Module 8: Interprofessional Collaboration for Patients with Problems of the Endocrine System

What is a thyroidectomy?

A total or partial thyroid removal

Thyroidectomy - pre-op

Iodine solution (e.g., Lugol’s solution or potassium iodide) is given to decrease blood flow to the thyroid, shrink the gland, and prevent thyroid storm.

Thyroidectomy - post-op

• Check the dressing

• Assess vital signs every 15 minutes, then every 30 minutes

• Assess the patient’s level of discomfort

• Place the patient in semi-Fowler’s position and support the head with pillows (avoid positions that cause neck extension)

• Monitor for hemorrhage, respiratory distress, hypocalcemia, and tetany

• Patients go home the next day, if there are no complications

What is a thyroid storm/thyroid crisis?

• A life-threatening event

• Uncontrolled hyperthyroidism, most often with Graves’ disease and a thyroidectomy

• Symptoms develop quickly

What are the s/s of a thyroid storm/thyroid crisis?

• Fever

• Tachycardia

• Hypertension

• Tremors

• Coma

• Seizures

What are the triggers of a thyroid storm/thyroid crisis?

Stressors such as trauma, infection, DKA, pregnancy, etc.

What are the most important considerations for a thyroid storm/thyroid crisis?

• Maintain airway

• Maintain cardiopulmonary status (watch for dysrhythmias)

What is hypothyroidism?

Reduced or absent thyroid hormone secretion

What is important history for a patient with hypothyroidism?

Family history of thyroid or endocrine disorders

What are the s/s of hypothyroidism?

• Goiter

• Excessive weight gain

• Dry skin

• Fatigue and weakness

• Muscle pain

• Constipation

• Thinning hair/hair loss

What does a psychosocial assessment of a patient with hypothyroidism look like?

They are withdrawn, have mood changes, and are depressed - it is often the reason patients seek help

Which labs should be taken to detect hypothyroidism?

• TSH (high)

• T3 (low)

• T4 (low)

What is myxedema coma?

Severe, life-threatening hypothyroidism, which can cause hypotension, hypoventilation, and cardiac dysrhythmias.

What are important teaching points for a patient with hypothyroidism being discharged?

• Monitoring O2, BP, HR, and assessing for chest pain

• Medications are a lifelong therapy (Synthroid)

• Hydrate, eat fiber, and exercise

What medications are used for hypothyroidism?

Levothyroxine, aka Synthroid

What is hyperthyroidism?

Excessive thyroid hormone secretion from the thyroid gland

What is the most common cause of hyperthyroidism?

Graves’ disease (an autoimmune disorder that attacks the thyroid gland, causing it to overproduce thyroid hormones), which happens more in women.

What are the s/s of hyperthyroidism?

• Bulging eyes (exophthalmos)

• Goiter

• Heat intolerance

• Palpitations

• Hypertensive episodes

• Can’t sleep at night

• Overstimulated!

What does a psychosocial assessment look like for patients with hyperthyroidism?

They are anxious, overstimulated, and displaying manic behavior

What labs should be taken for diagnosing hyperthyroidism?

• TSH (low)

• T3 (high)

• T4 (high)

What are other diagnostic methods for hyperthyroidism?

• Thyroid scan/ultrasound

• For palpitations → EKG

What are the nonsurgical treatments for hyperthyroidism?

• Monitoring apical pulse, BP, and temperature (most likely going to be warm)

• Reduce stimulation (quiet environment)

• Provide comfort (cool room, cool water, and fresh linen)

• Drug therapy

What medications are used for hyperthyroidism?

• Methimazole (lowers T3 and T4)

• Beta blockers (for elevated BP and palpitations)

• Iodine preparations (to help decrease thyroid-secreting hormones, IV or PO)

What is the surgery for hyperthyroidism?

Total/partial thyroidectomy (they will be on lifelong medication after - levothyroxine)

What is levothyroxine?

Thyroid hormone replacement (T4); a lifelong therapy

When is levothyroxine used?

• Hypothyroidism

• Myxedema coma

• Replacement therapy after total or partial thyroidectomy

How is levothyroxine given?

• PO

• IV (myxedema coma)

What is the important nursing consideration for levothyroixine?

Monitor TSH and T4 levels to make sure it isn’t working too well → hyperthyroidism

What is diabetes?

A common, complex, chronic condition where the ability to produce or utilize insulin is impaired, resulting in impaired glucose metabolism

What is the main difference between type I and type II diabetes?

• Type I: the body doesn’t make insulin

• Type II: the body makes insulin, but it becomes insulin-resistant

Which diabetes is insulin dependent, type I or type II?

Type I

When does type I diabetes usually occur?

Childhood

When does type II diabetes usually occur?

Adulthood

What is prediabetes?

Impaired glucose tolerance, impaired fasting glucose, or both

What is gestational diabetes?

Pregnancy-induced diabetes (temporary, but increases the chance of developing type II diabetes)

What are the chronic complications of diabetes?

• Cardiovascular disease

• Cerebrovascular disease (stroke risk increases)

• Diabetic retinopathy (eye and vision issues)

• Diabetic peripheral neuropathy (numbness, tingling, and altered perception in extremities)

• Diabetic nephropathy (kidney disease)

• Cognitive dysfunction

• End0stage renal disease

• Non-traumatic lower limb amputations

What is the etiology of diabetes?

• Genetics

• Autoimune

• Metabolic syndrome

• Environmental factors (neighborhood, food security, air quality, and overall access to healthcare)

What is the normal glucose range?

74-100 mg/dL

What are the 3 P’s of diabetes?

1. Polyuria (increased urine)

2. Polydipsia (increased thirst)

3. Polyphagia (increased hunger)

What are important diabetes education points?

• Hypoglycemia happens when you don’t eat enough, exercise too much, and/or drink alcohol

• Check blood sugar often

• Carry a snack (simple carbs are best)

• Wear a medical ID

• Hydrate!

• Take a sick day if needed (stress increases blood sugar)

Diabetes = HbA1c of ____ or higher.

Diabetes = HbA1c of 6.5% or higher.

What is hemoglobin A1c?

• Sugar in the blood cell content for the past three months

• People with diabetes should be knowledgable about their HbA1c

• With diabetes, an HbA1c of 7 or less is controlled

Is HbA1c used for diagnostic or monitoring purposes?

Both!

Diabetes = fasting plasma glucose level of ____ or greater.

Diabetes = fasting plasma glucose level of 126 mg/dL or greater.

What is fasting considered?

No caloric intake for at least 8 hours

Diabetes = two-hour plasma glucose level of ____ or greater.

Diabetes = two-hour plasma glucose level of 200 mg/dL or greater.

In a patient with polyuria, polydipsia, and unexplained weight loss, diabetes = a random plasma glucose level of _____ or greater.

In a patient with polyuria, polydipsia, and unexplained weight loss, diabetes = a random plasma glucose level of 200 mg/dL or greater.

What is important when teaching a patient self-injection of glucose?

Return demonstration!

What are important nursing considerations with rapid-acting insulins?

• Hold if the patient is NPO

• Needs to be timed with meals

What are the rapid-acting insulins?

• Aspart

• Glulisine

• Lispro (Humalog)

What is the onset of rapid-acting insulin?

10-15 minutes

What is the peak of rapid-acting insulin?

2-3 hours

What is the duration of rapid-acting insulin?

4-5 hours

What is the short acting insulin?

Regular

What is the intermediate-acting insulin?

NPH

What are the long-acting insulins?

• Glargine

• Detemir

What is the onset of long-acting insulins?

1 hour (slow, steady release)

What is the peak of long-acting insulins?

No peak

What is the ultra-long-acting insulin?

Degludec

What is the saying for hypoglycemia?

“Cool and clammy, have some candy.”

What are blood glucose levels for hypoglycemia?

Below 70

With hypoglycemia, if the patient is awake and alert…

• Give them a simple carb (apple juice, orange juice, graham crackers)

• Chocolate is not the best option to give because it has fat and does not break down as quickly

• Recheck blood sugar again in 15 minutes

With hypoglycemia, if the patient is unconscious and there is IV access available…

Push IV dextrose D5W

With hypoglycemia, if the patient is unconsious and there is no IV access available…

Administer glucagon IM

What is the saying for hyperglycemia?

“Hot and dry, sugar high.”

What medications do you give a hyperglycemic patient?

Administer insulin and fluids if necessary

The nurse is preparing to review a teaching plan for a patient with type 2 diabetes mellitus. To determine the patient's level of compliance with his prescribed diabetic regimen, which value would the nurse be sure to review?
a. Fasting glucose level
b. Oral glucose tolerance test results
c. Glycosylated hemoglobin level
d. Fingerstick glucose finding for 24 hours

c. Glycosylated hemoglobin level

HbA1c reflects an average blood glucose, long-term

A patient with type 1 diabetes reports feeling dizzy. What should the nurse do first?
a. Check patient's blood pressure
b. Give orange juice
c. Give the patient their morning dose of insulin
d. Use a glucometer to check blood sugar

d. Use a glucometer to check blood sugar

Always assess the blood pressure first before taking action. This could be either hypo- or hyperglycemia

The client is diagnosed with hypothyroidism. Which signs/symptoms should the nurse expect the client to exhibit?
a. Fatigue and hair loss
b. Exophthalmos and nervousness
c. Sweating and flushed skin
d. Tetany and stiffness of hands

a. Fatigue and hair loss

Hypothyroidism slows metabolism. The other options are hyperthyroidism, except for tetany and stiffness, which is often a sign of hypocalcemia.

The client diagnosed with type 1 diabetes is found lying unconscious on the floor of the bathroom. Which intervention should the nurse implement first?
a. Administer 50% dextrose
b. Notify healthcare provider
c. Move pt. to ICU
d. Check the serum glucose level

a. Administer 50% dextrose

Unconsciousness with type I diabetes is a sign of a hypoglycemic emergency. Administer the dextrose to rapidly raise their blood glucose

A nurse is caring for a client who has a blood glucose of 52 mg/dL. The client is lethargic but arousable. Which of the following actions should nurse the perform first?
a. Recheck blood glucose in 15 min
b. Provide carb and protein
c. Provide 15 g of simple carb
d. Report to provider

c. Provide 15 g of simple carb

Since they are awake, they can consume a simple carb, which is easy to digest and will raise glucose levels quickly. 

A nurse is preparing to administer a morning dose of insulin aspart to a client who has type 1 diabetes mellitus. Which of the following actions should the nurse take?
a. Check blood glucose immediately after breakfast
b. Administer insulin when breakfast arrives
c. Hold breakfast for 1 hr after insulin administration
d. Clarify prescription because insulin should not be administered at this time

b. Administer insulin when breakfast arrives

Insulin aspart is rapid-acting, which needs to be administered with meals.

The nurse is providing care for a patient who underwent a thyroidectomy 2 days ago. Which laboratory value requires close monitoring by the nurse?
a. Calcium
b. Sodium
c. Potassium
d. WBC

a. Calcium

With a thyroidectomy, there is a risk for accidental removal/injury of the parathyroid glands, which regulate calcium levels. A common complication is hypocalcemia.

A patient is admitted to the medical unit with possible Graves’ disease (hyperthyroidism). Which assessment finding by the nurse supports this diagnosis ?a. Periorbital edema
b. Bradycardia
c. Exophthalmos
d. Hoarse voice

c. Exophthalmos

Bulging eyes is a hallmark sign of Graves’ disease

The client diagnosed with type 1 diabetes has a glycosylated hemoglobin (A1c) of 8.1%. Which interpretation should the nurse make based on this result?
a. The result is below normal
b. The result in acceptable
c. The result is above the recommended levels
d. The result is dangerously high

c. The result is above the recommended levels

Clients with diabetes should have an HbA1c below 7%.