NOTES SEPTEMBER CH. 47,48,49

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CHAPTER 47 OUTLINE CHAPTER 48 OUTLINE Diabetes Mellitus Diabetes is a chronic disease involving either a lack of the hormone insulin or resistance to insulin. 7 TH leading cause of death in united states.  Etiology and Pathophysiology o The pancreas is both an exocrine gland and an endocrine gland.  Exocrine functions involve the secretion of amylase and lipase  Endocrine function involves the secretion of three hormones including insulin, glucagon, and somatostatin.  PREDIABETES: o A1C= 5.7-6.4% o 2 Hr GTT of 140-199 mg/dl o Intermittent Fasting Glucose 100-125 mg/dl o Increased risk for developing Type 2 diabetes o Hyperglycemia but not enough to be considered diabetic o Usually, asymptomatic  Type 1 diabetes (GENETIC) o Type 1 diabetes occurs as the result of autoimmune destruction of the insulin producing beta cells in the pancreas o More common in young people o Abrupt s/s of Polydipsia, polyuria, polyphagia, fatigue, weight loss without trying o Insulin therapy required for ALL  Type 2 diabetes (LIFESTYLE) o Type 2 diabetes is the problem that results from peripheral resistance to insulin. o More common in adults o Gradual s/s Often none seen. Fatigue, recurrent infections. May also have polyuria, polydipsia, and polyphagia o Pts often overweight or obese o Explain the 15/15/15 rule and educate a newly diagnosed type II diabetic about this rule.

 Blood sugar less than 70mg/dl take 15 grams of carbs  Check Blood sugar in 15 min if less than 70mg/dl repeat carbs  Clinical Manifestations, Diagnostic Studies, and Interprofessional Care for Both Type 1 and 2 o DIAGNOSTIC STUDIES:  1. A1C of 6.5% or higher (random blood glucose of over 200 mg/dL)  Requires repeat testing.  2. Fasting plasma glucose (FPG) level of 126 mg/dL (7.0 mmol/L) or greater. Fasting is defined as no caloric intake for at least 8 hours  Requires repeat testing  3. A 2-hour plasma glucose level of 200 mg/dL (11.1 mmol/L) or greater during an OGTT, using a glucose load of 75 g  Requires repeat testing  4. In a patient with classic symptoms of hyperglycemia (polyuria, polydipsia, unexplained weight loss) or hyperglycemic crisis, a random plasma glucose level of 200 mg/dL (11.1 mmol/L) or greater,  does not require repeat testing o INTERPROFESSIONAL CARE:  GOALS of diabetes management: 1. Reduce symptoms 2. Promote well-being 3. Prevent acute complications related to hyperglycemia and hypoglycemia 4. Prevent or delay the onset and progression of long-term complications  Drug Therapy o GOAL:IS TO MAINTAIN NEAR NORMAL BLOOD GLUCOSE LEVELS TO PREVENT COMPLICATIONS o Insulin  Produced by the beta cells in the islet of Langerhans in the pancreas o Storage and administration of insulin  Insulin vials and pens in use may be left at room temperature for up to 4 weeks unless the room temperature is higher than 86° F (30° C) or below freezing (less than 32° F [0° C]).  Teach patients to avoid prolonged exposure to direct sunlight.

 A patient who is traveling in hot climates may store insulin in a thermos or cooler to keep it cool (not frozen).  Store unopened insulin vials and pens in the refrigerator. o Problems with insulin therapy  hypoglycemia, allergic reactions, lipodystrophy (loss of subcutaneous fat if same spot used continuously) , hypertrophy ( injecting into a hypertrophy site may cause erratic insulin absorption), and the Somogyi effect. o Drug therapy non-insulin and injectables  Metformin (Biguanide) most widely used Oral  Reduces glucose production by the liver  It is also used to prevent type 2 diabetes in those with prediabetes who are younger than age 60 and have risk factors, such as hypertension or a history of gestational diabetes. o Table 48.7 Figure 48.4  Nutrition therapy o Exercise o Blood Glucose Monitoring  NORMAL GLUCOSE RANGE: 70-100 mg/dL o Table 48.10  Acute Care  Acute Complications of Diabetes o Table 48.14 o Table 48.15

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o Table 48.16  Hypoglycemia o Table 48.19 o Nursing and interprofessional management of hypoglycemia  Chronic Complications of Diabetes o Table 48.20  Review all drug alerts and gerontologic considerations Eli Lilley Novo-Nordisk Aventis Rapid insulin : Onset - 15 minutes Peak – 1.5 hours Duration – 3 hours Insulin Lispro (Humulog) Insulin Aspart ( Novolog) Insulin Glulisine (Apidra) Short insulin : Onset - 30 minutes Peak - 3 hours Duration – 6 hours Regular (Humulin R) (Walmart – ReliOn R) Regular (Novolin R) Intermediate insulin: Onset - 1 hour Peak - 6 hours Duration - 12 hours NPH Humulin N (Walmart – ReliOn N) NPH (Novolin N) Long insulin : Onset – 2 hours Duration – 24 hours Glargine (Basaglar – 100u/mL) Detemir (Levemir) Degludec (Tresiba) – U100 & U200 strengths Glargine (Lantus-100u/mL) Glargine (Toujeo- 300u/mL) CHAPTER 49 OUTLINE Pituitary Surgery Table 49.2 Nursing Management Care of the Patient After Pituitary Surgery • Monitor vital signs. Assess peripheral pulses and watch for orthostatic hypotension. • Monitor neurologic/cognitive status (e.g., level of consciousness, orientation, speech) hourly for the first 24 hr and then every 4 hr. • Assess extremity strength and reflexes. • Monitor field of vision, visual acuity, extraocular movements, and pupillary response. Notify HCP of any changes. • Assess dressing for type and amount of drainage. Notify HCP for excessive bleeding or CSF drainage. • Maintain strict intake and output and monitor fluid balance. Assess for DI or SIADH. • Keep head of bed always elevated at least 30 degrees. • Encourage deep breathing exercises and incentive spirometer use. • Monitor for pain and give analgesic medications as prescribed. • Encourage high-fiber diet to decrease potential for constipation. • Perform oral care every 4 hr. • Teach the patient to: • Avoid vigorous coughing, sneezing, and blowing the nose • Avoid bending over at the waist or straining at stool (Valsalva maneuver) due to potential increased intracranial pressure • Avoid use of toothbrushes until incision heals • Follow replacement hormone therapy plan

SIADH (SYNDROME OF INAPPROPRIATE ANTIDIURETIC HORMONE) Table 49.3 Causes of SIADH Cancer • Colorectal cancer • Lymphoid cancers (Hodgkin’s lymphoma, non-Hodgkin’s lymphoma, lymphocytic leukemia) • Pancreatic cancer • Prostate cancer • Small cell lung cancer • Thymus cancer CNS Disorders • Brain tumors • Cerebral atrophy • Guillain-Barré syndrome • Head injury (skull fracture, subdural hematoma, subarachnoid hemorrhage) • Infection (encephalitis, meningitis) • Stroke • Systemic lupus erythematosus Drug Therapy • carbamazepine (Tegretol) • Chemotherapy agents (vincristine, vinblastine, cyclophosphamide) • chlorpropamide • General anesthesia agents • Opioids • oxytocin • Thiazide diuretics • Selective serotonin reuptake inhibitor (SSRI) antidepressants • Tricyclic antidepressants Miscellaneous Conditions • Adrenal insufficiency • Chronic obstructive pulmonary disease • HIV • Hypothyroidism • Lung infection (pneumonia, tuberculosis, lung abscess) • Positive pressure mechanical ventilation

Diabetes Insipidus Figure 49.4 Pathophysiology of diabetes insipidus. Table 49.4 Types of Diabetes Insipidus Type Etiology Central (neurogenic) DI Interference with ADH synthesis, transport, or release Examples: Brain tumor, head injury, brain surgery, CNS infections Nephrogenic DI Inadequate renal response to ADH despite presence of adequate ADH Examples: Drug therapy (especially lithium), renal damage, hereditary renal disease Primary DI Excess water intake Examples: Structural lesion in thirst center, psychologic disorder Diabetes Insipidus  Not enough ADH  Hypovolemia  Kidneys not responding to ADH  Causes  Head injury  Pituitary tumor  Diagnostics i. Decreased urine specific gravity and osmolality ii. Increased blood osmolality and Hypernatremia  Signs and Symptoms Large amounts of dilute urine  Can urinate as much as 19 liters a day Medication  Drug Therapy: Desmopressin 1. Orally 2. Sublingual Melt 3. Intranasal spray  Weigh daily, check specific gravity  Teach patient- polyuria, polydipsia (need another dose)  Watch for signs and symptoms of water retention Hyperthyroidism  Table 49.6 Manifestations of Thyroid Dysfunction Hyperfunction Hypofunction Cardiovascular System • Systolic hypertension • ↑ Rate and force of cardiac contractions • ↑ Capillary fragility • ↓ Rate and force of contractions

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• Bounding, rapid pulse • ↑ Cardiac output • Systolic murmurs • Dysrhythmias • Palpitations • Angina • Varied changes in BP • Cardiac hypertrophy • Distant heart sounds • Anemia • Heart failure • Angina Gastrointestinal System • ↑ Appetite, thirst • Weight loss • ↑ Peristalsis • Diarrhea, frequent defecation • ↑ Bowel sounds • Splenomegaly • Hepatomegaly • ↓ Appetite • Weight gain • Nausea and vomiting • Constipation • Distended abdomen • Enlarged, scaly tongue • Celiac disease Musculoskeletal System • Fatigue • Weakness • Proximal muscle wasting • Dependent edema • Osteoporosis • Fatigue • Weakness • Muscular aches and pains • Slow movements • Arthralgia Nervous System • Hyperactive deep-tendon reflexes • Depression • Lack of ability to concentrate • Rapid speech • Insomnia • Difficulty focusing eyes • Nervousness • Fine tremor of fingers and tongue • Lability of mood, delirium • Restlessness • Personality changes of irritability, agitation • Stupor, coma • Prolonged relaxation of deep tendon reflexes • Anxiety, depression • Slowed mental processes • Slow, slurred speech • Sleepiness • Apathy • Lethargy • Forgetfulness • Hoarseness • Stupor, coma • Paresthesias Reproductive System • Menstrual irregularities • Amenorrhea • ↓ Libido • ↓ Fertility • Impotence and gynecomastia in men • Prolonged menstrual periods or amenorrhea • ↓ Libido • Infertility Respiratory • Dyspnea on mild exertion • ↑ Respiratory rate • Dyspnea • ↓ Breathing capacity Skin • Warm, smooth, moist skin • Thin, brittle nails detached from nail bed (onycholysis) • Hair loss (may be patchy) • Clubbing of fingers (thyroid acropachy) ( Fig. 49.7 ) • Palmar erythema • Fine, silky hair • Premature graying (in men) • Diaphoresis • Dry, thick, inelastic, cold skin • Thick, brittle nails • Dry, sparse, coarse hair • Poor turgor of mucosa • Generalized interstitial edema • Puffy face • ↓ Sweating • Pallor

• Vitiligo • Pretibial myxedema (infiltrative dermopathy) Other • Goiter ( Fig. 49.6 ) • Intolerance to heat • Elevated basal temperature • Lid lag, stare • Eyelid retraction • Exophthalmos • Goiter • Intolerance to cold • ↑ Risk for infection • ↑ Sensitivity to opioids, barbiturates, anesthesia • ↓ Hearing Table 49.8 Comparison of Hyperthyroidism in Younger and Older Adults Younger Adult Older Adult Common causes Graves’ disease in >90% of cases Graves’ disease or toxic nodular goiter Common symptoms Nervousness, irritability, weight loss, heat intolerance, warm moist skin Anorexia, weight loss, apathy, lassitude, depression, confusion Goiter Present in >90% of cases Present in about 50% of cases Ophthalmopathy Exophthalmos ( Fig. 49.6 ) present in 20%–40% of cases Exophthalmos less common Cardiac features Tachycardia and palpitations common, but without heart failure Angina, dysrhythmia (especially atrial fibrillation with rapid ventricular response), heart failure may occur Table 49.9 Interprofessional Care Hyperthyroidism Diagnostic Assessment • History and physical examination • Ophthalmologic examination • ECG • Laboratory tests • TSH levels, serum free T 4 • Thyroid antibodies (e.g., thyroid peroxidase [TPO] antibody) • Total serum T 3 and T 4 • Radioactive iodine uptake (RAIU) Management Drug Therapy • Antithyroid drugs • methimazole (Tapazole) • propylthiouracil • iodine (SSKI) Radiation Therapy • Radioactive iodine Surgical Therapy • Subtotal thyroidectomy Nutritional Therapy • High-calorie, high-protein diet • Frequent meals Table 49.11 Emergency Management Acute Thyrotoxicosis Etiology Assessment Findings Interventions • Infection, surgery, trauma in a patient with hyperthyroidism • Abdominal pain • Agitation • Begin fluid replacement with isotonic saline infusions containing dextrose.

• Thyroidectomy • Delirium • Diarrhea • Heart failure • Hyperthermia (up to 106° F [41.1° C]) • Seizures • Severe tachycardia • Shock • Vomiting • Monitor airway, breathing, and circulation. • Monitor vital signs at least every 30 min. • Apply continuous O 2 saturation and ECG monitoring. • Monitor serial serum electrolytes, serum glucose, ABGs, and serum calcium levels. • Monitor urine output hourly. • Apply ice packs and cooling blankets to reduce fever. Acetaminophen as needed. • Provide pulmonary hygiene. • Assess for manifestations of heart failure or pulmonary edema (e.g., extra heart sounds, adventitious lung sounds). • Decrease O 2 demands by decreasing anxiety and pain. • Restrict visitors, if needed. • Give prescribed drugs and monitor effects: • β-Adrenergic blockers • Antithyroid agents • Iodine compounds • Glucocorticoids TABLE 49.12 Nursing Management Care of the Patient After Thyroid Surgery • Assess vital signs every 15 min until stable and then every 30 min for the first 24 hr after surgery. • Monitor airway and respiratory status (patency, rate, rhythm, depth, and effort). • Assess the patient every 2 hr for 24 hr for signs of hemorrhage or tracheal compression (e.g., irregular breathing, neck swelling, frequent swallowing, choking, blood on the dressings, and sensations of fullness at the incision site). • Assist the patient with coughing and deep breathing. • Apply supplemental O 2 with humidification as ordered. • Have suction equipment and a tracheostomy kit available for immediate use. • Assess the ability to speak aloud, noting voice quality, tone, and any problems speaking. Notify the HCP of any permanent hoarseness or loss of vocal volume. • Monitor calcium levels and assess for signs of tetany and hypocalcemia (e.g., tingling in toes, fingers, around the mouth; muscular twitching; apprehension) and any difficulty in speaking and hoarseness. Check Trousseau’s sign and Chvostek’s sign • Keep calcium salts (calcium gluconate, calcium chloride) available for immediate IV use. • Assess condition of operative site and dressing. Monitor the area under the patient’s neck and shoulders for drainage. • Place the patient in a semi-Fowler’s position. Support the head and neck with pillows. Avoid neck flexion to prevent tension on the suture line. • Provide comfort measures and give analgesic medications as prescribed. Hypothyroidism Diagnostic Assessment • History and physical examination • Serum TSH and free T 4 • Total serum T 3 and T 4 • Thyroid peroxidase (TPO) antibodies Management • Thyroid hormone replacement (e.g., levothyroxine) • Monitor thyroid hormone levels and adjust dosage (if needed) • Nutritional therapy to promote weight loss

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• Patient and caregiver teaching  Table 49.14 Patient & Caregiver Teaching Hypothyroidism Include the following instructions when teaching the patient and caregiver about management of hypothyroidism:  Discuss the importance of thyroid hormone therapy: 1. Need for lifelong therapy 2. Taking thyroid hormone in the morning before food 3. Need for regular follow-up care and monitoring of thyroid hormone levels 4. Caution the patient not to switch brands of the hormone since the bioavailability of thyroid hormones may differ. 5. Emphasize the need for a comfortable, warm environment because of cold intolerance. 6. Teach ways to prevent skin breakdown. Use soap sparingly and apply lotion to skin. 7. Caution the patient, especially if an older adult, to avoid sedatives. If they must be used, suggest that the lowest dose be used. Caregiver should closely monitor mental status, level of consciousness, and respirations. 8. Discuss ways to minimize constipation, including: 9. Gradual increase in activity and exercise 10. Increased fiber in diet 11. Use of stool softeners 12. Regular bowel elimination time 13. Tell patient to avoid using enemas. They cause vagal stimulation, which can be hazardous if heart disease is present. Disorders of the adrenal cortex  Cushing syndrome  Table 49.16 Manifestations of Adrenocortical Dysfunction System Cushing Syndrome Addison’s Disease Glucocorticoids General appearance Truncal obesity, thin extremities, rounding of face (moon face), fat deposits on back of neck and shoulders (buffalo hump) Weight loss, emaciation Cardiovascular Hypervolemia, hypertension, edema of lower extremities Hypotension, tendency to develop refractory shock, vasodilation Gastrointestinal ↑ Secretion of pepsin and HCl acid, risk for peptic ulcer disease, anorexia Anorexia, nausea and vomiting, cramping abdominal pain, diarrhea Immune Inhibition of immune response, suppression of allergic response Tendency for coexisting autoimmune diseases Metabolic Hyperglycemia, negative nitrogen balance, dyslipidemia Hyponatremia, insulin sensitivity, fever Musculoskeletal Muscle wasting in extremities, fatigue, osteoporosis, awkward gait, back pain, weakness, compression fractures Fatigue Psychologic Euphoria, irritability, depression, insomnia, anxiety Depression, exhaustion or irritability, confusion, delusions Renal/urinary Glycosuria, hypercalciuria, risk for kidney stones Skin Thin, fragile skin, purplish red striae Bronzed or smoky hyperpigmentation of

Petechial hemorrhages, bruises. Florid cheeks (plethora), acne, poor wound healing face, neck, hands (especially creases) buccal membranes, nipples, genitalia, and scars (if pituitary function normal). Vitiligo, alopecia Mineralocorticoids Cardiovascular Hypertension, hypervolemia Hypovolemia, tendency toward shock, decreased cardiac output Fluid and electrolytes Marked sodium and water retention, edema, marked hypokalemia, alkalosis Sodium loss, ↓ volume of extracellular fluid, hyperkalemia, salt craving Androgens Musculoskeletal Muscle wasting and weakness ↓ Muscle size and tone Reproductive Women: Menstrual irregularities and enlargement of clitoris Men: Gynecomastia and testicular atrophy Women: ↓ Libido in women Men: No effect in men Skin Hirsutism, acne, hyperpigmentation ↓ Axillary and pubic hair (in women) Cushing's Syndrome  Cortisol-steroid hormone made by the adrenal glands  Regulates glucose, protein and lipid metabolism  Maintains blood pressure  Excess corticosteroids, cortisol esp. glucocorticoids  Most common cause is too much- administration of corticosteroids  ACTH secreting pituitary tumor  Adrenal tumors i. Assessment Findings ii. Diagnostics and Collaborative Care i. Surgery- adrenals or pituitary ii. Mitotane (Lysodren) suppresses cortisol production, decreases plasma and urine corticosteroid levels iii. Reduction of corticosteroid therapy gradually iv. Emotional support v. Immunosuppression Collaborative Care  Manage underlying cause  Glucocorticoid (prednisone, hydrocortisone)  Increase doses during stress  Mineralocorticoid (Fludrocortisone) Adrenocortical Insufficiency (ADDISONS) Diagnostic Assessment • History and physical examination • ACTH stimulation test • Serum cortisol and ACTH • Urine cortisol and aldosterone • CRH suppression test • Serum electrolytes • CT scan, MRI Management

• Daily glucocorticoid (e.g., prednisone, hydrocortisone) replacement (two thirds on awakening in morning, one third in late afternoon) • Daily mineralocorticoid (fludrocortisone) in morning • ↑ Salt in the diet • Androgen replacement with dehydroepiandrosterone (DHEA) for women • Salt additives for excess heat or humidity • ↑ Doses of glucocorticoid for stress situations (e.g., surgery, hospitalization) Addisonian Crisis 1. Triggered by stress or sudden withdrawal of glucocorticoids 2. S/S: a. Hypotension b. Shock and circulatory collapse. c. Dehydration d. Severe vomiting and diarrhea. TABLE 49.20 Patient & Caregiver Teaching Addison’s Disease Include the following information in the teaching plan for the patient with Addison’s disease and the caregiver: 1. Names, dosages, and actions of drugs 2. Symptoms of overdosage and underdosage 3. Conditions requiring increased dosage (e.g., trauma, infection, surgery, emotional crisis) 4. Course of action to take related to changes in medication 1. • Increased dose of corticosteroid 2. • Self-administration of large dose of corticosteroid IM 3. • Consultation with HCP 5. Preventing infection and need for prompt and vigorous treatment of existing infections 6. Need for lifelong replacement therapy 7. Need for lifelong medical supervision 8. Need to carry medical identification 9. Fall prevention 10. Adverse effects of corticosteroid therapy and prevention techniques 11. Special instruction for patients with diabetes and management of blood glucose when taking corticosteroids Corticosteroid Therapy TABLE 49.22 Drug Therapy Effects and Side Effects of Corticosteroids • Delayed wound healing with ↑ risk for wound dehiscence • Fat from extremities redistributed to trunk and face • Glucose intolerance • Hypertension with ↑ risk for heart failure • Hypocalcemia related to anti–vitamin D effect • Hypokalemia • ↑ Risk for infection • Infection develops more rapidly and spreads more widely • Mood and behavior changes • Pathologic fractures, especially compression fractures of the vertebrae (osteoporosis) • Peptic ulcer disease • Pituitary ACTH synthesis suppressed • Skeletal muscle atrophy and weakness • Suppressed inflammatory response Table 49.23 Patient & Caregiver Teaching Corticosteroid Therapy Include the following instructions when teaching the patient and caregiver to manage corticosteroid therapy:

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1. Follow a diet high in protein, calcium (at least 1500 mg/day), and potassium and low in fat and concentrated simple carbohydrates, such as sugar, syrups, and candy. 2. Ensure adequate rest and sleep, such as daily naps and avoiding caffeine late in the day. 3. Take part in an exercise program to help maintain bone integrity. 4. Recognize edema and ways to restrict sodium intake to <2000 mg/day if edema occurs. 5. Monitor glucose levels and recognize symptoms of hyperglycemia (e.g., polydipsia, polyuria, blurred vision). Report hyperglycemic symptoms or capillary glucose levels >120 mg/dL (10 mmol/L). 6. Notify HCP if heartburn after meals or epigastric pain that is not relieved by antacids occurs. 7. See an eye specialist yearly to assess for cataracts. 8. Use safety measures, such as getting up slowly from bed or a chair and good lighting, to avoid accidental injury. 9. Maintain appropriate hygiene practices. 10. Avoid contact with persons with colds or other contagious illnesses to prevent infection. 11. Inform all HCPs about long-term corticosteroid use. 12. Recognize need for ↑ doses of corticosteroids in times of physical and emotional stress. 13. Never abruptly stop the corticosteroids because this could lead to Addisonian crisis and death.  All drug alerts and gerontological considerations Diabetes Insipidus  Not enough ADH  Hypovolemia  Kidneys not responding to ADH  Causes  Head injury  Pituitary tumor  Diagnostics iii. Decreased urine specific gravity and osmolality iv. Increased blood osmolality and Hypernatremia  Signs and Symptoms Large amounts of dilute urine  Can urinate as much as 19 liters a day Medication  Drug Therapy: Desmopressin 4. Orally 5. Sublingual Melt 6. Intranasal spray  Weigh daily, check specific gravity  Teach patient- polyuria, polydipsia (need another dose)  Watch for signs and symptoms of water retention Hyperthyroid  Increased T3, T4 and Decreased TSH Hyperthyroid Treatment  Antithyroid drugs: Inhibits synthesis of hormone  Propylthiouracil (PTU)- also blocks peripheral conversion of T4-T3, 3 times a day  2 WEEKS TO SEE CHANGE  Methimazole (Tapazole), once a day  Block T3 and T4  Off the drugs- return of symptoms  Radioactive Iodine: damages and destroys thyroid tissue- yes or no radiation precautions  Affect may not be seen for several months  Monitor hormones.  Beta Blockers (decrease SNS response)

Exophthalmos  Thyroidectomy  Partial or Total  Large goiters- causing tracheal compression  Unresponsive to other therapy.  Cancer  How would you care for this patient???  Trach tray at bedside  Potential complication of laryngeal nerve damage (hoarseness beyond 4 days)  Assess for bleeding and tracheal compression  Semi-fowlers- don’t flex neck, pillows  Check for signs of tetany. Why?? Post-Op  Absolutely must have thyroid hormones monitored  Watch iodine intake  Avoid high environmental heat  Decrease calories Thyroid Storm  Hyper everything  Monitor heart rhythm  Oxygen  IV fluids for vomiting and diarrhea  Calm room  Cool room  Block hormone  Beta blockers- Block Sympathetic Response  Care in palpating thyroid Hypothyroid Hypothyroid Diagnostics and Treatments  High TSH  Low free T4  High cholesterol  High triglycerides  Anemia Treatment  Levothyroxine (Synthroid)- careful adjustment  When to take  Liotrix- synthetic  Can be absorbed better  Lifelong drug therapy Myxedema  Myxedema coma: emergency  Mechanical ventilation  Cardiac monitoring  Monitor temperature Cushing's Syndrome  Cortisol-steroid hormone made by the adrenal glands  Regulates glucose, protein and lipid metabolism

 Maintains blood pressure  Excess corticosteroids, cortisol esp. glucocorticoids  Most common cause is too much- administration of corticosteroids  ACTH secreting pituitary tumor  Adrenal tumors iii. Assessment Findings iv. Diagnostics and Collaborative Care vi. Surgery- adrenals or pituitary vii. Mitotane (Lysodren) suppresses cortisol production, decreases plasma and urine corticosteroid levels viii. Reduction of corticosteroid therapy gradually ix. Emotional support x. Immunosuppression Collaborative Care  Manage underlying cause  Glucocorticoid (prednisone, hydrocortisone)  Increase doses during stress  Mineralocorticoid (Fludrocortisone)

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NOTES SEPTEMBER CH. 47,48,49

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