MODULE 2 NON-REDUNDANT

Endocrine hormones

• Pineal gland = melatonin

Pituitary gland

• Anterior lobe = adenohypophysis

• Posterior lobe = neurohypophysis

• Anterior hormones = GH, TSH, ACTH, FSH, LH

• Posterior hormones = ADH/vasopressin and oxytocin

Growth hormone (GH)

• Regulation = GH-releasing hormone/somatropin stimulates release and somatostatin inhibits release

• Route = SubQ or IM only

• Timing = administer before fusion of epiphyses

• Prolonged use = may increase blood glucose by antagonizing insulin

Somatropin

• MOA = stimulates growth of essentially all body tissues, especially bone

• Use = drug of choice for child with growth failure from inadequate endogenous GH and dwarfism

• Therapy = discontinued once final height is achieved

Somatropin contraindications

• Pediatric patients with Prader-Willi syndrome

• Severe respiratory impairment

• Patients taking corticosteroids

• Patients taking antidiabetic drugs

Somatropin adverse effects

• Arthralgia = joint pain

• Cephalgia = headache

• Myalgia = muscle pain

• Paresthesia = abnormal sensation

• Peripheral edema = swelling

• Weakness

• Intracranial hypertension

• Leukemia

• Seizures

Growth hormone suppressant drugs

• Indications = excess GH secretion, gigantism, acromegaly

• Classes = GH receptor antagonists, somatostatin analogues, dopamine agonists

Pegvisomant

• Class = GH receptor antagonist

• MOA = blocks the GH receptor site

• Adverse effects = cephalgia, fatigue, hyperhidrosis, chest pain, elevated hepatic transaminases, hypertension

Lanreotide acetate

• Class = somatostatin analogue

• MOA = prevents pituitary secretion of GH

• Effect = dose-dependent

• Form = depot

• Route = deep SubQ

• Duration = about 28 days

• Adverse effects = abdominal pain, constipation, diarrhea, flatulence, nausea, vomiting, weight loss

Octreotide acetate

• Class = somatostatin analogue

• MOA = inhibits GH production

• Immediate-release = TID SubQ

• Depot = SubQ every month

• Adverse effects = bloating, flatus, nausea

• Serious effects = arrhythmia, bradycardia, cardiac toxicity

Bromocriptine mesylate

• Class = dopamine agonist

• MOA = inhibits GH secretion caused by pituitary tumor

• Route = oral

• Adverse effects = anorexia, dyspepsia, nausea, xerostomia

• Serious effects = hypertension, myocardial infarction, seizure, stroke

ACTH

• Full name = adrenocorticotropic hormone

• Function = stimulates release of glucocorticoids/cortisol, mineralocorticoids/aldosterone, and androgens

• Secretion = follows diurnal rhythm

• Disrupted by = surgery, stress, trauma

Cosyntropin

• Type = synthetic ACTH

• MOA = stimulates production and release of cortisol, corticosterone, and androgens

• Use = diagnostic test to differentiate pituitary vs adrenal causes of adrenal insufficiency

• Route = IM or IV

• Caution = patients receiving diuretics

• Side effect = peripheral edema

• Adverse effects = bradycardia, hypertension, sinus tachycardia

Corticotropin

• Type = exogenous ACTH

• MOA = controls synthesis of ACTH

• Uses = diagnose adrenal gland disorders, treat multiple sclerosis and infantile spasms

• Form = Repository Corticotropin Injection (RCI)

• Route = IM or SubQ

Diabetes insipidus (DI)

• Cause = decreased circulating ADH

• Main problem = kidney tubules fail to reabsorb water

• Result = excessive urination causing severe dehydration and electrolyte loss

• Signs/symptoms = dehydration, large amounts of dilute urine, inability to concentrate urine, low urine specific gravity, polydipsia

Antidiuretic hormone therapy

• MOA = promotes water reabsorption from renal tubules

• Contraindication = renal disease

• Examples = desmopressin and vasopressin

Desmopressin

• Routes = oral, intranasal, IV, or SubQ injection

• Uses = diabetes insipidus, Hemophilia A, von Willebrand disease type 1

Vasopressin

• Routes = IM, IV, or intranasal

• Effect = promotes water reabsorption and can induce ACTH release

Nursing interventions for ADH therapy

• Monitor vital signs

• Record urinary output

• Obtain daily weight using same scale and clothing

• Assess abdominal girth

Syndrome of inappropriate antidiuretic hormone (SIADH)

• Cause = increased circulating ADH

• Effect = excessive water retention expands intracellular and intravascular volume

• Result = water intoxication and dilutional hyponatremia

SIADH signs and symptoms

• Changes in level of consciousness/mental status

• Fluid overload

• Hypertension

• Low urinary output

• Concentrated urine

• Weight gain

Vaptans

• Full name = vasopressin receptor antagonists

• MOA = increase serum sodium and free-water clearance

• Contraindication = hypovolemia

• Examples = conivaptan and tolvaptan

Conivaptan

• Route = IV through large veins

• Site = rotate every 24 hours

• Contraindication = corn allergy

• Injection complications = phlebitis, pain, edema, pruritus

• Adverse effects = atrial fibrillation, electrolyte imbalance, hypertension, orthostatic hypotension, syncope

Tolvaptan

• Class = vasopressin receptor antagonist/vaptan

• Route = oral

• Effect = increases free-water clearance and serum sodium

Demeclocycline

• Class = tetracycline antibiotic

• MOA = induces nephrogenic diabetes insipidus

• Route = oral

• Use = produces water loss in SIADH

• Common complaint = photosensitivity

• Adverse effects = dental discoloration and enamel hypoplasia

Nursing interventions related to growth hormone therapy

• Monitor blood glucose

• Monitor serum electrolytes

Nursing interventions for Repository Corticotropin

• Monitor child growth and development

• Weigh daily

• Assess edema

• Reinforce adherence

• Monitor blood glucose

• Monitor serum electrolytes

• Assess infection

• Advise decreased sodium intake

Thyroid gland hormones

• T3 = triiodothyronine

• T4 = thyroxine

• Calcitonin

• Main thyroid effect = regulation of metabolic activity

Hypothyroidism

• Definition = decreased thyroid hormone secretion

• Primary = thyroid gland disorder

• Secondary = pituitary disorder causing lack of TSH

• Tertiary = hypothalamic disorder causing lack of TRH

• Signs/symptoms = dry skin, fatigue, cold feeling, itching, weight gain

Hyperthyroidism

• Definition = hyperfunction of thyroid gland with increased circulating T3 and T4

• Most common type = Graves' disease

• Also associated with = thyrotoxicosis

• Signs/symptoms = exophthalmos, heat intolerance, irritability, nervousness, tachycardia, weight loss

Myxedema

• Definition = severe hypothyroidism in adults

• Signs/symptoms = abnormal menses, deep/coarse voice, apathy, cold intolerance, constipation, dry skin, facial/eyelid edema, emotional changes, lethargy, memory impairment, slow pulse, slow speech, weight gain

Cretinism

• Definition = congenital hypothyroidism in children

• Effect = delayed physical and mental growth

Thyrotropin/thyroid-stimulating hormone

• MOA = stimulates thyroid gland to release T3 and T4

• Use = diagnostic agent to differentiate primary vs secondary hypothyroidism

• Indication = thyroid cancer

• Dose = 0.9 mg IM in gluteus maximus, second dose after 24 hours

Levothyroxine sodium

• MOA = increases T4 and is metabolically deiodinated to T3

• DOC = replacement therapy for primary hypothyroidism

• Route = PO

• Contraindications = myocardial infarction and thyrotoxicosis

• Side effects = nausea, vomiting, diarrhea, cramps, tremors, nervousness, irritability, insomnia, headache, weight loss

• Adverse effects = hypertension, osteoporosis, seizures

Levothyroxine drug interactions

• Decreases effect of insulin and oral antidiabetics

• Digoxin and lithium = increase action of thyroid drugs

Liothyronine sodium

• Type = synthetic T3

• Half-life = about 2.5 days

• Action = rapid onset

• Routes = PO or IV

• Uses = replacement/supplemental therapy for hypothyroidism and initial therapy for myxedema

Desiccated thyroid

• Contents = levothyroxine + liothyronine

• Route = PO

• Uses = hypothyroidism due to thyroid atrophy, hormone deficiency, or goiter

Liotrix

• Contents = levothyroxine sodium + liothyronine

• Ratio = 4:1

• Route = PO

Total thyroidectomy

• Medication need = lifetime thyroid hormone treatment is observed after removal of the entire thyroid gland

Antithyroid drugs

• Main class = thiourea derivatives/thioamides

• Main examples = propylthiouracil (PTU) and methimazole

• Purpose = reduce excessive thyroid hormone activity/secretion

Propylthiouracil (PTU)

• MOA = blocks thyroid action and reduces excessive thyroid hormone secretion

• Route = PO

• Drug interaction = enhances anticoagulant effect of warfarin

Methimazole

• Potency = about 10 times more potent than PTU

• Route = PO

• Half-life = longer than PTU

• Euthyroid state = achieved in about 2–4 months

• Preference = preferred because of fewer side effects

PTU vs methimazole

• PTU = less potent, usually 2–4 times/day, can be used during pregnancy

• Methimazole = 10 times more potent, once daily, longer half-life, preferred due to fewer side effects, may induce fetal goiter/cretinism

Nursing interventions for thyroid drugs

• Monitor vital signs

• Weigh daily using same scale and clothing

• Instruct patient to take medication at same time daily

• Monitor thyroid function before and after therapy

• Monitor adverse reactions

Parathyroid hormone (PTH/parathormone)

• Function = regulates serum calcium

• Promotes = calcium absorption from GI tract, calcium reabsorption from renal tubules, activation of vitamin D

Hypoparathyroidism

• Definition = decreased parathyroid function causing low PTH

• Causes = parathyroid damage, hypomagnesemia, hypocalcemia, renal impairment, diuretic therapy

• Signs/symptoms = paresthesia, muscle pain, fatigue, facial muscle twitching

Hyperparathyroidism

• Definition = increased circulating PTH

• Causes listed = lung cancer, hyperthyroidism

• Signs/symptoms = enuresis, polydipsia, muscle weakness, loss of concentration, fatigue, loss of appetite, osteoporosis, bone/joint pain

Calcitriol

• Class = vitamin D analogue

• MOA = promotes calcium absorption from GI tract and calcium movement from bone into bloodstream

• Route = oral

• Contraindications = hypersensitivity, hypercalcemia, hypervitaminosis D

Calcitriol side effects

• Fatigue, weakness, somnolence, cephalgia, nausea, vomiting, diarrhea, cramps, drowsiness, dizziness, vertigo, metallic taste, lethargy, constipation, xerostomia

Calcitriol adverse effects

• Anorexia

• Photophobia

• Dehydration

• Cardiac arrhythmias

• Decreased libido

• Hypertension

• Sensory disturbances

• Hypercalciuria

• Hypercalcemia

• Hyperphosphatemia

Calcitonin-salmon

• MOA = increases bone density

• Main use = prevent bone loss and fractures

• Contraindication = fish allergy

• Routes = IM or SubQ

• Side effects = nausea, vomiting, cephalgia

• Adverse effects = severe hypocalcemia, tetany, seizure

Cinacalcet

• Class = calcimimetic

• MOA = increases sensitivity of thyroid calcium-sensing receptors, reducing PTH

• Uses = hyperparathyroidism from chronic renal disease and parathyroid cancer

• Route = PO

Nursing interventions for parathyroid drugs

• Monitor serum calcium; normal = 8–10 mg/dL

• Monitor hypersensitivity reactions

• Assist ADLs

• Reinforce medication adherence

• Monitor untoward reactions

Adrenal glands

• Parts = adrenal medulla and adrenal cortex

• Medulla secretes = epinephrine and norepinephrine

• Cortex secretes = androgens, estrogen, glucocorticoids/cortisol, mineralocorticoids/aldosterone

Glucocorticoids

• Also called = cortisone

• Many names end in = -one

• MOA = suppresses inflammation, humoral immune response, and adrenal function

• Routes = oral, parenteral, topical, aerosol

Glucocorticoid uses

• Addison's disease • Inflammation • Allergic reactions • Debilitating conditions • Autoimmune disorders • Ulcerative colitis • Glomerulonephritis • Shock • Ocular/vascular inflammation • Polyarteritis nodosa • Hepatitis • Prevention of organ rejection after transplant

Prednisone

• Route = PO

• Intermediate Acting Glucocorticoids

• Contraindications = untreated serious infections, hypersensitivity, varicella

Methylprednisolone

• Methylprednisolone = PO

• Methylprednisolone acetate = IM

• Methylprednisolone sodium = IM or IV

• Class = intermediate-acting glucocorticoids

Cortisone acetate

• Route = oral

• Administration = given with food

• Short Acting Glucocorticoids

Hydrocortisone preparations

• Hydrocortisone cypionate = PO

• Hydrocortisone sodium phosphate = IM/IV/SubQ

• Hydrocortisone succinate = IM/IV

• Hydrocortisone acetate sodium suspension = IM

• Class = short-acting glucocorticoids

Glucocorticoid adverse effects

• Increased blood glucose • Moon face • Buffalo hump • Decreased extremity size • Muscle wasting • Edema • Sodium/water retention • Hypertension • Euphoria/psychosis • Thinned skin with purpura • Glaucoma • Peptic ulcers • Growth retardation

Glucocorticoid drug interactions

• Increases potency of concurrently taken aspirin/NSAIDs

Glucocorticoid therapy

• Meaning = administration of glucocorticoid drugs

• Indications listed = trauma, surgery, inflammation, emotional upset, anxiety

• Discontinuation = taper dose so adrenal cortex can resume cortisol and corticosteroid production

• Do not stop abruptly

Mineralocorticoid drugs

• Main example = fludrocortisone • MOA = promotes sodium reabsorption from renal tubules • Route = oral • Given with = glucocorticoids • Adverse effects = fluid overload and hypertension

Corticosteroid deficiency

• Mineralocorticoid deficiency usually occurs with glucocorticoid deficiency • Combined deficiency = corticosteroid deficiency

Nursing interventions for corticosteroids

• Monitor vital signs • Weigh daily • Obtain abdominal girth • Monitor potassium and sodium • Monitor glucose • Watch for hypokalemia • Avoid abrupt discontinuation • Monitor older adults for osteoporosis • Advise avoiding large crowds and people with respiratory infections

Diabetes mellitus

• Definition = chronic disease involving deficient glucose metabolism from insufficient insulin secretion • Management = cannot be cured but can be controlled • Types = Type 1, Type 2, secondary diabetes, gestational diabetes

Type 1 diabetes mellitus

• Also called = insulin-dependent/juvenile-onset diabetes • Pancreas = damaged and does not make insulin • Risk factors/causes listed = hereditary factors, pancreatic injury from tumor/infection/accident, autoantibodies • Onset = develops quickly over weeks or months • Treatment = insulin

Type 2 diabetes mellitus

• Also called = non-insulin-dependent/adult-onset diabetes • Pancreas = makes some insulin but insufficient or poorly used • Insulin resistance = cells do not respond properly to insulin • Complications = especially small blood vessels of kidneys, eyes, and nerves • Risk factors = hereditary, overweight/obesity, hypertension, physical inactivity, age 45+, smoking • Onset = develops over several years • Treatment = oral hypoglycemics and/or insulin

HbA1c

• Measures = glucose attached to hemoglobin • Reflects = average blood glucose over previous 2–3 months • Normal = less than 5.7% • Prediabetes = 5.7–6.4% • Diabetes = 6.5% or higher • Goal for diabetic patient = less than 7%

Fasting plasma glucose (FPG)

• Preparation = 8-hour fast • Timing = usually first thing in morning before breakfast • Normal = less than 100 mg/dL • Prediabetes = 100–125 mg/dL • Diabetes = 126 mg/dL or higher

Oral glucose tolerance test (OGTT)

• Type = 2-hour test • Procedure = blood glucose checked before and 2 hours after drinking a special sweet drink • Normal = less than 140 mg/dL • Prediabetes = 140–199 mg/dL • Diabetes = 200 mg/dL or higher

Random/casual plasma glucose test

• Timing = can be performed any time of day • Diabetes criterion in module = 200 mg/dL or higher

Insulin

• MOA = promotes uptake of glucose, amino acids, and fatty acids and converts them into stored substances in body cells • Types = rapid-acting, short-acting, intermediate-acting, long-acting

Commercially prepared insulin

• Human insulin = duplicates insulin produced by human pancreas; examples = Humulin R and Novolin N • Advantage = low incidence of allergic effects and insulin resistance • Human insulin analogues = modified human insulin with altered onset/duration; examples = insulin lispro and insulin aspart

Insulin onset, peak, duration

• Onset = time before insulin reaches bloodstream and begins lowering glucose • Peak = time when insulin has maximum glucose-lowering strength • Duration = how long insulin continues lowering blood glucose

Rapid-acting insulin

• Lispro/Humalog = onset 15–30 min, peak 30–90 min, duration 3–5 hr • Aspart/Novolog = onset 10–20 min, peak 40–50 min, duration 3–5 hr • Glulisine/Apidra = onset 20–30 min, peak 55 min, duration 1–2.5 hr • Afrezza inhaled insulin = onset 12–15 min, peak 53 min, duration 2.5 hr • Administration = 10–15 min before meals

Short-acting regular insulin

• Regular insulin/Humulin R/Novolin R • SubQ onset = 30 min • SubQ peak = 2.5–5 hr • SubQ duration = 4–12 hr • IV onset = 15 min • IV peak = 15–30 min • IV duration = 30–60 min • Administration = 30–60 min before meals

Intermediate-acting insulin

• NPH/isophane insulin • Appearance = cloudy • Onset = 1–2 hr • Peak = 4–12 hr • Duration = 14–24 hr

Long-acting insulin

• Glargine/Lantus = onset 1–1.5 hr, no peak, duration 24 hr • Detemir/Levemir = onset 1–2 hr, peak 6–8 hr, duration 24 hr • Degludec/Tresiba = onset 1 hr, peak 12 hr, duration 42 hr

Insulin storage

• Never freeze insulin • Avoid direct sunlight • Unopened vials = refrigerate until needed • Opened vials = room temperature for 1 month or refrigerator for 3 months

Insulin administration

• Route = SubQ • Common site = abdomen • Insulin syringe angle = 90° • Only regular insulin = may be injected IV • Heat/massage = increases SubQ absorption • Cooling/cold packs = slows absorption

Insulin injection-site changes

• Lipoatrophy = loss of subcutaneous fat at injection site • Lipohypertrophy = thickening/enlargement of fatty tissue at injection site • Prevention = rotate injection sites

Insulin rotation program

• Schedule = 8-day rotation • Injection = use a chosen site daily for 1 week • Distance = sites should be about 1.5 inches apart

Insulin syringe

• Route = SubQ • Angle = 90° • Disadvantage = painful and may cause injection-site reactions

Insulin pen

• Appearance = resembles fountain pen • Contains = disposable needle and insulin-filled cartridge • Route = SubQ at 90° • Advantages = simpler, accurate, convenient delivery • Types = prefilled and reusable • Capacity = 150–300 units

Insulin pump

• Used with = blood glucose monitoring and carbohydrate counting • Contains = insulin reservoir and programming capacity • Delivery = continuous rapid-acting insulin in varying amounts at different times over 24 hr • Route = SubQ

Insulin jet injector

• Function = shoots insulin through skin into fatty tissue without a needle • Uses = high-pressure delivery • Side effects = stinging, pain, burning, bruising

Insulin shock

• Cause = too much insulin

Somogyi effect

• Definition = hypoglycemic effect occurring around 2–4 AM • Signs = early-morning headache, night sweats, nightmares • Management listed = reduce bedtime insulin dose

Dawn phenomenon

• Definition = hyperglycemia on awakening • Management listed = increase bedtime insulin dose

Diabetic ketoacidosis (DKA)

• Cause = absolute/relative insulin deficiency prevents glucose from entering cells

Sulfonylureas

• MOA = stimulate pancreatic beta cells to secrete insulin • Related to = sulfonamides but lack antibacterial activity • Generations = first and second • Route = PO

Tolbutamide

• Class = first-generation sulfonylurea • Action = short-acting • Route = PO

Chlorpropamide

• Class = first-generation sulfonylurea • Action = long-acting • Administration = PO with breakfast • Avoid = older adults • Side effects = headache, dysgeusia, pyrosis, hypoglycemia, weight gain, weakness, dizziness, fatigue, blurred vision

Second-generation sulfonylureas

• Examples = glipizide, glyburide, glimepiride • Compared with first generation = greater hypoglycemic potency, longer duration, fewer side effects, lower effective doses, less displacement from protein-binding sites • Contraindication = liver or kidney dysfunction • Side effect = hypoglycemia • Adverse effects = aplastic anemia, leukopenia, thrombocytopenia, weight gain, seizure

Non-sulfonylurea oral antidiabetics

• Classes = biguanides, alpha-glucosidase inhibitors, thiazolidinediones/insulin-enhancing agents, meglitinides, incretin modifiers/DPP-4 inhibitors/gliptins

Metformin

• Class = biguanide • MOA = increases insulin binding to receptors and improves tissue sensitivity to insulin • Administration = with meals • Effect = does not produce hypoglycemia or hyperglycemia according to module • Absorption = small intestine • Metabolism = does not undergo hepatic metabolism • Elimination = unchanged in urine • Use = effective as monotherapy; useful with sulfonylureas in resistant patients • Side effects = dizziness, headache, flushing, weakness

Alpha-glucosidase inhibitors

• MOA = inhibit digestive enzymes in small intestine • Purpose = delay carbohydrate digestion/absorption • Examples = acarbose and miglitol

Acarbose vs miglitol

• Acarbose = not absorbed in GI tract; intended for patients not achieving results with diet alone • Miglitol = absorbed in GI tract