MedSurge test 2 endocrine II

thyroid function

regulates energy metabolism and growth and development

hyperthyroidism causes

autoimmune graves disease or nodular goiter, more common in females ages 20-40

Graves

autoimmune hyperthyroidism, antibodies develop against antigens called TSAbs that stimulate the TSH receptors to produce more thyroid (T3/T4) hormone

Nodular goiter for thyroid

causes hyperthyroidism, nodules secrete extra hormones, called a toxic goiter, slower disease progression than graves

what are the labs for Graves?

elevated T3/T4 and more free T4, low TSH

what is the most sensitive indicator of thyroid issues as a biologically active hormone

free T4

Sx of hyperthyroidism (Graves)

inc HR, A fib/angina, increase RR, inc appetite/thirst, weight loss, diarrhea, spleeno/hepatomegaly, skin is moist/warm/smooth, thin nails/hair loss, clubbing of nails, fatigue, depression, fine tremors, hyperreflexia, menstrual irregularity, impotence, amenorrhea, dec libido gynecomastia, intolerance to heat, goiter, exophthalmos

thyroid crisis sxs

severe tachycardia, HF, shock, hyperthermia, agitation, N&V, diarrhea, delirium

tx of thyroid crisis

PTU or Tapazole, iodine, BB, radioactive Iodine

nutritional therapy for hyperthyroidism

4,000-5,000 cals per day, 6 full meals per day, high protein snack and carbs, avoid highly seasoned and high fibers foods, decrease caffeine intake

tx of hyperthyroidism

surgery 90% of thyroid is removed, if too much then hypothyroidism, can have complication if laryngeal nerve impairment or the parathyroid gland can be damaged an hypocalcemia

pre-op for thyroid removal

pt told to hold head as they turn, ROM/ exercises, place in the room suction, O2 and trach set, paralysis of both cords=spasms (obstruction), swelling can obstruct, lose the airway here too, laryngeal stridor due to tetany, tx is calcium gluconate IV, bleeding

what is the biggest issue for post op of thyroidectomy?

swelling or airway, then it is bleeding

post-op for thyroidectomy

q2Hr check, semi-fowlers (30s), VS, assess for tetany, Trousseaus sign (carpal spasm with inflation of bp cuff), Chvostek's sign (facial spasm with finger stroke), control of post op pain

hypothyroidism is a result of

destroyed thyroid tissue, defective hormone synthesis in families, Hashimoto's thyroiditis autoimmune disease

sxs of hyporthyroidism (Hashimotos)

bradycardia, personality changes, impaired memory, slowed speech, dry skin and brittle nails, cold intolerance, weight gain, constipation, menorrhagia, anemia

myxedema coma what is it

medical emergency complication of hypothyroidism

myxedema sxs

subnormal temp, hypotension, hypoventilation

care for myxedema coma

life support, IV thyroid hormone

dx for hypothyroidism

increased TSH but dec T3/T4

tx for hypothyroidism

low calorie diet, synthetic hormones, may give levothyroxine, monitor for angina and cardiac changes, increase hormone at 1 and 4 wk intervals, supportive treatment of side effects

hyperparathyroidism is what

increased secretion of PTH, inc calcium

sx of hyperparathyroidism

dysrhythmias, hypertension, delirium, confusion, stupor, coma, hyperactive deep tendon reflexes

hypoparathyroidism iatrogenic cause

accidental removal or the parathyroids during neck or thyroid surgery, or occlusion/disruption of vascular supply to the gland, low Ca

sx of hypoparathyroidism

positive chevs, Tross tremors, disorientation, HA, seizures, depression, urinary frequency, cardiac issues (dec contractility dec CO), depressed resp function

care of hypoparathyroidism

tetany with IV calcium gluconate

hyper release of hormones from adrenal cortex causes what

Cushings syndrome

cushings syndrome def

excess corticosteroids, usually pituitary syndrome, cortical tumor and can do adrenalectomy

Cushings sxs

weight gain, HTN, muscle wasting, virilization in women, feminization in men, moon ace, purplish red striae, hirsutism, hyperglycemia, menstrual disorders, thein skin, bruising, osteoporosis

Cushings dx

24hr for free cortisol, dexamethasone suppression

dexamethasone suppression test for Cushings

Assess adrenal function

give 2mg at 11pm to suppress secretion of CRH

draw level at 8am

test should suppress cortisol by 50% (<2 normal)

cortex will not be suppressed with Cushing's!!!

tx of Cushings

lysodren suppresses cortisol production, medical adrenalectomy

hypo secretion from the adrenal cortex result in

Addisons

Addisons sxs

hyperpigmentation, hypotension, hyponatremia, hyperkalemia, N&V, diarrhea

complications of addisons

Addison's crisis after a stressor like infection, surgery, or trauma

dx of Addisons

plasma cortisol level dec, low Na, high L, ACTH stimulation test

ACTH stimulation test for Addisons

draw baseline cortisol

give synthetic ACTH IV as bolus

draw cortisol levels at 30 mins and 60 mins post op

plasma cortisol at 60 mins should be greater than baseline cortisol by >7

if it doesn't rise then a

Addisons is confirmed if not risen X2

tx for Addisons

daily cortisol replacement, mineralocorticoid replacement, salt additives for excess heat or humidity

pt education for Addisons

drug ed, medical bracelet, increase meds with infection, trauma, surgery, S/E meds

Conns syndrome

hyperaldosteronism, hypertension, inc Na, dec K, tx with adrenalectomy

pheochromocytoma

adrenal medulla tumor that produces excessive catecholamines, severe HTN, inc HR, profuse sweating, pounding HA, tx remove tumor

diabetes def

chronic multisystem disease related to abnormal insulin production, impaired insulin utilization or both

diabetes is the leading cause of

adult blindness, end stage kidney disease and non traumatic limb amputation

etiology of diabetes

genetic, autoimmune, environmental

DMI definition

total absence of insulin, patient is insulin dependent, autoimmune destruction of B cells, genetic predisposition and viral exposure, idiopathic diabetes, usually <30

sx of DMI

polydipsia, polyphagia, polyuria

tx of DMI

insulin dependent, ADA diet, lifestyle changes, exercise, monitor glucometers, monitor A1C frequently, foot care, medica alert bracelet

DMII definition

pancreas continues to procure some endogenous insulin, insulin is poorly utilized or insufficient

etiology of DMII

obesity is the greatest risk factor, genetic components increase insulin resistance and obesity

four metabolic abnormalities for DMII

1. insulin resistance

2. Dec insulin production by pancreas

3. inappropriate hepatic glucose production

4. altered production of hormones and cytokines by adipose tissue

DMII tx

start with ADA diet, exercise, lifestyle changes, oral hypoglycemics, insulin, monitor glucose level and A1C, foot care, medic alert bracelet

what annual test should diabetics get?

eye exam

foot care for diabetics

Teach to cut or file toenail straight across to just blunt the edges but don't file or round down

NEVER go barefoot, wash feet daily and pat completely dry including in between toes

Can put lotion but needs to be light and completely rubbed in nothing in the creases, never soak the feet,

Don't use harsh soaking salts like Epsom

prediabetes

individuals at risk for DMII, population on the rise, impaired glucose intolerance with OGTT 140-199, fasting glucose 100-125 (126=DM)

A1C is above what in diabetics?

6.5%

insulin therapy allergic reactions

local itching, erythema, burning at the site, systemic urticaria, anaphylactic shock

lipodystrophy

hypertrophy or atrophy of SC tissue, rotation WITHIN in the site

Somogyi definition

too much insulin causes hypoglycemia overnight then counter regulatory hormone release and rebound hyperglycemia, pt c/o HA on awakening and nightmares/night sweats

Somogyi tx

less insulin

Dawn phenomenon

dawn release of growth hormone or cortisol, causes hyperglycemia and ketonuria on awakening

tx of dawn phenomenon

either increase insulin or alter timing of insulin

DKA sxs

DMI complication, dehydration, N&V, Kussmaul breathing, fruity breath, renal failure, electrolyte imbalance, fruity breath, renal failure, comatose, death, ketosis

DKA tx

insulin, fluids, electrolyte replacement, K+ imbalances can be dangerous

hypoglycemia sxs

glucose <70, cold, clammy skin, numbness of fingers, toes, mouth, rapid heart rate, change in vision, hunger, slurred speech unsteady gat, coma, seizure

cause of hypoglycemia

too much insulin, too much exercise without insulin adjustment, too little food

tx of hypoglycemia

immediate ingestion of 5-20grams of simple carbs, repeat in 15 mins, seek help if no relief, give dextrose IV if cant take orally

Metformin MoA

biguanide that reduces glucose production by liver, enhances insulin sensitivity and improves glucose transport

metformin guidelines

withhold if pt is undergoing surgery or radiologic procedure with contrast medium a day or 2 before and at least 48 hrs after, monitor serum creatinine

contraindications to metformin tx

renal, liver, cardiac disease, excessive alcohol intake

sulfonylureas MoA

increased insulin production from pancreas

SE of sulfonylureas (gli/gly)

hypoglycemia, NSAIDS

meglitinides MoA

increase insulin production from pancreas, rapid onset, hypoglycemia

meglitinides guidelines (GLP2) (end in tide)

taken 30 mins to just before each meal, do not take if meal is skipped

A-glucoside inhibitors MoA

starch blockers, slow down absorption of carbohydrate in small intestine

A-glucoside inhibitors example and guideline

acarbose and miglitol, take with first bite of each meal

SGLT-2 inhibitors (flozin) MoA

block reabsorption of filtered glucose in the kidney, glycosuria

SGLT-2 inhibitors (flozin) SE

genital fungal infections in female, UTIs, increased urination

SGLT2 benefits

mod A1C reduction, oral once daily, fasting and post prandial BGs, weight reduction, minimal hypoglycemia, CVD/renal benefit

risks for SGLT2s

cost, unknown long term safety, UTI, genital fungal infections, diuresis, euglycemia DKA, hold 3-4 days prior to surgery, amputation risk

storing insulin guidelines

do not freeze, unopened in fridge until expiration, can be on cart at room temp for 1 month, keep out of direct sunlight and extreme heat

NPH and short acting insulin admin

pull up regular insulin first then NPH last

rapid acting insulin

aspart/lispro

onset of RA insulin

5-15 min

peak of RA insulin

1-2 hrs

duration of RA insulin

2-5 hrs

short acting insulin

regular

onset of SA insulin

0.5-1 hr

peak of SA insulin

1-2 hrs

duration of SA insulin

4-6 hrs

intermed acting insulin

NPH

onset of intermed acting insulin

1-2 hrs

peak of intermed insulin

4-8 hrs

duration of intermed insulin

10-20 hrs

long acting insulin

glargine

onset of LA insulin

1-2 hrs

peak of LA insulin

flat

duration of LA insulin

24 hrs

when are you at risk for a hyperglycemic event with insulin admin?

peak of insulin

when are they no longer at risk for hyperglycemia when giving insulin?

duration

when with insulin admin are they beginning to be at risk for hypeglycemia?

onset