Unit 1: Care of Patients with Adrenal Gland Problems PDF

***[Unit 1]*** - Care of Patients with Adrenal Gland Problems  - Adrenal glands - Each adrenal gland has two separate parts: - **Medulla - inner portion** - **Catecholamines** - **Epinephrine** - **N...

***[Unit 1]*** - Care of Patients with Adrenal Gland Problems  - Adrenal glands - Each adrenal gland has two separate parts: - **Medulla - inner portion** - **Catecholamines** - **Epinephrine** - **Norepinephrine ** - **Cortex - outer portion** - **Mineralocorticoids → aldosterone (salt)** - **Glucocorticoids → cortisol (sugar)** - **Androgens → sex hormones (sex)** - Each part secrets distinct hormones  - Adrenal Cortex: Mineralocorticoids (Aldosterone) - **Regulates extracellular fluid volume** - **Aldosterone causes: ** - **Sodium reabsorption, water reabsorption** - **Potassium loss/excretion **  - Adrenal Cortex: Glucocorticoids (Cortisol) - **Secreted in response to the release of:** - **Corticotropin releasing hormone (CRH) from hypothalamus, then stimulating anterior pituitary gland → then releases** - **Adrenocorticotropic hormone (ACTH) from anterior pituitary → then releases cortisol ** - Cortisol travels through blood and binds to glucocorticoids  - Aka the STRESS hormone - **Immune response** - **Regulation and decreases inflammatory responses (hence why we give steroids)** - **Blood glucose** - **Cortisol increases BG b/c of nucleogenesis in the liver and increases insulin effectiveness** - **Initially breaks down fat, but if high levels are maintained for a prolonged amount of time, it allows fat storage in the body rather than breaking it down ** - **Regulate BP** - **Cortisol increases BP by causing vasoconstriction and also increases GFR (glomerular filtration rate)** - **Emotional stability** - **Boosts alertness in the brain ** - **Bones** - **Causes the bones to weaken and slows bone growth process** - **Wounds** - **Causes them to heal slower ** - When are levels highest: **[in the morning!]** - Adrenal Cortex: Sex Hormones - **Androgens - male and female traits** - **These kick in to start puberty ** - Adrenal Medulla - **Center of the adrenal gland** - **Catecholamines cause "fight or fight" response** - Norepinephrine - Epinephrine - Adrenal Dysfunction - **Adrenal hypofunction** - Inadequate secretion of CRH from hypothalamus - Inadequate secretion of ACTH from anterior pituitary  - Decreased secretion of glucocorticoids and mineralocorticoids from adrenal cortex - Direct problems of adrenal glands  - **Primary: problem localized to adrenal glands** - Acute - **Waterhouse-Friderichsen** - **Complication of meningitis** - **Sudden increase in pressure in adrenal glands, causing them to rupture ** - **Adrenalectomy** - **Removal of adrenal gland(s)** - **Radiation therapy to abdomen ** - Chronic (ADDison's Disease) - **A**utoimmune - most common in US - **D**iseases - Tuberculosis (destroys cortex) - HIV  - Carcinoma  - **D**amage - Trauma (metastatic) - Exposure to toxins - Risk Factors for Primary Adrenal Insufficiency - Other autoimmune disorders - Age - Family hx  - **Secondary (most common): problem w/ pituitary or hypothalamus** - **Cessation of long corticosteroid therapy** - **Pituitary adenomas (pituitary tumors)** - **Can suppress release of ACTH** - **Hypophysectomy ** - **Pituitary gland removal ** - **Ischemic injury (Sheehan's syndrome)** - **When during childbirth, bleeding out causes ischemia to the pituitary and it essentially dies off ** - **Head trauma** - **Surgery ** - Risk factors: any cause of insufficient ACTH secretion - Pituitary adenomas - Large CNS tumors and those listed above  - Pathophysiology - **Symptoms may appear gradually** - **With acute adrenal insufficiency: Addisonian crisis occur very quickly/severe** - Decreased cortisol - sugar - Decreased aldosterone - salt - Decreased androgens - sex  - History - **Fatigue** - **Increased salt cravings ** - **Weight loss** - **Anorexia** - **Menstrual changes** - **Hair loss** - **Changes in distribution of body hair** - **GI disturbances** - **Low blood sugar** - **Muscle/joint pain** - **Irritable/depressed** - Assessment - Vitals - Fluid balance - \*A.D.: a chronic onset\* - Electrolyte levels - Report findings of crisis   - Diagnostics - Labs - **For decreased cortisol: low sugar/glucose** - **For decreased aldosterone: low sodium and high potassium** - **In primary adrenal hypofunction: high ACTH levels and high melanocyte stimulating hormone (MSH)** - **MRI/CT to assess adrenal gland and pituitary gland** - **ACTH stimulation test - GOLD STANDARD TO DIFFERENTIATE PRIMARY VS SECONDARY ** - **Giving ACTH to stimulate cortisol creation and excretion** - **Expectation:** increased cortisol - If they don't, it's **confirmation of primary adrenal insufficiency ** - Treatment - Hormone replacement therapy  - **Clients will need hormone replacement for life!** - **[Stopping it can cause an adrenal crisis/Addisonian crisis]** - - **Aldosterone deficiency** - Mineralocorticoid - **Fludrocortisone ** - Cortisol deficiency - Corticosteroids - **Hydrocortisone** - Androgen deficiency  - **Testosterone ** - **Adrenal Crisis/Addisonian Crisis ** - **Medical emergency! (Acute Adrenal Insufficiency)** - **Need for cortisol and aldosterone is greater than the body's supply!** - Causes: - **Added stress (surgery, sepsis)** - **Abrupt stop of steroids ("-sone")** - **Drop in BP (hypotensive shock; normal: 120/80)** - **Low BG** - Treatment - **Rapid IV treatment of [steroids, saline fluids and sugar]** - **Tx of H2 histamine blocker (Famotidine aka Pepcid) to prevent stress ulcers and gastroenteritis** - Interventions: - **Vital signs q 1-4 hrs** - **Monitor for dysrhythmias via EKG; cardiac monitoring in general ** - **Monitor I&Os** - **Daily weights** - **Slow position changes** - **Monitor lab values ** - **[Report to MD:]** - **Client develops arrhythmias** - **Administer IV glucose and insulin to decrease potassium levels** - **Can given K^+^ wasting diuretics (Furosemide, Hydrochlorothiazide)** - **Avoid K^+^ rich foods (bananas, oranges, kidney beans, dark leafy green vegetables, potatoes, dried apricot, avocado)** - Nursing Education - Wear a medical bracelet - Will never be completely cured, but can treat symptoms  - Can carry intramuscular glucocorticoid pens for emergencies  - Medications and dosages based on how our body regulates throughout the day  - Moderate exercising  - Teaching for Home Steroids - Interventions for adrenal hypofunction - ADD steroids - Hydrocortisone (Cortef, Hydrocortone, others0 - Administer \_\_\_\_\_\_\_\_\_\_\_\_ - What time? \_\_\_\_\_\_\_\_\_\_\_\_ - W/ or W/O food? \_\_\_\_\_\_\_\_\_\_ - Too much can \_\_\_\_\_\_\_\_\_\_\_ - Cardiovascular effects include HTN and tachycardia (use with caution) - LT therapy may result in: \_\_\_\_\_\_\_\_\_\_\_\_ - Treat w/ caution in: hypothyroidism - Adrenal Hyperfunction  - Cushing's Disease vs. Syndrome - **D**isease: en**D**ogenous **(something is wrong in the body)** - **Too much cortisol being released** - Causes: - **Tumor** (pituitary - secreting too much ACTH) - **Small cell lung cancer - MOST COMMON ** - **S**yndrome: exogenous (something is wrong outside of the body) - **Most likely taking high doses of steroids** (usually for like COPD, asthma, and RA) - Risk factors for Cushing Disease - Sex - Females 5X more likely to have this than males  - Age - 25-40 y.o. - Cushing Disease: Assessment - **History** - **Appetite** - **Weight gain** - **Changes in sleep** - **Easy bruising** - **Physical assessment**  - **Psychosocial assessment ** - Cushing Disease: Pathophysiology - Too much cortisol being released - Cushing Disease: Diagnostics   - **In ACTH plasma level test, we expect to see a low results b/c cortisol is already high** - **In overnight low-dose dexamethasone suppression test, in Cushing Disease, cortisol will be high in the AM** - Cushing Disease: Nursing Diagnoses - **Impaired mobility** - **Impaired skin integrity** - **Disturbed body image** - Cushing Disease: Interventions - **If due to exogenous medication (syndrome): ** - **Taper down steroids to allow slow adrenal recovery** - **Report temp over 100.4 - worry about infection ** - **If due to endogenous reasons (disease):** - **Restore and maintain fluid and electrolyte balance** - **Restrict sodium intake** - **Possibly restrict fluid intake (depends)** - **Take daily weights as same time every day ** - **Assess skin for any injuries and turn q2h** - **Avoid diuretic use ** - **Pharmacological interventions:** - **Treatment consists of drugs that interfere w/ ACTH production or adrenal hormone synthesis to decrease cortisol production** - **Steroidogenesis inhibitors:** - **Ketoconazole (Nizoral)** - **Metyrapone (Metopirone)** - **Aminoglutethimide (Elipten)** - **Mitotane (Lysodren)** - **Cyproheptadine (Periactin) - interferes w/ ACTH production** - **Mifepristone - for pts w/ T2DM who don't respond to other tx** - **Pasireotide (Signifor)** - **Inhibits ACTH secretion ** - **Nonsurgical Interventions** - **Preventing fluid overload** - **Assess q2h for fluid overload** - **Nutrition therapy** - **Prevent skin breakdown ** - **Surgical Options** - **Adrenalectomy - removal of adrenal gland ** - **Unilateral or bilateral depending on where the issue is** - **Goals:** - **Stabilize BP, sugar and potassium in prep for surgery** - **Provide post op care** - **Will to go ICU for observation and to ensure no adrenal crisis happens** - **VS q15 mins** - **Administer and titrate IV cortisone to meet therapeutic levels to prevent crisis ** - **Prevent complications ** - **Monitor for bleeding** - **Shock can occur** - **Monitor BP and HR - shock** - **Monitor urine output** - Discharge Planning/Education - Steroid replacement for life - Prevent injury (skin, fractures) - Prevent infection - Manage BG levels - Engage in weight-bearing exercises - Gradually return to normal activities - Stress mgmt - Follow-up care and lab monitoring - Prevent acute adrenal insufficiency - Discharge Planning (post-adrenalectomy) - Cortisol replacement - Avoid stress, temp extremes, and illness b/c they can cause crises - Contact HCP: - Fever \> 100.4 - Chills - Cough - Sore throat - Other s/s of illness - Monitor surgical incision - Lifting restrictions - Wear a medical alert bracelet   - Hyperaldosteronism - Increased secretion of aldosterone (excess mineralocorticoid) - AL: **A**dds sodium and water **IN**, **L**ets potassium **OUT** - Patho - **Primary (Conn's Syndrome)** - **Excess secretion of aldosterone from adrenal glands** - Cause: - **Adrenal adenoma (benign tumor)** - **Secondary ** - Excess secretion of aldosterone due to **high plasma renin** - Causes: - **CKD** - **Renin secreting tumor ** - Assessment - **Hypokalemia (\< 3.5)** - **S/S: ST depression, decreased deep tendon reflexes, constipation, hypoactive BS, polyuria, diluted urine (low specific gravity) ** - **Hypernatremia (\> 145)** - **S/S: polydipsia (excessive thirst), swollen dry tongue, increased muscle tone** - **Hypertension** - **High BP (over 140/90)** - **Headaches** - **Facial redness/flushing ** - Diagnostic: - **CT or MRI to look for adrenal adenoma** - Primary labs: - **Decreased serum potassium** - **Increased renin levels** - **Increased sodium** - **Increased aldosterone ** - Interventions - Tx of choice: **adrenalectomy (one or both)** - On a **sodium restricted diet** prior to surgery - Pre-op: **correct potassium levels by administering spironolactone** - **Goal: the lower the fluid volume, the lower the aldosterone!** - **Unilateral adrenalectomy will need temporary replacement of glucocorticoid (cortisol) both before and after surgery and if both are removed, it will be lifelong; it will prevent crisis** - Nonsurgical: - **Give spironolactone** - **Watch for/education:** - **Hypokalemia s/s** - **Hypernatremia s/s ** - Care of the Patient w/ Posterior Pituitary Problems - Posterior pituitary (neurohypophysis) - Contains:  - Made in hypothalamus, stored in posterior pituitary - Antidiuretic hormone (vasopressin) - Maintains osmolality of blood by water conservation or excretion - Normal range: 280-295 - ADH = Adds Da H~2~O - Oxytocin - Stimulates uterine contractions during childbirth  - Hypo-ADH = diabetes insipidus (DI) - **[First sign: polyuria - dumping lots of urine; polydipsia - very thirsty]** - **Central DI: problem w/ ADH synthesis, transport or release** - Causes: TBI, pituitary surgery, tumor, infections - **Nephrogenic: inadequate renal response to ADH** - Causes: drugs, renal artery stenosis - **Dipsogenic : excessive H~2~O intake** - Cause: psych or lesion in thirst center - Assessment: - Seven Ds for DI - **Diuresis** (lots of urine output; usually \>200 mL/hr) - **Diluted** (low specific gravity; usually \ - **Dry inside** (hypernatremia and blood osmolality is high) - **Drinking a lot** (polydipsia) - **Dehydrated** (dry mucosa, poor skin turgor) - **Decreased BP** (d/t low fluid volume)  - **Desmopressin** (tx; Vasopressin in ADH form) - Labs - 24 hr I&O - lg amount of output; can be up to 30 L - Plasma osmolality - increased - Serum Na^+^ levels - increased - Urine osmolarity - decreased - Urine volume - increased - Urine specific gravity - decreased b/c increased urine concentration - Diagnostics - differential - Hx and physical exam - Blood tests - refer to labs above  - Fluid deprivation test   - Treatment - Interventions - Maintain adequate fluid status - Monitor I&O - Monitor BP and HR - Monitor urine output - Monitor LOC - Monitor for overhydration s/s - Pt teaching for self-mgmt - Monitoring - Daily weights - Good oral hygiene - Meds and education - Take at same time every day - Overcorrection can lead to water intoxication  - Monitor for overhydration s/s - Will need lifelong medications - For central DI: medications - C/I: CAD and PVD - Desmopressin acetate (DDAVP) - Vasopressin  - For nephrogenic DI: tx - Low sodium diet - Monitor fluid intake - Thiazide diuretics (can increase water and sodium reabsorption) - Evaluation - Pt has restored fluid balance - Pt reports absence of nocturia - Pt understands how to use prescribed medication  - Pt being managed for DI is responding appropriately w/ urine output volume decreasing and specific gravity increasing - Hyper-ADH = SIADH - Syndrome of Inappropriate Diuretic Hormone (SIADH) - Causes:  - Small cell lung cancer - Severe brain trauma (trauma/surgery) - Sepsis infections of brain (meningitis) - Specific drugs  - Assessment - Seven S's for SIADH - Stop urination (urine output is very low) - Sticky and thick urine (specific gravity is \ 1.030) - Soaked inside (low sodium level; hyponatremia; hypo-osmolality) - Sudden weight gain  - Seizures (H/A, confusion; low Na leads to these) - Severe high BP (too much vasopressin causes too much vasoconstriction; JVD) - Stopping fluids - Labs - Decreased plasma osmolarity - Low Na level - Increased urine osmolarity - Decreased urine volume  - Increased urine specific gravity = increased urine concentration - Interventions/treatment - Safety  - Seizure precautions - Strict I&Os, daily weights, vitals - Heart and lungs sounds  - Fluid restriction - Can offer gum or ice chips  - Irrigation  - Sodium replacement - Medications  - Hypertonic saline (3%) - For correction of sodium levels - Give slowly - Don\'t increase sodium levels by no more than 8-12 mEq in a 24 hr period - Vasopressin receptor antagonist - blocks ADH activity; promotes sodium excretion w/o water loss  - Tolvaptan and conivaptan  - Diuretics (loop) - Can be used if sodium is above 125 - Issue: can still lose sodium and further drop - Mainly consider if not symptomatic  - Evaluation of tx - Provide a safe environment - Monitor response to therapy - Balanced I&Os, stable VS, stable weight - Appropriate neuro status - Complies w/ fluid restriction - Performs frequent oral hygiene - Notifies healthcare team of any changes  - Care of Patient w/ Anterior Pituitary Problems - Anterior pituitary (adenohypophysis) - Sits below hypothalamus - TSH  - ACTH - GH - FSH - LH - PRL - MRH - Anterior pituitary HYPOfunction  - Selective hypopituitarism - decrease in 1 or more hormones - Panhypopituitarism - decreased in all production of hormones in anterior pituitary   - Most dangerous?  - Etiology - Pituitary tumor - most common  - Benign tumor/adenoma on pituitary gland - Autoimmunity - Severe hypotension or shock/ischemia - Sheehan's syndrome - Infarct to pituitary gland due to significant blood loss  - Malnutrition - Infection - Destruction/trauma to pituitary gland (trauma, radiation, surgical procedures) - Idiopathic  - Risk factors: - TBI - Cocaine use - Head bleed - Postpartum hemorrhage (Sheehan's syndrome) - Skin color - Regardless, hypopituitarism causes decreased secretion of target gland hormones  - Diagnostics - Assessment  - Hx - S/S pt is having  - Recent trauma - What brought them in  - Labs - Direct and indirect measurements - CT/MRI - Angiogram - Provocative/simulation testing  - Clinical manifestations - Gonadotropin hormones (FSH/LH) - [Female s/s]: absence of secondary sex characteristics: amenorrhea, low estrogen, breast atrophy, decrease in axillary and pubic hair, decrease in libido, loss of bone density, infertility - [Male s/s]:  absence of secondary sex characteristics: loss of facial and body hair, decreased muscle mass, decreased libido, loss of bone density, infertility - [Kids]: absence of puberty - Tx: replacement of deficient hormone - Men: testosterone - Administration: start w/ high dose and give until virilization occurs (start looking manly); IM, transdermal, implant, topical gel - C/I: prostate cancer b/c testosterone can feed cancer growth - Effective when: virilization occurs, increased libido - S/E: salt and water retention, edema, acne and skin irritation - Monitor: too much testosterone can cause feminization; BP, HR, weight  - Adolescents: estrogen only - Low dose to imitate puberty and potentiate growth  - Do not add progesterone until 2-3 yrs - Women: estrogen/progesterone - Shouldn't be administered before puberty  - C/I: pulmonary embolism, breast cancer - Treatment - Surgical removal - Hypophysectomy - removal of entire pituitary gland - Issue: once the pituitary gland is removed, hypopituitarism occurs and will need tx for life  - Craniotomy - Non-surgical  - Radiation  - Hormones  - Anterior pituitary HYPERfunction - Increase in 1 or more hormones - The most common hormones produced in excess:  - Prolactin, ACTH, GH - Etiology - Pituitary adenoma/tumor  - First sign of these: vision changes and/or headache - Risk factors - Female - Family hx - Multiple endocrine neoplasia type 1 (MEN-1 syndrome) - Regardless, hypopituitarism, causes increased secretion of target gland hormones  - Diagnostics - Assessment - Labs - CT/MRI - Suppression testing  - Clinical manifestations - Female s/s: -- - Male s/s: -- - Kids: early puberty (precocious puberty; 9 in boys, 8 in girls) - Tx: primary goal is to allow kids to grow to adult height - GNRH inhibitors (implant, monthly shot) - Treatment - Surgical  - Hypophysectomy w/ resection (tumor taken out through the nose)  - Craniotomy - Non-surgical - Radiation - Hormones  - Considerations: Post-hypophysectomy - Priority nursing goals - Provide post op care - Fluid status mgmt - Monitor surgical site - Elevate HOB - Institute seizure precautions - Sneeze w/ mouth open, prevent coughing, etc. - Report any signs of: H/A, light sensitivity, N/V, halo's sign, visual changes, etc. - could be sign of meningitis  - In ICU for 1st 24 hrs and will need q1h neuro checks  - Monitor for complications of hormonal deficiency - Replace deficient hormones  - Wound care and monitoring for infection - Prevent brushing teeth for 10 days to prevent messing up surgical sutures  - Education - Lifelong hormone replacement therapy - Signs of meningitis - Avoid actions that increase ICP/frequent rest periods - Stool softeners, high fiber diet - Squat if needed - No lifting over 20 lbs - Sneeze w/ mouth open - Position/sleep w/ HOB increased - Nasal care - Blood tinged mucus is normal post op - If lots of bright red blood coming out or lots of clear fluid, notify MD - Irrigation of the nose is fine - Look for halo's sign - Keeping appointments  - Sudden changes in weight  - Growth hormone - GH induces growth in nearly every tissue and organ in the body. - However, it is most notorious for its growth-promoting effect on \_\_muscles\_\_\_\_\_\_\_\_\_ and \_\_\_bones\_\_\_\_\_\_\_\_, especially in the adolescent years. - ALSO activates \_\_\_IGF-1 (insulin-like growth factor)\_\_\_\_\_\_ , which is responsible for many of the growth-promoting effects attributed to GH.. - Furthermore, it acts to inhibit apoptosis of the cell, thus prolonging the lifespan of existing cells. - The net result is to encourage the growth of tissue and to create a \_\_\_\_\_\_\_ environment in the body. - In addition, GH actively promotes the breakdown of \_\_\_\_\_\_\_\_\_\_\_ and mobilizes fatty acids from fat stores, helping to lower \_lipid levels\_\_\_\_\_\_\_\_\_ in the bloodstream. - Diagnosis: - Clinical findings - CT or MRI - Insulin-like growth factor 1 (IGF-1) levels - GH levels  - HYPO: - IGF-1...therefore:  - Decreased bone density - Pathological fractures - Decreased muscle mass - Increase visceral fat mass - Increased cholesterol - Premature atherosclerosis - Increased fatigue - Kids: - Decreased/slow height growth - Doesn't affect a child's intelligence - Hypoglycemia  - Pituitary dwarfism  - Interventions - Surgery/tumor removal - Human growth hormone (Soma[tropin]) - Who can use: kids whose growth plates haven't closed - C/I: growth plates who have closed, acute critical illnesses - When to administer: w/ typical release of hormone (give at nighttime) to mimic normal release patterns - S/E: hyperglycemia - Monitor: glucose tolerance - Cost: \$12-36K/yr - Success: improved body composition, increased bone density - HYPER: - **Kids:** - **Gigantism ** - **Adults:** - **Acromegaly: gigantism but in adults** - **Enlarged hands, feet, lips and nose** - **Increasing head size** - **Protrusion of lower jaw (malocclusion of teeth)** - **Thickened tongue (speech and dental issues)** - **Hypertrophy of vocal cords (voice gets deeper)** - **Joint pain** - **Hyperglycemia** - **Sleep apnea** - **Enlarged heart, lungs, and liver ** - Treatment: - Pharmacological mgmt: may be used alone or w/ surgery/radiation - Acromegaly: - **Somatostatin analogs:** - **Octreotide (Sandostatin)** - **Growth hormone receptor blocker:** - **Pegivsomant (somavert) ** - Gigantism: - **Surgery** is the most common tx option - Prolactin (PRL) - Hypo: - A decrease in the amount of prolactin produced by the pituitary gland can lead to insufficient milk being produced after giving birth - Most people w/ low PRL levels don't have any specific medical problems  - Hyper: - Decreased libido  - Impotence - Infertility - Gynecomastia in men - Galactorrhea (men, women, or kids) - What blocks prolactin? Dopamine!  - Tx:  - Hyper:  - Dopamine agonists - stimulates dopamine receptors in the brain and inhibit release of GH and PRL (and can help shrink tumors) - **Bromocriptine mesylate (Parlodel)** - **Cabergoline (Dostinex)** - Thyroid Stimulating Hormone (TSH) - Adrenocorticotropic hormone (ACTH)  - Thyroid & Parathyroid - Hypothalamus → TRH → anterior pituitary → TSH → thyroid → T4 and T3 - T3 and T4 increase metabolic rate, stimulates bone resorption, activates sympathetic nervous system (increases cardiac output) - Thyroid Disorders  - Hyperthyroidism - [Primary]: problem w/ gland itself - Graves disease - most common cause; autoimmune - Risk factors: - Women - Ages 25-40 - Hx of autoimmune disorders - Toxic nodular goiter - follicles are producing thyroid hormone (independently of TSH) - Usually affects people over 40  - Adenoma - benign tumor where cells are releasing TSH - Thyroiditis - inflammation or damage to the thyroid gland  - [Secondary]: problems outside of thyroid - Pituitary tumor  - Exogenous hyperthyroidism  - Could be taking too much thyroid hormone  - Some drugs can cause this issue  - Pathophysiology - Thyroid is producing excess thyroid hormone for whatever contributing factors may be the cause  - Assessment - Hx - Physical (think High & Hot) - **Increased HR and BP** - **Increased energy (anxiety, fidgety, nervousness)** - **Decreased sleep (insomnia)** - **Decreased weight (fat metabolism has increased)** - **Increased appetite ** - **Heat intolerance (d/t metabolic rate increase) ** - **Increased gastric activity (diarrhea)** - **Increased libido** - **Smooth, warm, moist/sweaty skin ** - **Increased risk for osteoporosis ** - Diagnostics  - T3, T4 - increased - TSH - Primary - low - Antibodies to TSH receptor (Graves disease)  - Radioactive iodine uptake test/thyroid scan - Ultrasound - ECG  - Graves Disease S/S - Grape eyes - exophthalmos - Interventions: natural tears, lubricating drops, tape eyes shut to prevent irritation, sit up to prevent swelling, avoid contacts, use humidifiers - Goiter  - Interventions: no palpating goiters, secure the airway - Treatment - Medications - **Methimazole - 1st line tx** - **Preferred over PTU b/c it's a daily pill** - Should be taken at same time every day - Don\'t stop abruptly - **Leads to reduced thyroid hormone synthesis** - **Can take several weeks to see effects ** - **Don't use if pt has liver disease or pregnant** - **Must be on birth control while taking this med** - Lower risk for hepatotoxicity - **S/E: s/s of hypothyroidism (weight, cold intolerance)** - **Report s/s infection** - **Taken for 1-1.5 yr, then slowly taper off ** - **Propylthiouracil (PTU)** - **"Puts Thyroid Underground"** - **Taken 3X/day; not as convenient** - **Report: fever, sore throat, s/s infection** - **Taken for 1-1.5 yr, then slowly taper off** - **Safe for pregnancy in 1st trimester if absolutely necessary ** - Higher risk for hepatotoxicity  - **Potassium iodide (SSKI)** - **Reduced symphysis and blood flow through thyroid gland ** - **Given prior to surgery on thyroid (week before)** - **Only suppresses for about 10 days ** - **Taken after anti-thyroid meds** - **Reduces risk of bleeding during surgery** - **Can stain teeth, so drink through a straw** - **Beta blockers - propranolol** - **Controls cardiac s/s of hyperthyroidism ** - **Rapid correction of HR ** - Nonsurgical - **Diet - high in calories, protein, and carbs** - **Monitor:** - **VS** - **Cardiac rhythm** - **Reduce stimulation, provide quiet environment** - **Promote comfort (cooling measures, lubrication of eyes)** - **Drug therapy** - **Radioactive Iodine Therapy** - **Destroys the thyroid** - **Before: ** - **Must have a negative pregnancy test** - **5-7 days before: hold antithyroid meds** - **No anesthesia or conscious sedation for this** - **After: ** - **AVOID EVERYONE! - X2 wks** - **No pregnant people, crowds** - **Not same restroom (flush 3X)** - **Anything with body fluid on it should be flushed down the toilet or sealed in a ziplock bag** - **Not same food utensils** - **Not same laundry as your family ** - Surgical - **Thyroidectomy** - removal of thyroid gland - **Preop: get to a normal thyroid function** - **Antithyroid meds** - **Radioactive iodine X10 days** - **Postop:** - **Have suction and oxygen at bedside** - **Have trach tray/care kit at bedside** - **Monitor VS until stable** - **Keep neck in neutral position** - **Monitor resp. status closely** - **Report immediately any s/s of tracheal compression** - **Look for ability to swallow** - **Monitor neck dressing for bleeding** - **Monitor for low calcium levels and s/s of hypocalcemia ** - **Lifelong hormone replacement therapy will be needed if it's a total thyroidectomy** - Most critical complication: THYROID STORM - Occurs if hyperthyroidism is left untreated - Considered a medical emergency  - Key S/S: - Very high fever (\>104 degrees) - Tachycardia (\>140 BPM) - Palpitations - Chest pain - SOB - Risk factors: - Untreated Graves disease - Recent surgery on thyroid or trauma to thyroid  - Interventions - Supportive: - Airway and oxygenation - IV fluids to correct dehydration, correct circulation, prevent shock - Monitor - Medications to inhibit thyroid hormone synthesis and release: - Antithyroid drugs - 1st line - PTU via IV - Potassium iodine solution - Beta blocker  - Glucocorticoid (inhibits T4 to T3 conversion) - Cooling measures  - Tylenol - Ice packs - Avoid NSAIDs and ASA - Comfort measures  - Electrolyte correction - Ventilation support (possible) - Hypothyroidism