medsurge TEST 2 endocrine

the endocrine system does what 4 things

enables reproduction, growth and development, regulation of energy, mechanism for maintaining homeostasis

endocrine glands function to

synthesize hormones and secrete them into the bloodstream, hormones exert their effects on target tissues

organs also produce hormones

GI tract-peptides, gastrin

Heart- ANP/BNP

Kidney-erythropoietin

negative feedback loop definition

Hormones in opposite directions

Low levels of one hormone will stimulate the increased production of another

Increased levels of a hormone will suppress/decrease production of another hormone

hypocalcemia negative feedback loop

Decreased blood calcium causes increase of PTH from the parathyroid gland

PTH act on bone to release calcium into blood

hypercalcemia negative feedback loop

Increased levels of blood calcium will cause decreased PTH levels

So less calcium is released into blood or levels are normalized

resorption

Movement of calcium from stored in the bone to mobilized in the bloodstream (done by PTH)

absorption

When calcium is taken from the blood and absorbed into the bone

positive feedback loop definition

Hormones in the same direction

High levels of substance causes another hormone to be produced

the female menstrual cycle positive feedback loop

Ex: Increased levels of FSH and LH cause increased levels of estrogen

Ex: increased oxytocin in childbirth cause uterine contractions and increase more oxytocin

complex feedback loop

Hormones in both directions both up and also both up and down, many loops working together at the same time

nervous system and control of endocrine glands Override normal responses

Affected by pain

Emotion

Sexual excitement

Stress

example of override of normal responses

Stress sensed by CNS reaction-increased catecholamines -decreased insulin-liver-glucose

Hormones are secreted in patterns or rhythm

Predictable production rates in a 24 hr period

example of cortisol rhythm

Cortisol follows a diurnal pattern where its highest in the early am and drops in the evening and rises again during late sleep to peak again by morning

GH and prolactin peak during __________

sleep, do labs early in the morning

GH

from anterior pituitary, Target all body cells

Its normal to have >20 ng/ml 30 mins after vigorous exercise

Its abnormal to have >50 ng/ml (sign of acromegaly)

Glucose and GH have inverse relationship, neg feedback loop

blood draw with treadmill testing of GH

30 mins on treadmill then draw and send to lab stat

Pt NPO after midnight or at least 12 hrs before exercise testing

Blood draw that is sent to lab immediately

Assess pt history for cardiac problems prior to stress test (can use glucose load test instead)

If pt has HF or severe COPD, orthopedic instability etc do glucose test

Load the pt with glucose (OGTT) and GH should go down, but if they have acromegaly the GH will stay high despite the load

With theses test you expect the GH to rise to 20 at least but NOT 50, if it's 50 then its positive for too much GH

excessive GH cause and types

usually due to benign pituitary tumor, Gigantism during growth years (children)

Acromegaly (after growth plate closes, adults)

sxs of excessive GH (acromegaly/gigantism)

males>females, 30s/40s

Enlargement of bony structures

hands, feet, paranasal sinuses, spinal deformities

Soft tissue enlargement

Physical problems

HTN, cardiomegaly, LVH, diaphoresis, oily skin, peripheral neuropathies, muscle weakness, joint pain, irregular menstrual cycle

Thick tongue, sleep apnea

dx of excessive GH

GH levels

Response to oral glucose challenge (GH should fall but won't with acromegaly)

MRI looking for pituitary tumor

Surgery <10mm trans sphenoidal approach

surgery of GH tumor

Goal is to remove only tumor

If entire gland is removed then target hormones must be replaced lifelong

ADH, cortisol, thyroid hormone, sex hormones

pre op for removing GH tumor

Bacitracin nose drops

Education for mouth breathing (nose will be packed) and oral care (q 4 hrs - 6x daily)

Avoid:

Vigorous coughing

Sneezing

Valsalva maneuvers (CSF leak)

post op considerations with GH tumor removal

Increase HPB 30 degrees to decrease HA

Mouth care q 4 hrs

DONT brush teeth for 10 days bc bristles can disrupt suture line and cause meningitis, just use green toothette

Any clear nasal drainage sent to lab for glucose (>30-40=CSF leak)

Persistent or severe generalized or supraorbital HA may indicate spinal fluid leakage into sinuses

Halo signs

Report any HA with pupillary changes, n/v, HA not better with Tylenol, recent onset

what to do with leaks post tumor removal

Leaks usually resolved in 72 hrs with HOB elevated and bed rest

May see daily spinal taps to decrease pressure and help stop leaks

IV abxs to decrease risk of infection if persistent leak >72 hrs after surgery

radiation therapy for GH tumor

Done in conjunction with surgery for large tumors

Gamma surgery

Hold overnight for observations

Monitor VS, I&O, neuro checks

complications of GH radiation therapy

HA

N&V

Seizures

SIADH

DI

when pt is experiencing Na<125 then there is concern for what

seizures or coma

drug therapy for excessive GH

Dopamine agonist-Parlodel

Somatostatin analogs-Sandostatin

hypopituitarism def

decrease in one or more pituitary hormones

primary cause of hypopituitarism

Developmental or autoimmune disorder

Infections

Vascular disease or collapse

Destruction of the gland (trauma, surgery

sxs of hypopituitarism

Vague weakness, fatigue, headache, sexual dysfunction, fasting hypoglycemia

dry skin, fine wrinkles

dec stress tolerance

poor infection resistance

apathy, mental slowness, delusions

orthostatic hypotension

blindness

growth retardation

anorexia and bulimia

what hormone deficiency causes Vague weakness, fatigue, headache, sexual dysfunction, fasting hypoglycemia

Energy levels issue is not enough TSH/T3/4

Sexual dysfunction is not enough FSH and LH

Hypoglycemia is not enough cortisol

what hormone deficiency causes dry, fine wrinkles around mouth and eyes

Not enough cortisol or thyroid

what hormone deficiency causes Decreased tolerance for stress, poor resistance to infections

Not enough cortisol

what hormone deficiency causes apathy, mental slowness, delusions

Not enough TSH, cortisol

what hormone deficiency causes orthostatic hypotension

Not enough ADH

what hormone deficiency causes blindness

tumor

what hormone deficiency causes growth retardation after first 1 to 2 years of life

Not enough GH

what hormone deficiency causes Anorexia and bulimia

When any of these hormones are to high to too low can trigger this

Sheehan's syndrome (post partal)

Hx of hemorrhage or other hypoxic episode during delivery (pituitary infarcts)

Not extremely noticeable

Try to feed the baby but not enough pitocin/prolactin so no period bc loss FSH and LH

Need lifelong replacement of these

Failure to lactate

Scanty, irregular or absent menses

Decreased secondary sex characteristics

Hypothyroid s&s

s&s of glucocorticoid insufficiency

pituitary dwarfism def

Due to decreased GH levels

Lifelong SQ replacement

SIADH def

Too much ADH secreted from posterior pituitary

SIADH sxs

Fluid retention

Serum hypoosmolality

Hyponatremia

Hypochloremia

Normal renal function

Weight loss (if you discount the edema)

Gaining 5+ lbs in couple days is not normal

Normal serum osmolality

285-295

Urine specific gravity is

1.003-1.030

SIADH osmo and USG

dilutional hyponatremia

HA, NV, confusion, and coma

LOW serum osmolality (diluted)

<280

HIGH specific gravity (concentrated)

>1.25-1.030

Serum sodium <135-145

tx of SIADH

Fluid restriction of 800-1000cc/day

Daily weight

3-5% hypertonic saline solution IV fluid retention continues at slow rate

Replace NA

Lasix

Create nephrogenic diabetes insipidus by blocking ADH: Declomycin

Vasopressin receptor antagonist

Hx of intracranial trauma, surgery, tumors, meningitis)

DI def

not enough ADH secreted from posterior pituitary gland

cause of DI

Tumor

Closed head trauma

CNS infections

Vascular disorders

sx of DI

Polydipsia

Polyuria (5-20 liters/day)

Usually intake of large amounts of fluids preferable iced or cold drinks

Fatigue, nocturia, generalized weakness

DI osmo and USG

Low Urine specific gravity

<1.005 diluted

High serum osmolality

Concentrated

central DI

Neurogenic problem with ADH synthesis (hypothalamus) or release (pituitary)

nephrogenic DI

Problem with renal response to ADH, no ADH deficiency

Kidney not using, chronic kidney disease

Psychogenic/dipsogenic DI

Patient overhydrating self=hypervolemia

Psychological disorder or lesion in thirst center

nursing care and dx of DI

ADH-IM, IV, SC

IV D5W dextrose changes osmotic pressure

Diuretics (if nephrogenic), only if kidney issue

Glucometers urine collections for specific gravity

Daily weights

Water deprivation test

water deprivation tests

No tea, coffee, alcohol or smoking after 2400

Baseline weight, urine specific gravity, serum osmolality

No fluids

3 postural BPs, q hours, lay, sitting, and standing, stop if MAPs drop

Hourly samples for serum osmolality/USG

Weights at 4, 6, 7, 8 hours

Give ADH IV or SC

Used to differentiate causes of DI

If post water test there is no change what DI is it

nephrogenic

If post water test there is normalized specific gravity after giving ADH then what DI is it

central

If post water test no ADH but the levels normalize then its ___________ DI bc you just held water 8 hrs

psychogenic

how to protect yourself from the sun?

SPF 15 minimum, reapply every 2 hrs, stay out of the sun from 10-2pm

who is more at risk for skin cancer?

pale white with freckles

whos less at risk for skin cancer?

dark skinned

actinic keratosis

precancerous, hyperkeratotic papules and plaques that occur on sun exposed areas, premalignant form of squamous cell carcinoma, typical lesion is regular shaped, flat, erythematous papule with indistinct borders with an overlaying hard keratotic scale or horn

tx for skin carcinomas

cryosurgery, 5-FU (chemical peal), surgical removal, dermatological agents, electrodessication, radiation, surgery

squamous cell carcinoma

a malignant neoplasm of keratinizing epidermal cells, can be aggressive, superficial thin scaly erythematous without invasion of dermis, early firm nodules with indistinct borders, late covering of lesion with scale or horn from keratinization

basal cell carcinoma

a locally invasive malignancy arising from epidermal basal cells, most common type of skin cancer and least deadly, nodular small slow growing papules, pearly borders, depression at center, superficial erythematous sharply defined barely elevated multinodular plaque with scaling

malignant melanoma

a tumor arising from melanocytes and has ability to metastasize to any organ in the body, 10x more prevalent in white people than AA

watch what signs of nevi for malignant melanoma?

asymmetry, border, color, diameter(>6mm), evolving appearance

what is biggest indication for cancerous spots?

change

cellulitis care

warm moist hear, IV abx, elevation, prevent spread with handwashing and glove changes

herpes simplex 1 and 2 guidelines

no sex until all sores are gone in 2, no cure, exacerbated by stress, tx with antivirals

herpes zoster

linear distribution along a dermatome of vesicles that are painful

who can get herpes zoster?

only those who had chicken pox as a child

who can someone transmit herpes zoster to?

those without the vaccines or never got chicken pox, those who get it get chicken pox not HZ

who gets the herpes zoster vaccine?

age 50+, hx of chicken pox

how to tx fungal infecitons?

try OTC meds and if no change try another, still no change in 72 hours or gets worse, see health care provider

infestations and insect bites, allergy is best to do what?

avoid trigger, do not be in profession near it, wear a medic alert bracelet, carry epipen

allergic dermatitis

an immune response that is immediate with hives/urticaria

allergic contact dermatitis

delayed reaction to an allergen with urticaria

what is most important when teaching a patient about phototherapy?

protect the eyes

laser surgery nurse responsibilities

protect from the sun, watch for bacteria growth, help with pain and dressing changes as needed

face lift nursing care

never judge, give realistic expectations, lor of inflammation in 72 hours, do not put on makeup for several weeks after

contraindications for liposuction

anticoagulants, uncontrolled HTN, DM and poor cardiovascular status

preoperative management for cosmetic surgery

reinforce realistic expectations, explain healing timeframe, correct/control underlying health problems

post op management for cosmetic surgery

mild analgesia, teach s/s of infection, monitor for dec circulation, support dressings and ice packs early, avoid sun