Adult medsurge EXAM 3

Hyperthyroidism (e.g., Graves’ Disease)

• Excess T3 & T4 → Increased metabolism

• Low TSH (negative feedback)

• Signs:

  • Heat intolerance, weight loss, diarrhea

  • Tachycardia, hypertension, atrial fibrillation

  • Exophthalmos (bulging eyes)

Treatment for Hyperthyroidism (e.g., Graves’ Disease)

• Propylthiouracil (PTU) or Methimazole

  • Prevent thyroid hormone synthesis

• Beta-blockers (Propranolol) → reduce HR, tremors

• Radioactive iodine (RAI) (not for pregnancy)

  • Patient must follow radiation precautions after therapy

• Elevate HOB

• Tape eyelids if cannot close at night

• Avoid foods high in iodine if on antithyroid meds (seafood, iodized salt, soy).

• Teach never stop antithyroid medications abruptly

Hypothyroidism

• Low T3/T4, High TSH

  • Signs:

• Fatigue, weight gain, cold intolerance, constipation

• Bradycardia, depression, dry coarse skin
  

• Medication:

  • Levothyroxine (Synthroid):

• Take in the morning on an empty stomach

• Avoid sedatives/opioids → increased sensitivity

• Monitor for hyperthyroid symptoms (overdose)

• Avoid sedatives and opioids — increased sensitivity → respiratory depression.

• Encourage low-calorie diet if weight gain present.

• Monitor for myxedema crisis:

  • ↓LOC, hypothermia, bradycardia → emergency

Cushing’s Syndrome (Too Much Cortisol)

• Monitor blood glucose (hyperglycemia)

• Fall precautions (weakness + osteoporosis)

• Daily weights & assess edema (fluid retention)

• Skin care:

  • Use lift sheets

  • Avoid tape (fragile skin)

• Infection prevention:

  • Monitor wounds → slow healing

• Encourage low sodium, high protein diet

• Signs:

• Moon face, buffalo hump, truncal obesity

• Fragile skin, easy bruising, hyperglycemia

• Hypertension, infection risk, hypokalemia

Addison’s Disease (Not Enough Cortisol/Aldosterone)

• Signs:

  • Hyponatremia, hyperkalemia

  • Hypotension, weakness, weight loss

  • Bronze skin

• Crisis = Shock, severe hypotension & hypoglycemia → Give IV Hydrocortisone

• Monitor BP → risk for hypotension & shock

• Monitor electrolytes:

  • Hyponatremia, hyperkalemia

• Encourage high sodium, low potassium diet

• Require lifelong corticosteroid replacement

• Increase steroid dose during illness, stress, surgery
  (never skip or stop steroids abruptly)

Type 1 Diabetes

Problem: Autoimmune destruction of beta cells → no insulin production.

Key Signs:

• Polyuria

• Polydipsia

• Polyphagia

• Weight loss, fatigue

• Usually younger onset

Nursing Considerations:

• Requires lifelong insulin therapy

• Monitor for DKA during illness or infection

• Teach sick day rules (continue insulin even when not eating)

Type 2 Diabetes

Problem: Insulin resistance + decreased insulin secretion from pancreas over time

Risk Factors:

• Obesity

• Sedentary lifestyle

• Family history

• Hypertension, high cholesterol
  

  Metabolism Diabetes Fall 2025_N…

Nursing Considerations:

• First-line: diet + exercise + weight loss

• May require oral meds → may progress to insulin

• Monitor for chronic complications (kidneys, eyes, nerves)

Insulin Therapy

Types:

• Rapid: Lispro, Aspart

• Regular: Humulin R / Novolin R

• Intermediate: NPH

Long-acting: Glargine (Lantus), Detemir (Levemir)

Storage & Administration:

• Do NOT freeze or expose to heat

• Vials in-use may be kept at room temp for ~4 weeks

• Rotate injection sites → prevent lipodystrophy

Complications:

• Lipohypertrophy: repeated site use → spongy lump

• Lipoatrophy: loss of fat at injection site
  Fix → rotate injection sites

Insulin Complications Somogyi Effect

• Low glucose at 2–3 AM → Rebound high in morning

• Fix = Bedtime snack / adjust insulin

Dawn Phenomenon Insulin Complications

• High glucose at 2–3 AM and high in morning

• Fix = Increase bedtime insulin

Metformin

Actions:

• Improves insulin sensitivity

• Decreases liver glucose production

• Promotes mild weight loss

• Nursing Considerations:

• Does NOT cause hypoglycemia

• Hold 48 hrs before/after IV contrast dye

• Avoid alcohol → increases lactic acidosis risk

• Monitor renal function

Sulfonylureas (Glipizide, Glyburide, Glimepiride)

• Increase insulin secretion

• Risk = hypoglycemia

Hypoglycemia

Causes:

• Too much insulin

• Not enough food / delayed meals

• Exercise during insulin peak

• Alcohol use

Symptoms:

• “Cold and clammy → need some candy”

Shaking, sweating, irritability, headache, hunger

Treatment – Rule of 15:

1. Give 15 g fast-acting carb (4 oz juice, soda, glucose tabs)

2. Recheck glucose in 15 minutes

Repeat if still < 70

If unconscious:

• IV dextrose or IM glucagon

Sick-Day Rules (Critical Exam Point)

• Check glucose every 4 hrs

• Check ketones if BG > 240

• Continue insulin, even if not eating

• Drink 8–12 oz sugar-free fluids every hour

Foot Care

• Inspect feet daily

• Never go barefoot

• Trim nails straight across

• Wear proper fitting shoes

• Report skin breakdown immediately

DKA (Diabetic Ketoacidosis)

Cause:
Severe insulin deficiency → body burns fat → ketones → metabolic acidosis.
Most common trigger: Infection.Key Symptoms

• Polyuria, polydipsia, dehydration

• Kussmaul respirations (deep, rapid, “air hunger” breathing) Fruity/acetone breath

• N/V abdominal pain Dry skin, tachycardia, hypotension Weakness, confusion, or lethargy

Nursing Considerations

• Continuous cardiac monitoring (potassium shifts → dysrhythmias)

• Monitor potassium hourly when insulin is running

• Never start insulin if potassium is low → can cause fatal arrhythmias

• Strict intake & output to evaluate dehydration

• Maintain insulin drip until ketones resolve (not just until glucose improves)

• Assess for and manage infection (the #1 trigger)

DKA treatment 

Priority Treatment (Order Matters)

1. IV Fluids first

   • Start with 0.9% NS to restore circulation

2. Check Potassium before insulin

   • If K⁺ is low, replace first

3. Start IV Regular Insulin

   • Stops fat breakdown → stops ketones

4. When blood glucose improves → switch fluid to one containing dextrose

5. Treat the underlying cause (often an infection)

Thyroid Storm (Medical Emergency)

Triggered by: infection, surgery, stress, stopping meds.

Symptoms:

• Severe tachycardia (HR > 140)

• Extreme fever

• Agitation → delirium

• Hypertension

• Can progress to shock → death

Treatment Priority:

1. Airway

2. Beta blockers (lower HR)

3. Antithyroid meds

4. Cooling measures

5. IV fluids