NRSE 470: Exam #2

Endocrine System: Pathophysiology

• Glands in the endocrine system store and secrete hormones that regulate homeostasis in the body.

• Works on a negative feedback loop 

• Pituitary Gland 

  • Secretes hormones and influences other endocrine glands
    Hormones: ACTH 

Cushing’s Disease/Syndrome: Causes and Risk Factors 

• Causes 

  • Most Common Cause: Overuse of Corticosteroid medications

  • Pituitary gland tumor

    • Increase in ACTH

• Normal feedback is ineffective

Cushing’s Disease/Syndrome: Risk Factors

• Women between the ages of 20 and 40 years are five times more likely than men to develop Cushing’s syndrome.

• Adrenocortical carcinoma

• Pituitary carcinoma

• Glucocorticoid use d/t chronic disorders

Cushing’s Disease/ Syndrome: Clinical Manifestations

• Central Obesity

• Buffalo hump

• Moon face with red checks

• Thin and fragile extremities

• Osteoporosis

• GI distress / bleed

  • decrease mucus production in the stomach

• Purple Striae

• Visual disturbances (if they have pituitary tumor)

• Hyponatremic

  • Excess production of cortisol

  • This causes them to be hypokalemic, hypocalcemic

Cushing’s Disease/ Syndrome: Labs & Testing

• Labs:

• 2 out of these 3 tests need to come back as positive to receive a diagnosis 

  • Serum cortisol

  • Urinary cortisol

  • Low-dose dexamethasone suppression test

• Other Labs NOT used to diagnosis 

  • ACTH 

  • K, Ca, Na & Glucose 

Cushing’s Disease/ Syndrome: Treatments

• Treatments

  • Depends on the cause 

  • Adrenal

    • Correction

  • Pituitary

    • Surgical removal of the tumor

  • Corticosteroid medications

    • Decrease the dose

Cushing’s Disease/ Syndrome:Nursing Role & Complications

• Nursing Role 

  • Cardiac function

  • Decrease risk of injury

  • Risk for infection

    • Hand hygiene

    • Avoid large crowds

  • Promotion of Skin integrity

    • Paper tape 

  • Improving body image & coping

  • Dietitian to help with

    • hypokalemic, hypocalcemia, hypernatremia

      • Foods high in potassium, calcemic and low in sodium, high in protein and vitamin D

    • Fluid restriction

Cushing’s Disease/ Syndrome: Complications

• Adrenal crisis / Addisonian Crisis

• Ulceration

  • Decrease production of protective mucus in the lining of the stomach due to increased cortisol

• Bone fractures

• Immunosuppression

Addison’s Disease: Cause and Risk Factors

• Adrenal insufficiency

  • Dysfunction of the hypothalamus- pituitary gland- adrenal gland feedback

  • Insufficient production of steroids by the adrenal gland

• Risk Factors

• Primary

  • TB

  • Adrenalectomy

  • Metastatic cancers

  • Radiation therapy of the abdomen

  • Idiopathic autoimmune dysfunction

• Secondary

  • Steroid withdrawal

  • Pituitary neoplasm

  • High dose radiation of pituitary gland or entire brain

Addison’s Disease: Acute (Addisonian Crisis)

• Causes

  • Sepsis 

  • Trauma 

  • Stress 

  • Adrenal hemorrhage 

  • Steroid withdrawal 

Addison’s Disease: Clinical Manifestations

• Weight loss

• Craving for salt

• Hyperpigmentation of the skin & mucous membranes (increase in levels of ACTH)

• Weakens & fatigue

• Nausea & vomiting & anorexia

• Abdominal pain

• Constipation or diarrhea

• Sever hypotension (acute)

• Hypovolemia

• Electrolyte imbalance

  • Hyponatremia

  • Hyperkalemia

  • Hypoglycemia

  • Hypercalcemia

Addisonian Crisis

• Life threatening complication

• Clinical Manifestations

  • Hypotension

  • Cyanosis 

  • Fever

  • Nausea & Vomiting

• Signs of shock develops 

• Goal

  • Prevention of circulatory shock

Addison Disease: Labs & Testing

• Labs

  • Serum cortisol

  • Plasma ACTH stimulation test

  • Electrolytes

• Testing 

  • ECG 

Addison Disease: Treatments

• Avoiding circulatory shock !

  • Treat hypotension

• Antibiotics (if infection is cause)

• Replacement of corticosteroids & mineralocorticoids

• Dietary supplement

Addison Disease: Nursing Role & Complications

• Nursing role

  • Nursing diagnosis- interventions

  • Education

Addison Disease: Complications

• Addisonian crisis

• Hypoglycemia

• Hyperkalemia/ hyponatremia

Diabetic ketoacidosis AND Hyperosmolar Hyperglycemic State

• Lack of insulin 

• Usually in patients with Type 1 diabetes 

Diabetic ketoacidosis AND Hyperosmolar Hyperglycemic State: Risk Factors 

• EMERGENCY

• Result of physical stress on the body- examples:

  • Injury

  • Illness

  • Infection

  • Surgery

  • Excessive alcohol use

  • New onset diabetes

  • Elevated HbgA1C

  • Illicit drug use 

  • Polypharmacy

  • Noncompliance with insulin therapy

Diabetic ketoacidosis AND Hyperosmolar Hyperglycemic State: Medications

• Corticosteroids

• Antipsychotics

• Antidepressants

Diabetic ketoacidosis: Risk Factors 

• Age 13 to 25 

• Females 

• Pervious episodes of Diabetic ketoacidosis

Hyperosmolar Hyperglycemic State: Risk Factors

• Age older than 65

• African American

• Native American

• Hispanic

• Morbid obesity

Both (DKA& HHS): Causes

• Low income, homelessness, and lack of health insurance

• Elevated HbA1c

• Taking antipsychotic or antidepressant medications

• Acute infection or illness

• Excessive alcohol consumption

• Use of illicit drugs, especially cocaine

• Blood glucose levels that are not well managed

• Polypharmacy 

DKA: Clinical Manifestaions

• Metabolic acidosis

• Muscle weakness

• Dehydration leading to decreased cardiac output

• Loss of electrolytes

  • Cardiac arrhythmias

• Kussmaul respirations

  • Deep, rapid, labored breathing

• Decrease perfusion to the kidneys

Hyperglycemic Hyperosmolar State: Clinical Manifestations

• More profound neurological manifestations

• Muscle weakness

• Profound dehydration

• Thromboembolic disease (clot risk)

• Decreased perfusion to the kidneys

  • Acute Kidney Injury

• Loss of electrolytes

  • Cardiac arrhythmias

DKA and HHS: Lab and Diagnostic Studies

• Serum blood glucose’

• Serum Bicarb: LESS THAN 15

• Complete blood count: WBC

• Electrolytes

• ABGs

• Anion gap

• Serum osmolality

• Urine studies

  • Ketones present in urine for DKA

• Chest X-Ray

• ECG

• Blood and Urine Cultures

DKA and HHS: Treatments and Therapies

• Treatment similar for DKA and HHS

• Restore circulatory volume

• Treating hyperglycemia

• Correcting electrolyte imbalances

  • Monitor potassium levels 

    • Cannot be replaced too quickly 

    • Potassium is LESS than 3.3 that needs to be treated prior to start an insulin drip

    • Potassium that 3.3 to 5 can be given along side insulin drip

    • Potassium reaches 5 replaces stop and just monitor

• Treating any underlying causes.

• Insulin drip based on patient’s weight 

• Monitor their Anion gap

DKA and HHS: Role of the Nurse

• Education

  • Insulin

  • Sick day rules

  • Community support for insulin

  • home health to teach how to give insulin

  • Provide insulin supplies 

  • Teach to check for ketones if glucose greater than 240

• Monitor

  • Vital Signs

  • Labs 

  • Glucose

Meningitis

• Inflammation of meninges/subarachnoid space

• Causes 

  • Bacterial (severe, fatal if untreated)

  • Viral infection

Meningitis: Risk Factors 

• 16 to 23 years old 

• Group living 

• Immune compromised 

• Invasive neurosurgery 

• HIV

• CSF leak

Meningitis: Clinical Manifestations

• Fever 

• Headache 

• Stiff Neck 

• Rash 

• Seizures 

• Altered level of conciseness 

  • Kernig Sign

• Nurse flexes the patient's hip and knee to a 90-degree angle.

• Brudzinski Signs

  • Neck flexion sign: When the examiner passively flexes the patient's neck, the patient involuntarily flexes their hips and knees.

  • Contralateral leg sign: When the examiner flexes one of the patient's legs, the opposite leg involuntarily flexes.

Meningitis: Diagnostics 

• Lumbar Puncture

  • Unless increased Intracranial Pressure

• CT scan

Meningitis: Complications

• Increased Intracranial Pressure

• Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH

• Septic emboli.

Seizures & Epilepsy: Causes 

• Structural

• Genetic

• Infectious

• Metabolic

• Immune

• Unknown

Seizures: Types

• Generalized

• Focal

• Unknown

• Stages

  • Prodromal

  • Aura

  • Ictal

  • Postictal

Seizures & Epilepsy: Triggers

• Stress 

• Fatigue 

• Flashing lights 

• Alcohol 

• Stimulants 

Seizures & Epilepsy: Safety

• Airway protection

• Side-lying

• Padded rails

• NO objects in mouth

Seizures & Epilepsy: Treatments

• Antiseizure meds

  • Benzodiazepines first-line

  • Phenytoin

  • Levetiracetam

• Monitor drug levels & interactions

• Surgical/implant options

  • Vagus Nerve Stimulation

  • Responsive Neurostimulation

  • Laser Interstitial Thermal Therapy

Seizures & Epilepsy: Complications

• Status Epilepticus

• Sudden Unexpected Death in Epilepsy (SUDEP)

• Psychosocial impact.

Seizures & Epilepsy: Patient Education

• Seizure Journals

• Med Adherence

• Lifestyle Modifications.

Parkinson’s Disease: Clinical Manifestations

• Progressive loss of dopamine-producing neurons in substantia nigra; Lewy bodies hallmark.

• Tremors

• Rigidity

• Bradykinesia

• Postural Instability

• Depression

• Fatigue

• Autonomic Dysfunction.

Spinal Cord 

• Send sensory stimuli from the body to the brain

• Send motor instructions from the brain to the body

• Direct reflexes

Spinal Cord Injury: Risk Factors

• Motor vehicle

• Falls (over 65)

• Acts of violence

• Sports related

• More common in men than females

Spinal Cord Injury: Classification

• Classified on where the injury is located

• Types

  • Impact –consistent compression

  • Impact – intermittent compression

  • distraction injury

  • transection and laceration

Spinal Cord Injury: Clinical Manifestations

• C1 to C4

  • Ventilator dependence 

• C1 to C8 

  • Limited proprioception

• T1 to T8

  • Affects trunk movements 

  • Lack of abdominal control 

• T9 to T12 

  • Limited abdominal control 

• L1 to S5 

  • Loss of bowel and bladder functioning 

  • Affects sexual function

Spinal Cord Injury: Testing

• CT 

• MRI 

• X Ray

Spinal Cord Injury: Complications

• DVT

• Neurogenic Shock

  • Medical emergency 

  • within the first 24 hours 

  • Cant regular blood pressure , heart rate, temperature

  • Inadequate blood flow to vital organs 

• Autonomic Dysreflexia

  • Life threatening

  • Above the T6 level

  • Caused by a trigger

  • Can be triggered by different things:

    • Pain, impaction, a full bladder

  • Usually happens after the first year of a spinal cord injury

  • Clinical Manifestations

    • Severe headache 

    • Facial flushing 

    • Diaphoresis 

Spinal Cord Injury: Treatments

• Pain control – pharmacology

• Physical Therapy, Occupational Therapy, and Speech Therapy.

• Trach care

• Treatment depends on symptoms

Spinal Cord Injury: Key Take Aways

• Realignment and stabilization of the spine with the use of mechanical force or a brace must be done as soon as possible to prevent further damage.

• Halo Fixation device 

Head Injury: Types

• Concussion

• Subdural Hematoma

• Subarachnoid Hemorrhage 

Head Injury: Risk Factors

• Car accidents / Crashes

• Falls

• Males more than females 

  • Contact sports

  • Military service 

  • Substance use

• Falls 

• Polypharmacy 

Head Injury : Clinical Manifestations

• LOC - Difficulty waking

• Pupillary dilation

• Headache

• nausea

• Agnosia

• Ataxia

• Aphasia

• Loss of balance , Weakens of limbs

• Personality changes, Amnesia

• “Halo sign”

  • Indication of CSF leak

    • Runny nose, fluid coming out of ear’

  • Yellow ring our the fluid indicates leak 

  • Symptom management heals on its own 

Head Injury: Testing & Imagining

• CBC with Diff

• Blood Glucose

• Electrolytes

• Toxicology

• Imaging

  • CT, MRI, X-Ray

• ABGs

Head Injury: Complications

• Cushing's Triad

  • Late finding

  • Hypertension 

  • Low Blood respirations 

  • Bradycardia: Low heart rate 

  • Widening pulse pressure

• Frequent neuro checks: Glowscow Coma Scale 

  • Opening eyes: 1-4

  • Verbal response: 1-5

  • Motor Response: 1-6

• Increased Intracranial Pressure

• Brain Herniation

• Pulmonary Edema

Head Injury: Treatment/ Therapy/ interventions

• Frequent Assessment

• Medications

  • Anti-Seizure meds

  • Decrease ICP

  • Barbiturates

  • Opioids

• Craniotomy

• Therapeutic hypothermia

  • gets the brain swelling down 

• Spinal precautions

• Collar / back board / log rolling

Head Injury: Positioning

• Decorticate (Flexor)

• Decerebrate (Extensor)

• Decorticate has a better survival rate then Decerebrate

Head Injury Complication: Subdural Hematoma

• Older Adults at risk 

  • Can be misdiagnosed as a Stroke 

• Clinical Manifestations 

  • Persistent headache 

  • Confusion

  • Neasua and vomiting

  • Memory loss 

  • SEVERE

    • Seizures 

    • Patients taking blood thinners, hypoglycemic patients 

• Small hematoma: Treatment 

  • Rest 

  • Frequent monitoring

  • no long term complications 

  • Self healing

• Large hematoma: Treatment

  • EMEREGENCY TREATMENT

  • Surgical intervention to remove the hematoma

Head Injury Complication: Subarachnoid Hemorrhage

• Causes

  • Aneurysm rupture

  • Uncontrolled hypertension

• High mortality rate if left untreated

• Frequent monitoring

• Complete the Glowscow Coma Scale

• Monitor for signs of…

  • Brain Herniation

  • ICP

• Clinical Manifestations

  • “I have the worst headache of my entire life”

  • Nausea / Vomiting

(Syndrome of Inappropriate Antidiuretic Hormone Secretion) SIADH

• Body makes TOO MUCH Antidiuretic hormone 

Causes

• Stoke 

• Head trauma 

• Brain tumors 

• Risk Factor

  • Repetitive damage  to the pituitary or hypothallus 

• C

  • Urine output decrease

  • Hyponatremia 

    • Neurological manifestations can occur

      • Seizure 

      • Cerebral edema 

      • Coma

• Treatment

  • Fluids 

    • 3% sodium chloride 

  • Monitoring sodium intake hourly 

  • DO NOT REPLACE SODIUM TOO QUICKLY

  • Foods high in sodium 

Diabetes Insipidus

• Body does NOT MAKE enough Antidiuretic hormone

• Cause

  • damage to pituary and hypothalamus gland

• High Urine output 

• Hypernatremia 

• Complications

  • Dehydration 

  • Electrolyte imbalance 

• Medication

  • Desmopressin

• Treatment

  • Treat the underlying cause

    • Restore water balance and normalize Antidiuretic hormone

Stroke

• Disruption of blood supply

• Types

  • Ischemic

    • Risk Factor: A-Fib not on anticoagulants 

  • Hemorrhagic

• Injury on the right side of the brain, displays on the left side of their body 

• Injury on the left side of the brain, displays on the right side of the body

Stroke: Clinical Manifestations

• Sever headache

• Vertigo

• Gait impairment

• Trouble articulating

• Unilateral numbness

• Hemiparesis (one-sided muscle weakness)

• Expressive & Receptive Aphasia

• Loss of depth perception

• Vision changes

• Agnosia

  • Inability to recognize familiar people, objects or sounds 

Stroke: Risk Factors

• Hypertension

• Hyperlipidemia

• Diabetes

• Smoking/ alcohol / substance

• Maintain healthy weight/ regular exercise

Stroke: Screening

• NIH Stroke Scale (NIHSS)

• HIGHER than 10 = severe stroke

• Glasgow coma scale

Stroke: Testing

• CBC

• Coagulation Panel

• ECG

• CT/ MRI

  • Within 25 minutes of arrival to ED

  • Angiography

• Dysphagia screening

Stroke: Treatment/ Therapy/ Interventions

• TPA

  • give 3 to 4 hours after onset of an ischemic stroke 

  • Breaks down the clot 

  • Restores blood flow 

• Thrombolytic medication

  • Anticoagulants

  • Antiplatelets

  • Antiepileptics

  • Antihypertensives

• Other medications

  • Stool softeners, antianxiety

• Angioplasty

• Thrombectomy

• Carotid Endarterectomy

Stroke: Key Take Aways

• Patient Education

  • Modified diet

    • Thicken liquid

    • no straw 

    • Pureed diet 

• FAST

  • Facial drooping 

  • Arm weakness 

  • Speech 

  • Time 

Macular Degeneration: Risk Factors, Comorbidities & Impact on Health

• Wet Age-Related Macular Degeneration

  • causes fluid to leak under the macula

  • causing visual distortion

• Dry age-related macular degeneration

  • Causes the retinal tissue to break down

• Risk Factors

  • Smoking

  • Hypertension

• Comorbidities

  • Cardiovascular and renal conditions

• Impact on overall health

  • ADLs

  • Depression

  • Anxiety

  • Risk of Falls 

Macular Degeneration: Education

• Smoking session

• Diet

• Physical activity, maintain healthy weight

• Control chronic conditions

• Amsler grid

  • Vision test used to check for changes in central vision, particularly distortions or blind spots

Macular Degeneration: Treatment / Therapy

• Ophthalmological examination

  • Fluorescein angiography

    • Uses a fluorescent dye to visualize the blood vessels in the retina

• Early detection/ preservation of vision

• Medication

  • Carotenoids lutein

  • Zeaxanthin

• Anti-VEGF injections

• Photodynamic Therapy 

Cataracts: Risk Factors

• Age

• Diabetes mellitus

• Hypertension

• Traumatic eye injury/ surgery

• Use of steroids

• Previous eye surgery

• Family history

• Overexposure to sun or ultraviolet (UV) rays

• Smoking

• Alcohol use disorder

• Obesity

Cataracts: Clinical Manifestations

• Vision is not clear

• Hazy

• Pain- free

Cataracts: Patient Education

• Smoking cessation

• Diet

  • Leafy green vegetable

• protect from sunlight

• Fall risk

• Visual aids

  • Magnifier

  • Large print material

Cataracts: Treatment/ therapy

• Nurses will assess for _______ by first assessing visual acuity using a Snellen eye chart.

• Cataract extraction surgery

Glaucoma: Risk Factors & Comorbidities

• Irreversible loss of vision

• Elevated intraocular Pressure

• 2 types:

  • Primary Open Angle

  • Angle Closure

• Risk Factors 

  • Age

  • Black & Hispanic

  • Eye injury/ trauma

  • Family history

  • Chronic health conditions

• Comorbidities

  • High blood pressure

  • Diabetes

  • Hyperlipidemia 

Glaucoma: Treatments

• Tonometry

  • Measures the pressure inside the eye

• Eye drops

  • Lowering Intraocular Pressure (10 to 21 mm Hg)

  • Preserving vision

• Surgery

  • Post-op care

  • Post-Operative Infection

    • Elevated temperature

    • Purulent drainage

    • Vision changes

    • Intense eye pain

Glaucoma: Patient Education

• Lifestyle modifications

• Eye Drops

• Goal is preserving vision

• Frequent monitoring of Intraocular Pressure

  • Less than 21

Middle & Inner Ear : Risk Factors

• Middle ear

  • Recurrent colds

  • Enlarged adenoids

  • Trauma

  • Changes in air pressure

• Inner ear

  • Chronic- after age 40

  • No known cause

  • Autoimmune disorder

  • Viral infection

  • Genetic

Middle & Inner Ear: Clinical Manifestations

• Vomiting

• Nausea

• Blurry vision

• Cold sweats

• Trembling

• Hearing loss

• Headaches

• Imbalance/ dizziness

• Congestion in the ear

• Ear fullness

Middle & Inner Ear : Treatments

• Medications

  • Diuretics & Corticosteroids

  • Motion sickness medications

    • (Meclizine, valium, promethazine, ondansetron)

• Determine the cause of hearing deficit

  • Remove occlusion

• Hearing aids

• Cochlear implants

  • For severe hearing loss 

• Hearing test

  • Audiometry

  • Tympanogram

  • Weber and Rinne test

  • ENG

  • Finger rubs or Whispered voices

Middle & Inner Ear : Key Take-Aways

• Patient Education

  • Avoid foods high in sugar

  • Avoid nicotine, caffeine, and alcohol

  • Limit sodium (edema)

• Meniere’s disease

  • Causes debilitating vertigo.

  • Develops from an excessive accumulation of fluid in the inner ear..

  • Treatment with diuretics and steroids can help alleviate the manifestations.