Addison's and Cushing's Disease

Addison's Disease

• Consider it as hyperthyroidism symptoms
• Glucocorticoids are hyposecreted
• Insufficient aldosterone leads to water loss, similar to diuretics blocking aldosterone
• Results in hypovolemia and hot body temperature
• Increased potassium and calcium, decreased sodium
• Hypoglycemia occurs due to increased insulin production
• Wet skin can result
• Causes lethargy, fatigue, muscle weakness, and hypotension
• Weight loss occurs
• Can lead to decreased blood volume and shock
• Hyperkalemia can lead to metabolic acidosis and arrhythmias
• Treatment involves hormone replacement

Addisonian Crisis

• Defined as a medical emergency
• Critical deficiency of glucocorticoids occurs
• Generally follows acute stress, sepsis, trauma, surgery, or omission of steroid therapy
• Signs and symptoms include severe abdominal pain, sudden profound weakness, hyperpyrexia followed by hypothermia, coma, and renal failure

Cushing's Disease

• Consider it as hypothyroidism symptoms
• Glucocorticoids are hypersecreted
• Too much aldosterone leads to water retention
• Results in hypervolemia and cold body temperature
• Decreased potassium and calcium, increased sodium
• Hyperglycemia occurs due to decreased insulin production, potentially leading to ketoacidosis
• Dry skin results, along with generalized muscle wasting and weakness
• Hypertension occurs due to increased sodium levels
• Weight gain and slow healing are symptoms
• Physical signs include moon face, buffalo hump, obesity (trunk), thin skin, and reddish-purple striae
• Treatment involves hypophysectomy or adrenalectomy
• Osteoporosis can occur due to excess cortisol, leading to increased calcium reabsorption from bones

Hyperthyroidism

• Considered a fast process
• Metabolism increases
• Sympathetic nervous system symptoms are present
• Symptoms include nervousness, irritability, excitability, tachycardia, perspiration, flushed face, exophthalmos, increased appetite, limp hair, weight loss, and hypertension
• Heat intolerance occurs
• Iodine uptake increases
• Commonly associated with Graves disease

Hypothyroidism

• Considered a slow process
• Metabolism decreases
• Parasympathetic nervous system symptoms are present
• Symptoms include extreme fatigue, dry skin, coarse hair, numbness and tingling of fingers, alopecia, and weight gain
• Cold intolerance is present
• Iodine uptake decreases
• May lead to myxedema coma

Thyroid Storm

• Results in tachycardia
• Delirium symptoms are present
• Can lead to a coma
• Patients typically experience nervousness and insomnia
• Avoid placing patients in the same room due to overstimulation
• Private room is recommended

Removing Tubes and Things

• When removing chest tubes, patients should perform Valsalva maneuver or take and hold a deep breath
• For NG tube removal, have the patient take and hold a deep breath
• PICC line and TPN line removals also require the Valsalva maneuver

Hyperglycemia Hyperosmolar Nonketotic Syndrome (HHNKS)

• Typically occurs in people with DM-2
• Glucose levels exceed 800 ml/dL
• Gradual onset of symptoms occurs
• No presence of ketosis or acidosis
• Symptoms include polyuria, polydipsia, dehydration, mental status changes, weight loss, weakness, and headache
• Blood pressure decreases
• Treatment involves fluid replacement, correction of electrolyte imbalances, and insulin administration along with exercise
• Skin becomes warm, dry, and the mucus membrane dries out with a high temperature

DKA

• Typically occurs in people with DM-1
• Glucose levels range from 300-800 mg/dL
• Sudden onset of symptoms
• Characterized by ketosis, acidosis, and fruity breath odor
• Symptoms Include polyuria,dehydration, weight loss, dieresis with decreased blood pressure and tachycardia
• Treatment includes vasopressin and IV fluids along with regular insulin
• Kussmaul respirations occurs which presents as rapid and deep breathing
• Expected outcome leads to increased responsiveness

Sympathetic Nervous System

• Involves anticholinergic drugs
• Vasoconstriction occurs
• Tachycardia occurs
• Pupils dilate
• Digestion is inhibited, leading to constipation
• Nasal secretions are inhibited

Parasympathetic Nervous System

• Utilizes beta blockers
• Vasodilation occurs
• Bradycardia occurs
• Pupils constrict
• Digestion is stimulated, leading to diarrhea
• Nasal secretions are stimulated

Breath Sounds

• Tracheal breath sounds are very loud and high pitched
• Heard over the trachea, inspiration equals expiration
• Vesicular breath sounds are soft and low pitched
• Represents a normal breath sound, heard over lungs
• Inspiration is greater than expiration
• Bronchial breath sounds are very loud and high pitched
• Heard over the manubrium, consolidation if heard elsewhere
• Expiration is greater than inspiration
• Bronchovesicular breath sounds have intermediate intensity and pitch
• Heard in the first and second intercostal spaces on the anterior chest and between the scapula on the posterior chest
• inspiration equals expiration

Brain Lobe Functions

• Parietal lobe stands as the primary center for sensation
• Temporal lobe includes auditory reception areas
• Frontal lobe involved in personality, behavior, emotions, intellectual function, and difficulty comprehending language if injured
• Occipital lobe functions as the primary visual receptor center

Maslow's Hierarchy of Needs

• Self-Actualization focuses on achieving one's full potential, including creative activities
• Esteem Needs involves prestige and feeling of accomplishment
• Belongingness and Love Needs includes intimate relationships and friends
• Safety Needs focuses on security, safety, and protection
• Physiological Needs includes basic needs such as warmth, rest, thirst and hunger

Lab Values

• Potassium (K) normal range 3.5 – 5.1
• Sodium (Na) normal range 135 – 145
• Magnesium (Mg) normal range 1.6 – 2.6
• Chloride (Cl) normal range 98 – 107
• Calcium (Ca) normal range 8.6 – 10
• White blood cell count (Wbc) normal range 4500 – 11000
• Serum osmolality normal range 285 – 295; Elevated levels signify dehydration
• Decreased levels signify overhydration
• Hemoglobin (Hgb) normal range 14-16.5
• Hematocrit (Hct) normal range 42-52%
• Amylase normal range 25-151; Levels increase with pancreatitis
• Albumin normal range 3.4 – 5
• Iron (Fe) normal range 65-175
• ALT/AST normal range 5-60/5-43 and indicates liver function
• Uric acid normal range in men: 4.5 – 8 and Women: 2.5 – 6.2; levels increase with gout

More Lab Values

• Lipase normal range 10 – 140; Levels increase in liver disease
• Decreased levels of calcium can have + Trousseau’s sign in the arm, and + Chvostek’s sign on the cheek
• CK enzymes include MB (cardiac muscle), BB (brain), and MM (skeletal muscle)
• Troponins is a better indicator of detecting myocardial infarction
• Chloride(Cl-)range range >60
• IOP/ICP range 10-20
• Urine specific gravity range 1.010 – 1.025; > 1.030 dehydration
• Mantoux skin test result: >5mm with AIDS/HIV and >10mm normal
• Sedimentation rate rate increases with more inflammation
• ESR normal range in Men: 0-15mm/hr, Women: 0-20mm/hr
• HbA1c reflects glucose control over the past 3-4 months
• Diabetic with control is 7%
• Kidney disease causes false (-) low levels
• Hyperglycemia causes it to increase
• High triglycerides cause false (+) high levels

Conversions:

• 1cc is equal to 1ml and 15gtt
• 30cc is equal to 1oz
• 5cc is equal to 1tsp
• 15cc is equal to 1Tbs
• 1mg is equal to 1000mcg
• 60mg is equal to 1 grain

Medical Abbreviations

• bid means 2x a day
• tid means 3x a day
• qid means 4x a day
• qod means every other day
• ac means with each meal
• hs means at bedtime

Vital Signs

• Increased ICP leads to increased BP and decreased HR
• Shock leads to decreased BP and increased HR
• Bleeding leads to decreased BP and increased HR
• Cushing’s Triad (widening pulse pressure) leads to increased BP and decreased HR
• Autonomic dysreflexia leads to increased BP and decreased HR
• Air embolus leads to decreased BP and increased HR

Eye Medications and Conditions

• Mydriatic eye drops dilate pupils, large word = big pupils
• Miotic eye drops constrict pupils, little word = little pupils
• Glaucoma leads to optic nerve damage causing irreversible blindness
• Associated with blurred vision, halos, and loss of peripheral vision
• CVD patients are at risk
• Treat with meds to decrease IOP (B-blockers) and miotics, increase outflow of aq humor
• Goal is to prevent further deterioration
• Cataracts leads to lens opacity or cloudiness causing painless, blurry vision
• Patients surroundings are dimmer
• Diplopia is present
• Macular degeneration can be dry (nonexudative/slow) or wet (exudative/fast); drusen (tiny yellow spots)

Ulcers

• Arterial leg ulcers are small, circular, and deep
• Venous leg ulcers are large, irregular, and superficial
• Venous ulcers exhibit granulation tissue and are highly exudative
• Pain in arterial leg ulcers is intermittent claudication caused by activity
• Pain in venous leg ulcers is aching heaviness

Nephritis vs Nephrotic Syndrome

• Think "I" (thin kid)
• Presents with periorbital edema and facial edema
• High BP
• Anorexia
• Decreased urine output
• Hematuria
• Pallor, irritability, lethargy
• Proteinuria
• Increased BUN and ASO titer if pt had infection, creatitine
• Treatment involves antibiotics and antiHTN
• Nephrotic Syndrome or Nephrosis think "O" (round kid)
• Increased edema (ascites) and periorbital edema
• Low BP ,Lethargy, pallor, and anorexia
• Decreased urine output
• Swollen abdomen, labia, and scrotum
• Massive proteinuria
• Treatment includes steroids

Important Drugs:

• Olol is a beta blocker, affecting decrease HR and BP
• Pine is a Ca channel blocker that decreases HR and BP
• Pril is an ACE inhibitor affecting decrease BP and vasodilation
• Sartan is similar to ACE inhibitors

Digoxin Considerations

• Toxicity includes nausea/anorexia (early signs), green halos, and decreased urine output
• Monitor potassium and magnesium; low levels can increase toxicity
• Therapeutic level has to be less than 2 (0.8 – 1.5)
• Monitor K if pt is given with lasix
• Hypothyroidism patients are sensitive to dig (↓K)
• Calcium can worsen toxicity (↓Ca = ↓K)
• Usual dose = 0.25mg/day
• Decreases the workload of the heart and increases myocardial function
• Involves assessing apical pulse before administration and increasing intracellular Ca

Theophylline

• For ashtma, or COPD
• Should NOT give with food/drinks that contain caffeine

Miscellaneous Drugs

• MgSO4 therapeutic level is 4-7.5 and used for eclampsia and as a tocolytic
• Toxicity includes flushing, decreased RR, DTR, BP, UO and pulmonary edema
• Drugs that stimulate B1 increases HR
• Drugs that stimulate B2 dilate lungs
• Clozapine is an antipsychotic that poses a risk for agranulocytosis hence give an anticholinergic
• Treat pt give with Benztropine
• Tetracycline should be taken on an empty stomach and dairy may hinder can bind to it by preventing absorption

Lithium Toxicity

• Therapeutic level must be be 0.5 – 1.2
• Lidocaine causes drowsiness and CNS disturbances
• Lasix causes renal failure (↓OU), blood dyscrasias, and hearing loss
• Methergine increases ctx
• Terbutaline decreases ctx
• Bethanechol is a cholinergic med used for urinary retention
• Fosamax should be taken on an empty stomach
• Morphine signs of toxicity involves pinpoint pupils, and decreased RR
• Diuretics block aldosterone retaining H2O and Na and depleting K

Drug Information

• Infusion rate too fast causes hypotension
• Clomipramine (Anafranil) tricyclic antidepressant for depressed pt with OCD
• Clonidine treat HTN and opiate w/d
• Coumadin monitor PT with vit K as antidote
• Heparin monitor aPTT with protamine sulfate as antidote

Mental Health - Schizophrenic Patients

• Remember SDS = Structure, Diversion, Stress reduction
• Provide them major needs
• Paranoid patients do not encourage their coping mechanisms
• Ask is if they “hear voices?”

Panic Attacks

• Include sympathetic NS symptoms like HTN, increased HR, increased alertness, SOB and trembling
• Alcohol withdrawl symptoms are treated with Librium
• Must have balance of safety/ security/ belonging/ love/esteem/self-actualization

Crisis Types

• Situational involves an external source, unanticipated
• Divorce / Loss of job / Death of loved one / Abortion / Severe physical or mental illness
• Maturational happens at a developmental stage
• Marriage / Birth of child or retirement
• Adventitious is a crises form of disaster that is no part of every day life
• Have them reorganize something

Manic Patient

• Requires them to reorganize something
• Akathisia presents as restlessness, pacing, inability to set still
• Dystonia presents as tonic contractures of muscles in the neck, mouth, tongue
• Parkinsonism presents with muscle rigidity, shuffling gait, stooped posture, flat-faced affect with tremors, drooling
• Previous coping skills has the greatest influence on the outcome of a crisis situation
• In cases of extreme stress do not teach or educate patients because learning is limited

Syndrome Types

• Serotonin syndrome side effects involves diarrhea, irrititablity, restlessness
• Double blind communication is when the pt says “I love you” but has a grimace on the face
• Always chose least restrictive intervention for Restraining

Precautions

• In Standard uniform level of caution that should be used in all patients in a primary goal that prevents of nosocomial infection
• Follow through with hand hygiene and glove usage
• Follow though with masks, eye protection, and gown for other misc barriers
• In Contact organisms are easily spread by in skin-to-skin contact by patients
• The pt may required to have their personal environment
• Follow through with enteric infections with low infectious doses with c-diff,GI, and wound infections
• Follow through with RSV plus skin infection shingles and conjunctivitis

Food Restrictions

• Tyramine is avoided for MAOIs patients; examples figs, avocados, bananas plus cheese and wine
• Purine is avoided with gout
• Vitamin k and Thiamine are use for Coumadin diet
• Folic acid can be found in papaya and peanuts
• Theophylline avoided with caffeine

Vitamin Toxicity:

• Vitamin D toxicity includes GI upset with metallic taste, HA, weakness and hypertension
• Vitamin A toxicity includes hair loss, weakness, renal insufficiency

Other Medications

• Glucocorticoids cause hyperglycemia which required insulin
• BetaBlockers effects for hyperkalemia
• Lidocaine for dysrythmia
• Mannitol for ICP
• Furosemide (Lasix) for fluid overload
• Antibiotics for infections

Burns

• Partial Thickness involves sunburn, blistered, no edema, painful and red
• Deep Partial Thickness involves all dermis level and involves edema plus blistered or red skin
• Full Thickness has all damage until muscle/bone skin with dry and no blister
• Fluid Replacement is high risk with potassium change, electrolyte and fluid shift

Illnesses

• Guillain Barre causes increase weakness
• Syndrome c/o resp or GI infection and causes loss of myelin sheath and lead breathing problem or paresthesis

Surgeries Pt Must Know

• Hip Replacement includes post-op: external and internal rotation
• No side-lying and maintain supine position or maintain non-operative
• Do not cross legs with and use pillows

Heart Problems

• Cardiac Tamponade involves fluid heart which causes chest pain or SOB
• Med problems involve monitor pt lab values for electrolyte imbalance or toxicity
• Peripheral Vascular disease involves blood pooling in extremities which must promote rest with high blood, promote stockings

Maternal Care

• Maternal Care
• Ectopic pregnancy requires that a rupture has occurred and assess Cullen sign
• HTN
• HCG
• HELLP
• Spontaneous abortion

Labor

• Monitor station level or contractions
• Previa/ Abrupto with P+A and BPP
• Promote baby with fluid and increase heartbeats

Baby Care

• Vitmain K for injection
• Know APGAR to provide accurate care
• Know formula intake for moms

Medications

• Dilantin
• Sinemet
• Imirex
• Aricept
• Nucain
• Narcan
• Morphine
• Elavil
• B12
• Aldactone
• Tylenol
• Lasix
• Proza