V. ENDOCRINE A.

Thyroid Gland: Produces 3 hormones (T3, T4, Calcitonin) Calcitonin DECREASES serum Ca+ levels by taking the calcium out of the blood and pushing it back into the bone. You need IODINE to make hormones. (This is dietary iodine) Thyroid hormone gives us ENERGY! 1. Hyperthyroid: TOO MUCH ENERGY!! (Graves Disease) a. S/S: Nervous Weight DECREASE Sweaty/hot Exophthalmos Attention span DECREASE Appetite INCREASE Irritable GI FAST BP UP Thyroid UP b. Dx: If you drew a serum T4 (thyroxine) or T3 (triiodothyronine)level on this client would it be increased or decreased? INCREASED Thyroid scan Client must discontinue any iodine containing medication ONE week prior to the thyroid scan. c. Tx: 1) Anti-thyroids: Propylthiouracil (PTU), Methimazole (Tapazole) Stops the thyroid from making thyroid HORMONE. Its used PREOP to stun the thyroid. We want this client to become euthyroid (eu=NORMAL) 2) Iodine Compounds: Potassium Iodine (SSKI), Strong Iodine Solution (Lugols solution) DECREASE the size and the vascularity of the gland

ALL endocrine glands are VERY VASCULAR! Give in milk, juice, and use straw. Why? STAIN THE TEETH 3) Beta Blockers: PROPRANOLOL(Inderal) Decreases myocardial contractility Could decrease cardiac output Decreases HR, BP DECREASE anxiety. 4) Radioactive Iodine ( ONE dose) Given P.O. (liquid or tablet form) **Rule out pregnancy first** Destroys thyroid cells HYPOTHYROID Follow radioactive precautions. Stay away from BABIES for 24 hours. Dont anyone for 24 hours. Watch for thyroid storm (thyrotoxicosis, and thyrotoxic crisis). It is hyperthyroidism multiplied by 100. Could be rebound effect postradioactive iodine *TESTING STRATEGY* Do not give beta blockers to asthmatics or diabetics. 54 Hurst Review Services 5) Surgery: thyroidectomy (partial/complete) Post op: Teach how to support neck. Put personal items NEXT to them. Positioning: HOB? ELEVATED TO DECREASE EDEMA Check for bleeding where? BEHIND THE NECK. Nutrition (pre & post op) need MORE calories. Assess for recurrent laryngeal nerve damage by listening for HOARSNESS AND WEAK VOICE. Could lead to vocal cord paralysis, if there is paralysis of both cords

LARYNGEAL obstruction will occur requiring immediate OPERATION. Teach to report any c/o PRESSURE. Trach set at bedside 1) Swelling 2) Recurrent laryngeal nerve damage (vocal cord paralysis) 3) Hypocalcemia Assess for removal. How? S/S of SEIZURE, RIGID MUSCLE, LARYNGOSPASM. Eye care is important for a client with hyperthyroidism. If client cant close their eyelids, hypoallergenic tape may be applied to close lid (to help prevent injury or irritation). Dark glasses may be worn if photosensitivity is present. Artificial tears are used to prevent drying of the eyes. Treatment of hyperthyroidism DOES NOT correct any eye or vision problems. Hurst Review Services 55 2. Hypothyroid (Myxedema): a. S/S: No ENERGY When this is present at BIRTH its called cretinism (very dangerous, can lead to slowed mental and physical development if undetected). Fatigue GI INCREASE Weight INCREASE Hot or cold? COLD Speech SLOW/SLURRED No expression You may be taking care of a totally immobile client b. Tx: Levothyroxine (Synthroid), Thyroglobulin (Proloid), Liothyronine (Cytomel) Do they take these meds forever? YES

What will happen to their energy level when they start taking these meds? INCREASE c. People with hypothyroidism tend to have CORONARY ARTERY DISEASE. B. Parathyroid Problems: The parathyroids secrete PTH which makes you pull calcium from the UP and place it in the blood. Therefore, the serum calcium level goes HIGH. If you have too much parathormone in your body the serum calcium level will be HIGH. If you do not have any parathormone in your body the serum calcium level will be LOW. 1. Hyperparathyroidism = Hypercalcemia = Hypophosphatemia: a. S/S: Too much PTH Serum calcium is HIGH. Serum phos is LOW. Other S/S LOOKS SEDATED b. Tx: Partial parathyroidectomy when you take out 2 of your parathyroids. PTH secretion DECREASE. What are you going to monitor post op? HYPOCALCIMIC 2. Hypoparathyroidism = Hypocalcemia = Hyperphosphatemia: a. S/S: Not enough PTH, Serum calcium is LOW. Serum phos is HIGH. Other S/S: NOT SEDATED b. Tx: IV CALCIUM Phosphorus binding drugs Hurst Review Services 57 C. Adrenal Glands: Need your adrenals to handle STRESS You have two parts to your adrenal gland: adrenal medulla and the adrenal cortex.

1. Adrenal medulla: (epinephrine, nor nonepinephrine) Adrenal Medulla Problems: Pheochromocytoma Benign tumors that secrete epi and norepi in boluses a. S/S: BP? UP HR and Pulse? UP Flushing/diaphoretic b. Dx: VMA (vanillylmandelic acid) test: a 24 hour urine specimen is done and you are looking for increased levels EPI and NOREPI (also called catecholamines). With a 24 hour urine you should throw AWAY the first voiding and KEEP the last voiding. c. Tx: Surgery to remove TUMORS 58 Hurst Review Services 2. Adrenal cortex: (Glucocorticoids, Mineralocorticoids, and Sex hormones) a. Adrenal Cortex Steroids: 1) Glucocorticoids: Change your mood. Example: insomnia, depressed, psychotic, euphoric Alter defense mechanisms Immunosuppressed High risk for INFECTION Breakdown FAT and proteins Inhibit insulin H y p e rglycemic Do accuchecks 2) Mineralocorticoids: Aldosterone Make you retain SODIUM & POTASSIUM Make you lose POTASSIUM Too Much Aldosterone. Fluid volume excess Serum Potassium: DOWN Not Enough Aldosterone. Fluid volume deficit Serum Potassium: INCREASE 3) Sex hormones: **See Cushings notes**

Adrenocorticotropin hormones (ACTH) are made in the pituitary and they stimulate cortisol to be made. Cortisol is a hormone of the adrenal cortex. So no matter what fancy word NCLEX Lady usesyou will still get the same resultthink steroids. ACTH = Cortisol level Too many steroids = Hypercortisolism (just another word). Hurst Review Services 59 b. Adrenal Cortex Problems: 1) Addisons disease: (Adrenocortical insufficiencynot enough steroids) a) Pathophysiology: They do not have enough glucocorticoids, mineralocorticoids, or sex hormones. Aldosterone (mineralocorticoids) Normally, aldosterone makes us retain SODIUM and WATER and lose POTASSIUM......Now we dont have enough (insufficient) so we will lose SODIUM and WATER and retain POTASSIUM. The serum K+ will be HIGH. b) S/S: Initially, the majority of the S/S are a result of the hyperkalemia. Beginning with muscle twitching, then proceeds to weakness, then flaccid paralysis. Other S/S: Anorexia/nausea Hyperpigmentation-bronzing color of the skin and mucous membranes Decreased bowel SOUNDS GI upset White patchy area of depigmented SKIN (vitiligo) Hypotension Decrease Na, increased K+ and WATER 60 Hurst Review Services

c) Tx: Combat shock (losing SODIUM and WATER) INCREASE sodium in their diet Processed fruit juice/broth (has lots of SODIUM) I & O and daily weight If this client is losing Na and water their BP will probably be LOW. They will probably be gaining/losing weight? LOSING Nursing DX: Fluid Volume DEFICIT Will be placed on the mineralocorticoid drug Fludrocortisone (Florinef) (aldosterone) Rule: When on a medicine where weight has to be monitored, keep weight within 2-3 lbs (+ or -) of their normal weight. WEIGHT is very important in adjusting their medication. Critical Thinking Exercise: If you have a client at home taking Fludrocortisone (Florinef) and the following occurswhat should the CLIENT do? (1) Overnight gain of 7 lbs. what do they do with their AM dose? DECREASE or HOLD (2) Overnight loss of 7 lbs. what do they do with their AM dose? HOLD IT, AND CALL THE DOCTOR If the nurse is taking care of the client in the hospital on Fludrocortisone (Florinef) and the following occurswhat should the NURSE do? (1) Client has edema or their BP is up INCREASE DOSE (2) Clients BP is steadily going down DECREASE *TESTING STRATEGY* Addisonian Crisis = severe hypotension and vascular collapse Hurst Review Services 61 2) Cushings: a) S/S:

These clients have too many glucocorticoids, mineralocorticoids, and sex hormones. Growth arrest Thin extremities/skin (lipolysis) Increased risk of infection Hyperglycemia Too Psychosis to depression Many Moon faced (fat redistribution or fluid retention) Truncal obesity (fat redistribution; lipogenesis) Buffalo hump (fat redistribution) Oily skin/acne Too Women with male traits Many Poor sex drive (libido) High BP CHF Too Weight gain Many Fluid Volume EXCESS Since the client has too much mineralocorticoid (aldosterone), the serum K+ will be LOW. If you did a 24 hour urine on this client the cortisol levels would be HIGH. b) Tx: Adrenalectomy (unilateral or bilateral) *If both are removed lifetime replacement Quiet environment Diet pre-treatment? K+ INCREASE Na DECREASE Protein INCREASE Ca INCREASE Avoid infection. What might appear in their urine? KETONES, GLUCOSE Hint: Steroids decrease serum Calcium by excreting it through the GI tract. 62 Hurst Review Services D. Diabetes: 1. Classification: a. Type 1: (IDDM) They have little or no insulin. Usually starts in childhood First sign may be DKA. Appears ABRUPTLY

1) Pathophysiology: You have to have INSULIN to carry glucose out of the vascular space into the cellsince there is no insulin, the glucose just builds up in the VASCULAR space, the blood becomes hypertonic and pulls fluid into the vascular spacethe kidney filter excess glucose and fluids (polyuria and polydipsia) the cells are starving so they start breaking down protein and fat for energy (polyphagia)when you break down fat you get KETONES (acids)Now this client is METABOLIC ACIDOS (respiratory or metabolic?) 2) S/S: Polyuria Polydipsia Polyphagia 3) Tx: Will oral hypoglycemia agents work for this client? NO They have to have insulin. Normal Lab Value Blood Glucose: 70-110 mg/dL Hyperglycemia = 3 Ps Polyuria think shock first. Hurst Review Services 63 b. Type II: (NIDDM) 1) Pathophysiology: These clients dont have enough INSULIN or the insulin they have is no good. These clients are usually OVERWEIGHT. They cant make enough insulin to keep up with the GLUCOSE load the client is taking in. This type of diabetes is not abrupt as Type I. Its usually found by accident; or the client keeps coming back to the

doctor for things like a wound that wont heal, repeated vaginal INFECTION, etc. Individuals with Type II diabetes should be evaluated for METABOLIC syndrome. This includes: insulin resistance, obesity, increased triglycerides, decreased HDL, increased BP, and CAD. 2) Tx: Start with diet and exercise, then add oral agents, then some clients take INSULIN. c. Gestational Diabetes: Resembles Type II Mom needs 2-3x more CALORIES than normal. If mom is over 25 or has family history, screen at _______ weeks gestation. Complication to baby: Increased birth weight anD PROTEINURIA 64 Hurst Review Services 2. General Treatment of Diabetes: (Type I and Type II) a. Diet: Majority of calories should come from: *complex carbohydrates 55-60% *fats 20-30% *protein 12-20% Diabetics tend to have CAD disease. Why are diabetics prone to CAD? Sugar destroys vessels just like FAT. High FIBER diet (keeps blood sugar steady; client may have to decrease insulin) High fiber slows down absorption in the intestines, therefore, eliminating the sharp rise/fall of all blood sugar. b. Exercise: Wait until blood sugar NORMALIZES to begin exercise.

What should the client do pre-exercise to prevent hypoglycemia? EAT Exercise when blood sugar is at its highest or lowest? HIGHEST Exercise SAME time and amount daily. c. Medications: How do oral hypoglycemic agents work? STIMULATE pancreas to make insulin. *Note: not all oral hypoglycemic agents stimulate the pancreas to make insulin. Oral Anti-Diabetic Agents: Glipizide (Glucotrol), Metformin (Glucophage), Pioglitazone (Actos) Only give to Type II How is the insulin dose determined? The dose is increased until the BLOOD SUGAR is normal and until there is no more GLUCOSE & KETONES in urine. Reg (CLEAR).NPH (CLOUDY) Lantus is also clear and is considered a LONG ACTING insulin. What is the only type of insulin you can give IV? REGULAR When drawing up regular and NPH, which one do you draw up first? REGULAR *TESTING STRATEGY* Extreme blood sugar = Vascular damage Hurst Review Services 65 d. Client Teaching Education: Glycosylated Hemoglobin (Hb A1c): blood test; gives an average of what your blood sugar has been over the past 3 MONTHS. Client should eat when insulin is at its PEAK. What happens to your blood sugar when you are sick/stressed? INCREASED

Normal pancreas can handle these fluctuations; an increase in the blood sugar when sick/stressed is a normal reaction to help us fight the illness/stressor. ILLNESS = DKA Rotation of sites (Rotate WITHIN an area first) Aspirate? NO e. Insulin Infusion Pumps: Alternative to daily insulin injections Obtain better control: receiving a basal level of insulin from pump along with additional insulin as needed with MEAL, and if they have an ELEVATED blood sugar. f. Hypoglycemic/Hyperglycemic Episodes: What are the S/S of hypoglycemia? If hypoglycemic, what should the client do? EAT SUGAR After the blood sugar is up, what should they do? COMPLEX CARBS You enter a diabetic clients room and they are unconscious do you treat this client like he is hypo or hyperglycemic? HYPOGLYCEMIC D50W (hard to push; and if you have a choice you need a large bore IV) Injectable glucagon (GlucaGen) (used when there is no IV access; given IM) Prevention: (1)EAT (2)TAKE INSULIN (3)EXERCISE For people with diabetes, the ideal goal for their HbA1c is 4-6 % or less. ADA < 7% *TESTING STRATEGY* Illness = DKA 66 Hurst Review Services 3. Complications of Diabetes: a. Diabetic Ketoacidosis (DKA):

1) Pathophysiology: Anything that increases blood sugar can throw a client into DKA (infection, illness, skipping insulin). DKA may be the first sign of DIABETES. Have all the usual S/S of Type I diabetes Patho: Absent or inadequate insulin blood sugar goes sky high Polyuria, Polydipsia, Polyphagia Fat breakdown (acidosis) Kussmauls respirations (trying to blow off CO2 to compensate for the metabolic acidosis). Also, as the client becomes more acidotic the LOC goes down. 2) Tx: Find the cause. Hourly blood sugar and K+ IV insulin-Insulin decreases HYPOGLYCEMIA & HYPOKALEMIA by driving them out of the vascular space into the cell. ECG Hourly OUTPUT ABGs IVFs Start with NSthen when the blood sugar gets down to about 300 switch to D5W to prevent throwing the client into HYPOGLYCEMIA. Anticipate that the doctor will want us to add POTASSIUM to the IV solution at some point. Hurst Review Services 67 b. Hyperosmolar hyperglycemic nonketosis (HHNK) or Hyperosmolar hyperglycemic nonketosis coma (HHNC): Looks like DKA, but NO ACIDOSIS Making just enough insulin so they are not breaking down body FAT No fat breakdown.no KETONES No ketonesno ACIDS

Will this client have Kussmauls respirations? NO c. Vascular Problems: Will develop poor circulation everywhere due to VESSEL damage (sugar irritates the vessel lining; accumulation of sugar will decrease the size of vessel lumen therefore decreasing blood flow) 1) Diabetic retinopathy 2) Nephropathy d. Neuropathy: 1) Sexual problems: impotence/decreased sensation 2) Foot/leg problems: pain/paresthesia/numbness Review of Diabetic Foot Care 3) Neurogenic bladder: bladder does not empty properlythe bladder may empty spontaneously, INCONTINENCE or may not empty at all, RETENTION. 4) Gastroparesis: stomach emptying is delayed so there is an increased risk for ASPIRATION. e. Increased Risk for INFECTION *TESTING STRATEGY* In the NCLEX world: Type I DKA Type II HHNK