NSG 260 Endocrine, AIDS, Chronic Renal Failure, & Chronic Liver Failure

• Stimuli (envoronmental/sensory input) triggers the release of hormones from the hypothalamus
• Hormones (Releasing factors and Inhibiting factors) from the hypothalamus are sent to the anterior pituitary gland
• Inhibiting factors instruct the pituitary to stop releasing hormones
• Releasing factors trigger the release of tropic hormones from the pituitary to a target organ
• Target organs release hormones that are then read by either the pituitary or the hypothalamus as a negative feeback mechanism, resulting in the stop of hormone flow to that organ

• Made: in the hypothalamus
• Stored: in the posterior pituitary
• Released: from the posterior pituitary

• Controls water balance by increasin water absorption
• "Stop peeing hormone"
• Stimulates the contraction of smooth muscle in intestines and blood vessels
• Vasoconstricts arterioles

Promotes retention of sodium and elimination of potassium

Promotes preadolescent growth spurts

• Teaching: 12S's
• Most critical issue: must wean off steriods, could induce adrenal crisis

• Paraneoplastic disease
• Lung disease, small cell/oat cell lung cancer
• Duodenal cancer
• CNS disorders
• Trauma
• Increased ICP
• Medications: Diabinese, Thiazides, Tegretol, Nicotene, Morphine, anesthetics

• Dilutional hyponaterimia (< 130meQ)
• Serum hypo-osmolarity
• Poor urinary output
• High urine specific gravity (>1.030)
• Decreased BUN, H&H, etc. due to hemodilution
• Weight gain
• Hypertension
• Confusion
• Lethargy
• Convulsions

• Surgical removal of ADH secreting tissue
• Restrict fluids (I=O), no more than 800-1000mL/day
• Lasix (may need potassium supplements)
• Hypertonic saline if severe
• Chronic management: declomycin, urea, lithium (all interfere with ADH release or synthesis

• Dx: Fluid Volume Excess
• Restrict total fluids , I&O
• HOB flat or <10 degree elevation (enhances left atrial filling pressure and reduces ADH release)
• Hourly urine specific gravity measurements
• Daily weights
• Vital signs
• Monitor LOC - convulsions, N/V, muscle cramping, side rails & seizure precautions
• Monitor cardiopulmonary status - CHF

• CNS disorders
• Tumors
• Infection
• Trauma (usually self limiting)
• Post-op brain surgery (may be permanent)
• Pituitary tumor
• S/P hyperphysectomy

• Polyuria (5-20 liters/day)
• Dilute urine (specific gravity <1.005)
• Polydipsia
• Dehydration
• Orthostatic hypotension
• Vascular collapse
• Increased serum osmolarity
• Hypernatremia
• Inelastic skin turgor
• Weight loss + fluid deprivation test

• IV therapy
• Surgery or radiation if tumor is present
• Drug therapy: Thiazides, Tegretol, Diabenese to induce an SIADH reaction
• ADH hormone replacement - DDAVP (desmopressin) nasal spray, Vasopressin SQ/IM, Pitressin in oil

• Dx: Fluid Volume Deficit
• Monitor IV flow rate
• I&O - hourly measurements of urine specific gravity
• Daily weights
• Vital signs

• Dx: Altered urinary elimination - perineal care
• Dx: Sleep disturbance - Adjust DDAVP
• Dx: Medication Knowledge deficit (DDAVP) - monitor output, reduce nocturia
• S/E - nasal irritation (hyponatremia, headache & nausea may indicate overdosage)

• Adrenal tumor
• Hyperplasia or cancer of the adrenal gland
• Paraneoplastic disease
• Secondary: pituitary dysfunction
• Iatrogenic: steroid dependency

• Hyper glycemia, hypernatremia & hypokalemia
• Hypertension & edema
• Cetripedal obesity, Moon face, buffalo hump
• Hirsuitism, gynemastia, amenorrhea
• Bruisability & thin skin
• Depressed immunity, risk for infections
• Gastric ulcers, osteoporosis, cataract
• Increase WBCs and platelets, decrease lymph

• Radiation/surgery for pituitary tumor
• Cortisol cytotoxics: stop production of cortisol (give with food)
• Miotane - lysodren
• Metyrapone (S/E - N/V, GI bleed, rash)
• Aminoglutethiamide - cytadren
• Ketoconazole - nizoril (block cortisol production)
• Steroid weaning
• Aldactone - spirolactone
• Adrenalectomy

• High risk for infection (assess WBCs, hand washing, private room)
• High risk for injury (prevent falls, appropriate weight bearing, nutrition)
• Altered nutrition (increase calcium and protein, decrease calories and fat)
• Skin integrity (assess skin, gentle handling)
• Monitor vital signs, I&O, glucose

• Primary: autoimmune destruction of adrenal gland (infection, hemorrhage)
• Secondary: pituitary adenoma or hemorrhage
• Iatrogenic: sudden withdrawl of steriods
• TB, AIDS, metastatic cancer, chemotherapy

• Cortisol deficiency: hypoglycemia, intolerance to stress, weight loss, vasomotor collapse, increased pigmentation (include mucous membrane) decreased serum cortisol
• Aldosterone deficiency: hypotension, hyponatremia, hyperkalemia

• Replacement of glucocorticoids: cortisone (2/3 in AM, 1/3 in PM)
• Replacement of mineralcorticoid: florinef

• Dx: Activity intolerance r/t weak hypotension
• Altered nutrition: increase sodium

• Signs:Profound asthenia, severe pain (abdomen, lower back, legs), peripheral vascular collapse, weak rapid pulse, renal shutdown with azotemia (kidney failure). Body temp may be low, severe fever often occurs, especially in acute infection. Shock and fever may be the only signs
• Treatment: Replace cortisol in times of stress (surgery, trauma, dental work, flu), have 100mg Cortisol pen, wear medicalert bracelet

• Pre:
• Post: HOB (30 degrees) to decrease ICP and possible CSF leak (signs - postnasal drip, halo signs, clear fluid test positive for glucose)
• Wound care - no tooth brushing (10 days), soft toothettes, rinse with saline or baking soda
• Anorexia r/t decreased olfactory sense (increase fluids after nausea)
• Assess for complications - meningitis (h/a, fever, nuchal rigidity), diabetes insipidus (excess urination, vasopressin needed), increased ICP (avoid coughing, sneezing, nose blowing, bending over, straining), may need hormone replacement

Catecholamine producing tumor of adrenal gland

• Hypertension (350/200)
• Hyperglycemia
• Hypermetabolism
• Throbbing headache, sweating, tachycardia
• Increased serum catecholamines
• Increased VMA and metaphrines in urine

• Alpha and Beta blockers
• Inderal
• Clonidine
• Regitine
• Nipride
• Removal of tumor (adrenalectomy)

• Monitor hypotension post-op
• Monitor pulse, respiration, blood sugars

• Pre:
• Post:

• Rapid HIV test: results in 20 minutes
• EIA or ELISA: enzyme linked immunosorbent assay (1% error)
• Western Blot: along with ELISA's (0.005% error)
• RIPA: radioimmunoprecipitation assaym looks at HIV protein instead of antibodies
• IFA: immunoflourescent assay
• CD4 cell count: normal 800-1600/mm³, relatively healthy until they drop below 500
• CBC: decrease in lymphs, neutrophils, & platelets
• Viral lode: measures HIV RNA viral particles

Body fluid contact: blood, semen, vaginal secretions, breast milk, cerebral spinal fluid, synovial fluid, pleural fluid, peritoneal fluid, amniotic fluid, pericardial fluid

• Highly Aggressive/Active Antiretroviral Therapy
• Combination therapy requiring 100% compliance/adherence
• Take medication on time 100% to prevent HIV from developing drug resistance (may be taking 12-20 pills/day)
• HAART has decreased the death rate by 66%
• Treat when CD4 cells are 200 or below
• Higher risk of cardiac disease, diabetes and liver disease with meds

Becomes part of HIV DNA and disrupts its building process, virus can't control the cell

S/E: anemia, neutropenia

S/E: lactic acidosis, peripheral neuropathy, pancreatitis, liver dysfunction, bone marrow suppression

Prevent protease enzyme from cutting HIV viral proteins (viron), can't infect new lymphocytes

S/E: hemolytic anemia, parathesia, kidney stones, altered taste, diabetes

• S/E: Kidney stones, fat redistribution
• Note: No St. John's Wort

S/E: Kidney stones, fat redistribution

S/E: Kidney stones, fat redistribution

Attach to reverse transcriptase enzyme, preventig the enzyme from converting HIV RNA to DNA

S/E: liver disease, numbness, psychological isues, muscle pain

S/E: rash

• S/E: rash
• Note: decreases effectiveness of birth control pills

• Clinical signs: cottage cheese drainage or lesions in the mouth, esophagus, mucus membranes, vagina
• Medications: ketoconazole, amphotericin B, nystatin

• Clinical signs: Vesicular lesions coalesce and rupture
• Medications: acyclovir, foscarnet, valtrex

• Symptoms: coughing (initially nonproductive), fever, dyspnea on exertion (DOE), patchy infiltrates on chest x-ray (CXR)
• Treatment: oxygen, pentamidine (now aresol, will decrease blood sugars and BP), dapsone (also used for leprosy) trimethoprim-sulfamethoxazole (Bactrim, bone marrow depression)

• Symptoms: productive cough, fever, night sweats, +/- PPD
• Treatment: isoniasid, rifampin (orange body fluids, will stain contact lenses), ethambutol, streptomycin (for at least 9 months prophylactically for high risk)

• Symptoms: patches (flat/pink, eventually violet/black), in HIV it occurs in men who have had sex with other men
• Treatment: interferon, radiation, antivirals

• Symptoms: visual acuity lost, floaters, retina looks like cottage cheese and ketchup, 30% will develop blindness
• Treatment: ganciclovir, foscarnet

• BUN
• Creatinine
• Potassium
• Phosphate
• Triglycerides
• Sodium (initally low, but elevate as disease progresses to end stage)

• Hypertension (r/t volume overload)
• Lipidemia
• Palpitations

Elevated potassium (normally 3.5-5, 7-8 may be fatal) and phosphate, decreased calcium, sodium levels are initially low but elevate later

Renal osteodystrophy (can't convert vitamin D to active form, calcium can't be absorbed), parathyroid hormone is secreted (takes calcium out of the bones), and blood levels eventually drop

• Proteinuria (especially albumin)
• Urine not concentrated (polyuria, nocturia progressing to anuria)
• Metabolic acidosis (kidneys can't excrete acid load and ammonia)

• N/V/A
• Hiccups
• Peptic ulcer disease
• Constipation
• Uremic fetor ("pee breath")
• Metallic taste
• Halitosis (bad breath)
• Weight loss

• Pruritis
• Dry skin
• Uremic frost
• Yellow gray skin tone
• Nail changes
• Thinning hair
• Edema

• Anemia (r/t loss of erythropoetin and iron deficiencies)
• Folic acid deficiencies (r/t dialysis)
• Bone marrow fibrosis (r/t over excretion of parathyroid hormone)

• Normal value: 135-145
• Usually remains normal to low until end stage renal failure

• Normal value: 3.5-5
• Excreted mainly by kidneys, increased in renal disease

• Normal value: 9-11
• Decreased in renal disease due to decreased ability of calcium absorption

• Normal value: 3-4.5
• Inversely related to calcium, kidney's responsible for excretion

• Low protein (may increase when on hemodialysis)
• Low phosphate (avoid: fish, pork, beef, chicken, nuts, whole grains, cereals, chocolate, pop)
• Low potassium (avoid: avocado, rasins, meat, cantaloupe, spinach, bananas, fish, oranges, strawberries, mushrooms, carrots, potatoes, tomatoes)
• Low sodium (avoid: table salt, soy sauce, cured pork, cheese, milk, butter, mustard, bacon, frankfurter, lunch meat, canned meat, processed food, most snack foods)