week 13 : Hormonal Regulation Flashcards
what are the concepts related to hormone regulation?
fluid and electrolytes
stress and coping
reproduction
development
nutrition
glucose regulation
intracranial regulation
nursing assessment - endocrine
remember things are muddy !
often non specific manifestations ire. fatigue, altered mood, sleep pattern
non specific changes that occur should raise flag for possible endocrine etiology
clinical manifestations may be system wide
lac of clear manifestations makes a detailed health history is very important
where is the thyroid located? anatomy!
it’s in the anterior to the trachea
true or false. Lack of clear manifestations makes a detailed health history very important
true
anatomy of the neck - regarding thyroid
thyroid cartilage
trachea
sternocleidomastoid muscle
thyroid: lobe and isthmus
thyroid: what does this gland do ?
re-call : TRH secreted from hypothalamus stimulates release of TSH from anterior pituitary which stimulates release of thyroid hormone from thyroid gland
name more characteristics
produces thyroxine (T4), triiodothyronine ( T3), calcitonin
major function - production, storage, and release of T4 & T3
iodine needed for synthesis of thyroid hormones
what are the effects of thyroid hormones on our body?
heart
muscles
GI
fat
bones
skin
nerves
cholesterol
thyroid disorders
name them
thyroid disorders
thyroid storm ( hyper)
hyperthyroidism
euthyroid
hypothyroidism
myxedema coma ( hypo)
hyperthyroidism :clinical manifestations
clinical manifestations related to metabolism and sensitivity to stimulation from SNS
true or false.
true
HYPERTHYROIDISM: CLINICAL MANIFESTATIONS
Clinical manifestations r/t increased metabolism & sensitivity to stimulation from SNS
THINK “FAST”
*Heart beat is rapid and strong
*Nervous, insomnia, rapid thoughts/speech *Weak
*Increased temp
*Weight loss
*Menstrual irregularities/infertility
hyperthyroidism
exopthalmos
( 20 - 50% of younger Graves patients )
name the characteristics :
impaired drainage from orbit,
increasing fat and edema in retro orbital tissues= increased pressure, forces eye outward
corneal surfaces become dry and irritated
hyperthyroidism: how is it diagnosed ?
history and physical exam
blood test for TSH, T4 , and if needed, T3
hyperthyroidism: how is it diagnosed ?
what are the other diagnostics we need to look at ?
RAIU ( radioactive iodine uptake test )
hyperthyroidism : how’s it treated ?
drug therapy :
methimazole (tapazole )
B adrenergic blocker ( propranolol )
and
iodine
radioactive iodine
surgical
hyperthyroidism : how’s it treated ?
go more in depth with the categories listed :
methimazole
b-adnergic blocker ( propranolol)
antithyroid drugs inhibits synthesis of thyroid hormone and PTU , also blocks peripheral conversion of T4 and T3
B adrenergic blocker ( propranolol often used )- symptoms relief due to high B adrenergic receptor stimulation from thyroid hormones
true or false. methimazole : antithyroid drugs inhibits synthesis of thyroid hormone and PTU , also blocks peripheral conversion of T4 and T3
true
true or false. b-adnergic blocker ( propranolol): B adrenergic blocker ( propranolol often used )- symptoms relief due to high B adrenergic receptor stimulation from thyroid hormones
true
when should propranolol not be used ?
this will act on the lung which will block the lung from parasympathetic nervous system COPD - asthma we do not want do this will cause bronchoconstriction, we do not want to give this to someone who has COPD or asthma
define what iodine, radioactive mean in terms of hyperthyroidism and how it is treated ?
iodine- short term prior to surgery or in crisis- rapidly inhibits T3 & T4 synthesis & release, decreases vascularity of thyroid gland
define the characteristics that undergoes radioactive Iodine ( RAI ) under hyperthyroidism and how it is treated
destroys thyroid tissue ( cannot have if pregnant )
true or false. Hyperthyroidism and how it’s treated : define if this statement is true or false. subtotal thyroidectomy, removes significant part of thyroid gland
true
how is hyperthyroidism treated?
drug therapy:
methimazole (tapazole) - antithyroid drug inhibits the synthesis of thyroid hormone and PTU and blocks peripheral conversion of T4 to T3
beta adrengeric blocker (propranolol) symptoms relief d/t high beta adrenergic receptor stimulation from thyroid hormones
iodine -short term prior to surgery or in crisis – rapidly inhibits T3&T4
synthesis & release, decreases vascularity of thyroid gland
radioactive iodine (RAI) destroys thyroid tissue (cannot have if pregnant)
Surgical - subtotal thyroidectomy, removes significant part of thyroid gland
drug card: Methimazole (Tapazole)
antithyroid med
MOA: suppress synthesis of thyroid hormone (does not destroy store of thyroid hormone so may take 3-12 weeks to become euthyroid)
used to treat: Graves’ disease, adjunct to radiation therapy, prior to surgery
plasma half life 6-13 hours (allows for once day dosing)
adverse effects: generally well tolerated (but should be avoided by pregnant women)
what is the most dangerous toxicity with methimazole?
agranulocytosis (will reverse once med stopped)
whats the right education for methimazole?
if the pt develops sore throat - tell health care provider - low blood cell counts can occur with this drug
what else is considered with treatment for hyperthyroidism?
nutritional therapy
high cal for hunger and prevent tissue breakdown - could be eating 4000 to 5000 cals and still losing weight
protein allowance 1-2g/kg for ideal body weight
avoid caffeine high seasoned food high fibre food to decrease abdominal pain
what is hypothyroidism?
insufficient thyroid hormone - most often AUTOIMMUNE “Hashimoto’s thyroiditis”
affects approx 2% of the population
what disease affects approx. 2% of the population?
hypothyroidism
what are the symptoms of hypothyroidism ?
symptoms related to decreased metabolism
think SLOWWWWWW
unless due to thyroidectomy or antithyroid treatment symptoms usually subtle for months to years
symptoms:
VS change
goitre (lump or swelling in front of neck)
fatigue, lethargy
constipation, weight gain
cold intolerance, susceptibility to infection
mental changes
what is myxedema?
this is an undiagnosed or untreated SEVERE hypothyroidism (rare)
what is this describing: thickened, non-pitting edematous changes to the soft tissues
Causes puffiness, periorbital edema, masklike affect
hypothyroidism: Myxedema
is myxedema coma a medical emergency?
YESSS
what is this describing? Gradual or sudden advancement in
sluggishness, drowsiness & lethargy of hypothyroidism progresses to impaired LOC→ coma. May
need ventilator
Myxedema coma
more for myxedema coma?
Precipitated by stress: infection, drugs (esp. narcs, tranqs, barbs) exposure to cold, & trauma
↓ T, ↓ B/P, & hypoventilation
Tx: support vital functions, hormone replacement, ventilate, manage clinical manifestations
what is this describing? A–edema of the face B– coarse skin, thin hair, brittle nails, & non-pitting edema of the lower extremities
thick mucus substance - all the ATP sitting in the cells, not being used
myxedema
how is hypothyroidism diagnosed?
history and physical exam
blood test for TSH (increase) and T4 (look for decrease)
look for TPO antibodies against thyroid
may have increase cholesterol and triglycerides, anemia, increased creatine kinase
what does nurses need to know with hypothyroidism meds?
Levothyroxine (T4)
brand name Synthroid
used to treat primary hypothyroidism, myxedema coma, simple goitre
Oral absorption is reduced by food
! Should be taken on an empty stomach in the morning (30-60 mins before breakfast)
Highly protein bound (99.97%)
! Half life is about 7 days (allows for once-a-day dosing, but takes about 1 month to reach plateau
adverse effects for levothyroxine?
rare with appropriate dosing.
! Acute overdose can cause thyrotoxicosis.
! Chronic overdose can lead to accelerated bone loss and increased risk of afib (esp in older adults)
drugs that reduce levothyroxine:
H2 receptor blockers
! Proton pump inhibitors (PPIs) ! Aluminum containing antacids ! Calcium supplements (Tums)
true or false; Levothyroxine enhances the effect of warfarin and dosing may have to be adjusted
yes true
what is the goal for treatment of hypothyroidism?
euthyroid state
what is the treatment for hypothyroidism?
Pharmacotherapy:
Levothyroxine (Synthroid)
- Low calorie diet to promote weight los
what to assess for with hypothyroidism?
Ongoing symptoms
*Worsening symptoms
*Symptoms of hyperthyroidism
history and physical exam related to thyroid disorders
what should we look or assess for when looking a their history ?
History
OPQRSTUV - related to current symptoms
Review of systems - head to toe
( dont forget about reproductive/menstrual history )
PMHx/fam Hx- any autoimmune disease
meds
allergies
immigration from iodine-deficient area
history and physical exam related to thyroid disorders
what should we look or assess for when looking a their physical ?
vital signs
general head to toe- inspection, palpation, ausculation
▪ Head, neck, eyes
▪ Integumentary
▪ Respiratory
▪ Cardiovascular
▪ Abdominal
▪Special assessment – thyroid gland
Part 2 Adrenal disorders
adrenal glands: what do these do ?
re-call
medulla secretes what ?
* cortex- secretes > 50 steroid hormones, collectively known as what ? categorized as ?
medulla secretes catecholamines ( epinephrine )
cortex secretes more than 50 steroid hormones, collectively known as corticosteroids, categorized as glucocorticoids( i.e cortisol ), mineral corticoids ( i.e aldosterone), androgens
adrenal glands: how do they function?
Re-call : that this is controlled by the ?
hypothalamus anterior pituitary
Adrenal glands: How do they function?
- Hypothalamus releases corticotropin releasing hormone which stimulates anterior pituitary
- Anterior pituitary releases adrenocorticotropic hormone (ACTH) which stimulates adrenals
- Adrenals produce corticosteroids
Physiologic vs Pharmacologic effect of corticosteroids:
adrenals : closer look at corticosteroids
what is the main function of the various
corticosteroids ?
glucocorticoids ( main one : cortisol ) :
-helps maintain blood glucose ( as the name indicates ) causes elevation
- has anti inflammatory action by suppressing immune system and supportive action to respond to stress
Physiologic vs Pharmacologic effect of corticosteroids :
adrenals: closer look at corticosteroids
define what undergoes mineralcorticoids ( main one aldosterone )
essential for maintenance of fluid and electrolyte balance
Physiologic vs Pharmacologic effect of corticosteroids :
adrenals: closer look at corticosteroids
define what undergoes androgens ?
produced and secreted in small but significant amounts
stimulate pubic axillary hair growth and sex drive in females
cushing’s : what are the manifestations ?
Re-call that this is one of the manifestations :
cortisol breaking everything down
androgen increases facial hair
what else are there?
Thinning of hair
acne
red cheeks
buffalo hump
supraclavicular fat pad
thin extremities with muscle atrophy
thin skin and subcut tissue
slow wound healing
true or false. Cushings clinical manifestations these are a part of this :
weight gain
moon face
purple striae
pendulous abdomen
ecchymosis resulting from easy bruising
this is all true
this is when cortisol suppressing the immune system, what is the clinical manifestation that is occurring within the Cushing?
ecchymosis resulting from easy bruising
this is when the cortisol is destroying the tissues , what clinical manifestation is occurring ?
purple striae
cushing’s how is it diagnosed ?
SELECT ALL THAT APPLIES
a. 24 hour urine for free cortisol
- cortisol release follows a circadian rhythm so this will catch it at different times of day
b. Low dose dexamethasone suppression test
c. CT or MRI of pituitary and/or adrenals for tumour localization
all
what are the clinical manifestations of Addisons disease?
insidious (sneaky) progressive,
primary features include:
weakness, fatigue, weight loss, anorexia
others: skin hyperpigmentation, nausea and vomiting, hypotension, diarrhea, irritability, depression
true or false. When we don’t see it come from the urine the Cushing is not present
this is true
Cushing’s: What’s the treatment ?
If d/t corticosteroid use ( most common ) => gradually taper off or switch to alternate day regimen
what should we keep in mind ?
never discontinue corticosteroids abruptly
what’s a complication of Addisons?
addisionian crisis (acute adrenal insufficiency)
LIFE THREATENING
triggered by stress sudden corticosteroid withdrawal, adrenal surgery, sudden pituitary gland destruction
GI manifestations: nausea and vomiting, diarrhea, abdominal pain
what is treatment for complications with addison’s?
shock management and aggressive hydrocortisone replacement
what is this describing: corticosteroid deficiencies are severe during crisis: hypotension, tachycardia, dehydration, hyponatremia, hyperkalemia, hypoglycemia, fever, weakness, confusion => can lead to shock and circulatory collapse
complication of addison’s
If tumour is culprit, surgical removal of gland or tumour. Is this true or false?
this is true
how is addison’s diagnosed?
through ACTH stimulation test: ACTH tries to stimulate cortisol levels - in this case it would be low
Other abnormal lab results: * hyperkalemia
* hyponatremia
* hypoglycemia
* anemia
* increased BUN
* low urine cortisol and aldosterone
Cushing is common with rheumatoid arthritis, autoimmune, and which type of transplant is this common ?
bone marrow transplant
Cushing’s: what’s the nurse to do ?
nursing assessment :
monitor
vital signs
daily weight
blood glucose
signs and sx of infection - redness, fever, may be minimal
signs and sx of thromboembolic phenomena
Cushing’s what’s the nurse to do?
monitor :
vital signs
daily weight
blood glucose
go more in depth
increase in blood pressure
increase in weight
increase in sodium and water retention
hypervolemic
because they are immunosuppress
EMOTIONAL SUPPORT!
addison’s disease : what’s the cause (etiology)
recall : lack of endogenous corticosteroids
primary : addison’s disease
- all mineralcorticoids, corticosteroids, and androgens are reduced
what else would you use to diagnose Addisons?
even though we dont diagnose you gotta knowww:
EKG may see arrhythmias
CT and MRI
treatment for addison’s
Hydrocortisone replacement therapy – dose needs to be increased with stress
Increased salt in diet
this is most often autoimmune in nature- greatest prevalence in causian women
addison’s disease
addison’s what are the manifestations ?
insidious onset, progressive
primary features:
- weakness, fatigue, weight loss, anorexia
other features :
skin hyperpigmentation, N&V, hypotension, diarrhea, irritability, depression
what are the nursing implementations for addisons?
frequent assessments
medications: glucocorticoids, mineralocorticoids
which disease is skin hyperpigmentation associated with?
Addison’s disease
