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Questions and Answers
What type of anemia is characterized by microcytic, hypochromic cells?
Which condition is associated with a beefy red tongue and nerve degeneration due to vitamin B12 deficiency?
What vitamin is essential for the absorption of iron in the body?
What condition arises when the rate of red blood cell destruction exceeds the formation rate?
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Which of the following describes the blood cell characteristics of megaloblastic anemia?
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What can continuous oozing of blood after surgery lead to?
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What is a key symptom of thyroid crisis post-operation?
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In Type 1 diabetes mellitus, which is a characteristic?
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What is the primary management for diabetic ketoacidosis (DKA)?
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What is the expected onset time for rapid-acting insulin?
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What is a common cause of altered level of consciousness?
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In diabetes management, what dietary component should comprise 45-65% of the diet?
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What is a key difference between Type 1 and Type 2 diabetes?
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What is the earliest manifestation of thyroid crisis post-op?
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Hypoglycemia symptoms include all of the following except:
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What dietary adjustments are recommended for a patient experiencing diabetes?
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Which insulin type has the longest duration of action?
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Which of the following represents the mechanism of action for sulfonylureas?
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What observation should be made in a patient with potential hypoglycemia?
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What is a common manifestation of Cushing's syndrome due to increased cortisol levels?
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Which hormone is primarily deficient in Addison's disease?
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What is the primary cause of Conn's disease?
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Which test measures the level of catecholamines in the blood?
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What effect does long-term steroid use have related to Addison's disease management?
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What symptom is characteristic of hypothyroidism in adults?
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Which of the following is managed by administering mineralocorticoids?
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What is the typical laboratory finding in primary hyperthyroidism?
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What participates in the feedback mechanism controlling T3 and T4 production?
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Which of the following is a common complication following a total thyroidectomy?
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What electrolyte imbalance is typically associated with Addison's disease?
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What is the primary pharmacological treatment for hyperthyroidism?
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Which symptom is NOT typically associated with Addisonian crisis?
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Which of the following would be an expected urinary finding in hyperthyroidism during a VMA test?
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What is primarily responsible for the occurrence of hemolytic anemia?
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Which of the following can lead to hypoplastic or aplastic anemia?
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What condition is associated with decreased levels of circulating red blood cells due to blood loss?
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Which symptom indicates cerebral hypoxia caused by anemia?
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Which dietary component is essential for erythropoiesis in anemia management?
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What is the primary treatment for severe hypoplastic anemia?
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What is a significant risk factor associated with thrombocytopenia in patients with aplastic anemia?
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Which of the following is a potential cause of secondary polycythemia vera?
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What nursing responsibility is important when managing a patient with bone marrow depression?
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What is a characteristic symptom of hemolytic jaundice resulting from hemolysis?
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What condition is characterized by an increased production of cerebrospinal fluid (CSF)?
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Which drug is known as a hyperosmolar agent that helps draw fluid from interstitial spaces to reduce intracranial pressure?
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What is the recommended position for someone who has undergone supratentorial surgery?
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Which cranial nerve tumor is specifically known as a neuroma?
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When addressing increased CO2 levels, which management technique focuses on promoting hyperventilation?
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What is a common complication associated with the use of anticoagulants like warfarin?
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Which test is used to monitor the therapeutic levels of heparin?
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Which drug can cross the blood-brain barrier and is effective in reducing cerebral edema?
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What is the purpose of plasminogen activators in medical treatment?
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What is the main goal when positioning a patient who has undergone infratentorial surgery?
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Which of the following is a potential danger associated with the use of thrombolytic therapy?
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What is the first sign of increased intracranial pressure associated with a brain tumor?
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What position should a client be in after craniotomy to prevent increased ICP?
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Which of the following is a common side effect associated with antiplatelet medications like aspirin?
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What is the action of dexamethasone in the management of increased intracranial pressure?
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Study Notes
Vitamin D
- Vitamin D increases calcium reabsorption
Hyperparathyroidism/Hypercalcemia
- Increased parathyroid hormone levels leading to increased calcium levels in the blood
Adrenal Glands
- Adrenal cortex produces cortisol, mineralocorticoids, and androgens
- Adrenal medulla produces catecholamines (epinephrine and norepinephrine)
Cushing's Syndrome
- Hyperactive adrenal cortex
- Increased cortisol production
- Increased sugar, salt, and sex hormones
- Increases gluconeogenesis leading to hyperglycemia
- Increases lipolysis leading to abnormal fat distribution (moon face, buffalo hump)
- Increases protein catabolism leading to muscle wasting
- Decreases fibroblastic activity leading to skin thinning and striae
- Increases mineralocorticoid production (aldosterone) leading to fluid and sodium retention
- Increases blood volume, leading to increased blood pressure
- Increases sodium and decreases potassium levels in blood
- Increases androgen production leading to virilism (masculinization), hirsutism (excessive hair growth)
- Increased sugar, salt, and sex hormones
- Can be caused by prolonged steroid therapy
- Management
- Adrenalectomy
- Cortisol inhibitors (aminoglutethimide)
- Trilostane
- Metyrapone
- Mitotane
Addison's Disease
- Hypoactive adrenal cortex
- Decreased cortisol, salt, and sex hormones
- Decreased sugar hormone leads to hypoglycemia and increased ACTH production
- Increased ACTH leads to skin hyperpigmentation
- Decreased salt hormone leads to decreased blood volume and hypovolemia
- Decreased blood volume causes hypotension
- Hypokalemia and hypernatremia can occur
- Decreased sex hormone leads to loss of axillary and pubic hair
- Management
- Steroid supplementation (prednisolone, dexamethasone, hydrocortisone, betamethasone)
- Can cause hyperglycemia and require blood sugar monitoring
- Can cause fluid and sodium retention requiring sodium restriction and fluid intake monitoring
- Can cause osteoporosis and require calcium supplementation
- Can lead to fragile capillaries and risk of ecchymosis; avoid trauma or injury
- Suppresses immune system and requires taking precautions to avoid infection
- Requires tapering the dosage to prevent Addisonian crisis
- Aldosterone supplementation (fludrocortisone/Florinef)
- Steroid supplementation (prednisolone, dexamethasone, hydrocortisone, betamethasone)
Addisonian Crisis
- Can occur if steroid dosage is not tapered
- Hypoglycemia, hypotension, hyperkalemia, hyponatremia can occur leading to cardiac arrest
Conn's Disease
- Results from an adenoma (benign tumor) of the adrenal cortex
- Increased aldosterone production
- Fluid and sodium retention and hypervolemia
Pheochromocytoma
- Results from adenoma (benign tumor) of the adrenal medulla
- Increased catecholamine (epinephrine and norepinephrine) production
- 5 Hs:
- Hypertension
- Headache
- Hyperglycemia
- Hypermetabolic
- Hyperhidrosis
- VMA test
- Evaluates the level of catecholamines in the blood and urine
- Collect a 24-hour urine specimen
- Management
- Adrenalectomy
Thyroid Glands
- Anterior aspect of the neck contains two thyroid lobes connected by the isthmus
- Produces T3 (triiodothyronine), T4 (thyroxine), and thyrocalcitonin
- Iodine + tyrosine = thyroglobulin (storage form of thyroid hormone)
- Released into circulation as T3 and T4
- Feedback mechanism
- Anterior pituitary gland produces TSH (thyroid-stimulating hormone) which stimulates the thyroid gland to produce T3 and T4
- Low levels of T3 and T4 stimulate TSH production
- High levels of T3 and T4 inhibit TSH production
- Anterior pituitary gland produces ACTH (adrenocorticotropic hormone) which stimulates the adrenal cortex to produce cortisol, mineralocorticoids, and androgens
- Anterior pituitary gland produces TSH (thyroid-stimulating hormone) which stimulates the thyroid gland to produce T3 and T4
- T3 and T4 are needed for growth and development
Thyroid Disorder Tests
- PBI (Protein Bound Iodine)
- Evaluates the amount of iodine attached to the protein molecules in the blood
- Normal: 4-8 ug%
- Below 4 = hypothyroidism
- Above 8 = hyperthyroidism
- Avoid food and drugs containing iodine for 2-3 days prior to blood test
- T3T4
- Evaluates the levels of T3 and T4 in the blood
- Normal:
- T3 = 70-170 ug%
- T4 = 4.7-11 ug%
- Directly proportional to thyroid function
- High levels = hyperthyroidism
- Low levels = hypothyroidism
- No NPO required
- TSH
- Evaluates the levels of TSH in the blood
- Normal: 0.6-4.7 ug/ml
- Inversely proportional to thyroid function due to negative feedback mechanism
- High levels = hypothyroidism
- Low levels = hyperthyroidism
- No NPO required
- BMR (Basal Metabolic Rate Determination)
- Evaluates O2 consumption when the client is at rest
- NPO 12 hours prior to the test
- Patient must have had a good night's sleep
- Client breathes into a tube connected to an O2 tank and a machine that measures O2 consumption
- TBMR (Theoretical Basal Metabolic Rate Determination)
- Pulse pressure + pulse rate/min - 111
- Normal: 20-30
- Not definitive due to factors that can influence BP and heart rate; only a rough estimate
- RAIU (Radioactive Iodine Uptake)
- Evaluates the amount of radioactive RAI131 accumulated by the thyroid gland and excreted by the kidneys
- Normal:
- Uptake = 15-40%
- Urine = 40-80%
- Avoid food or drugs containing iodine prior to the procedure
- Administer RAI131 cocktail orally
- Collect 24-hour urine specimen
- After 24 hours, scan with a geiger counter
- Normal: 15-40% of the original amount (1.2-3.2 millicuries)
- Less than 1.2 millicuries (15%)= hypothyroidism
- More than 3.2 millicuries (40%) = hyperthyroidism
- Normal: 40-80% of the original amount in urine (3.2-6.4 millicuries)
- Less than 3.2 millicuries (40%) = hypothyroidism
- More than 6.4 millicuries (80%) = hyperthyroidism
- Normal: 15-40% of the original amount (1.2-3.2 millicuries)
- Reuptake is directly proportional to thyroid function; urine excretion is inversely proportional to thyroid function
- Thyroid Scan
- Evaluates the size, shape, and function of the thyroid gland
- Only measures the amount of RAI131 stored by the thyroid gland
Hypothyroidism
- Decreased T3 and T4 production
- Decreased activity of sebaceous and sweat glands
- Accumulation of mucopolysaccharide subcutaneously
- Mucinous facies or myxedema (non-pitting edema, thickened skin, enlarged tongue, dry waxy edema, deepening of the voice)
- Can occur during childhood (cretinism) or adulthood (myxedema)
- Primary Hypothyroidism
- Thyroid gland fails to produce T3 and T4
- Secondary Hypothyroidism
- Anterior pituitary gland fails to produce TSH
- Symptoms:
- Stunted growth
- Delayed puberty
- Hypometabolic
- Below normal vital signs
- Decreased appetite and weight gain
- Poor memory
- Mental sluggishness
- Difficulty tolerating cold weather
- Management
- Supplemental thyroid preparations (thyroxine/Levothyroxine/Liothyronine, proloid (thyroglobulin), cytomel, synthroid, euthroid, thyrolar, thyrax, thydin, eltroxin)
Hyperthyroidism
- Graves' Disease/Basedow/Parry's Disease/Thyrotoxicosis/Toxic Goiter
- Theories:
- LATS - gamma globulin in the blood known as long acting thyroid stimulator (LATS) → iodine accumulation & thyroid hyperplasia → manifests goiter
- EPS - anterior pituitary gland releases an exophthalmos-producing substance → eye signs
- Triad symptoms:
- Goiter (enlargement of the thyroid gland)
- Eye signs (exophthalmos, proptosis (downward displacement of eyeball), lid lag, infrequent blinking (Dalrymple's sign), fixed stare, periorbital edema, von Graefe's sign)
- Hyperthyroidism (elevated T3 & T4)
- Hyperactive, hypermetabolic
- Increased appetite but no weight gain
- Overexcitation of SNS (tremors, diaphoresis, palpitations, nervousness)
- Diarrhea (most common GI problem in Graves' disease)
- Constipation (most common GI problem in uncontrolled advanced Graves' disease)
- Simple Goiter
- Enlarged thyroid gland but no exophthalmos or tremors
- Due to iodine deficiency (endemic goiter in mountainous areas)
- Toxic Goiter/Grave's Disease
- Elevated T3 & T4
- Any goiter can become toxic
- Management
- Anti-thyroid medications
- Tapazole/methimazole, PTU - propylthiouracil, Neomercazole/carbimazole
- Agranulocytosis (decreased neutrophils, eosinophils, basophils) can occur; monitor differential count or CBC
- Iodine preparation
- Lugole solution, KISS (potassium iodide saturated solution) / SSKI (saturated solution of potassium iodide)
- Reduces vascularity
- Increases firmness of the gland
- Promotes storage of T3 and T4
- Adrenergic blocking agents
- Propanolol, Inderal, betaloc, atenenolol, Naldol
- To control the symptoms of SNS overexcitation (decreases BP, tremors, etc)
- RAI131
- Reduces the size of the gland through isotope destruction
- Risks: congenital abnormalities and genetic mutations
- Surgery - thyroidectomy
- Sistrunk - removal of thyroglossal cyst
- Right/left thyroid lobectomy - removal of left or right thyroid lobe
- Isthmusectomy - removal of the connection between the thyroid lobes
- Radical/total thyroidectomy - removal of 5/6 of the gland to prevent hypothyroidism (unless cancerous)
- Requires thyroglobulin supplementation for life to prevent hypothyroidism
- Anti-thyroid medications
Nursing Responsibilities
- Establish patent airway; semi-Fowler's position; No high Fowler's position to prevent strain on suture line
- Encourage cough exercises and turning from side to side
- Monitor cardiopulmonary function and vital signs until stable
- Promote adequate nutrition and fluid/electrolyte balance
- Food can be given when gag reflex returns
- Promote adequate elimination
- Expect urination 6-8 hours after anesthesia return
- Encourage early ambulation to shorten recovery time and prevent post-op complications
- Monitor for post-op complications:
- Tetany (calcium and Vitamin D supplementation)
- Hoarseness & aphonia (No voice)
- Bleeding
Post-Thyroidectomy
-
Bleeding can occur after a thyroidectomy.
- Failure to Ligate Bleeders can lead to a hematoma, which can occlude the trachea and cause airway obstruction.
- Signs of Bleeding: Dampness under the nape, tightness around the neck, choking sensation, rapid, weak, feeble, and thready pulse, decreased blood pressure, rapid but shallow respirations.
- Respiratory Obstruction can occur secondary to bleeding.
-
Laryngospasm and laryngeal edema can occur due to surgical trauma, anesthesia, or hypocalcemia.
- Emergency Tracheostomy may be necessary.
-
Thyroid Crisis/Storm
- Preoperative anxiety and postoperative infection can cause thyroid storm.
- Elevated T3 and T4 levels preoperatively.
- Antithyroid medications are administered to achieve a euthyroid state.
- Stress or wound infection postoperatively can cause the remaining thyroid gland to compensate, leading to elevated T3 and T4.
- Earliest Manifestation: Fever and tachycardia.
- Management: Same as hyperthyroidism.
- Tracheostomy set must be at the bedside.
Post-Thyroidectomy Health Teachings
-
Diet: High in calories, carbohydrates, protein, and unsaturated fats.
- Avoid stimulants: Colas, caffeinated beverages.
- Increase fluid intake due to diaphoresis.
- Physical and mental rest is necessary.
- Quiet, calm, and restful environment is essential.
-
Eye Signs:
- Exophthalmos: Instill saline to moisten the eye and use dark glasses.
- Periorbital edema: Elevate the head on several pillows to promote drainage.
- Medical and surgical treatment cannot regress the eye signs.
Diabetes Mellitus
-
Diagnostics:
- FPG (Fasting Plasma Glucose): Fasting blood sugar.
- RBS (Random Blood Sugar): No NPO required.
- PPBS (Postprandial Blood Sugar): Determined 2 hours after a meal containing at least 100g of carbohydrates.
- Hgt/CBG (Hemoglucotest/Capillary Blood Glucose)
- OGTT (Oral Glucose Tolerance Test)
- BT/CT (Benedicts Test/Climistert Test): For glycosuria.
- Acetate Test: For ketonuria (ketone bodies in the urine).
-
Hgb A1C (Glycosylated Hemoglobin): Evaluates the amount of glucose attached to hemoglobin for the previous 120 days (RBC lifespan).
- Evaluates compliance to medical management after 3-4 months of continuous treatment.
Type 1 Diabetes
- Absolute Insulin Deficiency
- Age: 15-30 years old.
- Body type: Slender.
- Prone to DKA (Diabetic Ketoacidosis)
- Best way to control blood sugar: Insulin.
Type 2 Diabetes
- Relative Insulin Deficiency (due to insulin resistance)
- Age: Over 40 years old.
- Body type: Obese.
- Prone to HHNS (Hyperglycemia Hyperosmolar Nonketotic Syndrome)
- Best way to control blood sugar: Oral hypoglycemic agents, weight management, regular exercise, dietary regimen.
Diabetes Symptoms
- Tissue Starvation: Polyphagia, weight loss.
- Failure of cells to utilize glucose for energy: Weakness, hyperglycemia.
- Hyperosmolarity due to hyperglycemia: Polyuria, glycosuria.
- Extracellular fluid dehydration: Polydipsia.
Insulin Management
-
Insulin Types:
- Rapid Acting: Onset 10-15 minutes, peak 30 minutes-1 hour, duration 3 hours.
- Short Acting: Onset 30 minutes-1 hour, peak 2-4 hours, duration 6 hours.
- Intermediate Acting: Onset 2-4 hours, peak 6-12 hours, duration 24 hours.
- Slow Acting/Long Acting: Onset 6-8 hours, peak 18-24 hours, duration 36 hours.
-
Insulin Administration: Subcutaneous, intramuscular, intravenous.
- Not administered orally: Proteinase (gastric enzyme) destroys insulin.
- Most common insulin given intravenously: Humulin R, Crystalline Zinc Insulin, Regular Insulin.
- D5W + Insulin: Increases reuptake of potassium, used to treat hyperkalemia.
Hypoglycemia/Hyperinsulinism/Insulin Shock
- Causes: Insulin overdose, prolonged NPO and vomiting, long interval between insulin administration and food intake.
- Symptoms: Hunger pangs, double vision, pallor, cold clammy skin, profuse perspiration, decreased temperature, normal blood pressure, tremors.
DKA/Hyperglycemia/Diabetic Coma
- Causes: Missed insulin dose, infection, stress.
- Symptoms: Thirst, dim vision, flushed skin, warm to touch, cherry red lips, increased temperature, blood pressure below normal, Kussmaul respirations, fruity acetone breath.
Diabetes Management
- Ketoacidosis: Administer rapid-acting insulin (intravenous regular insulin preferred over intramuscular rapid-acting insulin).
-
Hypoglycemia: Initially administer 10-15g of carbohydrates.
- If altered level of consciousness, place 1 tablespoon of sugar in the oral cavity.
- If not corrected, administer epinephrine (1:1,000 subcutaneous), glucagon (1-2mg intramuscular), or intravenous glucose.
Dawn Phenomenon
- Happens during sleep: Normal or below normal blood sugar.
- Counterregulatory hormones (thyroxine, epinephrine) are released at 2-3am.
- Consider insulin timing and peak of action.
- Do not attempt to give a midnight snack.
Somogyi Effect
- Patient goes to sleep with normal blood sugar.
- Rebound hyperglycemia occurs around 2-3am.
Oral Hypoglycemic Agents (OHA)
- Contraindications: Pregnancy, infection, surgery, stress, signs of allergy, kidney or liver disease.
- Onset: 1-3 hours after administration.
- Peak: 4-8 hours after administration.
-
Duration: 12-24 hours after administration.
-
Sulfonylureas:
- Stimulates the beta cells of the islets of Langerhans to secrete endogenous insulin.
- Common adverse effects: Headache, body weakness, gastrointestinal upset, paresthesia, tinnitus.
-
Biguanide:
- Increases glucose uptake by the cells.
-
Alpha Glucosidase Inhibitors:
- Delays glucose absorption.
-
Thiazolidinedione:
- Enhances the effect of insulin at the receptor site without increasing insulin release from beta cells.
- Combination of Biguanide and Thiazolidinedione (Actosmet):
-
Sulfonylureas:
Diabetes Health Teachings
-
Dietary Regimen:
- Carbohydrates (45-65%):
- Simple carbohydrates: Fruits, sugar.
- Complex carbohydrates: Rice, starch, bread, noodles, pasta.
- Protein (15-20%).
- Fat (10-15%).
- Carbohydrates (45-65%):
-
Regular Exercise:
- Working muscles use stored glucose for energy (insulin not needed).
- Take snacks between exercises to prevent hypoglycemia.### Anemia
- Characterized by a decrease in the oxygen-carrying capacity of the blood
- Causes:
-
Hemolysis: RBC destruction greater than formation
- This can be caused by: exposure to ionizing radiation, post-viral diseases, toxic drugs and chemicals (prolonged use of penicillin, chloramphenicol), and improperly cross-matched blood transfusions.
-
Bone marrow repression:
- Example: bone marrow depression associated with chemotherapy or radiotherapy
-
Blood loss:
- Examples: menstruation, trauma, surgery
-
Iron deficiency anemia:
- Cells are microcytic and hypochromic.
- Signs: dysphagia (difficulty swallowing), atrophic glossitis (inflammation of the tongue), stomatitis/mucositis (inflammation of the oral mucosa)
-
Folic acid deficiency anemia:
- Cells are macrocytic and hyperchromic.
-
Pernicious anemia:
- Cells are macrocytic and hyperchromic.
- Signs: beefy red tongue due to gastric atrophy and malabsorption of Vitamin B12, paresthesia (nerve degeneration manifested by numbness or tingling)
-
Hemolysis: RBC destruction greater than formation
-
Symptoms:
- Decreased hemoglobin count, causing reduction in oxygen-carrying capacity leading to tissue hypoxia.
-
Signs of tissue hypoxia:
- Brain: restlessness, headache, syncope (fainting), irritability
- Heart: anginal pain, increased PR interval, weakness, easy fatigue (earliest indicator of anemia)
- Respiratory: increased respiratory rate, dyspnea (difficulty breathing)
- Gastrointestinal: anorexia, angular cheilosis (lesion at the corners of the mouth)
- Skin and mucous membranes: pallor (paleness), brittle hair, intolerance to cold, brittle nails (including a characteristic "spoon-shaped" appearance known as koilonychia)
Nursing Responsibilities
-
Address decreased erythropoiesis (blood production):
- Provide high-protein diet and include folic acid-rich foods (green leafy vegetables, eggs, milk)
- Administer hematinic agents to increase blood heme (iron)
- Ensure a warm environment.
-
Reduce energy expenditure:
- Encourage moderation in physical activity with periods of rest.
-
Bone marrow depression:
- Practice reverse isolation to prevent infection (due to leukopenia - low white blood cell count)
-
Avoid trauma and injury due to thrombocytopenia (low platelet count):
- Use soft-bristled toothbrushes, electric razors, avoid forceful blowing of the nose, prevent constipation, avoid parenteral injections (if absolutely necessary, use the sharpest needle)
-
Blood transfusions:
- Packed red blood cells for cases of decreased erythropoiesis and hemolysis
- Fresh, whole blood transfusion for cases of bone marrow depression and blood loss
-
Surgical management:
- Hemolytic anemia: splenectomy (removal of the spleen, which can act as a reservoir for abnormal RBCs)
-
Hypoplastic anemia: bone marrow transplantation
-
Donors (compatible based on human leukocyte antigen - HLA)
- Twin (syngeneic bone marrow transplantation)
- Related/unrelated individual (allogeneic bone marrow transplantation)
- Patient himself (autologous bone marrow transplantation), harvested during remission periods
-
Donors (compatible based on human leukocyte antigen - HLA)
Polycythemia Vera
- Primary polycythemia vera: hyperproliferative bone marrow of unknown cause
- Secondary polycythemia vera: result from tissue hypoxia (e.g., chronic lung disease)
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