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Med Surg II - Thyroid & Adrenal

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olanjones's version from 2017-03-22 16:55

Thyroid

Question Answer
Thyroid Hormone & Negative FeedbackAmount of T4 produced by the thyroid gland is controlled by TSH; amount of TSH that the pituitary sends into the blood stream depends on the amount of T4 that the pituitary senses. If pituitary senses ↓T4, then it produces ↑TSH to tell thyroid to produce ↑T4. Once the T4 in blood stream goes above a certain level the pituitary’s production of TSH is shut off
Hypothyroidism causes↓secretion of TSH by pituitary, ↓function of thyroid gland (commonly Hashimoto’s), destruction of thyroid d/t hyperthyroid treatment
s/s of hypothyroid↓HR, ↓BP, fatigue, constipation, cold intolerance, brittle nails –in pt on meds: insufficient dosing; patient may not be taking as directed (at same time, on empty stomach, without other meds)
Hypothyroidism Patient/Family EducationDiet-Iodized Salt, High fiber, Recognizing s/s of medical emergency, Monitor weight, Lifelong drug therapy is stressed (levothyroxine), take 1-2 hours prior to breakfast (same time daily), monitor drug levels to ensure proper dose
Myxedema comamedical emergency d/t severe hypothyroidism, characterized by loss of consciousness. S/S: hypothermia, ↓BP, ↓BS, enlarged tongue, lactic acidosis, hypoventilation; can lead to CV collapse
Myxedema coma ManagementVS/weight/I&O/edema. Vital functions are supported, Airway, IV fluids, Warmth, Vasopressors, IV Levothyroxine, IV Glucose, IV corticosteroids (all IV d/t possible paralytic ileus)
s/s of hyperthyroidnervousness, tachy/palpitations, heat intolerance, wt loss, fine/soft hair, exophthalmos, diarrhea – in meds: dosing is too high (Can also dysrhythmias, chest pain, murmurs, hepatomegaly, muscle weakness, osteoporosis, emotional lability, ↓fertility, sexual function)
Most common cause of hyperthyroidismGraves' disease (auto-immune hypersecretion of T3/T4)
Thyrotoxicosisexcess TH secreted from thyroid gland (caused by hyperthyroidism, toxic multinodular goiter, thyroid cancer/removal); MEDICAL EMERGENCY: death occurs in 48 hrs.
S/S Thyroid Storm (Thyrotoxicosis) All hyperthyroid manifestations are heightened- High fever (105 F), Severe tachycardia/HF- can cause seizures, shock, coma.
Thyroid Storm (Thyrotoxicosis) Managementmonitoring for cardiac dysrhythmias and decompensation, ensuring adequate oxygenation, & admin IV fluids to replace F&E losses; Admin meds to block thyroid hormone production and the sympathetic nervous system [Beta blockers (↓ tachycardia, nervousness, tremors)] BOLO: Resp distress
5 ‘Bs’: Block synthesis (antithyroid drugs); Block release (iodine); Block T4->T3 conversion (PTU, propranolol, corticosteroid); Beta-blocker; & Block enterohepatic circulation (cholestyramine)
Hyperthyroidism tx propylthiouracil (also for thyroid storm); use radioactive isotope sodium iodide-131 (RAI); removal of thyroid gland – teach pt about s/s hypothyroidism
Hyperthyroidism Patient/Family EducationExophthalmos (risk for corneal abrasion, ulcers, loss of vision)- lightly tape eyes shut at night, use artificial tears; Elevate HOB at night, Diet-Restrict salt intake, High calorie/high protein, Supplemental vitamins, Weigh daily
Radiation thyroiditis/parotiditismay cause dryness/irritation of the mouth & throat
-Relief with frequent sips of water/ice chips/salt and soda gargle three or four times per day (1 tsp salt & 1 tsp of baking soda in 2 cups warm water; discomfort should subside in 3-4 days)
-To ↑ comfort when eating -mixture of antacid (Mylanta or Maalox)/diphenhydramine/viscous lidocaine can be used to swish & spit
Home precautions for RAI 1. use private toilet facilities- flush 2-3 times after each use
2. separately launder towels, bed linens, clothes daily at home
3. do not prepare food for others
4. avoid being close to pregnant women/children for 7 days after therapy
Presence of goiterin hypo r/t TSH trying to get thyroid to work; in hyper r/t overproduction of T3/T4
Goitrogensthyroid-inhibiting substances
-Drugs: PTU, methimazole, ↑doses of iodine, sulfonamids, salicylates, lithium, amiodarone
-Foods: broccoli, Brussel sprouts, cabbage, cauliflower, kale, mustard, peanuts, turnips
Goiter Assessment/ManagementTSH & T4 levels are measured to determine if goiter is associated with hyperthyroidism, hypothyroidism, normal thyroid function
ThyroidectomyDone endoscopically or as open procedure in pts unresponsive to tx or w/ cancer (ask if parathyroid glands are left in). Clients must take thyroid hormones permanently
Thyroidectomy Preoperative-Admin antithyroid drugs, iodine, & beta blockers to achieve a euthyroid state; Iodine reduces vascularization of the thyroid gland, reducing the risk of hemorrhage
-Assess for s/s of iodine toxicity (swelling of buccal mucosa/mucous membranes, ↑salivation, N&V, skin reactions)
-Teach about comfort/safety measures for post-sx (how to support head, ROM exercises, IV, difficulty speaking)
Thyroidectomy Postoperative-Monitor q 2 hr for 1st day for hemorrhage/trach compression by edema; placed in Semi-Fowlers, avoid pressure on sutures (no neck flexion)
-Monitor for hypocalcemia (signs of tetany; tingling in toes/fingers/around the mouth/muscular twitching/apprehension; evaluate difficulty speaking /hoarseness; monitor Trousseau’s & Chvostek’s sign)
Post-op BOLOInfection/hemorrhage, Thyroid storm, Respiratory obstruction, Laryngeal edema, Vocal cord injury (r/t nerve damage). Removal of parathyroid glands- watch for hypocalcemia (have IV calcium salts at bedside)
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Adrenal

Question Answer
Adrenal cortexProduces steroid hormones/Corticosteroids: glucocorticoids- regulate glucose metabolism & are critical in physiologic stress response (cortisol); mineralocorticoids- regulate sodium & potassium balance (aldosterone); gonadocorticoids - contribute to G&D in both genders & sexual activity in adult women (androgen/estrogen)
Adrenal insufficiency - PrimaryAddison’s Disease: Idiopathic atrophy/destruction of adrenal glands by autoimmune process or other disease. All steroids hormones are reduced
Adrenal insufficiency - SecondaryLack of cortisol only; caused by long-term steroid use or damage to pituitary (radiation/cancer) - also from sx/trauma/post-partum hemorrhage -Sheehan’s
Adrenal Insufficiency Clinical ManifestationsUsually insidious, progressive weakness, fatigue, weight loss/anorexia; bronze-colored skin hyperpigmentation; orthostatic hypotension, tachycardia, hyponatremia, salt-craving, hypoglycemia, hyperkalemia, N&V, diarrhea; irritability & depression
Adrenal/Addisonian CrisisEmergent condition, Acute adrenal insufficiency (↓Plasma/urinary cortisol levels, ACTH may be ↓or↑ depending on cause); ECG may show low voltage and peaked T waves caused by hyperkalemia; CT /MRI may be used to identify other causes of symptoms
Adrenal Crisis CausesStress (pregnancy/surgery/infection/psychological distress), Sudden w/drawal of corticosteroid tx, Adrenal sx, Sudden pituitary gland distruction
Adrenal Crisis Clinical ManisSevere vomiting, diarrhea, pain in the abd, lower back, legs. Hypotension (particularly postural), Tachycardia, Dehydration, Hyponatremia, Hyperkalemia, Hypoglycemia, Fever, Weakness, Confusion. Hypotension may lead to shock. Circulatory collapse associated w/ adrenal insufficiency is often unresponsive to usu tx (vasopressors/fluid replacement)
Adrenal Crisis ManagementCorrect F&E imbalances, Rapid rehydration with .9% NS, Replace steroids (hydrocortisone), Correct hypoglycemia, 5% Dextrose IV, Vasopressors, Kayexalate (tx of hyperkalemia); Establish baseline data - mental status, VS, weight; Watch for infection, keep stressors ↓ (no cortisol = cannot handle stress)
Addison’s Pt/Family EdRecognizing the need for extra medication & techniques for stress management. Stressors may inc: fever, influenza, extraction of teeth, rigorous physical activity; Wear Medic Alert bracelet, patient should carry an emergency kit at all times with 100 mg of IM hydrocortisone, syringes, and instructions for use; Notify PCP if N&V, diarrhea, s/s of steroid deficiency or excess
Hypercortisolism (Cushing’s) CausesMedical interventions (corticosteroid administration) account for most cases, Adrenal tumor, Excessive ACTH secretion, Pituitary hypersecretion secondary to pituitary tumor
Cushing’s Clinical ManisNormal function of the glucocorticoids become exaggerated, Poor wound healing, Osteoporosis, Muscle wasting, Masculine characteristics in women, Memory loss, poor concentration, Persistent hyperglycemia, Potassium depletion, Sodium & water retention, HTN, Abnormal fat distribution, Moon-face, Fat pad on back of neck (buffalo hump), Obesity with slender limbs, Thin, fragile skin, Purple striae on breasts & abdomen
Cushing’s Lab Findings↑Plasma cortisol/urine cortisol, ↓Plasma ACTH (may also be nl or ↑ depending on cause); may see leukocytosis, lymphopenia, eosinopenia, hyperglycemia, glycosuria, hypercalciuria, hypokalemia, alkalosis
Cushing’s Diagnostics24 hour urine collection for free cortisol, High dose dexamethasone suppression test (to see how taking corticosteroid changes cortisol levels in blood), CT (pituitary & adrenal glands), MRI
Cushing’s Management↓corticosteroid use over time while still managing condition (example: asthma/arthritis), Meds that interfere w/ ACTH production/adrenal hormone synthesis, Surgical (adrenalectomy), Lifelong glucocorticoid/mineralocorticoid replacement, Most physical manifestations resolve after bilateral adrenalectomy, Surgical (resection of pituitary tumors), Transsphenoidal adenomectomy, Surgical removal of a small, well-defined pituitary adenoma
Hypophysectomy or Adrenalectomy Pre-opHypertension & hyperglycemia must be controlled; Hypokalemia must be corrected w/ diet & potassium supplements; High-protein diet helps correct the protein depletion; Pre-op teaching for expectations of sx & after-effects
Hypophysectomy or Adrenalectomy Post-opSurgery on adrenal glands poses ↑risks than other operations; Adrenal glands are vascular ↑risk of hemorrhage; Manipulation of gland during surgery may release ↑amounts of hormones into the circulation, producing marked fluctuations in the metabolic processes (BP, F&E balance). Monitor VS, I&Os, urine samples in AM for cortisol measurement, be aware of infection risk
Cushing’s Pt/Family EdPatients on corticosteriods are at risk for Cushing’s, Recognizing manifestations “Don't reduce dose of corticosteroid drugs or stop taking them on your own.”
Hyperaldosteronism Clinical ManisMay be asymptomatic, HTN, Hypernatremia, Hypokalemia, Excessive urinary excretion, Muscle weakness, Cardiac dysrhythmias (Aldosterone conserves sodium & promotes potassium excretion)
Hyperaldosteronism DiagnosisSerum potassium levels, Alkalosis, ↑urine/plasma aldosterone levels
Hyperaldosteronism Management Primary Spironolactone (Aldactone) – drug of choice, To increase sodium excretion, Treat HTN, Improves hypokalemia, Surgery, Unilateral or bilateral adrenalectomy, Temporary/permanent replacement therapy
Pheochromocytomaadrenal tumor that produces excessive catecholamines (revs the system up)
Pheochromocytoma ManisSevere, episodic HTN accompanied by classic triad of-severe, pounding headache, tachycardia w/ palpitations & profuse sweating, unexplained abd/chest pain
Pheochromocytoma Attacks may be provoked by many meds, including Antihypertensives, Opioids, Radiologic contrast media, TCAs
Pheochromocytoma dx & tx CT; surgical removal of tumor (usu given alpha/beta blocker for BP control 7-10 days pre-op)
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