal medulla disorders:
___________ = too much epinephrine and norepinephrine
Thyroid disorders:
_________(_______) = overactive thyroid
__________(______) = underactive thyroid
Pancreatic disorders:
___________ = hyperglycemia due to the body’s inability to produce or effectively use the hormone insulin
ADH disorders:
- SIADH (syndrome of inappropriate ADH) = too much ADH (holding onto water)
- diabetes insipidus) = not enough ADH (losing water like crazy)
Adrenal cortex disorders:
- addisons disease = not enough 3 S’s/cortisol
- Glucocorticoids - Cortisol (steroids)
- Mineralocorticoids – aldosterone (salt)
- Sex steroids – testosterone (sex)
- cushing disease/syndrome = too much 3 S’s/cortisol
- Glucocorticoids - Cortisol (steroids)
- Mineralocorticoids – aldosterone (salt)
- Sex steroids – testosterone (sex)
Adrenal medulla disorders:
- pheochromocytoma = too much epinephrine and norepinephrine
Thyroid disorders:
- hyperthyroidism (grave’s disease) = overactive thyroid
- hypothyroidism (Hashimoto’s thyroiditis) = underactive thyroid
Pancreatic disorders:
- diabetes mellitus = hyperglycemia due to the body’s inability to produce or effectively use the hormone insulin
Negative feedback cycle and the thyroid gland:
hyperthyroidism = T3/T4 will be ______ and TSH will be _______
Negative feedback cycle and the thyroid gland:
- hyperthyroidism = T3/T4 will be high and TSH will be low
hyperthyroidism treatment: surgical therapy
endoscopic vs subtotal?
1. _________ thyroidectomy
- Removal of a _________ of the thyroid gland
- If too much is taken = __________
- Indications – not responsive to ________ therapy, very large ______, possibility of _________
2. __________ thyroidectomy – less invasive, used for __________
Post op interventions:
- Assess for s/s _________
- Assess for ______ compression
- would these signs be concerning? Irregular breathing, neck swelling, frequent swallowing, choking, blood on dressing, sensations of fullness at incision site
- Place in _________ with head on pillow
- Avoid flexion or any tension on ________
- Monitor vs
- parathyroid close to thyroid - Monitor serum ________ levels, tetany, “AMB?”, tingling in toes/fingers/mouth, muscular twitching, apprehension, trousseaus sign and chvosteks sign
- Subtotal thyroidectomy
- Removal of a large portion of the thyroid gland
- If too much is taken = hypothyroidism
- Indications – not responsive to anti-thyroid therapy, very large goiter, possibility of malignancy - Endoscopic thyroidectomy – less invasive, used for small nodules
Post op interventions:
- Assess for s/s hemorrhage (thyroid very vascular)
- Assess for tracheal compression (thyroid close to airway)
- Irregular breathing, neck swelling, frequent swallowing, choking, blood on dressing, sensations of fullness at incision site
- Place in semi fowlers with head on pillow
- Avoid flexion or any tension on suture lines
- Monitor vs
- parathyroid close to thyroid - Monitor serum calcium levels, tetany, “AMB?”, tingling in toes/fingers/mouth, muscular twitching, apprehension, trousseaus sign and chvosteks sign
hyperthyroid Treatment: drug therapy
1. anti-thyroid meds = _________
- improvements in 1-2 weeks, good results 4-8 weeks
2. _______ therapy = SSKI and Lugol’s solution
- used to prep pt for __________
- when given in _____, _______ doses - inhibits synthesis of T3 and T4, lowers the vascularity of the thyroid gland, makes surgery easier and safer
3. beta blockers
- used for s/s relief of ________
4. radioactive iodine therapy – 1st line for non-pregnant adults
- route?
- require hospitalization?
- The radioiodine is rapidly incorporated into the thyroid and its beta emissions result in extensive local tissue damage
- ________ is radio active for a period of time
- Delayed response – _______ of thyroid function over a period of 6-18 weeks
- Anti-thyroid drugs and ______ given together to help s/s management
- Radioactivity is gone within______ days
- Radioactivity precautions –
minimize ________ for 2-3 days,
__________ toilet,
separately _______ clothes
Treatment
- drug therapy
- anti-thyroid meds = methimazole
- improvements in 1-2 weeks, good results 4-8 weeks
- idodine therapy = SSKI and Lugol’s solution
- used to prep pt for thyroidectomy
- when given in rapid large doses - inhibits synthesis of T3 and T4, lowers the vascularity of the thyroid gland, makes surgery easier and safer
- beta blockers
- used for s/s relief of thyrotoxicosis
- radioactive iodine therapy – 1st line for non-pregnant adults
- PO solution/capsule
- Doesn’t require hospitalization
- The radioiodine is rapidly incorporated into the thyroid and its beta emissions result in extensive local tissue damage
- Excretions are radio active for a period of time
- Delayed response – ablation of thyroid function over a period of 6-18 weeks
- Anti-thyroid drugs and beta blockers given together to help s/s management
- Radioactivity is gone within a few days
- Radioactivity precautions –
minimize direct contact for 2-3 days,
double flush toilet,
separately launder clothes and towels
ADH disorders:
which one are you holding onto water?
which one are you losing water like crazy?
ADH disorders:
- SIADH (syndrome of inappropriate ADH) = too much ADH (holding onto water)
- diabetes insipidus) = not enough ADH (losing water like crazy)
SIADH Patho
1. ___creased ADH
2. ___creased water reabsorption in kidneys
3. ___creased intravascular fluid volume
4. dilutional hyp___natremia and ___creased serum osmolality
Patho
1. increased ADH
2. increased water reabsorption in kidneys
3. increased intravascular fluid volume
4. dilutional hyponatremia and decreased serum osmolality
- parathyroid gland (buried in the _______ gland)
Parathyroid regulates
(2)
If the parathyroid is removed = hyp___calcemia = check for what?
- parathyroid gland (buried in the thyroid gland)
Parathyroid regulates
- calcium
- phosphorus
If the parathyroid is removed = hypocalcemia = treuseaus and chovsteks signs
Negative feedback cycle
Example:
- stress occurs
- triggers release of ______ from hypothalamus
- reaches target organ: _______ gland
- releases _______
- reaches target organ: __________
- releases ________
- blood sugar _______ and body prepares for fight or flight in response to stress
Negative feedback cycle
Example:
- stress occurs
- triggers release of CRF from hypothalamus
- reaches target organ: pituitary gland
- releases ACTH
- reaches adrenal cortex
- releases cortisol
- blood sugar rises and body prepares for fight or flight in response to stress
Adrenal cortex dx tests: cortisol
- evaluates status of adrenal cortex function
- serum cortisol is affected by
- __________ – higher in ______
- ________– higher when _______
- urine cortisol – 24 hour urine, excreted from urinary tract
Adrenal cortex dx tests: cortisol
- evaluates status of adrenal cortex function
- serum cortisol is affected by
- Diurnal variation/circadian rhythm – higher in AM (body preparing for day)
- Stress – higher when stressed
- urine cortisol – 24 hour urine, excreted from urinary tract
cushing syndrome/disease s/s r/t high cortisol:
1. ____creased glucose availability = glucose intolerance, hyperglycemia
2. impacts vascular system = hyp___tension, capillary _______ leads to ________
3. _______ breakdown = muscle wasting, muscle weakness, thinning of skin, osteoporosis, bone pain
4. fat breakdown = redistribution of fat to _______, _______, and _______
5. suppression of _______ and _________ responses = impaired wound healing, impaired immune response, risk for infection
6. _____ excitability = mood swings, insomnia
cushing syndrome/disease s/s r/t high cortisol:
1- increased glucose availability = glucose intolerance, hyperglycemia
2- impacts vascular system = hypertension (fluid retention), capillary friability/fragile/rupture leads to bruising/ecchymosis
3- protein breakdown = muscle wasting, muscle weakness, thinning of skin, osteoporosis, bone pain
4- fat breakdown = redistribution of fat to abdomen, shoulders, and face
5- suppression of immune and inflammatory responses = impaired wound healing, impaired immune response, risk for infection
6- CNS excitability = mood swings, insomnia
hypothryoid treatment:
1 - thyroid hormone replacement = ________
2- monitor thyroid hormone levels and adjust dosage prn
- T3 and T4 ______
- TSH _______ = when defect is in thyroid
- TSH______ = when defect is in pituitary or hypothalamus
- presence of antibodies indicates its ______
3 - nutrition to promote weight _____
- thyroid hormone replacement = levothyroxine
- monitor thyroid hormone levels and adjust dosage prn
- T3 and T4 low
- TSH high = when defect is in thyroid
- TSH low = when defect is in pituitary or hypothalamus
- presence of antibodies indicates its autoimmune
- nutrition to promote weight loss
thyroid is regulated by _______ (which comes from anterior pituitary)
thyroid secretes:
(3)
- most abundant
- together with PTH regulates calcium balance
- most potent
thyroid is regulated by TSH (which comes from anterior pituitary)
thyroid secretes:
- thyroxine (T4)
- triiodothyronine (T3)
- calcitonin
- T4
- calcitonin
- T3
Thyroid labs and dx studies
- blood studies: TSH (secreted from anterior pituitary, target organ is thyroid)
- blood studies: T3 and T4
- Most sensitive test used for evaluation of thyroid dysfunction?
- Used for evaluation of thyroid function and monitoring thyroid therapy?
TSH
T3 and T4
hyperthyroid vs hypothyroid treatment:
1. levothyroxine
2. idodine therapy = SSKI and Lugol’s solution
3. nutrition to promote weight loss
4. methimazole
5. beta blockers
6. radioactive iodine therapy
7. Subtotal thyroidectomy
8. Endoscopic thyroidectomy
- hypo (replacement)
- hyper
- hypo
- hyper (anti-thyroid meds )
- hyper used for s/s relief of thyrotoxicosis
- hyper – 1st line for non-pregnant adults
- hyper
- hyper
addisons disease: Early s/s
- hunger?
- weight gain or loss?
- strength?
- malaise
- apathy
- hyp___kalemia
- skin hyp___pigmentation
s/s r/t hypoaldosterone:
(Think _______ and ______ problems)
- hyp___tension
- diminished vascular tone
- reduced CO
- inadequate circulating blood volume
- _____ craving
- Low serum Na levels
- Dehydration
s/s r/t hypocortisolism:
(think lack of stress hormones = no ______)
- hyp___glycemia
- weakness and fatigue
- unsuppressed ACTH production = hyp___pigmentation
Early s/s
- anorexia
- weight loss
- weakness!! – r/t fluid and electrolyte imbalance
- malaise, apathy
- hyperkalemia (low aldosterone, low Na, high K+)
- skin hyperpigmentation
Hypoaldosterone s/s
(Think Na and water retention problems)
- hypotension
- diminished vascular tone
- reduced CO
- inadequate circulating blood volume
- salt craving
- Low serum Na levels
- Dehydration
Hypocortisolism s/s
(think lack of stress hormones = no energy)
- hypoglycemia
- weakness and fatigue
- unsuppressed ACTH production = hyperpigmentation
Addisons disease = not enough 3 S’s/cortisol
1. Glucocorticoids - Cortisol (_________one)
2. __________coids – aldosterone
3. Sex steroids – testosterone
- primary stress hormone?
- male hormone?
- steroid hormone, causes Na and water retention, and increased BP?
- Glucocorticoids - Cortisol (hydrocortisone)
- Mineralocorticoids – aldosterone
- Sex steroids – testosterone
- primary stress hormone? Glucocorticoids - Cortisol (hydrocortisone)
- male hormone? testosterone
- steroid hormone, causes Na and water retention, and increased BP? Mineralocorticoids – aldosterone
ADH disorders:
- SIADH (syndrome of inappropriate ADH) =
- DI (diabetes insipidus) =
Adrenal cortex disorders:
- addisons disease =
- cushing disease/syndrome =
Adrenal medulla disorders:
- pheochromocytoma =
Thyroid disorders:
- hyperthyroidism (grave’s disease) =
- hypothyroidism (Hashimoto’s thyroiditis) =
Pancreatic disorders:
- diabetes mellitus =
ADH disorders:
- SIADH (syndrome of inappropriate ADH) = too much ADH (holding onto water)
- diabetes insipidus) = not enough ADH (losing water like crazy)
Adrenal cortex disorders:
- addisons disease = not enough 3 S’s/cortisol
- Glucocorticoids - Cortisol (steroids)
- Mineralocorticoids – aldosterone (salt)
- Sex steroids – testosterone (sex)
- cushing disease/syndrome = too much 3 S’s/cortisol
- Glucocorticoids - Cortisol (steroids)
- Mineralocorticoids – aldosterone (salt)
- Sex steroids – testosterone (sex)
Adrenal medulla disorders:
- pheochromocytoma = too much epinephrine and norepinephrine
Thyroid disorders:
- hyperthyroidism (grave’s disease) = overactive thyroid
- hypothyroidism (Hashimoto’s thyroiditis) = underactive thyroid
Pancreatic disorders:
- diabetes mellitus = hyperglycemia due to the body’s inability to produce or effectively use the hormone insulin
addisons disease s/s
- r/t low levels of _______ and ________
- depends on rate of onset and severity of symptoms
- Slow/rapid? degenerative destruction = subtle onset of s/s
- Slow/rapid? onset = severe, life threatening s/s
s/s
- r/t low levels of cortisol and aldosterone
- depends on rate of onset and severity of symptoms
- Slow degenerative destruction = subtle onset of s/s
- Rapid onset = severe, life threatening s/s
Hormones that affect blood sugar
- __crease = insulin
- __crease = glucagon
-__crease = epinephrine
-__crease = glucocorticoids
-__crease = growth hormone
Hormones that affect blood sugar
- decrease = insulin
- increase = glucagon
- increase = epinephrine
- increase = glucocorticoids
- increase = growth hormone
Adrenal cortex dx tests: Aldosterone (regulator of sodium)
- used to assess for hyperaldosteronism
- maintain assigned position for 2 hours
- levels vary depending on ________
- high aldosterone = _____ NA retention, _____ water retention, ______ blood volume
Adrenal cortex dx tests: Aldosterone (regulator of sodium)
- used to assess for hyperaldosteronism
- maintain assigned position for 2 hours
- levels vary depending on position
- high aldosterone = high NA retention,
high water retention,
high blood volume
s/s of ____________
- thin body hair
- upper body/truncal obesity
- moon face – round face
- buffalo hump – neck of neck
- hirsutism – hair growth in unexpected places
- skin – fragile and thin
- bruising – petechiae and ecchymosis
- poor healing
- striae – purple stretch marks on abdomen, thighs, butt, arms, breasts
- mental depression or euphoria, lability (mood swings), irritability
- glucose intolerance
- HTN – 2ndary to cortisol’s salt retaining activity and increased blood volume
- hypokalemia – high cortisol stimulates mineralcorticoid/aldosterone = increased Na and decreased K+
- bone demineralization – spontaneous fractures possible
cushings
ACTH dx tests: ACTH tests (secreted by anterior pituitary, target organ is adrenal cortex)
- evaluates how adrenal cortex function and how the body responds to ACTH
- serum ACTH
- ACTH stimulation/suppression test – synthetic ACTH given
- ACTH stimulation/suppression test – dexamethasone given
- ACTH stimulation test – synthetic ACTH given
- ACTH suppression test – dexamethasone given
Cushings syndrome/disease s/s:
- _____ body hair
- ________ obesity (where?)
- ______ face
- _________– back of neck
- _________ – hair growth in unexpected places
- skin – _______ and ________
- bruising – _________ and _________
- _____ healing
- ________ – purple stretch marks on abdomen, thighs, butt, arms, breasts
- mental depression or ________, _______ility (mood swings), _______ility
- glucose _________
- BP?
- hyp___kalemia
- bone ____________
s/s
- thin body hair
- upper body/truncal obesity
- moon face – round face
- buffalo hump – neck of neck
- hirsutism – hair growth in unexpected places
- skin – fragile and thin
- bruising – petechiae and ecchymosis
- poor healing
- striae – purple stretch marks on abdomen, thighs, butt, arms, breasts
- mental depression or euphoria, lability (mood swings), irritability
- glucose intolerance
- HTN – 2ndary to cortisol’s salt retaining activity and increased blood volume
- hypokalemia – high cortisol stimulates mineralcorticoid/aldosterone = increased Na and decreased K+
- bone demineralization – spontaneous fractures possible
Addisons disease: Drug therapy teaching hormone/3 S’s replacement
- critical
- closely follow rx dosing schedule
- never _______ stop therapy
- replacement therapy is ______ long
- when body is stressed = 3x3 rule = 3x _____ dose for 3 _____
- always have an emergency supply of meds
- wear medic alert bracelet
- carry emergency kit – hydrocortisone 100mg IM, syringes, instructions
- critical
- closely follow rx dosing schedule
- never abruptly stop therapy
- replacement therapy is life long
- when body is stressed = 3x3 rule = 3x normal dose for 3 days
- always have an emergency supply of meds
- wear medic alert bracelet
- carry emergency kit – hydrocortisone 100mg IM, syringes, instructions
addisons disease = hyp__kalemia
(___ aldosterone, ___ Na, ___ K+)
cushings = hyp__kalemia
(___ aldosterone, ___ Na, ___ K+)
addisons disease = hyperkalemia
(low aldosterone, low Na, high K+)
think jfK = think hyperK+
cushings = hypokalemia
(high aldosterone, high Na, low K+)
Myxedema vs myxedema coma
- Myxedema
- changes seen in the skin and tissues, with prolonged hyp___thyroidism
- swelling is hard/soft? and pitting/non-pitting?
- permanent or can be reversed with thyroid hormones? - myxedema coma
- sever hyp__thyroidism, with very ____ thyroid hormone levels
- medical emergency
- give IV thyroid hormones and steroids
- AMS, may be unresponsive
- caused by – HF, stroke, infections, not taking prescribed thyroid meds,
- hypothyroidism complication
Myxedema –
- changes seen in the skin and tissues, with prolonged hypothyroidism
- swelling is hard and non-pitting
- can be reversed with thyroid hormones
myxedema coma –
- sever hypothyroidism, with very low thyroid hormone levels
- medical emergency
- give IV thyroid hormones and steroids
- AMS, may be unresponsive
- caused by – HF, stroke, infections, not taking prescribed thyroid meds,
- hypothyroidism complication
Caused by
- Hashimoto’s thyroiditis
Caused by
- grave’s disease – most common, autoimmune
- toxic multi-nodular goiter
hypo
hyper
patho T1 DM
1. genetics, environment factors
2. autoantigens form on insulin producing ____ cells and circulate in the blood stream and lymphatics
3. activation of cellular immunity (macrophages and T cytotoxic cells) and humoral immunity (autoantibodies) toward beta cells
4. destruction of beta cells with decreased insulin secretion
Patho T2 DM
1. insulin ________ on cells lose their glucose sensitivity
2. glucose can’t leave blood stream and go into cell
patho T1 DM
1. genetics, environment factors
2. autoantigens form on insulin producing beta cells and circulate in the blood stream and lymphatics
3. activation of cellular immunity (macrophages and T cytotoxic cells) and humoral immunity (autoantibodies) toward beta cells
4. destruction of beta cells with decreased insulin secretion
Patho T2 DM
1. insulin receptors on cells lose their glucose sensitivity
2. glucose can’t leave blood stream and go into cell
hypothyroidism s/s:
- weight ?
- depression
- fatigue
- slow mentation
- slow speech
- somnolence
- low exercise tolerance
- DOE
- anemia
- diarrhea or constipation?
- warm skin or cold intolerance?
- hair?
- moist or dry skin?
- goiter?
- difficulty swallowing
- myxedema
(think metabolism turned down)
- weight gain
- depression
- fatigue
- slow mentation
- slow speech
- somnolence
- low exercise tolerance
- DOW
- anemia
- constipation
- cold intolerance
- hair loss
- dry skin
- goiter
- difficulty swallowing
- myxedema
hypothyroidism: Myxedema vs myxedema coma
- __________ –
- changes seen in the skin and tissues, with prolonged hypothyroidism
- swelling is hard and non-pitting
- can be reversed with thyroid hormones - ___________ –
- sever hypothyroidism, with very low thyroid hormone levels
- medical emergency
- give IV thyroid hormones and steroids
- AMS, may be unresponsive
- caused by – HF, stroke, infections, not taking prescribed thyroid meds,
- hypothyroidism complication
Myxedema
myxedema coma
________ studies: water deprivation test
Adrenal studies: ________, _______, ACTH
Adrenal _________ dx tests: cortisol
Adrenal cortex dx tests: Aldosterone (regulator of _________)
ACTH dx tests: ACTH tests
________ labs and dx studies: TSH, T3, T4, thyroid scan, ultrasound and radioactive iodine uptake
________ blood studies: fasting blood glucose, casual blood glucose, A1C, OGTT
Pancreas _______ studies: ketones
Pituitary studies: water deprivation test (b/c this is an ADH test and ADH comes from posterior pituitary gland)
Adrenal studies: cortisol, aldosterone, ACTH
Adrenal cortex dx tests: cortisol
Adrenal cortex dx tests: Aldosterone (regulator of sodium)
ACTH dx tests: ACTH tests
Thyroid labs and dx studies: TSH, T3, T4, thyroid scan, ultrasound and radioactive iodine uptake
Pancreas: blood studies: fasting blood glucose, casual blood glucose, A1C, OGTT
Pancreas: urine studies: ketones
does ADH impact potassium?
does aldosterone impact potassium?
No
yes
Desmopressin/DDAVP:
- synthetic form of vasopressin/____
- very _____ doses
- route – nasal spray, PO, IV, SQ
- hormone therapy and fluid = cornerstone of treatment for ne____ogenic DI
Desmopressin/DDAVP:
- synthetic form of vasopressin/ADH
- very small doses
- route – nasal spray, PO, IV, SQ
- hormone therapy and fluid = cornerstone of treatment for neurogenic DI
SIADH Care
- restore normal fluid volume and osmolality/concentration of blood
- mild s/s and mild hyponatremia (<125) =
- 1000 ml/day fluid ________
- severe s/s and/or severe hyponatremia (<120) =
- give ________ IV, admin rate?
- 500 ml/day fluid ________
- drug therapy only in acute or chronic?
- Diuretics
- Demeclocycline (blocks ADH effects)
Care
- restore normal fluid volume and osmolality/concentration of blood
- mild s/s and mild hyponatremia (<125) =
- 1000 ml/day fluid restriction
- severe s/s and/or severe hyponatremia (<120) =
- give 3-5% NS IV, admin SLOWLY, over hours to days
- 500 ml/day fluid restriction
- drug therapy only in chronic
- Diuretics
- Demeclocycline (blocks ADH effects)
SIADH s/s
- depends on hyponatremia severity (<____) and rate of onset
- muscle ________
-breathing?
- fatigue?
- neurologic – (3)
- GI – (2) taste, eating
s/s
- depends on hyponatremia severity (<100) and rate of onset
- muscle cramping
-dyspnea
- fatigue
- neurologic – dulled senses, confusion, lethargy
- GI – impaired taste, anorexia
Nursing care: pre-diabetic patient
T/F
1- high risk of developing T1
2- may be no s/s, but damage is occuring
3- teach lifestyle modifications
4- encourage blood glucose and A1C monitoring
5- teach monitor for s/s of T2 DM
Nursing care: DM
- ______ meds started at low dose and increased gradually based on A1C and fasting glucose levels
- hold _______ before procedures
- ___crease insulin when patients are sick – steroids, stress will cause the glucose to ____
- b_____ – scheduled time, long acting
- b_____ - correction SSI, short/rapid acting
1 F - T2
2 - T
3 - T
4 T
5 T
Nursing care: DM
- oral meds started at low dose and increased gradually based on A1C and fasting glucose levels
- hold metformin before procedures
- increase insulin when patients are sick – steroids, stress will cause the glucose to rise
- basal – scheduled time, long acting
- bolus - correction SSI, short/rapid acting
addisons disease Complications: Addisonian crisis
s/s
- Sudden _______ _______ in lower back, abdomen, legs
- Severe ______ and ________
- hydration?
- BP?
- LOC?
treatment
1. IV ________sone, s______, and d________
2. When the pt can take fluids and meds PO = ___________sone dose is decreased until a maintenance dose is achieved
3. If ________one is low = maintenance therapy includes fludrocortisone acetate
if untreated can be ______
- s/s
- Sudden penetrating pain in lower back, abdomen, legs
- Severe vomiting and diarrhea
- Dehydration
- Low BP
- Loss of consciousness
- treatment
- IV hydrocortisone, saline, and dextrose
- When the pt can take fluids and meds PO = hydrocortisone dose is decreased until a maintenance dose is achieved
- If aldosterone is low = maintenance therapy includes fludrocortisone acetate
- if untreated can be fatal
Adrenal (medulla) disorders:
pheochromocytoma = ________ epinephrine and norepinephrine
dx
- elevated 24 hour urine and plasma
- often missed initially bc very rarely is _____ caused by pheochromocytoma
s/s
monitor for intractable (can’t be controlled) _____
and
P –
H –
E –
Adrenal (medulla) disorders
pheochromocytoma = too much epinephrine and norepinephrine
dx
- elevated 24 hour urine and plasma
- often missed initially bc very rarely is HTN caused by pheochromocytoma
s/s
monitor for intractable (can’t be controlled) HTN and
P – palpitations!!
H – h/a!!
E – episodic sweating (diaphoresis)!!
DI = Not enough ADH
- __________ = head trauma (ADH issue)
- Usually more/less abrupt onset
- more/less severe s/s
- Self-limitng
- ___________ = (kidney issue) there is enough ADH but kidney doesn’t respond to ADH
- more/less abrupt onset
- more/less severe s/s
Most common cause of drug induced nephrogenic DI
(1)
Diabetes insipidus (DI)
Not enough ADH
- neurogenic = head trauma (ADH issue)
- Usually more abrupt onset
- Most severe s/s
- Self-limitng
- nephrogenic = (kidney issue) there is enough ADH but kidney doesn’t respond to ADH
- Less abrupt onset
- Less severe s/s
Most common cause of drug induced nephrogenic DI
- lithium
Thyroid labs and dx studies:
- thyroid ultrasound
- thyroid scan
- Used to evaluate ________ in the thyroid
- Radioactive isotope given PO or IV
- Scanner passes over thyroid
- ______ modules = warm spot (uptake isotope)
- ______ tumors = cold spot (did not uptake)
- reaction to iodine is rare, minimally used, encourage fluids after to flush kidneys
- radioactive iodine uptake
- evaluates___________ in the thyroid
- provides direct measure of thyroid activity
- Radioactive isotope given PO or IV
- Uptake is measured at several intervals- 2-4 hours, 24 hours
- Values expressed in %
- which one gives more info?
- thyroid ultrasound
- thyroid scan
- Used to evaluate nodules in the thyroid
- Radioactive isotope given PO or IV
- Scanner passes over thyroid
- benign modules = warm spot (uptake isotope)
- malignant tumors = cold spot (did not uptake)
- reaction to iodine is rare, minimally used, encourage fluids after to flush kidneys
- radioactive iodine uptake
- evaluates function of nodules in the thyroid, gives more info than just a thyroid scan
- provides direct measure of thyroid activity
- Radioactive isotope given PO or IV
- Uptake is measured at several intervals- 2-4 hours, 24 hours
- Values expressed in %
- radioactive iodine uptake
Hyperglycemia
1. caused by illness, infection, self management, stress
2. s/s – weak, fatigue, blurry vision, h/a, n/v/d
3. treatment – check urine ketones, insulin, drink fluids, education
4. complications
- _________ – damage to retina r/t chronic hyperglycemia
- ________– damage to small blood vessels in the kidneys r/t chronic hyperglycemia
- ________– nerve damage due to metabolic imbalances r/t chronic hyperglycemia
Hyperglycemia
- caused by illness, infection, self management, stress
- s/s – weak, fatigue, blurry vision, h/a, n/v/d
- treatment – check urine ketones, insulin, drink fluids, education
- complications
- Retinopathy – damage to retina r/t chronic hyperglycemia
- Nephropathy – damage to small blood vessels in the kidneys r/t chronic hyperglycemia
- Neuropathy – nerve damage due to metabolic imbalances r/t chronic hyperglycemia
DI patho
1. ___creased ADH
2. __creased water reabsorption in kidneys
3. __creased intravascular fluid volume
4. __creased serum osmolality and excessive, very diluted _______
DI Patho
1. decreased ADH
2. decreased water reabsorption in kidneys
3. decreased intravascular fluid volume
4. increased serum osmolality (hypernatremia) and excessive (very diluted) urine output
________
- lispro, aspart, glulisine
________
- regular
_________
- NPH
________
- glargine, detemir, degludec
Rapid
Short
Intermediate
Long
DM diet
- _____ fiber, _____ fat, _____ cholesterol
1- carbs – grains, fruit, legumes, milk ?
2- carbs - pasta, bread ?
3- fats – whats good?
4- ______ – beans veg, oats, whole grain
5- ______ – meats, egg, fish, nuts, beans
6- alcohol – ?
1 good
2 - limit simple carbs like pasta, bread
3 fish
4 fiber
5 protein
6 limit intake
addisons disease Complications: _________
- Acute adrenal ________
- medical emergency
causes – sudden insufficiency of serum __________
- Sudden ____ of gland
- Sudden ___crease in stress in chronic condition
- Sudden _______ of corticosteroid drug therapy
addisons disease Complications: Addisonian crisis
- Acute adrenal insufficiency
- medical emergency
causes – sudden insufficiency of serum corticosteroids
- Sudden loss of gland
- Sudden increase in stress in chronic condition
- Sudden cessation of corticosteroid drug therapy
hyperthyroidism complications: thyroid storm/acute thyrotoxicosis/thyrotoxic crisis
T/F
1- acute and severe
2- rare
3- death is common
4- caused by stressors – infection, trauma, surgery - in pt with hyperthyroidism
5- pts having thyroidectomy are not at any higher risks
6- s/s same as hypothyroidism, more severe
1 T
2 T
3 F - death is rare when treatment is early
4 T
5 F - pts having thyroidectomy are at risk – d/t manipulation of the hyperactive thyroid
6 F - s/s same as hypERthyroidism, more severe
hypo vs hyper thyroidism or both
1 - weight gain
2 - increased HR
3 murmurs,
4- depression
5- fatigue
6 angina
7- slow mentation
8 dysrhythmias
9 palpitations
10 - slow speech
11- somnolence
12- low exercise tolerance
13 increased RR
14- DOE
15- anemia
16 - increased appetite and thirst
17- constipation
18 - weight loss
19 - increased peristalsis, diarrhea
20- cold intolerance
21- hair loss
22- dry skin
23 - memory lapses, short attention span
24 - warm, moist, smooth skin
25- goiter
26 - palmar erythema (red palm)
27- difficulty swallowing
28 - fine silky hair
29 - diaphoresis
30- myxedema
31 - vitiligo (autoimmune, depigmentation of skin)
32 - bruit over thyroid gland – d/t increased vascularity
33 - exophthalmos - abnormal protrusion/bulging of the eyeballs from the eye sockets
1 hypo
2 hyper
3 hyper
4 hypo
5 hypo
6 hyper
7 hypo
8 hyper
9 hyper
10 hypo
11 hypo
12 hypo
13 hyper
14 both
15 hypo
16 hyper
17 hypo
18 hyper
19 hyper
20 hypo
21both
22 hypo
23 hyper
24 hyper
25 both
26 hyper
27 hypo
28 hyper
29 hyper
30 hypo
31 hyper
32 hyper
33 hyper
Sodium = 80% of body’s osmolality
- if pt is hypernatremic = cells _______
- if pt is hyponatremic = cells _______
(with both, patient is ________)
Sodium = 80% of body’s osmolality
- hypernatremic cells shrink
- hyponatremic cells swell
(with both, patient is confused)
Thyroid disorders:
Think thyroid, think ________
Thyroid secretes
TSH = thyroid stimulating hormone
T4 (thyroxine)
T3 (tri-iodothyronine)
- active hormone, activates and energizes all cells of the body?
- shut off valve?
- inactive hormone?
- T3
- TSH
- T4
_______ = Too much ADH
causes:
- excess water ________
- _____ serum sodium levels (dilutional or true?)
- cells _______ as fluid shifts into intracellular spaces
Most common cause
(1)
SIADH = Too much ADH
- causes excess water reabsorption
- and dilutional low serum sodium levels
- cells swell as fluid shifts into intracellular spaces
Most common cause
- ectopic hormone production from lung cancer cells (paraneoplastic disorder)
HOLDING ONTO WATER
- Oxytocin - secreted by _______
target organ - _________ - ADH/antidiuretic hormone - secreted by ________
target organ - _______ - TSH - secreted by ________
target organ - ________ - ACTH - secreted by _______
target organ - _________
- Oxytocin - secreted by Posterior pituitary gland (master gland)
target organ - (uterus, mammary) - ADH/antidiuretic hormone - secreted by Posterior pituitary gland (master gland)
target organ - (kidneys) - TSH - secreted by Anterior pituitary gland (master gland)
target organ - (thyroid) - ACTH - secreted by Anterior pituitary gland (master gland)
target organ - (adrenal cortex)
___________ studies: cortisol, aldosterone, ACTH
- urine cortisol – 24 hour urine
- ACTH stimulation and suppression
- CT/MRI
Adrenal studies: cortisol, aldosterone, ACTH
- urine cortisol – 24 hour urine
- ACTH stimulation and suppression
- CT/MRI
Integumentary assessment: shows maybe uncontrolled/undiagnosed DM
- _____________ – reddish/brown spots usually on shins
- _____________– brown/black thickening of skin, often seen in skin folds
______________ – red patches around blood vessels
acanthosis nigricans
Diabetic dermopathy
necrobiosis lipoidica diabeticorum
- Diabetic dermopathy – reddish/brown spots usually on shins
- acanthosis nigricans – brown/black thickening of skin, often seen in skin folds
- necrobiosis lipoidica diabeticorum – red patches around blood vessels
