S3 Exam 2

Hypo/Hyperthyroidism, Addison's Disease, Cushing's syndrome, Preschooler Growth and Development, End of Life, Cystic Fibrosis, COPD, Asthma/Exacerbation, Eating Disorders, Personality Disorders, OCD

Hypothyroidism

Hypothyroidism: Reduced or absent hormone secretion from the thyroid gland that results in whole-body decreased metabolism from inadequate cellular regulation

• Primary: Thyroid cannot produce adequate amounts of thyroid hormones

• Secondary: Thyroid isn’t being stimulated by the pituitary gland to produce hormones

Hashimoto’s thyroiditis: Autoimmune disorder in which infection and inflammation of the thyroid gland causes the production of autoantibodies to thyroglobulin (Tg) or thyroid peroxidase (TPO),, which results in extensive tissue destruction and reduced secretion of thyroid hormones

Diagnosis: High TSH and low T4 (and T3)

Cause of Hypothyroidism

Primary Causes

• Decreased Thyroid Tissue

  • Surgical or radiation-induced thyroid destruction

  • Autoimmune thyroid destruction

  • Congenital (poor thyroid development)

  • Cancer (thyroidal or metastatic)

• Decreased Synthesis of Thyroid Hormone

  • Endemic iodine deficiency

  • Drugs:

    • Amiodarone

    • Guaifenesin

    • Lithium

Secondary Causes

• Inadequate Production of Thyroid-Stimulating Hormone

  • Congenital pituitary defects

  • Pituitary tumors, trauma, infections, or infarcts

  • Hypothalamic tumors, trauma, infections, or infarcts

Risk Factors of Hypothyroidism

• Females (especially African Americans)

• Pregnancy (multiparous)

• Radiation to upper chest or neck region

• Thyroid surgery

• Type 1 Diabetes

• Family history of thyroid disease

• Anti-thyroid hormone treatment for hyperthyroidism

• 30 years and older

• BMI >25

• Deficient iodine intake

Maternal/Fetal Risks of Hypothyroidism During Pregnancy

Risks to the pregnant client can range across all pregnancy trimesters

• Repeated first-trimester pregnancy loss through spontaneous miscarriage

• Increased risk of developing gestational diabetes

• Preeclampsia

• Placental abruption

• Preterm labor

• Postpartum hemorrhage

• Increased risk of psychological manifestations in the postpartum period

Fetal Risks

• Placenta dysfunction

• Preterm birth

• Rare potential for development of a goiter

Signs/Symptoms of Hypothyroidism (CV, Respiratory, GI, Metabolic, Reproductive, Psychosocial)

• Bradycardia

• Decreased activity intolerance

• Diastolic hypertension

• Pericardial effusion

• Dyspnea

• Hypoventilation

• Pleural effusion

• Abdominal distention/ascites

• Constipation

• Weight gain

• Decreased basal metabolic rate

• Decreased body temperature

• Cold intolerance

• Anovulation (absence of ovulation)

• Decreased libido

• Menstrual changes (amenorrhea or prolonged periods)

• Impotence (men)

• Apathy

• Depression

Signs/Symptoms of Hypothyroidism (Integumentary, Neuromuscular, Physical)

• Cool, pale/ash gray, dry, coarse, scaly skin

• Decreased hair growth, with loss of eyebrows hair

• Dry, coarse, brittle hair

• Thick, brittle nails

• Confusion

• Decreased tendon reflexes

• Hearing loss

• Impaired memory

• Inattentivemess

• Lethargy or somnolence

• Muscle aches and pain

• Slowing of intellectual functions

• Slowness or slurring of speech

• Facial puffiness

• Goiter (enlarged thyroid gland)

• Hoarseness

• Nonpitting edema of the hands and feet

• Periorbital edema

• Thick tongue

• Weakness, fatigue

Treatment of Hypothyroidism

• Lifelong thyroid hormone replacement

  • Take in the morning on an empty stomach with water 30 - 60 minutes before eating

  • Take at the same time each morning

  • Use the same drug manufacturer (have prescriber write “no substitutions” on the prescription)

  • Space iron, calcium, and magnesium 4 hours from ingestion (reduces absorption of levothyroxine)

  • Start on lowest dose and gradually increase if needed

• Yearly thyroid hormone labs

Myxedema Coma

Myxedema Coma: A serious complication of untreated or poorly treated hypothyroidism with dangerously reduced cardiopulmonary and neurologic functioning, although few affected adults become comatose. Decompensated metabolic state.

Cellular energy is decreased, and metabolites that are compounds of proteins and sugars called glycosaminoglycans (GAGs) build up inside cells. GAG buildup increases mucus and water, forming cellular edema (myxedema)

Precipitating Factors:

• Infection

• Cold exposure

• Stroke

• Meds (amiodacrone, lithium)

Signs/Symptoms of Myxedema Coma

• Enlarged and thicken tongue

• Non-pitting edema (pretibial, top of feet/hands, elbows, and face)

• Bradycardia (Decreased CO and perfusion)

• Decreased gas exchange

• Hypothermia

• Hypotension

• Greatly reduced level of consciousness and cognition

• Constipation

• Poor appetite

• Infertility, heavy menstruation

• Cool extremities and swelling of the limbs

• Enlarged thyroid (goiter)

• Thinning hair, hair loss

• Loss of eyebrow hair

• Puffy face

• Carpal tunnel syndrome

Findings and Treatment of Myxedema Coma

• Serum glucose levels: increased (hypoglycemia)

• ABGs: hypoxemia, hypercapnia

• ECG: prolonged QT, low voltage

• Pericardial effusion

Treatment

• Supportive (airway, rewarming)

• Hydrocortisone

• IV Levothyroxine (T4) and T3 supplementation

• IV glucose

• Monitor vital signs hourly (BP, temperature)

• Monitor level of consciousness

• Institute aspiration precaution

Hyperthyroidism

Hyperthyroidism: Excessive thyroid hormone secretion from the thyroid gland

• Subclinical hyperthyroidism will decrease the serum level of TSH but not change the serum level of T4. Therefore, no subjective or objective manifestations of hyperthyroidism will exist.

• In overt hyperthyroidism, there will be a decrease in the serum level of TSH, an increase in the serum level of T4, and the presence of subjective and objective findings.​​​​​​​

Graves Disease: Autoimmune disorder in which the production of autoantibodies (thyroid-stimulating immunoglobulins) that attach to the thyrotropin (TRAb) receptor on the thyroid gland greatly increases thyroid hormone production

• Non-hispanic white females between 30 - 50

Diagnosed: Low TSH and High T4/T3

Risk Factors for Hyperthyroidism

• Autoimmune disorders

• Grave’s Disease

• Family history of thyroid disease

• Pregnancy or recently postpartum

• Adrenal insufficiency

• Pernicious anemia (VItamin B12 deficiency)

• Type I Diabetes Mellitus

• Smoking

• Over consumption of iodine containing foods

• Low socioeconomic status

• Toxic multinodular goiter (TMNG)

• Excessive use of thyroid replacement hormones

• Thyroiditis

  • Subacute thyroiditis: an enlarged thyroid that is inflamed and causes the client pain

  • Postpartum thyroiditis: an enlarged thyroid that develops after giving birth

  • Painless thyroiditis: likely an autoimmune condition of an enlarged thyroid without the level of pain of subacute thyroiditis

Signs/Symptoms of Hyperthyroidism

• Chest pain

• Dysrhythmias

• Increased systolic blood pressure

• Palpitations

• Rapid, shallow respirations

• Tachycardia

• Increased appetite

• Increased stools (diarrhea)

• Weight loss

• Fatigue

• Heat intolerance

• Increased basal metabolic rate

• Amenorrhea

• Erectile dysfunction

• Gynecomastia

• Anxiety

• Mood swings

• Hyperactivity

• Restlessness

• Diaphoresis

• Fine, soft, silky body hair

• Smooth, warm, moist skin

• Thinning of scalp hair

• Eyelid retraction, eyelid lag

• Hyperactive deep tendon reflexes

• Insomnia

• Muscle weakness

• Tremors

• Goiter

• Wide-eyed or startled appearance (exophthalmos)

Maternal/Fetal Risks for Hyperthyroidism During Pregnancy

Threats to the pregnant client can range across all pregnancy trimesters

• Preeclampsia

• Preterm labor

• Thyroid storm

Fetal Risks

• Preterm birth

• Small for gestation age (SGA) measurement

• Fetal demise

• Congenital malformations

• Fetal tachycardia

• Fetal hyperthyroidism

• Development of a fetal goiter

Both PTU and methimazole carry a risk of fetal congenital disabilities when taken in the first trimester. There are also risks associated with impairment to the fetal thyroid function and the potential for goiter formation since the placental transfer of these medications exists. PTU has a lower risk and, therefore, is recommended for the first 4 months of pregnancy or up to week 16. Pharmacological therapy should then be changed to methimazole for the remainder of the pregnancy.

Treatment for Hyperthyroidism

• Methimazole (also decreases the immune response)

  • Suppresses synthesis of thyroid hormones

  • Monitor for symptoms of hypothyroidism

• Propylthiouracil

  • Suppresses synthesis of thyroid hormones

  • Darkening of the urine, pale stools, and jaundice can indicate liver toxicity or failure

• Beta blockers

  • For symptom control (relieves diaphoresis, tachycardia, anxiety, and palpitations)

• Iodine (Saturated solution of potassium iodine [SSKI])

  • Control transport of iodine into the thyroid

  • Given 1 hour after other medications

  • Radioactive iodine is given 1 week after admin to decrease the risk for an exacerbation of hyperthyroidism

  • Radiation precautions: sit to urinate, close the lid and flush 2 – 3 times, avoid contact with pregnant women/infants/young children for 1 week, stay 6 feet away from people, don’t share drinks/food, don’t prepare food for others

• Partial or Total Thyroidectomy

  • Complications include hemorrhage, respiratory distress, parathyroid gland injury (resulting in hypocalcemia), tetany, damage to the laryngeal nerves, and thyroid storm

Thyroid Storm

A life-threatening event that occurs in patients with uncontrolled hyperthyroidism, most often with Graves disease

Other Risk Factors

• Trauma from injury, surgery, or burns

• COVID-19

• Diabetic ketoacidosis

• Pregnancy

• Infections

• Drug reactions

• Strong cardiovascular system connection

  • cardiovascular disease, hypertension, tachyarrhythmias, ischemic heart disease

Signs/Symptoms of Thyroid Storm

• Thyrotoxicosis

• Respiratory distress

• Arrhythmias

• Severe hypertension

• High fever (104 - 106 F)

• Tachycardia

• Agitation

• Delirium

• Congestive heart failure

• Loss of consciousness

• Seizures

• Death

Treatment of Thyroid Storm

• Maintain a patent airway and adequate ventilation.

• Give oral antithyroid drugs as prescribed: methimazole or propylthiouracil.

• If antithyroid drugs cannot be used, a bile acid sequestrant such as chole-styramine may be ordered to help reduce thyroid levels.

• Administer iodide solution, nonsalicylate antipyretic drugs, and glucocorticoids as prescribed.

• Give oral propranolol as prescribed to control heart rate.

• Monitor continually for cardiac dysrhythmias.

• Monitor vital signs every 15 to 30 minutes.

• Provide comfort measures, including a cooling blanket.

• Correct dehydration with normal saline infusions per orders.

• Apply cooling blanket or ice packs to reduce fever.

Anorexia nervosa

• Persistent energy intake restriction leading to significantly low body weight in context of age, sex, developmental path, and physical health

• Fear of gaining weight or becoming overweight

• Disturbance in self-perceived weight or shape

• Restricting type: The individual drastically restricts food intake and does not binge or purge.

• Binge-eating/purging type: The individual engages in binge eating or purging behaviors (self-induced vomiting, laxative, diuretics, and/or enemas)

Characteristics

• Patients are preoccupied with food and the rituals of eating, along with a voluntary refusal to eat.

• This condition occurs most often in female patients from adolescence to young adulthood

• Onset can be associated with a stressful life event, such as college.

• Compared to patients who have restricting type, those who have binge-eating/purging type have higher rates of impulsivity and are more likely to abuse drugs and alcohol.

Signs/Symptoms for Anorexia Nervosa

• Body weight that is less than 85% of expected normal weight

• Patient perception that they are severely overweight and sees this image reflected in the mirror

• High interest in food but not eating; terrified of gaining weight

• Fine, downy hair (lanugo) on the face and back

• Yellowed skin (elevated carotene levels)

• Pale, cool extremities

• Poor skin turgor

• Muscle weakness

• Decreased vital signs (low BP, low PR, low temp, irregular HR)

• Fluid and electrolyte imbalances (dehydration)

  • hypomagnesium, hypophosphatemia, hypochloremia, hyponatremia, hypokalemia

  • metabolic alkalosis (vomiting) or metabolic acidosis (laxative use)

• Amenorrhea

• Purging type: dental erosions/caries, enlargement of the parotid glands

• Constipation (dehydration) or diarrhea (laxative use)

• Russell’s sign: self-induced vomiting causes calluses or scars on the hands

• Decreased estrogen (females) and testosterone (males)

Bulimia Nervosa

 An episodic, uncontrolled, compulsive, rapid ingestion of large amounts of food in a short time period, followed by purging behaviors to prevent weight gain.

• Purging type: The client uses self-induced vomiting, laxatives, diuretics, and/or enemas to lose or maintain weight.

• Nonpurging type: The client can compensate for binge eating through other means (excessive exercise and the misuse of laxatives, diuretics, and/or enemas).

Characteristics

• Most patients who have bulimia nervosa maintain a weight within a normal range or slightly higher. BMI is 18.5 to 30

• The average age of onset in female patients is late adolescence or early adulthood.

• Between binges, patients typically restrict caloric intake and select low-calorie "diet" foods.

• The dentist is often the first person to notice bulimia due to tooth enamel erosion

Signs/Symptoms of Bulimia Nervosa

• Weight within a normal range or slightly higher. BMI is 18.5 to 30

• Esophageal tears, gastric rupture

• Can exhibit low self-esteem, impulsivity, and difficulty with interpersonal relationships

• Need for an intense physical regimen

• Purging type: dental erosions/caries, enlargement of the parotid glands

• Diarrhea (laxative use)

• Russell’s sign: self-induced vomiting causes calluses or scars on the hands

• Hypokalemia

• Loss of bone density

• Menstrual irregularities

Cognitive Distortions with Eating Disorders

• Overgeneralization: "Other people don't like me because I'm fat."

• "All-or-nothing" thinking: "If I eat any dessert, I’Il gain 50 pounds."

• Catastrophizing: "My life is over if I gain weight."

• Personalization: "When I walk through the hospital hallway, I know everyone is looking at me."

• Emotional reasoning: "I know I look bad because I feel bloated."

• Distorted body image: “When I look in the mirror, I see myself as obese.”

Risk Factors for Eating Disorders

• Involved in modeling, ballet, or athletics where weight is monitored and thinness is encouraged

• History of obesity

• Family history of eating disorders

• Being a picky eater in childhood

• Interpersonal relationships (overly controlling parents)

• Feelings of ineffectiveness, helplessness, and depression

• Distorted body image

• Media influence and pressure from society to have the “perfect body”

• Hypothalamic, neurotransmitter, hormonal, or biochemical imbalance

• History of abuse

Early Manifestations of Eating Disorders

PRODROMAL MANIFESTATIONS

• Increase or decrease in weight that is not related to a medical condition

• Abnormal eating habits, like severe dieting

• Ritualized mealtime behaviors, like counting calories

• Lying about food intake

• Preoccupation with weight and body image

• Compulsive and/or excessive exercising

Interventions for Eating Disorders

• Positive approach to support and promote self-esteem

• Provide a highly structured environment

• Set meal times, small frequent meals, liquid supplements, high fiber, vitamin supplement

• Limit caffeine, high-fat, high-sodium foods

• Rewards for completing meals or consuming certain number of calories

• Allow patient to make choices where appropriate

• Monitor bathroom use after meals

• Monitor amount of exercise

• Establish realistic goals (2-3 lbs/week)

• Monitor vital signs, intake & output

• Individual, group, family counseling

• Nutrition education

Personality Disorders Clusters

Cluster A: Odd or eccentric thinking or behaviors or traits

• Paranoid, Schizoid, Schizotypal

Cluster B: Dramatic, emotional or erratic/impulsive traits

• Antisocial, borderline, histrionic, narcissistic

Cluster C: Anxious and fearful traits

• Avoidant, dependent, obsessive-compulsive

Cluster A: Paranoid Personality Disorder

Paranoid: Characterized by distrust and suspiciousness toward others based on unfounded beliefs that others want to harm, exploit, or deceive the person

Cluster A: Schizoid Personality Disorder

Schizoid: Characterized by emotional detachment, disinterest in close relationships, and indifference to praise or criticism; often uncooperative

Cluster A: Schizotypal Personality Disorder

Schizotypal: Characterized by odd beliefs leading to interpersonal difficulties, an eccentric appearance, and magical thinking or perceptual distortions that are not clear delusions or hallucinations

Cluster B: Antisocial Personality Disorder

Antisocial: Characterized by disregard for others with exploitation, lack of empathy, repeated unlawful actions, deceit, failure to accept personal responsibility; evidence of conduct disorder before age 15; sense of entitlement; manipulative, impulsive, and seductive behaviors; non-adherence to traditional morals and values; verbally charming and engaging

Patient’s diagnosed with borderline personality disorder are at a higher risk for danger to others

Cluster B: Borderline Personality Disorder

Borderline: Characterized by instability of affect, identity, and relationships, as well as splitting behaviors, manipulation, impulsiveness, and fear of abandonment; often self-injurious and potentially suicidal; ideas of reference are common; often accompanied by impulsivity

Patient’s diagnosed with borderline personality disorder are at a higher risk for danger to self

Cluster B: Histrionic Personality Disorder

Histrionic: Characterized by emotional attention-seeking behavior, in which the person needs to be the center of attention; often seductive and flirtatious

Cluster B: Narcissistic Personality Disorder

Narcissistic: Characterized by arrogance, grandiose views of self-importance, the need for consistent admiration, and a lack of empathy for others that strains most relationships; often sensitive to criticism

Cluster C: Avoidant Personality Disorder

Avoidant: Characterized by social inhibition and avoidance of all situations that require interpersonal contact, despite wanting close relationships, due to extreme fear of rejection; have feelings of inadequacy and are anxious in social situations

Cluster C: Dependent Personality Disorder

Dependent: Characterized by extreme dependency in a close relationship with an urgent search to find a replacement when one relationship ends

Cluster C: Obsessive-Compulsive Personality Disorder

Obsessive-Compulsive: Characterized by indecisiveness and perfectionism with a focus on orderliness and control to the extent that the individual might not be able to accomplish a given task

Risk Factors for Personality Disorders

• Comorbid substance use disorders

• History of nonviolent and violent crimes

• Prior childhood abuse/trauma

• Emotionally reactive/detached caregivers

• Genetic and biochemical influences

• Cultural factors

General Characteristics with Personality Disorders

• Inflexibility/maladaptive responses to stress

• Compulsiveness and lack of social restraint

• Inability to connect in social/professional relationships

• Tending to provoke interpersonal conflicts

LIFESPAN CONSIDERATIONS

• Children may exhibit difficulties in developing social relationships and school classwork.

• Adolescents may report being bullied for having odd habits, behaviors, or ideas.

• Adults may have trouble forming intimate relationships, maintaining or establishing careers, and fulfilling opportunities to mentor future generations.

Defense Mechanisms used by Patient’s with Personality Disorders

Repression: Unconsciously putting unacceptable ideas, thoughts, and emotions out of awareness

• ADAPTIVE USE: A person preparing to give a speech unconsciously forgets about the time when they were young and kids laughed at them while on stage.

• MALADAPTIVE USE: A person who has a fear of the dentist continually forgets to go to their dental appointments.

Suppression: Voluntarily denying unpleasant thoughts and feelings

• ADAPTIVE USE: A student puts off thinking about a fight they had with a friend so they can focus on a test.

• MALADAPTIVE USE: A person who has lost their job states they will worry about paying bills next week.

Regression: Sudden use of childlike or primitive behaviors that do not correlate with the person's current developmental level

• ADAPTIVE USE: A young child temporarily wets the bed when they learn that their pet died

• MALADAPTIVE USE: A person who has a disagreement with a co-worker begins throwing things at their office.

Undoing: Performing an act to make up for prior behavior (most commonly seen in children).

• ADAPTIVE USE: An adolescent completes their chores without being prompted after having an argument with their parent.

• MALADAPTIVE USE: An individual buys their significant other flowers and gifts after an incident of partner abuse.

Splitting: Demonstrating an inability to reconcile negative and positive attributes of self or others into a cohesive image (commonly associated with borderline personality disorder)

• ADAPTIVE USE: n/a

• MALADAPTIVE USE: A client tells a nurse that the nurse is the only one who cares about them, yet the following day, the client refuses to talk to that nurse.

Interventions for Personality Disorders

• Structured milieu therapy

• Safety: self-harm/suicide risk especially with borderline personality disorder; risk of harming others with antisocial personality disorder

• Cluster A: emphasize pre-existing patient strengths and skills, develop resources to find and maintain personal relationships

  • Schizoid or schizotypal types tend to isolate themselves, nurses should respect that need.

• Cluster B: develop skills to limit dramatic/emotional behaviors

  • Limit-setting and consistency are essential with patients who are manipulative (borderline and antisocial)

  • Histrionic types benefit from assertiveness training and modeling as well as psychotherapy

• Cluster C: develop skills to manage feelings of anxiety

  • Dependent types benefit from assertiveness training and modeling as well as psychotherapy

• Medications: Antidepressants, anxiolytic, antipsychotic, or mood stabilizers

• Psychotherapy, group therapy, and case management

OCD

OCD: A mental health condition that is characterized by intrusive thoughts of unrealistic obsessions and tries to control these thoughts with compulsive behaviors, such as repetitive cleaning of a particular object or washing hands.

• There are many who have OCD tendencies, but these thoughts and actions may not necessarily interfere with one’s everyday life.

• When the ability to function normally is affected, one becomes maladaptive and in need of help.

Risk Factors for OCD

• Female gender

• Family history of OCD

• Stressful life events

• Comorbid mood or personality disorders (especially anxiety disorders)

Signs/Symptoms of OCD

Obsessions or compulsions are time-consuming and result in impaired social and occupational functioning

Common obsessions:

• Fear of germs, dirt, or contamination

• Fear of losing control over yourself

• Fear of forgetting something important

• Intrusive thoughts of aggression, harm, or inappropriate behavior

• Desire to have things in a certain order or place

Common compulsions:

• Excessive cleaning or handwashing

• Ordering, numbering, counting, or arranging things in a particular way

• Repeatedly checking things

• Repeating mantras or prayers

Motor or verbal tics

Interventions for OCD

• Assess anxiety level

• Assess suicidality

• Provide calm, quiet environment

• Therapeutic communication strategies

• Relaxation techniques

• Allow time for client rituals

• Psychotherapy

• Medication (SSRIs: Fluvoxamine, paroxetine, fluoxetine, Buspirone for long-term management)

• Support groups

• Exercise

Hypothalamic-Pituitary Axis

• An information system in the body in which the hypothalamus receives feedback from multiple areas of the central nervous system and hormone levels in the endocrine glands and sends a message to the pituitary gland to release or hold hormones.

• The hormones involved include thyroid-stimulating hormone (TSH), follicle-stimulating hormone (FSH), luteinizing hormone (LH), growth hormone, prolactin, and adrenocorticotropic hormone. 

• The hypothalamus and the pituitary gland regulate many body functions, such as body temperature (through TSH thyrotropin-releasing hormone), fluid balance (antidiuretic hormone or vasopressin), blood pressure (dopamine), appetite, stress (cortisol), sleep (melatonin via the pineal gland), and reproductive health (gonadotropin-releasing hormone).

Addison’s Disease

Addison’s disease is a disorder of the adrenal glands in which the glands are damaged and unable to produce adequate amounts of cortisol and aldosterone. An insufficient amount of these hormones diminishes the body’s ability to maintain metabolism, electrolyte balance, blood pressure, and blood glucose levels and also creates an inability to control inflammation

Causes of Addison’s Disease

Primary

• Autoimmune dysfunction

• Tuberculosis

• Metastatic cancer

• HIV-III (AIDS)

• Hemorrhage

• Gram-negative sepsis

• Adrenalectomy (usually as treatment for Cushing’s syndrome)

• Abdominal radiation therapy

• Drugs (mitotane) and toxins

Secondary

• Pituitary tumors

• Postpartum pituitary necrosis

• Hypophysectomy (removal of the pituitary gland)

• High-dose pituitary or whole brain radiation

• Cessation of long-term corticosteroid drug therapy

Signs/Symptoms of Addison’s Disease

• Hypoglycemia (from decreased cortisol)

• Peptic Ulcers (from decreased gastric acid)

• Excessive BUN levels (from decreased glomerular filtration)

• Anorexia and weight loss (from decreased glomerular filtration)

• Fluid and Electrolyte Imbalances

  • Hyperkalemia, hypercalcemia, hyponatremia

  • Hypovolemia

• Hypotension

• Salt cravings

• Metabolic acidosis (potassium retention promotes reabsorption of hydrogen ions)

• Decreased body, axillary, and pubic hair in females (low adrenal androgen levels)

• Hyperpigmentation

• Vitiligo

• Nausea, vomiting, abdominal pain

• Joint/muscle pain

• Muscle weakness

• Fatigue

• Menstrual changes (women) and impotence (men)

Addisonian Crisis (Acute Adrenal Insufficiency)

Medical emergency in which the need for cortisol and aldosterone is greater than the body’s supply. It often occurs in response to a stressful event (e.g. surgery, trauma, severe infections, adrenal hemorrhage, etc.) especially when the adrenal hormone output is already reduced.

Problems are the same as chronic adrenal insufficiency, but more severe and life-threatening symptoms can appear without warning

• S/s: severe hypotension, hypoglycemia, hyperkalemia, abdominal pain, weakness, weight loss

Treatment:

• Administer glucocorticoids, glucagon/glucose and insulin w/ dextrose (for hypoglycemia), loop/thiazide diuretics (for hyperkalemia)

• Place in Trendelenburg to improve blood pressure

Emergency Management for Acute Adrenal Insufficiency

Hormone Replacement

• Start rapid infusion of normal saline or dextrose 5% in normal saline.

• Initial higher doses of hydrocortisone sodium or dexamethasone are administered as an IV bolus.

• Administer additional hydrocortisone sodium by continuous IV infusion over the next 8 hours.

• Give an additional dose of hydrocortisone intramuscularly concomitantly with hydration every 12 hours.

• Initiate an IV H2 histamine blocker (e.g., cimetidine) for ulcer prevention.

Hyperkalemia Management

• Administer insulin and dextrose intravenously to shift potassium into cells. Dosing is often based on renal function.

• Give potassium binding and excreting resin.

• Give loop or thiazide diuretics. Avoid potassium-sparing diuretics.

• Cardiac cell membrane stabilization with IV calcium.

• Initiate potassium restriction.

• Monitor intake and output.

• Monitor heart rate, rhythm, and ECG for signs and symptoms of hyperkalemia (slow heart rate; heart block; tall, peaked T waves; fibrillation; asystole.

Hypoglycemia Management

• Administer IV glucose as per orders.

• Prepare to administer glucagon as needed and as per orders.

• Maintain IV access.

• Monitor blood glucose level hourly.

Labs/Diagnostics for Addison’s Disease

• Low sodium

• High potassium

• High calcium

• High bicarbonate

• Normal to low glucose (fasting)

• High BUN

• High cortisol (serum and saliva)

• ACTH stimulation test (definitive test)

  • IV ACTH is given and plasma cortisol levels are taken at 30 & 60 mins

  • No cortisol response in primary Addison’s; increased cortisol response for secondary Addison’s

Primary Addison’s

• Elevated eosinophils

• Elevated ACTH

Nursing Interventions for Addison’s Disease

• Daily weights and I&O

• Orthostatic BP assessments

• Preventing hypoglycemia

• Assessing cardiac function (telemetry)

• Vital signs every 1-4 hours

• Monitor lab values to identify hemoconcentration

• Hormone replacement therapy

  • Hydrocortisone IV or prednisone PO to correct glucocorticoid deficiency

  • Fludrocortisone (mineralocorticoid) may be needed to restore fluid and electrolyte balance

Cushing’s Syndrome

Cushing’s syndrome is a disorder in which excessive amounts of cortisol are excreted. This results in associated health problems such as hypertension, osteoporosis, metabolic syndrome, diabetes, and increased risk for infections.

• Cushing’s disease is caused by endogenous factors: adrenal hyperplasia, adrenocortical tumor, pituitary tumor, lung/GI/pancreatic tumors (these secrete ACTH)

• Cushing’s syndrome is caused by chronic therapeutic use of glucocorticoids for organ transplant, chemotherapy, autoimmune diseases, asthma, allergies, or chronic fibrosis

Signs/Symptoms of Cushing’s Syndrome/Disease

• Increased total body fat with fat redistribution

  • Truncal obesity, “buffalo hump.” and “moon face”

• Increased breakdown of tissue protein

  • Decreased muscle mass/strength, thin skin (striae on abdomen, thighs, and upper arms), and fragile capillaries

• Bone density loss (osteoporosis)

  • Fragility fractures, decreased height/vertebral collapse, aseptic necrosis of the femur head, slow or poor healing of bone fractures

• Increased risk for infection and decreased inflammatory response

  • Reduced number of circulating lymphocytes, inhibited macrophage activity, reduced antibody synthesis, and inhibited production of cytokines and inflammatory chemicals (e.g. histamine)

• Increased androgen production

  • Acne, hirsutism, clitoral hypertrophy, thinning hair

• Decreased estrogens and progesterones

  • Oligomenorrhea (scant or infrequent menses)

• Hypertension, bounding pulses

• Cardiac hypertrophy

• Frequent dependent edema

• Increased appetite

• Peptic ulcers (increased HCl acid and decreased gastric mucus)

• Bruising, petechiae

• Impaired glucose intolerance (hyperglycemia)

• Sleep disturbances

Labs/Diagnostics for Cushing’s Syndrome/Disease

Labs

• High cortisol (serum, saliva, and urine)

• ACTH levels (high, if pituitary is the cause; low, if adrenal dysfunction/medication is the cause)

• Increased blood glucose levels

• Decreased lymphocyte counts

• Increased sodium levels

• Decreased calcium and potassium levels

• 24-hour urine collection: high free cortisol levels

• Dexamethasone suppression test: uses administration of dexamethasone at bedtime, then 8 a.m. blood draw for serum cortisol levels and another 24-hr urine collection to measure cortisol excretion

  • When cortisol levels are suppressed vey dexamethasone, Cushing’s disease is not present

Diagnostics

• X-ray, MRI, CT can reveal tumors or lesions on pituitary gland, adrenal gland, GI tract, lung, and

  pancreas

Treatment for Cushing’s Syndrome/Disease

• Tapering or eliminating corticosteroids (for Cushing’s syndrome)

• Drug therapy (ketoconazole, mitotane, hydrocortisone)

• Fluid and sodium restrictions

• Chemotherapy (for removal of tumors causing disease)

• Hypophysectomy (removal of pituitary gland, if cause of disease)

  • Monitor for CSF leaks through sinus cavity (test fluid for glucose, look for “halo” appearance)

  • Provide glucocorticoid replacement therapy

  • Avoid brushing teeth for 2 weeks

  • Avoid anything that increases intracranial pressure (bending, straining, etc)

• Adrenalectomy (removal of one or both adrenal glands)

  • Provide glucocorticoid and hormone replacement therapy

  • Patient will be in ICU for recovery