1. What hormones does the thyroid gland produce
    • three hormones:
    • T3
    • T4
    • Calcitonin
  2. What is calcitonin
    • A hormone that decreases serum calcium levels by taking calcium out of the blood and pushing it back into the bone
    • Is also given as a drug to treat osteoporosis
  3. What do you need to make hormones?
    Iodine... dietary iodine!!
  4. What does the thyroid hormone give us?
  5. Describe s/s of hyperthyroidism
    • Common cause is Graves Disease
    • Nervous, irritable
    • Decreased attention span
    • Sweaty/Hot
    • GI is fast -
  6. Exophthalmos
    • Bulging eyes 
    • caused by hyperthryoidism
    • can be irreversible
  7. If you drew a serum thyroxine (T4) on a hyperthyroid pt, what would you see
    Increased levels of T4
  8. for hyperthyroid, is you checked TSH what would you see?
    • It would be low
    • Thyroid Stimulating Hormone
  9. If a hyperthyroid pt needs a scan with iodine, what do you educate?
    • Discontinue any meds containing iodine one week prior to thyroid scan
    • Wait 6 weeks before resuming.
    • Iodine is tough on kidneys
  10. What is a drug that contains high levels of iodine?
    • Amiodarone
    • may affect thyroid function
  11. What type of treatment is there for hyperthyroidism?
    • Anti-thyroid meds
    • Iodine compounds
    • Beta Blockers
    • Radioactive iodine therapy
  12. Name some anti-thyroid medications
    • Methimazole - which is drug of choice
    • Propylthiouracil
  13. What do anti-thyroid meds do?
    • Stops thyroid from making thyroid hormone
    • Sometimes used preoperatively to stun thyroid
  14. Name an iodine compound drugs used for hyperthyroidism
    Potassium iodine
  15. What do iodine compounds to for hyperthyroidism
    • *This is the drug iodine, not the dietary iodine
    • This will decrease the size and vascularity of the gland. 
    • Give with milk or juice, and use a straw cause it will stain teeth
  16. Name a beta blocker and why is it used with hyperthyroidism
    • Propanalol
    • It doesn't fix the problem, but helps with the symptoms
  17. How does beta blockers help with symptoms?
    • Decreases myocardial contractility, which would decrease cardiac output
    • Therefore, HR and BP would decrease
    • Can also decrease anxiety as it doesn't allow the release of epi or norepi.  Leaves them cool and calm.
  18. What two pt would you NOT give a beta blocker to?
    • Asthmatics or diabetics
    • The beta blocker will block the feelings of hypoglycemia or an oncoming asthma attack
  19. Radioactive Iodine therapy for hyperthyroidism
    • Before administering, rule out pregnancy!
    • Only one dose
    • Given PO 
    • Destroys thyroid cells so hyper turns to hypothyroidism
  20. What precautions should be taught for radioactive iodine therapy
    • Stay away from babies for 1 week
    • Don't kiss anyone for 1 week
  21. After a thyroidectomy, where should you check for bleeding?
    at the insicion site and at the back of the neck (in case of pooling)
  22. How would they diagnose hypothryoidism? (Think lab values)
    • T4 would be low
    • TSH would be high
    • *just the opposite of lab values for hyperthryoidism
  23. Drugs to treat hypothryoidism
    • Levothyroxine
    • Liothyronine
  24. What will you worry about when a pt starts meds for hypothyroidism
    • An MI
    • people with hypothyroidism tend to have palpitations. 
    • These meds will cause in increase in BP and HR
    • need to be started at a low dose and increased slowly
  25. What does the parathyroid do?
    • It secretes PTH (Parathyroid hormone) which makes you pull calcium from the bones and place it in the blood
    • Therefore, it increases your serum calcium level
  26. If you don't have any parathormone in your body, what happens?
    The serum calcium level will be low
  27. What happens with hyperparathyroidism?
    Same s/s as hypercalcemia and hypophosphatemia
  28. S/S of hyperparathryoidism
    • Means too much PTH
    • Serum calcium is high and serum phosphorus is low
  29. Treatment for hyperparathyroidism
    • Partial parathyroidectomy - take 2 of the parathyroids
    • PTH secretion decreases which means calcium goes down
  30. What would you monitor for after a partial parathyroidectomy?
    • Calcium will be low, so monitor for tight, ridged muscles. 
    • Could lead to tentany
  31. What is equal to hypoparathyroidism?
    Hypocalcemia & hyperphosphatemia
  32. S/S of hypoparathyroidism
    • Not enough PTH
    • Serum calcium is low and phosphorus is high
    • Their NOT SEDATED
  33. Treatment for hypoparathyroidism
    • Give IV calcium
    • Can give a phosphorus binding drug which would make phosphorus go down and bring calcium up
  34. Explain adrenal glands
    • Need adrenals to handle stress
    • Two parts: adrenal medulla and adrenal cortex
  35. What does the adrenal medulla do?
    secretes epi and norepi
  36. What problem can occur with adrenal medulla?
    • Pheochromocytoma which is a benign tumor that secretes epi and norepi in boluses
    • Tend to be familial, so screen the family
  37. S/S of Pheochromocytoma
    • *You have a surge of epi/norepi
    • Increased BP/HR
    • Palpitations
    • Flushing and diaphoretic
    • HA!!
  38. How do they diagnose pheochromocytoma
    • catecholamine levels (catecholamine is epi and norepi)
    • 24 hr urine test
    • *both are looking at epi and norepi levels.  Educate pt not to do anything that will increase levels (no stress)
  39. What tests the catecholamine levels?
    • VMA (vanillylmandelic acid) test
    • Metanephrine (MN) test
  40. Education prior to the VMA and/or MA test
    • Avoid foods that can alter test:
    • Anything with vanilla in it
    • caffeine
    • Vit B
    • fruit juices and bananas
  41. What is secreted from adrenal cortex?
    • Glucocorticoids, mineralcorticoids, and sex hormones
  42. What are the 4 actions of glucocorticoids?
    • Change your mood (can be excessively happy or depressed)
    • Alters defense mechanisms (immunosuppressed = high risk for infection)
    • Breakdown of fats and proteins (think cushings)
    • Inhibits insulin = can become hyperglycemic
  43. What mineralcorticoid is secreted from adrenal cortex?
    • Aldosterone!!
    • Makes you retain water and sodium
    • Makes you lose potassium
  44. What sex hormones are released by adrenal cortex?
    testosterone, estrogen, and progestrone
  45. what happens with too many sex hormones?
    • hirsutism
    • Acne
    • irregular menstrual cycle
  46. what happens with not enough sex hormones
    • Decreases axillary/pubic hair
    • Decreased libido
  47. Adrenocorticotropin hormones
    • ACTH
    • made in the pituitary and they stimulate cortisol to be made
    • Cortisol is a hormone secreted by the adrenal cortex
    • Just think STEROIDS!
  48. What happens with increased ACTH levels
    Increased Cortisol levels
  49. What is another word for too many steroids?
  50. Adrenal cortex Problems:
    • Not enough steroids
    • shock
    • Hyperkalemia
    • Hypoglycemia
  51. What disease involves not enough steroids? (Adrenocortical insufficiency)
    • Addison's disease
    • recall if we don't have enough aldostrone, we lose sodium and water and retain potassium.
  52. S/s of Addison's disease
    • Extreme fatigue
    • N/V and diarrhea
    • Weight loss
    • hypotension (decreased BP)
    • Confusion
    • Decrease sodium, increased potassium, and hypoglycemia (your not eating!)
  53. What are s/s of the skin pertaining to addisons disease?
    • Hyperpigmentation - bronzing color of skin and mucous membranes
    • Vitiligo - white patchy area of depigmentation
  54. How do we treat Addison's
    • Combat shock
    • increase sodium in diet (processed fruit juice, broth has lots of sodium)
    • I&O and daily weights
    • Their BP will be low as they are in fluid volume deficit
  55. Medication for Addisons
    • Prednisolone
    • Fludrocortisone
  56. How will prednisolone be given?
    • Twice a day
    • 2/3 in morning and 1/3 in evening
    • this is similar to how body naturally secretes hormones
  57. What is Fludrocortisone
    Aldosterone as a drug
  58. What happens in Addison's crisis
    • Acute onset of severe hypotension and vascular collapse
    • Can occur with infections, emotional stress, physical exertion or stopping steroids abruptly
    • 100x worse than Addisons
  59. What is Cushings
    Too many steroids
  60. S/S of too much glucocorticoids
    • Growth arrest (breaks down fat/protein)
    • Thin extremities
    • Increase risk for infection
    • Hyperglycemia
    • Mood changes (psychosis to depression)
    • Moon faced (fat redistribution)
    • Buffalo hump (fat redistribution)
  61. Treatment for Cushings
    • Adrenalectomy (either unilateral or bilateral)
    • If both are removed, will need lifetime replacement hormones
    • *These pt need a quiet environment as they can't handle stress
  62. Diet pretreatment for cushings?
    • *Remember, too much hormones/steroids!
    • Increase potassium, decrease sodium (aldostrone)
    • Increase protein
    • Increase Calcium (steroids decrease Ca by excreting it through GI Tract)
  63. Describe Diabetes type 1
    • Usually diagnosed in childhood
    • They have little or no insulin
    • First sign may be DKA
    • Appears abruptly, despite years of beta cell destruction
  64. What causes diabetes type 1?
    • Auto immune response
    • or
    • Idiopathic (cause unknown)
  65. What are the classic 3 P's?
    • Polyuria
    • Polydipsia
    • Polyphagia
  66. Explain pathophysiology for DKA
    • Normally, you have insulin to carry glucose out of blood and into cell
    • Since DM type 1 have no insulin, glucose builds up in blood
    • Blood becomes hypertonic and pulls fluid into vascular space
    • Kidneys filter excess glucose and gluids
    • Cells are starving so they start breaking down protein and fat for energy
    • This results in ketones, which is an acid
    • Eventually, development of metabolic acidosis
  67. What respirations will be seen in DKA pt
    • Kussmaul respirations which is a deep and labored breathing pattern
    • they are trying to blow off CO2
  68. Treatment?
    • Must have insulin
    • Oral hypoglycemic agents wont work for this pt
  69. Explain type 2 DM
    • These clients have insulin, just not enough insulin or the insulin they have is no good
    • Can't make enough insulin for the glucose load the client is taking in
    • Usually found by accident
    • *Usually don't see DKA with type 2 as they don't usually break down fat
  70. What should type 2 diabetics me assessed for?
    Metabolic syndrome or Syndrome X
  71. What is Metabolic Syndrome?
    • must have 3 or more of these:
    • Large waist circumference
    • Triglycerides greater than 150
    • High HDL
    • Blood pressure above 130/85
    • FBS greater than 100
  72. Treatment of Type 2 diabetics
    • Will start with diet and exercise
    • Some pt's may need to include insulin
  73. Explain gestational diabetes
    • Resembles Type 2
    • Mom needs 2-3x more insulin than normal
    • If mom is at high risk, will be screened at first visit.
    • ALL moms screened at 24 - 28 weeks gestation
  74. What complications can baby have with gestational diabetes?
    • Increased birth weight
    • Hypoglycemia
  75. What happens with extreme blood sugar? 
    • Vascular damage
    • Sugar destroys vessels just like fat.
  76. What type of diet is recommended for both types of diabetes
    • Majority of calories should come from COMPLEX carbs, then fats, then protein. 
    • Carbs: 45%
    • Fats: 30-40%
    • Protein: 15-20%
  77. What should be taught to the pt about exercise
    • Wait until blood sugar normalizes to begin exercises
    • Eat before to prevent hypoglycemia
    • Exercise with BS is highest
    • Exercise same time and amount daily
  78. How do oral anti-diabetics and non-insulin injectable medications work?
    • They improve how the body produces insulin, and how the body uses insulin and glucose
    • ONLY prescribed for type 2 diabetes when diet and exercise doesn't work.
  79. Most widely used oral anti-diabetic medication
    • Metformin
    • It's the first choice for most clients.
    • Reduces glucose and enhances how glucose enters cells. 
    • Does NOT stimulate the release of more insulin, so wont see hypoglycemia with this drug.
  80. If metformin isn't controlling BS levels, what might be ordered
    • Lantus
    • It is a Long acting anti-diabetic medication
  81. You have a client on metformin. They are going to undergo a radiologic procedure that involves contrast dye. What should you educate?
    • With any surgery or radiologic procedure that involves contrast dye, temporarily discontinue metformin. 
    • They can resume after 48 hours after the procedure if kidney function has returned and creatinine is normal.
  82. With rapid acting insulin:
    • Onset: 15 mins
    • Peak: 1-3 hr
    • Duration: 3-5 hr
    • Novolog
  83. Regular insulin:
    • Onset: 30 mins
    • Peak: 2-4 hrs
    • Duration: 6-8 hr
  84. NPH insulin:
    • Onset: 1.5 hr
    • Peak: 4-12 hr
    • Duration: 16-24 hr
  85. Long Acting Insulin
    • Onset: 2-4 hours
    • Peak: NO PEAK
    • Duration: 24 hours
    • Example: Lantus
  86. Compare Reg insulin to NPH
    • Reg insulin is clear
    • NPH is cloudy as it has lots of particles to make it time released
  87. Can you draw up reg insulin with NPH?
    • Yes!
    • Just draw up the clear on first.
  88. Can you mix a long acting insulin?
    • NO!! 
    • They are also clear
  89. Most common method of daily dosing insulin
    • Basal /Bolus method
    • combination of long acting and rapid acting insulin
    • Long acting is given once a day
    • Rapid acting is given throughout day, before meals in divided doses
    • *Snacks are not required, but clients still must eat with rapid-acting insulin. So have food available.
  90. What should be tested every 3-6 months on diabetics
    • HbA1c or Glycosylated Hemoglobin
    • Gives average of blood sugar over past 3-4 months
  91. What is the goal level for HbA1c?
    • greater than or equal to 6.5% is diagnostic for diabetes
    • for people with diabetes, the ideal goal is less than or equal to 7%
  92. What is the standard insulin that can be given in IV fluids as an infusion
    Regular Insulin
  93. What insulin can be given via subQ insulin infusion pump
    • Rapid-acting insulin
    • these are small computerized devices warn by client that provides both continuous (basal) dosing and on-demand (bolus) dosing
  94. What should you give a pt who is hypoglycemic?
    • First do a simple carb
    • Snacks should be 15 grams of carbs
  95. Why would you not want to give a hypoglycemic pt something with alot of fat
    Glucose absorption is delayed in foods with lots of fat
  96. Whats the rule to remember when treating hypoglycemia
    • 15-15-15
    • give 15 grams of carbs
    • Wait 15 mins
    • Give 15 more grams of a complex carb
  97. To prevent hypoglycemia, what should you teach your pt
    • Have to eat
    • Take insulin regularly
    • Know s/s of hypoglycemia
    • Check BS regularly
  98. What two major complications can occur with diabetes/
    • DKA
    • HHNK(HHS)
    • Vascular problems
    • Neuropathy
    • Increased risk for infection!
  99. How do you treat DKA
    • Find the cause (illness, infection, skipped insulin?)
    • Hourly BS and Potassium levels
    • IN insulin
    • ECG
    • Hourly output
    • ABG's - worried about metabolic acidosis
    • IVF
  100. Why are you worried about hourly potassium levels with DKA
    • You'll give insulin
    • Insulin decreases blood sugar and potassium by driving them out of the vascular space and into the cell. 
    • Therefore, potassium will decrease
  101. What is HHNK or HHS
    • Hyperosmolar Hyperglycemic Nonketosis
    • and
    • Hyperglycemic Hyperosmolar State
  102. Explain HHNK
    • Looks just like DKA, but no acidosis
    • BS is greater than 600
    • The body is making just enough insulin so they aren't breaking down body fat.
    • Therefore, no ketones, no acidosis, no Kussmaul respirations
  103. What vascular problems can develop?
    Poor circulation can develop everywhere from vessel damage (similar to atherosclerosis)

    • Diabetic retinopathy
    • Nephropathy
  104. What about Neuropathy?
    • Sexual problems: impotence/decreased sensation
    • Foot/leg probs
    • Neurogenic bladder
    • Gastroparesis
  105. What is neurogenic bladder
    • Bladder that does not empty properly
    • Bladder may empty spontaneously (incontinence) or it may not empty at all (retention)
  106. What is gastroparesis?
    Stomach emptying is delayed so there is an increased risk for aspiration
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