1
Q
Thyroid gland
• hormones?
• what the hormones do?
• what do we need in our diet to make hormones?
A
- produces 3 hormones - T3, T4, Calcitonin
- Calcitonin ↓ serum calcium levels by taking calcium out of blood and push back into bones
- Thyroid hormones give us ENERGY
- Need dietary IODINE to make hormones
2
Q
Hyperthyroid (Graves’ Disease) S/SX
A
- nervous
- irritable
- attention span ↓
- appetite ↑
- weight ↓
- sweaty/hot
- exophthalmos (bulging eyes, irreversible)
- GI FAST (diarrhea, hyperactive bowel sounds)
- BP and Pulse ↑
- Arrhythmia/palpitations (d/t ↑ workload in heart)
- Thyroid size ENLARGES
3
Q
Hyperthyroid (Graves’ Disease) Diagnosis
• serum?
• scan? what to discontinue prior? how long to wait to restart meds?
A
• ↑ Thyroxine (T4), ↓ TSH
• Thyroid scan
—Discontinue any iodine-containing meds 1 WEEK prior to thyroid scan and wait 6 WEEKS to restart meds
• Ultrasound/MRI/CT
4
Q
Hyperthyroid (Graves’ Disease) treatment
Anti-thyroids
A
methimazole (Tapazole), propylthiouracil (PTU)
• stops thyroid from making thyroid hormones
• used pre-op to stun thyroid
• want client to be EUTHYROID
5
Q
Hyperthyroid (Graves’ Disease) treatment
Iodine Compounds
• important teaching when taking it?
A
potassium iodine (SSKI and Lugol’s solution)
• DECREASE size and vascularity of gland
• ALL endocrine glands are very VASCULAR
• Give in milk or juice and use a straw because it STAINS the teeth
6
Q
Hyperthyroid (Graves' Disease) treatment Beta Blockers (supportive therapy)
A
propranolol (Inderal) • ↓ myocardial contractility • ↓ cardiac output • ↓ HR, BP • ↓ anxiety
7
Q
Hyperthyroid (Graves' Disease) treatment Radioactive Iodine Therapy • dose? • route? • action? • radioactive precautions
A
- one dose
- PO (liquid or tablet form)
- destroys thyroid cells
- stay away from babies for 1 WEEK and Don’t KISS anyone for 1 WEEK
8
Q
Do not give BETA BLOCKERS to ____ or ____
A
asthmatics (cause bronchoconstriction); or diabetics (mask s/sx of hypoglycemia)
9
Q
Amiodarone (Cordarone) antiarrhythmic drug, contains high levels of ____ and may affect ____ function
A
iodine, thyroid
10
Q
HYPERTHYROIDISM MEDICAL EMERGENCY
A
Thyroid storm (thyrotoxicosis and thyrotoxic crisis)
–Hyperthyroidism times 100!!!!
• ↑ temp, BP, HR
• could be rebound effect post-radioactive iodine
11
Q
Surgery: Thyroidectomy (partial/complete) • Post-op PRIORITY? • Assess? • Trach set at bedside, why? • Teaching/Nursing interventions?
A
• Priority: REPORT feelings of PRESSURE; Check bleeding from front and back
• ASSESS recurrent laryngeal nerve damage → listen for HOARSENESS → could lead to VOCAL PARALYSIS;
when there’s paralysis of both cords = airway obstruction → NEED TRACH!!!
• Trach for:
- swelling
- laryngeal nerve damage (vocal cord paralysis)
- Hypocalcemia – assess for parathyroid removal; s/sx (tight and rigid muscles); NOT SEDATED
• Teach how to support neck; Put personal items close to client; HOB elevated; (pre/post op) client needs MORE CALORIES
12
Q
Hypothyroid S/SX
A
• no energy
• fatigue
• no expression
• speech slow, slurred
• weight ↑
• myxedema (facial puffiness)
• GI slow (constipation, hypoactive bowel sounds)
• Cold (bring blanket, wear warm clothes–NOT HEATING PAD)
• Amernorrhea
***may take care of totally immobile client
13
Q
Hypothyroid Diagnosis
A
↓ Thyroxine (T4), ↑ TSH
14
Q
Hypothyroid Treatment
• med? important thing to know about dosing when starting on these meds?
• do they take these meds forever?
• on empty or full stomach?
• hypothyroidism clients tend to have ____;
• what happens to their energy
A
• levothyroxine (Synthroid), liothyronine (Cytomel)
—start w/ LOW dose then gradually increase
• take on empty stomach
• tend to have CAD (worry about MI when meds are started) – d/t ↑LDL, chest pain/rhythm changes
• YES, take meds forever
• energy ↑
15
Q
Parathyroid Problems
• secrete what hormone? function?
• too much of this hormone?
• too little of this hormone?
A
- secrete PTH = pull calcium from bone and place it in blood = serum Calcium ↑
- too much PTH = serum Calcium ↑
- don’t have PTH = serum Calcium ↓
16
Q
Hyperparathyroidism = ____ = ____
S/SX
Treatment (what surgery? what to monitor post-op?)
A
Hyperparathyroidism = HYPERCALCEMIA = HYPOPHOSPHATEMIA
S/SX • ↑ PTH • serum Calcium ↑ • serum Phosphate ↓ • SEDATED
Treatment
• Partial parathyroidectomy → take out 2 parathyroids = PTH secretion ↓
• monitor for HYPOCALCEMIA (tight, rigid muscles = tetany)
17
Q
Hypoparathyroidism = ____ = ____
S/SX
Treatment (what meds? any precautions?)
A
Hypoparathyroidism = HYPOCALCEMIA = HYPERPHOSPHATEMIA
S/SX • not enough PTH • serum Calcium ↓ • serum Phosphate ↑ • NOT sedated
Treatment
• IV Calcium (give SLOWLY, put on cardiac monitor)
• Phosphorus binding drug (sevelamer, calcium acetate)
18
Q
Adrenal glands
• function?
• 2 parts?
A
- handle stress
* adrenal medulla and adrenal cortex
19
Q
Adrenal Medulla Problem: Pheochromocytoma
• what is it?
• S/Sx?
A
• benign tumor = secrete epi and norepi in boluses
• S/SX
↑ BP, ↑ HR, Palpitations, Flushing/extremely diaphoretic, Headache
20
Q
Adrenal Medulla Problem: Pheochromocytoma
Diagnosis
• called what?
• what’s done to screen for high levels of epi and norepi?
• throw away what? keep what?
• avoid what? must be ____?
A
- Catecholamine levels: VMA (vanillylmandelic acid) test or Metanephrine (MN) test – 24 hour urine test
- 24 hr urine specimen is done to screen for ↑ levels of epi and norepi (catecholamines)
- w/ 24 hr urine – throw away FIRST voiding, keep LAST voiding
- Avoid activites that ↑ epi and norepi (NO STRESS) – nor smoking/running, must be calm
21
Q
Foods that alter the VMA and MN test
how long to avoid these?
A
anything w/ vanilla caffeine Vitamin B fruit juices bananas
***avoid for several days to a week
22
Q
Adrenal Medulla Problem: Pheochromocytoma
Treatment
A
Surgery to remove tumors
23
Q
Adrenal Medulla Problem: Pheochromocytoma
ALERT
A
AVOID PALPATING ABDOMEN → cause sudden release of catecholamines (epi, norepi) = SEVERE HTN
24
Q
Adrenal Cortex
• what steroids are secreted?
A
- Glucocorticoids
- Mineralocorticoids
- Sex hormones
25
Glucocorticoids
| • 4 functions?
1) Changes mood (depressed, psychotic, euphoric, insomnia
2) Alter defense mechanisms
- immunosuppressed; high risk for infection
3) Breakdown fats and proteins
4) Inhibit insulin
- Hyperglycemic; Do bg monitoring
26
Mineralocorticoids
Aldosterone
| retain SODIUM and WATER, lose Potassium
27
Sex hormones
• too many?
• not enough?
too many
• hirsutism (Facial hair)
• acne
• irregular menstrual cycle
not enough
• ↓ axillary/pubic hair
• ↓ libido
28
↑ ACTH = ____ level
| Too many steroids = Hyper_____
Cortisol
| Hypercortisolism
29
Adrenal Cortex problems
* not enough steroids
* shock
* hyperkalemia
* hypoglycemia
30
Addison's Disease
| • Patho
adrenocortical insufficiency--not enough steroids
| • not enough glucocorticoids, mineralocorticoids, sex hormones
31
Addison's Disease
| S/SX
* extreme fatigue
* N/V/D
* anorexia/weight loss
* hypotension (↓ BP)
* confusion
* ↓ Na, ↓ bg (hypoglycemia)
* ↑ K
* Hyperpigmentation-BRONZING color of skin and mucous membranes
* white patchy area of depigmented skin (VITILIGO)
32
```
Addison's Disease
Treatment
• combat what?
• diet?
• monitor what?
• losing ____ and ____= ___ BP = ___ weight = Fluid Volume ___
```
* combat shock (losing sodium and water)
* ↑ SODIUM, have processed fruit juice/broth
* monitor I/O, daily weight
* losing sodium and water = ↓ BP = LOSING weight = Fluid Volume DEFICIT
33
```
Addison's Disease
Medications
• Glucorticoid?
• Mineralocorticoid?
• MOST IMPORTANT thing to know about steroids?
```
• prednisolone (Prednisone)
twice a day--- 2/3 AM dose, 1/3 PM dose
• fludrocortisone acetate -- synthetic aldosterone
monitor daily weights and BP
• NEVER STOP TAKING STEROIDS ABRUPTLY!!!
34
Addisonian Crisis
• what is it?
• occur with?
* severe HYPOTENSION and vascular COLLAPSE
| * occur w/ infections, emotional stress, physical exertion or stopping steroids ABRUPTLY
35
Cushing's S/SX
```
TOO MANY STEROIDS!
1) too many GLUCOCORTICOIDS
• growth arrest
• thin extremities/skin (lipolysis)
• ↑ risk of infection
• psychosis, depression
• ↑ bg (hyperglycemia)
• moon-faced (fat redistribution/fluid retention)
• truncal obesity (fat redistribution; lipogenesis)
• buffalo hump (fat redistribution)
```
2) too many SEX HORMONES
• oily skin/acne
• women w/ male traits (hirsutism)
```
3) too many MINERALOCORTICOIDS
• ↑ Na
• ↑ BP
• CHF
• weight gain
• fluid volume EXCESS
```
** ↓ K, ↑ cortisol levels
36
```
Cushing's Treatment
• surgery?
• what environment?
• avoid what?
• diet pre-treatment?
```
* Adrenalectomy (unilateral/bilateral)--if both removed = lifetime replacement
* QUIET environment -- away from stress
* avoid INFECTION
* ↑ K, ↓ Na, ↑ protein, ↑ Calcium
37
Steroids decrease serum ____ by excreting it thruu GI tract
Calcium
38
Long term steroid use cause what in bones?
brittle bones or osteoporosis
39
What lab values of a client on long-term steroid therapy are expected to be altered in urine?
Glucose and Ketones
- Protein only in kidney damage
- RBC and uric acid (has nothing to do w/ steroids--indicates kidney stones)
40
```
Type 1 Diabetes
• insulin?
• diagnosed when?
• causes?
• 1st sign?
• onset?
• Classic 3 P's?
```
* little or no insulin
* usually dx in childhood
* causes - Auto-immune response (Type 1A) or Idiopathic (Type 1B)
* 1st sign = DKA
* Appears ABRUPTLY
* 3 Ps - Polyuria, Polydipsia, Polyphagia
41
Type 1 Diabetes
Patho
• normal function of insulin?
• process of type 1 DM?
* normal --- insulin carry glucose out of blood and into the cell
* no insulin → glucose builds up in blood → blood is hypertonic and pulls fluid into vascular space → kidneys filter excess glucose and fluids (polyuria, polydipsia) → cells are starving → cells break down protein and fat for energy (polyphagia) → breakdown fat → get ketones (acids) → client is in METABOLIC ACIDOSIS → Kussmaul RR (lungs compensating = blow off CO2 = ↑ RR)
42
Type 1 Diabetes
• S/SX
• Treatment
S/SX
→ Polyuria (excessive UO = losing volume)
→ Polydipsia (drinking too much coz thirsty)
→ Polyphagia (eating a lot coz brain doesn't have energy)
Treatment
• Insulin
**oral hypoglycemic agents DO NOT work for this client
43
normal Blood Glucose (fasting)
70 - 110 mg/dL
44
Type 2 Diabetes
Patho
• insulin?
• weight?
• can't make enough ____ to keep up with ____?
• onset?
• usually found by accident when client keeps coming back to PHP for?
• clients w/ type 2 should be evaluated for what?
* not enough insulin or insulin they have is NO GOOD
* OVERWEIGHT
* can't make enough INSULIN to keep up w/ GLUCOSE load the client is taking in
* not abrupt as type 1
* wound that don't heal, repeated vaginal infections
* be evaluated for Metabolic Syndrome (Syndrome X)
45
Type 2 Diabetes
| • Treatment
diet, exercise, oral agents, sometimes insulin
46
Features of Metabolic Syndrome
• Waist Circumference
> 40 in males, >35 in females
• Triglycerides
> 150 mg/dL
• HDL
<40 mg/dL in males
<50 mg/dL in females
• BP
>130/85
• FBS
>100 mg/dL
47
Metabolic Syndrome know to ____ risk factor for developing Type 2 Diabetes and cardiovascular disease
INCREASE
48
```
Gestational Diabetes
• resembles ____
• Mom needs? when?
• if mom has risk factors for GD, screen when?
• screen all moms when?
• complications to baby?
```
* resembles TYPE 2
* Mom needs 2-3X MORE INSULIN; 2nd half of pregnancy b/c hormones of placenta has anti-insulin effect
* if mom has risk factors for GD, screen 1ST PRENATAL VISIT
* screen all moms at 24 - 48 WEEKS GESTATION
* complications to baby: ↑ BIRTH WEIGHT, HYPOGLYCEMIA
49
normal Newborn blood glucose
40 - 60 mg/dL
50
Gestational Diabetes
| when mom's insulin dosage needs decreased, what to do?
DELIVER BABY d/t placental insufficiency!!
51
Extremes in blood sugar = ____ ____
VASCULAR DAMAGE
52
Diabetes: DIET
• Majority of calories should come from?
• why are we worried about carbohydrates?
• High fiber slows down what? causing what?
* Complex carbohydrates (45% of diet) → fats (30-40%) → protein (15-20%)
* sugar DESTROYS VESSELS just like fat
* High fiber slows down GLUCOSE ABSORPTION in intestine = eliminate sharp rise/fall in bg
53
Diabetes: EXERCISE
• wait until blood sugar ____ to begin exercise
• what should the client do pre-exercise to prevent hypoglycemia?
• exercise when blood sugar is at highest or lowest?
• exercise _____ time and amount daily
* wait until bg NORMALIZES to begin exercise
* EAT A SNACK to prevent hypoglycemia
* exercise when bg is at HIGHEST
* exercise SAME time and amount daily
54
Diabetes: MEDICATIONS
Oral Anti-diabetics and Non-insulin injectables
• use for what type of Diabetes?
• route?
• action?
• most widely used med? uses? why is it a favorite? if it doesn't work, what else is ordered? ALERT w/ this med?
* used for Type 2
* oral, subq
* improve how body produces insulin; improve how body uses insulin and glucose
• metformin (Glucophage)
- -used for wt control in type 2 sometimes type 1;
- -favorite b/c ↓ glucose production and enhances how glucose enters cell;
- -glargine (Lantus) is ordered if metformin is not controlling bg levels
- -ALERT: discontinue metformin before surgery/radiologic procedures that involves CONTRAST DYE → resume after 48 hrs after if kidney function and creatinine levels are normal
55
how is the Insulin dose determined?
| average adult dose?
* based on body weight
| * adult: 0.4 - 1 units/kg/day
56
Insulin dose is adjusted until ____ is normal and there's no more glucose or ____ in urine
blood sugar, ketones
57
INSULIN
Colors:
• Regular?
• NPH
Reg (clear)
| NPH (cloudy)
58
INSULIN
| When drawing up Regular and NPH insulin together, draw up which one FIRST?
CLEAR one -- Regular!
59
INSULIN
| All ____ are also clear but what?
All LONG-ACTING INSULINS are also clear but CANNOT be mixed w/ any other insulin or given IV
60
INSULIN
| Standard insulin given thru IV?
* Regular
| * also, rapid acting insulin
61
INSULIN
• Plan is based on?
• Goal before meal blood glucose?
* lifestyle, diet, activity
| * 70 - 130 mg/dL
62
INSULIN
| Most common method of daily dosing insulin
basal-bolus dosing
63
INSULIN
• total daily dose of insulin w/ Basal/Bolus method are combination of what insulins?
• when are they given?
* long-acting and rapid-acting insulin
* long-acting insulin --- Once a day
* rapid-acting insulin --- given throughout the day before meals
64
INSULIN
| Are snacks required w/ Basal-Bolus method?
No but client must eat when dosing w/ rapid-acting insulin
65
INSULIN
| Clients should eat when insulin is at its?
PEAK
66
INSULIN
| When insulin is at its PEAK, the blood sugar is at its
LOWEST
67
INSULIN
| Always monitor a client on insulin for ____
Hypoglycemia!
68
INSULIN: Client Teaching/Education
• what's Glycosylate Hemoglobin (HbA1c) blood test?
• what happens to blood sugar when sick or stressed?
• Illness = ____
• Rotation of sites (Rotate ____ an area first) why? and then?
* average of blood sugar over the past 3 - 4 MONTHS
* goes UP
* Illness = DKA
* Rotate WITHIN an area first to avoid HYPERTROPHY then let HEAL for 2-3 weeks
69
Insulin Infusion Pumps
• what type of insulin is used?
• purpose?
• only RAPID
• obtain better control
--receive continuous (basal) level from pump and on-demand (boluses) of additional insulin PRN w/ meals or ↑ blood sugar
70
HbA1c
• diagnostic for diabetes?
• goal for people w/ diabetes?
* dx: ≥ 6.5%
| * GOAL: ≤ 7%
71
Hypoglycemic/Hyperglycemic Episodes
• s/sx of hypoglycemia
• if hypoglycemic, what to do?
• snacks should be ____ grams of carbohydrates
• glucose absorption is delayed in foods w/ lots of ____
• what's the 15-15-15 rule?
• once bg is up, what to do?
• if unconscious, treat this client as (hypo or hyper -glycemic)? what to use?
```
• s/sx of hypoglycemia (cold and clammy, need some candy)
Tachycardia (↑HR)
Irritability
Restless
Excessive hunger
Diaphoresis
```
• if hypoglycemic, what to do?
---eat something (simple carb)
* snacks: 15 GRAMS of carbohydrates
* glucose absorption is delayed in foods w/ lots of FATS
• what's the 15-15-15 rule?
---15 g carb → wait 15 mins and check bg → if not fixed, give another 15 g carb
• once bg is up, what to do?
---eat a complex car w/ protein (peanut butter cracker)
• if unconscious, treat this client as (hypo or hyper -glycemic)? what to use?
- --hypoglycemic
- --D50W (hard to push; need large bore IV)
- --Injectable glucagon (GlucaGen) (when no IV access, given IM)
72
Prevention for Hypoglycemic episodes
| 4 things
1. Eat
2. Take insulin regularly
3. Know s/sx of hypoglycemia
4. Check blood sugar
73
Diabetic Ketoacidosis (DKA)
• what is it?
• Patho
* anything that can increase bg → (ILLNESS, infection, skipping insulin) = DKA!
* 1st sign of diabetes
* same s/sx of type 1
Patho
• absent/inadequate insulin = ↑ bg 3 P's = fat breakdown (acidosis) → Kussmaul RR = LOC ↓
• very little/no insulin and severe HYPERGLYCEMIA = METABOLIC ACIDOSIS
74
```
Diabetic Ketoacidosis (DKA)
Treatment
• find the ____
• hourly checks of ?
• IV insulin used for?
• ECG for?
• ABGs for?
• IVFs -- polyuria causes _____; what to do about it? how to prevent hypoglycemia?
• anticipate PHP's order of _____ at some point; why?
```
Treatment
• find the cause
• hourly blood sugar and potassium levels; hourly output (oliguria/anuria)
• IV insulin ↓ glucose and K (drive them out of vascular space and put into cell)
• ECG for lethal arrhythmias (insulin decreases K, may throw client into hypokalemia = arrhythmias)
• ABGs check for metabolic acidosis
• IVFs -- polyuria causes SHOCK;
---start w/ NS → when bg is down to 250-300 mg/dL → switch to D5W to prevent hYPOGLYCEMIA
• anticipate PHP's order of POTASSIUM at some point
(insulin decreases K, may throw client into hypokalemia)
75
Hyperosmolar Hyperglycemic Nonketosis (HHNK) or Hyperglycemic Hyperosmolar State (HHS)
• like DKA, but no ____
• making just enough insulin so they're not breaking down ____
• no ___ breakdown = no ___ = no ___
• will they have Kussmaul RR?
* like DKA, but no ACIDOSIS
* making just enough insulin so they're not breaking down FAT
* no FAT breakdown = no KETONES = no ACIDOSIS
* DO NOT HAVE Kussmaul RR
76
DIABETES Vascular Problems: Macrovascular and Microvascular
• will have what? because of?
• examples?
• Will develop POOR CIRCULATION everywhere;
d/t VESSEL DAMAGE (sugar irritates vessel lining → accumulation of sugar = ↓ size of vessel lumen = ↓ blood flow
• examples
1. Diabetic retinopathy → blindness
2. Nephropathy → client on dialysis
77
```
DIABETES Neuropathy
• sexual problems?
• foot/leg problems? diabetic foot care?
• neurogenic bladder? at risk for?
• gastroparesis? at risk for?
```
• sexual problems
impotence or ↓ sensation
```
• foot/leg problems - PAIN/PARESTHESIA/NUMBNESS
Diabetic Foot care
--inspect/look at feet on mirror every day
--no lotion between toes
--no harsh chemicals on feet
--cut toenails straight across
--dry completely between toes
--cotton/wool socks
--no open toed shoes or heels
```
• neurogenic bladder
- -may empty sponataneously = "incontinence"
- -may not empty at all = "retention"
- -at risk for UTI
• gastroparesis
- -delayed stomach emptying
- - ↑ risk for aspiration
78
DIABETES
| Increased risk for ____
INFECTION
NCLEX
flashcards
Decks in class (24)
# Cards
-
Normal Lab Values62
-
Insulins & IV Solutions14
-
Analgesics4
-
Common drugs (suffixes)59
-
Stages: Freud, Erikson, Maslow18
-
Infection Control42
-
Leadership/Community44
-
Fluid & Electrolytes91
-
Acid Base Balance31
-
Burns53
-
Oncology46
-
Endocrine78
-
Cardiac76
-
Psych19
-
Renal9
-
GI15
-
Respiratory9
-
Ortho63
-
Neuro40
-
Maternity85
-
Pediatrics67
-
Management of Care38
-
Asthma5
-
Immunization (peds)9
