Med-Surg Study Guide PDF

Med-Surg Study Guide Table of Contents Burns 2 Hematologic Disorders 63 Cancer 7 Musculoskeletal 65 Cardiac 10 Musculoskeletal System 65 Cardiac Basics...

Med-Surg Study Guide Table of Contents Burns 2 Hematologic Disorders 63 Cancer 7 Musculoskeletal 65 Cardiac 10 Musculoskeletal System 65 Cardiac Basics 10 Fracture 68 Heart Failure 12 Osteoarthritis 71 Coronary Artery Disease 14 Rheumatoid Arthritis 72 Angina Pectoris 16 Osteoporosis 75 Myocardial Infarction 18 Gout 78 Electrolyte Imbalances 20 Neurology 80 Sodium 20 Brain Anatomy and Physiology 80 Potassium 21 Stroke 82 Calcium 22 Seizure 87 Magnesium 23 Increased Intracranial Pressure 90 Phosphorus 24 Multiple Sclerosis 93 Chloride 25 Parkinson's Disease 95 Relationships 26 Myasthenia Gravis 98 Endocrine 27 Guillain-Barre Syndrome 100 Endocrine System 27 Renal 102 Thyroid Gland and Disorders 29 Kidneys, Nephrons and RAAS 102 Hyper- and Hypoparathyroidism 32 Chronic Kidney Disease 105 Adrenal Glands and Disorders 34 Acute Kidney Injury 107 DI vs SIADH 37 Renal Calculi 109 Diabetes Mellitus 39 Urinary Tract Infections 112 Gastrointestinal 44 Glomerulonephritis 114 The Digestive System 44 Nephrotic Syndrome 115 Gastroesophageal Reflux Disease 46 Dialysis 116 Peptic Ulcer Disease 47 Diuretics 118 Inflammatory Bowel Disease 48 Respiratory Disorders 121 Diverticulosis and -itis 51 Lung Anatomy and Physiology 121 Celiac Disease 52 Pneumonia 122 Hepatitis 53 COPD 123 Cirrhosis 56 Asthma 124 Pancreatitis 58 ARDS 125 Cholecystitis 60 Pleural Effusion 126 Appendicitis 61 Shock 127  BURNS Damage to the skin's integrity by some kind of energy source Types of Burns Thermal - Most common - caused by flame, flash, scald or contact with hot objects (liquid, steam, fire); e.g. from cooking, burning leaves, smoking Chemical - caused by contact with acids, alkali or organic compounds - no heat needed acids (e.g. hydrochloric, oxalic, hydrofluoric) alkali (e.g. cement, oven/drain cleaners, heavy industrial cleaners); harder to treat because adheres to tissue organic compounds (e.g. phenols and petroleum products) Electrical - caused by intense heat generated from an electric current that passes through the body and damages tissue hard to determine extent of damage because most of damage is below the skin - 'iceberg effect' Cold - caused by cold exposure to skin; frostbite Radiation - caused by sun or cancer treatment Friction - caused by abrasion to skin road rash (car accident) Superficial partial Epidermis rope burn thickness (1st degree) Sweat Deep partial gland Dermis Burn Severity Depends on: thickness Hair Depth of Burn (2nd degree) Follicle Extent of Burn Calculated in % of TBSA Fat Use Rule of 9s (see next page) Full thickness Location of Burn (3rd & 4th Muscle Patient risk factors degree) If they experienced an inhalation Bone injury or not Skin Structure and Degree of Burn Location of Burn - potential problems Respiratory - face, mouth, neck, trunk (due to edema or eschar) Disability - Eyes, hands, feet, joints (due to damage to nerves) Infection - Perineum (due to infection from urine/feces) and ears, nose (thin skin) Trouble Healing - Ears, nose (due to thin skin and poor blood supply) Compartment syndrome - Full thickness circumferential burns  Extent of Burn To determine the extent of burn, calculate the TBSA burned using the Rule of Nines and then use the Parkland Formula to calculate the fluids needed Rule of Nines Purpose: 4.5% 4.5% To calculate the total body surface area burned (TBSA%) for 2nd, 3rd and 4th degree burns To determine the amount of fluid therapy needed using the 18% 18% Parkland Formula 4.5% Front 4.5% 4.5% Back To determine if the patient meets criteria for burn unit 4.5% Add the percent of each body part 1% burned. 9% 9% 9% 9% Use for 2nd This number equals the TBSA%. degree burns or greater Parkland Formula Purpose: To calculate the total volume of fluids 4 mL X TBSA (%) X Body weight (kg) = (mL) that a patient needs total mL of fluid (lactated Ringer's) needed 24 hours after experiencing a burn. Make sure TBSA is NOT a decimal! Give first half of Give second half of the For instance, if a patient has a TBSA% = 45%, the solution in the solution over the next 16 use 45 in the equation, NOT.45 first 8 hours hours Patient Risk Factors Inhalation Injury Preexisting heart, lung, kidney Damage to respiratory system due to disease (body already taxed) breathing in toxic substances Diabetes Affects: Upper & lower airways Peripheral Vascular Disease Signs: Burned in enclosed space Any chronic disease that causes Burned on face weakness Spit, mouth, nose have soot If burn patient also has fractures, Hair singeing (head & nose) head injuries, other trauma Brignt red skin Age - children or elderly Hoarse voice  Depth of Burn st Degree rd Degree Superficial partial thickness Full thickness Epidermis only All layers are damaged Least severe Not painful due to damage to nerves Heals in 7 days Skin will NOT heal - needs skin grafting Erythema Will take months to heal Blanching on pressure Dry, leathery hard skin (eschar) Pain/mild swelling May be black, yellow, red, waxy white Skin pink/red Warm to touch Eschar - dead tissue - dangerous if around No blisters torso or extremity; will need to be Usually no scarring removed via escharotomy th Degree nd Degree Deep full thickness Deep partial thickness All layers destroyed and In Full Thickness, watch Epidermis and dermis extends to muscles, bone, for acute tubular necrosis Very painful ligaments (ATN), due to the release Blisters NO pain sensation of myoglobin and Redness that blanches Black, charred with eschar hemoglobin that block Swelling (mild - moderate) Months to heal kidney tubules. Shiny red/pink and moist Will need skin grafts If severe, may need skin grafting Pre-Hospital and Emergency Care At scene - Cool large burns no longer than 10 minutes Remove from source of burn Do not immerse in cool water Stop the burning process Do not cover with ice Small thermal burns (10% or less TBSA) Do remove as much burned clothing as Cover with cool, clean, tap water-dampened possible towel Do wrap in sheet/blanket If >10% TBSA or electrical/inhalation burn and Chemical burns - remove all chemicals from skin; patient unresponsive: remove clothing containing chemical and then Focus on CAB flush skin with water C - Circulation - check for pulse and Monitor patient with inhalation injury for signs elevate burned limb(s) of respiratory distress A - Airway - check for patency, soot around nose and on tongue, singed nasal hair, darkened oral or nasal membranes B - Breathing - check for ventilation → → If patient is responsive, do A B C  Phases of Burn Management Emergent Phase Onset of burn until 24 - 48 hours post Time required to resolve the immediate, life-threatening problems Main concerns: onset of hypovolemic shock and edema formation Hypovolemic shock is the greatest initial threat to a patient with a major burn Phase ends when fluid mobilization and diuresis begin Pathos: Increased capillary permeability causes: Plasma fluid to leave intravascular space ↑ Hct, ↑ K+, ↓Na+, ↓ WBC Na+ & Albumin follow ↓ Fluid may lead to hypovolemic shock: Fluids shift to interstitial tissue ↑ HR Edema results ↓ CO Blood thickens ↓ BP Interventions: IV access (2) Pain meds via IV initially; opioids Calculate fluids (lactated Ringer's) using May need intubation (esp face/neck burn) formula Wound care can begin once proper airway, Electrical burns need higher fluids and circulation and fluid replacement achieved possibly osmotic diuretic (mannitol) Monitor for: Catheter to monitor urinary output Hypovolemic shock Monitor every hr Electrolyte imbalances Goal >30cc/hr Renal failure Albumin may be administered GI problems Monitor urine for Hg and Mb (ATN) Wound Care: Open or Closed Open: open to air with topical antimicrobial - often limited to facial burns Closed: topical antimicrobial and area covered with sterile dressing Debridement - necrotic tissue removed Positioning - no pillows (esp with neck/ear burns); rolled towel under shoulders Elevate extremities - helps prevent edema and contractures Do not let 2 burn areas touch (to prevent webbing) ROM/splints to prevent contractures Premedicate w/pain meds before dressing changes or debridement! Graft types: autograft (self), allograft (cadaver), CEA (grown from pt own skin), artificial skin  Acute Phase 48 - 72 hours after burn until wound heals ↑ Fluid has mobilized and subsequent diuresis has begun ( urine production) May last weeks to months Focus: prevent infection, pain management, nutrition, wound care Interventions: Monitor: NPO until bowel sounds + order to eat: Proper urine output ↑ Will need Cal/Pro/Carb diet Signs of GI distress (pain, vomiting, blood in May need enteral stool - may be Curlings ulcer; constipation) Watch for hyperglycemia Bowel sounds (no sounds may be paralytic ulcer) ↓ Early nutrition will complications and May need NG tube for suctioning (to remove ↑ mortality and healing fluids, gas) Tetanus shot, antibiotics, ulcer meds Compartment syndrome if circumferential May also need: sedative, hypnotics, burns antidepressants Distal extremity pulse absent/weak, cool to Pain meds- IV best route b/c skin layer may be touch, abnormal color damaged as well as muscle Respiratory status esp with chest, face, neck Avoid infection: sterile linens, gowns, gloves, burn or inhalation injury protective isolation Electrolyte imbalances: Stretch ROM and move as much as possible to sodium and potassium avoid contractures ↑ ↑ ↓ ↓ Infection signs ( HR, RR, BP, UO, Keep room temp at least 85F ↓ confusion, chills, appetite) Will need systemic abx Neurology: watch for signs of delirium Rehabilitative Phase Wound closure to patient's optimal level Burn has healed and patient functioning again (physically and mentally) May happen as early as two weeks post-burn to 7-8 months after Focus: psychosocial, ADLs, PT, OT, cosmetic correction Goals: Educate: Prevent scars/contractures (ROM & splints) Moisturizing for scar Activities of daily living (ADLs) management Psychosocial Sun management PT/OT/Cosmetic consults PT and OT importance  Cancer Disease characterized by uncontrolled and unregulated growth of cells Pathophysiology Cancer 1. Defective cell proliferation: Occurs in all ages, higher in men than women Normal cells proliferate only at cell death or when The second most common cause of death in physiologically necessary (such as infection) and U.S exhibit contact inhibition (respect cell boundaries) 1/3 of all cancer-related deaths in U.S. due to Cancer cells proliferate indiscriminately and have tobacco use, unhealthy diet, physical no contact inhibition; form tumor inactivity and/or obesity 2. Defective cell differentiation: Normal cells mature and perform one specific Types of Cancer function Leukemias and lymphomas - cancers of the Cancer cells have a defect and perform more than blood and blood-forming tissues one function Carcinomas - cancers of the cells that line the skin, lungs, digestive tract, and internal organs 3 Stages of Cancer Sarcomas - cancers of the mesodermal Initiation - mutation/change in DNA occurs (exposure to cells (e.g. muscles, blood vessels, bone) carcinogen) Most cancers not due to inherited genes, but to Prevention ** KEY damage during lifetime Carcinogens (cancer-causing agents) ↓exposure to carcinogens (smoking, Chemical - e.g. benzene, arsenic, formaldehyde tanning beds, sun) Radiation - e.g. UV radiation Diet - ↑veggies/fruits/whole grains, Viral - e.g. Epstein-Barr virus, HIV, Hep B ↓dietary fat and preservatives Promotion - proliferation of ALTERED cells by promoters Limit alcohol intake; regular exercise (e.g. dietary fat, obesity, cigarette smoke, alcohol Healthy weight; 6-8 hrs consumption); Reversible at this stage ↓ sleep/night; stress Latent period - 1-40 yrs between initial genetic Regular physical exam; self-exam alteration and clinical evidence Follow cancer screening guidelines; know 7 Progression - Increased growth rate of tumor, increased warning signs invasiveness, metastasis (spread of cancer to a distant site). Most frequent sites of metastasis are lungs, liver, C hange in bowel or bladder habits bone, brain and adrenal glands A sore that does not heal Cancer Classification Based on: U nusual bleeding or discharge Anatomic Site T hickening or a lump in the breast/body Histology (grading) - I, II, III, IV, X (better I ndigestion or difficulty swallowing → prognosis worse) O bvious change in a wart or mole Anatomic extent of disease (varies widely per cancer type) N agging cough or hoarseness  Treatment Diagnosis - Pathologic evaluation of a tissue sample is the only definitive means to diagnose cancer Surgery - to eliminate or reduce the risk of cancer development; includes prophylactic removal of non-vital organs (e.g. mastectomy, thyroidectomy, hysterectomy) Chemotherapy (antineoplastic therapy); a systemic therapy and a mainstay of cancer tx for most solid tumors and hematologic malignancies (e.g. leukemia, lymphomas) Goal is to eliminate or reduce the number of cancer cells in the primary tumor and metastatic tumor site Methods: oral or IV (most common; may cause local tissue breakdown/necrosis) Regional chemotherapy - delivery of drug directly to the tumor site; reduced systemic toxicity Chemotherapy agents cannot distinguish between normal cells and cancer cells Side effects are result of destruction of normal cells, especially rapidly proliferating ones (e.g. bone marrow, lining of GI system, skin/hair/nails) Long-term side effects: damage to heart, lungs, liver, kidneys Radiation therapy - local therapy; high-energy beams delivered into tissue to break the chemical bonds in DNA; only has effect on tissues within tx field Teletherapy - exposed to radiation via machine Brachytherapy - implanting radioactive material directly into tumor Immunotherapy (biologic therapy); uses the immune system to fight cancer; e.g. cytokines, vaccines, monoclonal antibodies (most successful) Targeted therapy - acts on specific targets associated with cancer; does less damage to normal cells than chemo; e.g. tyrosine kinase inhibitors Hormone therapy - can block the effects of certain hormones that enhance the growth of cancer (e.g. corticosteroids, estrogen receptor blockers, androgen receptor blockers) Hematopoietic stem cell transplantation (HSCT)- originally called BMT or PSCT Goal is to eradicate diseased tumor cells and/or clear the bone marrow of its components to make way for engraftment of transplanted, healthy stem cells; used for pt w/tumors resistant to chemo or rad tx Uses high levels of chemo and/or radiation to clear the bone marrow; healthy stem cells are infused afterwards Intensive procedure with high risks Complications: bacterial, viral, fungal infections; graft-vs-host disease Complications of Cancer Malnutrition - Seen as fat/muscle depletion ↑ Cancer cachexia - Wasting syndrome ( morbidity risk) ↑ ↑ Small meals/ cal/ pro Anorexia, unintended weight loss and appetite Encourage nutrition supplements (Ensure); Tissue wasting, skeletal muscle atrophy, immune ↑ ↓ cal/ density foods (e.g. oils, butter) dysfunction Weigh at least 2x/wk Cannot be reversed nutritionally Oncologic emergencies - life-threatening ↑ Best management is to treat cancer; nutrition Obstructive - tumor obstruction of an organ intake; Megace may help or blood vessel (e.g. superior vena cava Infection - a primary cause of death in pt with cancer syndrome, spinal cord compression) Instruct - call HCP if temp is 100.4 F or higher Metabolic - hypercalcemia, SIADH, tumor Dysgeusia - altered taste sensation lysis syndrome Encourage experimenting with different foods and Infiltrative - Cardiac tamponade spices Potential Side Effects of Chemotherapy or Radiation and Management Mucositis/Stomatitis/Esophagitis Fatigue (universal symptom) look for any Assess oral mucosa daily reversible cause: Instruct to avoid hot/spicy foods Anemia Saline oral rinse Hypothyroidism; Dehydration Artificial saliva Depression; Anxiety No tobacco or alcohol Encourage rest/exercise as tolerated Topical anesthetics (e.g. viscous lidocaine) Anorexia Nausea/Vomiting Small, frequent meals high pro/cal Antiemetics (Zofran, Reglan) Monitor wt and look for dehydration Before chemo and as needed Nutr supplement drinks (Ensure, etc) Monitor for dehydration If severe- parenteral or enteral nutrition Diarrhea Bone Marrow suppression (one of most common Antidiarrheal drugs → symptoms) anemia At least 3 L fluid/day Monitor: neutrophils, PLT, RBC Constipation Iron supps/erythropoetin Stool softeners Leukopenia ↑ fiber foods Monitor WBC (esp. neutrophils) ↑ fluids Monitor body temp/signs of infection Activity if tolerated May need WBC growth factors Thrombocytopenia Hepatotoxicity Watch for bleeding (e.g. petechiae) Monitor liver fnx tests Monitor PLT Nephrotoxicity Neutropenia Monitor BUN/CR Prevent infection! Hand washing May need Sodium Bicarbonate and allopurinol Monitor temp Cardiotoxicity Intracranial Pressure Monitor EKG Monitor neurologic status; may need Hyperuricemia corticosteroids ↑ Monitor UA levels; fluids Pneumonitis Allopurinol prophylactically Monitor for dry, hacking cough; fever Skin changes Pericarditis/Myocarditis Erythema (patches of red skin) Monitor for CV symptoms (e.g. dyspnea) Protect from temp extremes, tight Alopecia garments, harsh chemicals Avoid excessive brushing, shampooing, hair Lubricate dry skin, aloe vera gel drying, curling, etc Photosensitivity/hyperpigmentation Suggest hair pieces, scarves, wigs Avoid sun exposure Cognitive changes (brain fog) - Encourage: Pain management - moderate to severe in 50% pt Exercise brain (word puzzles, etc) NSAIDs, opioids, morphine, fentanyl Use detailed planner; no multitasking Monitor for constipation Sleep/rest  Cardiac Basics To body Flow of Blood through the heart Aorta To lungs To lungs Superior Vena Pulmonary Cava Artery Pulmonary Pulmonary Veins Veins Left Atrium Right Pulmonary Mitral Valve Atrium Valve Aortic Valve Left Tricuspid Valve Ventricle Inferior Right Vena Ventricle Cava Right Side - Deoxygenated blood Left Side - Oxygenated blood 1. Superior/Inferior Vena Cava (from body) 7. Pulmonary Veins (from lungs) 2. Right Atrium 8. Left Atrium 3. Tricuspid Valve 9. Mitral Valve 4. Right Ventricle 10. Left Ventricle 5. Pulmonary Valve 11. Aortic Valve 6. Pulmonary Artery (to lungs) 12. Aorta (supplies body) Heart Sounds S1 Closing of the atrioventricular valves; high-pitched, use diaphragm. NORMAL S2 Closing of the semilunar valves; high-pitched, use diaphragm. NORMAL S3 Heart may be in fluid overload or failure; low-pitched, use bell. MAY BE ABNORMAL S4 Ventricle resistance; low-pitched, use bell. ABNORMAL Murmurs May indicate wall defect or valve problem; low-pitched, use bell. MAY BE ABNORMAL  Cardiac Basics Cardiac Terms Volume of blood in the ventricles at end of Preload: diastole The resistance the left ventricle must Afterload: afterload= cardiac workload overcome during systole The amount of blood pumped out of the Stroke Volume: Normal = 60-100 ml/beat ventricles with each beat Cardiac Output: The amount of blood the heart pumps in 1 CO = HR X SV minute (in liters) (Normal = 4-8L/min) Volume of blood expelled with every Ejection Fraction: Normal = 50-70% contraction Cardiac Biomarkers Normal Cardiac Troponin: 0-0.4 ng/mL Protein released into the bloodstream when the heart muscle (cTnT) >1.5 = critical is damaged. BEST INDICATOR OF ACUTE MI! Creatine Kinase: Enzyme released into the bloodstream when heart, brain or 0-5 ng/mL (CK-MB) skeletal muscle damaged. Brain Natriuretic Peptide released into the bloodstream when ventricles fill with 40mg/dL and LDL55 yrs Poor DB management Thrombosis Emotional stress High cholesterol/TG Heart failure Weather extremes High BP Valve disorders Heavy meals Family history Aortic stenosis  Angina Pectoris Signs and Symptoms Chest pain that may radiate to SOB Feeling of gas, indigestion jaw, neck, shoulders, back Diaphoresis Women: Pressure Weakness/fatigue Nausea Squeezing Pallor SOB Burning Dizziness Abdominal pain Fullness Nausea/vomiting Discomfort in neck, jaw, back Diagnosis Interventions EKG Instruct Diet Stress test Echocardiogram BP control Low fat Coronary angiography Smoking cessation Cholesterol 145 mEq/L Hyponatremia < 135 mEq/L Causes Causes IV fluids (hypertonic NaCl, Diarrhea ↓ ECF volume ↑ ECF volume excessive isotonic NaCl) Diabetes Insipidus Diarrhea/vomiting Excessive hypotonic IV Hypertonic tube feeding w/o Cushing syndrome NG suction fluids water supplements Hyperglycemia due to Diuretics Primary polydipsia Near-drowning in salt water uncontrolled DM Adrenal insufficiency SIADH Unconscious/cognitively impaired Primary Burns, wound drainage Heart failure (unable to detect thirst) hyperaldosteronism Fasting/NPO Primary hypoaldosteronism High fever, heat stroke (dehydration) Signs/Symptoms Signs/Symptoms ↓ If due to ECF volume ↑ If due to ECF volume Irritability Headache Restlessness Dry swollen tongue Apprehension/confusion Apathy Agitation Increased reflexes Dizziness Confusion Intense thirst Seizures, coma Tremors/seizures/coma Muscle spasms Flushed skin ↑ BP Dry mucous membranes Thready pulse Seizures/coma N/V/Diarrhea Cold, clammy skin Ab cramps Management If water deficit, replace Seizure precautions if Management fluid orally or IV (isotonic altered mental state 0.9% NaCl slowly) Monitor serum Na+ levels ↓ If due to ECF volume ↑ If due to ECF volume Restrict sodium intake Replace fluid using Fluid restriction Diuretics if water excess isotonic sodium- Loop diuretics and containing solutions demeclocycline Encourage oral Na+ IV 3% NaCl (low rate) intake ADH antagonists for Withhold all diuretics heart failure or SIADH  Electrolyte Imbalances Potassium (K+) Normal: 3.5 - 5 mEq/L High Potassium Foods Major cation in ICF (Intracellular fluid) Roles: Baked potato Sending nerve impulses Sweet potato Assists in cardiac function Banana, avocado Assists in neuromuscular function Watermelon Blood pressure maintenance Spinach Regulation of acid-base balance Canned clams Helps regulate fluid balance Helps deposit glycogen in muscle and liver cells Inverse to Sodium Similar to Magnesium Hyperkalemia > 5 mEq/L Hypokalemia < 3.5 mEq/L Causes Causes Excessive or rapid parenteral Adrenal insufficiency Diarrhea Alkalosis administration Meds: Vomiting Fasting/NPO K+-containing salt substitute Angiotensin II NG suction Inadequate K+ in parenteral Acidosis receptor blockers Diuretics fluids Tissue damage (fever, crush ACE inhibitors Hyperaldosteronism MG deficiency injury, sepsis, burns) Heparin Diaphoresis Long-term laxative use Renal disease/failure (most K+-sparing diuretics Dialysis Corticosteroids common) NSAIDS Insulin therapy Signs/Symptoms Signs/Symptoms Fatigue Irregular pulse Fatigue Shallow respirations Irritability, confusion Tetany Muscle weakness Weak, irregular pulse Muscle weakness, ECG changes: Leg cramps Hyperglycemia cramps Tall peaked T wave Decreased reflexes ECG changes: ↓ muscle tone Prolonged PR interval Constipation Flattened T wave ↓ reflexes Widening QRS Nausea Prominent U wave Abdominal cramping Loss of P wave Paralytic ileus Peaked P wave Diarrhea/vomiting Management Management Discontinue parenteral K+ IV regular insulin usually Hold K+-wasting diuretics IV KCl infusion (diluted) intake given with albuterol K+-retaining diuretics Rate should not exceed ↓ K+ dietary intake IV sodium bicarbonate if Oral K+ supplements (given 10 mEq/hr Loop or thiazide diuretics acidotic with food) Given via infusion pump Patiromer and/or IV calcium chloride or ↑ K+ dietary intake never IV push or bolus Kayexalate calcium gluconate Monitor ECG Irritating to vein- Dialysis Monitor ECG monitor q hr  Electrolyte Imbalances Calcium (Ca++) Normal: 9 - 11 mg/dL High Calcium Foods Major cation in bones and teeth Roles: Dairy foods Blood clotting Sardines Transmission of nerve impulses Brazil nuts Myocardial contractions Canned salmon Muscle contractions Green leafy Requires active form of Vit D for absorption vegetables like curly Levels regulated by PTH and calcitonin (PTH kale, okra, spinach increases serum Ca++, calcitonin decreases serum Ca++) Inverse to Phosphorus Similar to Vitamin D and Magnesium Hypercalcemia > 11 mg/dL Hypocalcemia < 9 mg/dL Causes Causes Hyperparathyroidism Paget's disease Primary Bisphosphonates Hematologic malignancy Adrenal insufficiency hypoparathyroidism Loop diuretics Malignancies with bone Thiazide diuretics Renal insufficiency Chronic alcoholism metastasis Ca++-containing Acute pancreatitis Diarrhea Prolonged immobilization (e.g. antacids Elevated serum phosphorus Alkalosis paralysis) Acidosis Vit D deficiency Insufficient Ca++ intake Vit A or D overdose Mg deficiency Malnutrition Signs/Symptoms Signs/Symptoms Fatigue, weakness Bone pain, fractures Weakness, fatigue Tetany (Chvostek's sign, ↓ memory Polyuria, dehydration Depression Trousseau's sign, dysphasia, ↓ reflexes Seizures, coma Irritability, confusion numbness and tingling in ↑ BP Nephrolithiasis Hyperreflexia extremities and around mouth) Confusion ECG changes: Muscle cramps ECG changes: Anorexia Shortened ST segment ↓ BP Elongation of ST segment N/V Shortened QT interval Prolonged QT interval Management Management Discontinue: Adequate hydration ↑Ca++ dietary intake Discontinue loop diuretics Vit D supplements Administer: Ca++ and Vit D supplements and switch to thiazide IV or PO calcium IV isotonic saline IV Ca gluconate (slowly) Monitor for falls as pt at Thiazide diuretics Bisphosphonate For tetany: risk for fracture ↓ dietary calcium Calcitonin Breathe into paper bag ↑ wt-bearing activity Dialysis as last resort Sedation possibly  Electrolyte Imbalances Magnesium (Mg++) Normal: 1.5 - 2.5 mg/dL High Magnesium Foods Roles: Assists in: Pumpkin seeds Carbohydrate metabolism Dark chocolate DNA and protein synthesis Almonds BG control Cashews BP regulation Spinach Required for production of ATP Avocadoes Muscle contraction/relaxation Brazil nuts Neurologic functioning Salmon Neurotransmitter release Similar to Calcium and Potassium Inverse to Phosphorus Hypermagnesemia > 2.5 mg/dL Hypomagnesemia < 1.5 mg/dL Causes Causes Renal failure Metastatic bone disease Diarrhea Hyperglycemia IV administration of Mg++ Adrenal insufficiency NG suction PPI Therapy (especially for eclampsia) Mg++ containing antacids Chronic alcoholism Diuretics Hypothyroidism Mg++ containing Malabsorption syndromes Tumor lysis syndrome laxatives Malnutrition Fasting/NPO ↑ urine output Signs/Symptoms Signs/Symptoms Lethargy Resembles hypocalcemia Hyperactive DTR Drowsiness Confusion Chvostek's and Trousseau's Muscle weakness Muscle cramps signs N/V ↓ Tremors ↑ pulse DTR Flushed, warm skin (especially face) Seizures ↑ BP Vertigo Dysrhythmias ↓ ↓ pulse, BP Urinary retention Management Management Discontinue Mg++ ↑ fluids/diuretics to ↑Mg++ dietary intake containing: promote urinary excretion Oral supplements Meds (if renal function adequate) IV Mg++ (e.g. Magnesium Laxatives Dialysis if impaired renal sulfate) Antacids function Use infusion pump ↓ Mg++ dietary intake IV Calcium gluconate Slowly Monitor vitals  Electrolyte Imbalances Phosphorus (PO4 ) Normal: 2.5 - 4.5 mg/dL High Phosphorus Foods Primary anion in ICF; 85% located in bones Roles: Milk and cheese Bones/teeth Egg yolks Muscle function Chocolate RBCs Soft drinks Nervous system Beer Acid-base buffering system Fish Formation of ATP Beef and chicken Uptake and use of glucose Nuts and beans Carbohydrate/protein/fat metabolism Inverse to Calcium and Magnesium Vit D and PO4 assist in absorption of each other PTH maintains serum PO4 levels Hyperphosphatemia > 4.5 mg/dL Hypophosphatemia < 2.5 mg/dL Causes Causes AKI and CKD Thyrotoxicosis Chronic diarrhea Diabetic ketoacidosis Phosphate enemas Hypoparathyroidism Malnutrition Hyperparathyroidism Phosphate-containing Sickle cell anemia Vitamin D deficiency Respiratory alkalosis laxatives Hyperthermia Parenteral nutrition with Refeeding syndrome Rhabdomyolysis inadequate PO4 replacement Tumor lysis syndrome Chronic alcoholism PO4-binding antacids (long- term) Signs/Symptoms Signs/Symptoms Often asymptomatic unless Seizures Mild/moderate often Coma also hypocalcemia Calcium-phosphate asymptomatic Cardiac problems Tetany including numbness precipitates in skin, soft Confusion (dysrhythmias, heart failure) and tingling in extremities tissue, cornea, viscera, Muscle weakness Osteomalacia/rickets - from and around mouth blood vessels (including respiratory) chronic hypophosphatemia Hyperreflexia Itchy skin Polyneuropathy Rhabdomyolysis Muscle cramps Seizure Management Management ↑ Decrease intake of phosphorus foods ↑PO4 dietary intake and fluids Oral PO4 supplements Oral PO4-binding agents (Ca Carbonate or IV Na+ phosphate or K+ Ca acetate) - given with food phosphate Dialysis Monitor Ca++, K+ levels Loop diuretics Monitor BP and ECG  Electrolyte Imbalances Chloride (Cl-) Normal: 95 - 105 mEq/L High Chloride Foods Major anion in ECF; also found in gastric and Table salt pancreatic juices, sweat, bile, saliva Seaweed Roles: Rye Acid-base balance Tomatoes Maintains osmotic pressure along with Na+ Lettuce Food digestion (HCl) Celery Produced in stomach (where it combines w/H+) ↓ ↓ Linked with Na+: of Na+ will show a of Cl- Olives and vice versa Inverse relationship to Bicarbonate Mainly obtained from table salt Hyperchloremia > 105 mEq/L Hypochloremia < 95 mEq/L Causes Causes Head trauma Excessive sweating GI tube drainage Metabolic alkalosis Renal failure Severe diarrhea Gastric surgery or suctioning Blood transfusions Excessive NaCl infusions Diuretics Severe vomiting/diarrhea ACTH with water loss Metabolic acidosis Administraton of Cl-deficient Corticosteroids Corticosteroid use IV solutions Laxatives Dehydration ↓ salt intake SIADH Vomiting Diuretics CHF DI Burns Signs/Symptoms Signs/Symptoms Tachypnea ↓ CO Agitation Tetany Lethargy/weakness Dyspnea Irritability Slow shallow respirations Deep rapid respirations Tachycardia Tremors Seizures Confusion Extreme thirst Muscle cramps Dysrhythmias ↓ cognitive status ↓ UO Ab cramps Coma Hyperactive DTR Hypertonicity Management Management Hold NaCl infusions IV NS or 1/2 strength saline Lactate Ringer's solution Discontinue diuretic (loop, IV sodium bicarbonate thiazide, osmotic) Diuretics Ammonium chloride (acidifying Restrict: Na+, Cl-, fluids agent) - but not with impaired liver or renal function Electrolyte Relationships Sodium / Potassium = INVERSE + Na = K+ Calcium / Phosphorus = INVERSE ++ 3- Ca = PO4 Calcium / Vitamin D = SIMILAR ++ Ca = Vit. D Calcium / Magnesium = SIMILAR ++ ++ Ca = Mg Magnesium / Potassium = SIMILAR Mg++= K+ Magnesium / Phosphorus = INVERSE ++ 3- Mg = PO4  The Endocrine System A network of glands and organs that regulate and control various body functions by producing and secreting hormones. Pineal Hypothalamus Major Endocrine Glands Pituitary 1. Hypothalamus 6. Thymus Parathyroid Thyroid 2. Pituitary 7. Adrenal 3. Pineal 8. Pancreas Thymus 4. Parathyroid 9. Ovaries 5. Thyroid 10. Testes Adrenal Hypothalamus Gland Pancreas Location: Base of brain Function: Major role in endocrine system; maintains Ovaries body's homeostasis; releases hormones that (female) stimulate the pituitary gland Testes Main Hormones: Oxytocin, Anti-Diuretic Hormone (male) (ADH/Vasopressin) Pituitary Gland - AKA 'Master' gland Location: Connected to hypothalamus in brain Function: Secretes hormones that send signals to other endocrine glands to release or inhibit their own hormone production Main Hormones and target organ: Growth hormone - Bones, muscles, organs Thyroid-stimulating hormone (TSH) - thyroid to Prolactin - Breasts (mammary glands) to stimulate produce thyroid hormones milk production ADH (made in hypothalamus but stored in pituitary) - Luteinizing hormone (LH) - ↑ kidneys to water absorption in blood ovaries to produce estrogen/progesterone Oxytocin (made in hypothalamus but stored in testes to produce testosterone pituitary) - breasts (for milk production) and uterus Follicle-stimulating hormone (FSH) - same as LH (for contractions) Adrenocorticotropic hormone (ACTH) - adrenal glands to produce corticosteroids Pineal Gland Location: Between two hemispheres in brain Function: Regulates circadian rhythm and reproductive hormones Main Hormone: Melatonin  Endocrine System Parathyroid Glands Thyroid Gland Location: Four glands in the neck BEHIND Location: Lies just below the Adam's apple in No relation the thyroid the neck other than Function: Regulate calcium and phosphate Function: Regulates the body's metabolism name levels Main Hormones: T3 (Triiodothyronine), T4 Main Hormone: Parathyroid hormone (PTH) (Thyroxine- converts to T3), Calcitonin Thymus Gland Adrenal Glands - AKA Suprarenal Location: Behind sternum between lungs Location: Two glands located one on top of each kidney Function: Stimulates the development of T cells Function: Two parts to each gland (Medulla and Cortex), which are sent to lymph nodes to help fight each with its own function. disease. Only active until puberty then shrinks Medulla: Secretes epinephrine and norepinephrine to and becomes fat! help control activities of sympathetic nervous Main Hormone: Thymosin system (blood pressure, heart rate, sweating) Cortex: Secretes two types of corticosteroid Ovaries hormones: 1. Glucocorticoids: Location: On either side of uterus a. Hydrocortisone (cortisol) - helps convert Function: For proper physical development of food to energy girls and to ensure fertility b. Corticosterone - regulate immune Main Hormones: Estrogen, Progesterone response 2. Mineralcorticoids: The main one is aldosterone Testes - maintains balance of salt and water to control Location: Within the scrotum blood pressure Function: For proper phys. development of boys, Main Hormones: Epinephrine, Norepinephrine, then libido, muscle strength, bone dens. Hydrocortisone, Corticosterone, Aldosterone Main Hormone: Testosterone Pancreas - belongs to both endocrine and digestive systems Location: Next to stomach, connected to duodenum Function: Main endocrine function is to regulate blood glucose levels; only 5% of pancreas is endocrine cells (Islets of Langerhans) Main Hormones: 1. Gastrin - stimulates cells in stomach to produce acid for digestion 2. Glucagon - stimulates cells to release glucose to raise blood glucose levels 3. Insulin - regulates blood glucose levels by allowing cells to absorb & use glucose (thus lowering blood glucose levels) 4. Somatostatin - released when insulin and glucagon get too high 5. Vasoactive intestinal peptide (VIP)- controls H2O secretion/absorption from intestines  Disorders of the Thyroid Gland The Thyroid Gland Graves Disease Location: Lies just below the Adam's apple in the neck Autoimmune disorder where the antibody Function: Regulates the body's metabolism (Thyroid Stimulating Immunoglobulin - TSI) Main Hormones: T3 (Triiodothyronine), T4 (Thyroxine- stimulates the thyroid to produce and secrete converts to T3), Calcitonin excess thyroid hormones into the blood; often hereditary Thyroid uses iodine in food we eat to make the two Signs/Symptoms include those for main hormones (T3 and T4) hyperthyroidism (see next page) PLUS : T3 & T4 function: Protruding eye balls/puffy eyes Regulate metabolism Double vision; sensitive to light Affect: Pretibial Myxedema - red, swelling on the Heart rate skin, lower legs and feet (has an orange SNS peel texture) Growth/development TX- same as for hyperthyroidism, PLUS Body temperature For eyes: Elevate HOB, eye drops, selenium, Fertility diuretics Digestion/burning calories Corticosteroid cream for itchy skin Muscle contraction Calcitonin helps incorporate calcium into bone Hypothalamus releases Thyrotropin-releasing Thyroid Storm- → Hormone (TRH) Pituitary releases Thyroid- a life-threatening emergency! → stimulating Hormone (TSH) thyroid produces Sudden, extreme overactivity of the thyroid T3 & T4 gland Too much T3 & T4 in blood stimulates pituitary to Cause: Pt w/hyperthyroidism that is stop releasing TSH (negative feedback loop) unmanaged/ill-treated or is ill (sepsis; DKA; If the thyroid is enlarged, a goiter may appear surgery); post-thyroidectomy; taking below or to the sides of the Adam's apple salicylates; pregnant, or exposed to radioactive iodine therapy Thyroid Function Tests S/S: Typical hyperthyroidism s/s to the Blood tests: EXTREME! Fever, HTN and tachycardia (may TSH - Best indicator of thyroid function ↑ lead to CHF or MI), RR (may lead to resp Need to test along with T4 & T3 to see if failure), restless and confused (may lead to problem lies with thyroid or pituitary seizures, delirium, come) T4 & T3 Interventions: Monitor HR, BP, RR, EKG, TRH temperature; sedatives, no iodine Thyroid Binding Globulin (TBG) (carries T3 & Meds: Antithyroids (Methimazole, PTU) - block T4 in blood) synthesis; Iodide solution - blocks secretion; Antibodies (to check for autoimmune disease) Tylenol (no salicylates), Beta Blockers Biopsy (if cancer suspected) (Inderal) - block conversion; Glucocorticoids Ultrasonography (if growths are detected) (Dexamethasone) - suppresses immune system Radioactive iodine uptake test (to measure thyroid activity)  Disorders of the Thyroid Gland Hyperthyroidism Condition that occurs when there is a high level of thyroid hormones in the blood - AKA Overactive Thyroid Causes Signs and Symptoms - think FAST Graves Disease (see Graves Disease section) - Enlarged thyroid gland (goiter) most common Sped up body functions Toxic multinodular goiter - Plummer Disease - ↑ HR/BP many nodules that secrete excess thyroid Palpitations due to arrhythmias hormones Excess sweating/hot Thyroiditis - Inflammation caused by: Shaky hands Virus Nervous/anxious/irritable Autoimmune Insomnia Single toxic nodule - abnormal tissue within the ↑ Wt loss/ appetite thyroid produces excess thyroid hormones Frequent BM/diarrhea Certain meds Change in menstrual cycles Iodine (too much) Elderly - 'Masked' hyperthyroidism Overactive pituitary gland - rare Weak Confused Treatment (Will depend on cause) Withdrawn Depressed Iodine - not used long-term; given when tx Other s/s if caused by Graves (see Graves Disease needed fast (i.e. thyroid storm - see Thyroid section) Storm section) Radioactive iodine - destroys part or all of Intervention thyroid gland; may need HRT for rest of life Thyroidectomy - removal; will need HRT for Cool, calm environment; daily wts rest of life Monitor EKG, HR, BP, for thyroid storm ↓ Beta-blockers - HR, tremors and anxiety Educate on: Meds Radioactive iodine therapy Thyroidectomy Medications Do not abruptly stop meds Take meds same time each day Antithyroid meds: Avoid iodine-rich foods, aspirin/salicylates Methimazole - most common Propylthiouracil (PTU) - watch for liver If thyroidectomy: damage Monitor for possible parathyroid issues and Stop the production of T3 & T4 thyroid storm Watch Ca levels Keep pt in Semi-Fowler's position Keep trach kit, oxygen nearby  Disorders of the Thyroid Gland Hypothyroidism Condition that occurs when there is a low level of thyroid hormones in the blood Causes Signs and Symptoms- think SLOW Primary Affects mainly women middle to older aged Hashimoto's thyroiditis - most common- Possible enlarged thyroid gland (goiter)- usually autoimmune disorder where body attacks w/Hashimoto's thyroid Slowed down body functions Thyroiditis - usually temp Fatigued- usually 1st sign Tx for hyperthyroidism or thyroid cancer Eyelids droop; eyes/face puffy (myxedema) Low iodine in diet (rare in U.S.) Voice hoarse/speech slow Radiation to head & neck Hair sparse, coarse, dry ;skin coarse, dry, scaly Genetic disorder Wt gain; constipated; muscle cramps Secondary- rare ↓ No tolerance to cold; HR When pituitary gland fails to secrete enough Change in menstrual cycles TSH Elderly may appear depressed, confused, forgetful, demented Intervention Monitor for myxedema coma Medications Administer meds as prescribed and not within 4 hrs: Thyroid hormone replacement Carafate Synthroid Aluminum Hydroxide Thyrolar Simethicone Educate pt: Cytomel Multivitamin Don't abruptly stop NO sedatives/narcotics - increase Monitor for hyperthyroidism taking meds; take same risk for myxedema coma (see NO sedatives or narcotics time every day Myxedema Coma section) Medication interactions Myxedema Coma - a life-threatening emergency! Sudden, extreme underactivity of the thyroid gland; rare Interventions: Cause: Pt w/hypothyroidism that is unmanaged/ill- Monitor HR, BP, EKG, Wt treated or is ill, abruptly stops taking thyroid Monitor resp status (may need mech vent) replacement meds, takes sedatives or lithium, or thyroid Keep warm gland is removed IV solutions as prescribed: S/S: Typical hypothyroidism s/s to the EXTREME! Normal saline and glucose ↓ ↓ ↓ ↓ ↓ HR, BP, Temp, BG , Na Synthroid (monitor for toxicity) Resp failure; Myxedema (swelling of eyes/face) Glucose Drowsy; may lead to confusion, stupor, coma No sedatives or narcotics  Hyper- and Hypoparathyroidism The main purpose of the parathyroid glands is to control blood calcium levels. Role of Calcium in body Parathyroid glands monitor the Ca level 24 hrs/day. Nerve impulse transmission Muscle contraction ↓ When the level , the glands make and release Bone health parathyroid hormone (PTH). Blood clotting ↑ When the level , the glands make less PTH or It's all about stop the release altogether. (PTH negative feedback loop) the calcium! Normal Ca levels = 8.6 - 10.0 mg/dL When Ca level is low, PTH is sent to: Kidneys to: Bones to release Ca into blood Reabsorb Ca (and stop the release into urine) ↑ Intestine to absorption of Ca from diet Stimulate the production of active Vit D (needed to absorb Ca) Block phosphate from being reabsorbed (excretes in urine instead) Hyperparathyroidism Disorder caused by over-production of PTH by a parathyroid gland. Leads to Hypercalcemia and Hypophosphatemia 2 types: Primary - Caused by enlarged parathyroid Secondary - Caused by another condition gland(s) ↓ that causes Ca levels in the body Noncancerous growth - ** Most common Severe Ca deficiency Enlargement (hyperplasia) Severe Vit D deficiency Cancerous tumor (very rare) Chronic kidney failure (kidneys can't covert Vit D so SI can't absorb Ca) Complications Diagnosis Signs and Symptoms Osteoporosis Blood tests: Osteoporosis Kidney stones Ca ↑ Kidney stones ( Ca levels cause kidney CVD PO4 to reabsorb Ca) In pregnant women may cause Mg ↑ Excess urination ( Ca levels cause ↑ neonatal hypoparathyroidism PTH urine production) Sometimes: Risk Factors N/V; no appetite Radiation tx for cancer in Urine for Ca EKG ↑ Ab pain ( stomach acid); constipation Feeling ill in general; tired/weak neck area Bone density Bone and joint pain; depressed/forgetful Lithium (bipolar disorder)  Hyper- and Hypoparathyroidism Hyperparathyroidism, cont. Intervention Medications Surgery (parathyroidectomy) is the main Calcimimetics 'Senispar' - mimics role of treatment for Primary Hyperparathyroidism ↓ Ca in blood to PTH levels - used in pt ↓ ↑ Admin meds per MD order; Diet: Ca, PO4 w/secondary hyperparathyroidism- take Monitor: vitals; EKG; Ca/PO4 levels; renal status w/food to avoid GI distress I/Os, encourage fluids Calcitonin - injected or nose spray -↓ Post-op: ↑ osteoclasts and kidney excretion of Ca Monitor resp status; trach kit, oxygen, suction on hand ↓ Loop diuretics 'Lasix' - Ca reabsorption Keep in Semi-Fowler's position in renal tubules- monitor K+ levels ↓ Watch for Ca levels: tingling; twitching, + Trousseau's Bisphosphonates 'Aredia' or 'Fosomax' - Sign; + Chvostek Sign slows down osteoclasts Watch for: Laryngeal nerve damage (voice changes, trouble swallowing or speaking) Hypoparathyroidism Disorder caused by decreased production of PTH by the parathyroid glands. Very Leads to Hypocalcemia and Hyperphosphatemia RARE Causes Medications Following thyroid or PT surgery IV calcium - slowly, can cause tissue sloughing, watch if pt on Accidental removal during thyroid Digoxin (risk of toxicity) surgery Oral Ca w/Vit D - give separate times than Fe and thyroid Parathyroidectomy (usually transient) hormone Inability of kidneys and bones to respond PO4-binders - Aluminum carbonate - given after meals to ↑ to PTH (pseudo-hypoparathyroidism) excretion of PO4 by GI system Congenital (Neonatal hypoparathyroidism- PTH replacement - Natpara - Monitor Ca levels; watch for GI due to pregnant mom with distress, paresthesia hyperparathyroidism) Immune system develops antibodies Intervention against PT tissue Monitor Ca and PO4 levels Hypomagnesemia Have trach kit, oxygen and Usually caused by chronic alcoholism suction at bedside Meds per MD order Signs and Symptoms ↑ ↓ Diet Ca, PO4: Encourage: Avoid: Parathesia - Severe tetany - Beans, almonds Soft drinks, coffee tingling, numb skin bronchospasm, Dark green, leafy Eggs, red meat +Trousseau's Sign laryngospasm, hand/feet veges Alcohol, tobacco +Chvostek Sign spasm, seizures, EKG changes Dairy ↓ ↑Ca, PO4 Fortified cereals, OJ  Disorders of the Adrenal Glands Adrenal Glands Location: Two glands located one on top of each kidney Adrenal glands Function: Two parts to each gland (Medulla- inner layer and Cortex- outer layer), each with its own function. Medulla: Secretes epinephrine and norepinephrine to help control activities of sympathetic nervous system (blood pressure, heart rate, sweating) Cortex: Secretes two types of corticosteroid hormones: Kidneys Glucocorticoids: Hydrocortisone (cortisol) - regulates metabolism Adrenal Adrenal Corticosterone - regulate immune response Cortex Medulla Mineralcorticoids: The main one is aldosterone - maintains balance of salt and water to control blood pressure Kidney Main Hormones: Epinephrine, Norepinephrine, Hydrocortisone, Corticosterone, Aldosterone Hypothalamus releases Corticotropin- In response to stress, the hypothalamus stimulates the releasing Hormone (CRH) → Pituitary medulla to release epinephrine and norepinephrine releases Corticotropin (ACTH) → The renin-angiotensin-aldosterone system (regulated by adrenal glands release glucocorticoids kidneys) stimulates adrenal glands to produce more or less aldosterone Cushing's Syndrome Condition due to very high level of cortisol released from adrenal glands Causes: Signs and Symptoms Large doses of corticosteroids (ex. Excessive fat on torso & top of back (known as Prednisone, Dexamethasone) buffalo hump) Asthma, rheumatoid arthritis, lupus Large round face (moon face) Tumor in adrenal glands Weak muscles; fatigue; depression Tumor outside the pituitary glands- Thin skin, bruise easily; striae on abdomen/chest producing corticotropin (ACTH) ↑ ↑ ↓ BP, BG, K Osteoporosis; irregular menstrual cycles in women Syndrome Cushing's Disease ↑ ED in men, body and facial hair, women balding and Very high level of cortisol due Hirsutism in women to pituitary gland producing too Children: grow slowly, short stature Disease much ACTH. Usually caused by not the a tumor in the pituitary. The same! adrenal glands are normal.  Disorders of the Adrenal Glands Cushing's Syndrome, cont. Treatment Diagnosis Will depend on cause Measure cortisol in urine/saliva/blood for ↓ corticosteroids if possible (weigh benefits) ↑ 24 hr pd (will be all day in Cushing's) ↑ pro, ↑ K diet CT, MRI, chest x-ray to look for tumors Radiation tx Meds to ↓ cortisol and its effects: Intervention Metyrapone Surgery Prep for surgeries Ketoconazole Remove tumors Monitor for infection/skin breakdown Mifepristone Adrenalectomy Monitor BG, K, Na, Ca Addison's Disease Deficiency of cortisol and aldosterone due to underactive adrenal glands AKA Primary Adrenal Insufficiency Signs and Symptoms Causes: Develop slowly over time, vary/person Weak, tired, dizzy Autoimmune reactions - body Dark patches of skin (knuckles, scars, attacks adrenal cortex Treatment creases, gums) Cancer Goal is to replace Black freckles; wt loss/no appetite Tuberculosis/infections cortisol & aldosterone Muscle aches; N/V/Ab pain/Diarrhea Trauma to adrenal cortex In infants/children: genetic with meds- will need ↓ No tolerance to cold; BP, dehydration for life Crave salt; Depression ↓ ↓ ↑ ↑ Na, BG, K, Ca Irregular menstruation in women; ED in men Diagnosis S/S slow to show, no definitive Intervention blood test so difficult to dx ↓ ↑ Blood tests may show Na, K, Monitor BG and K ↓ ↑ cortisol, ACTH Administer meds as prescribed Educate: Medications Don't abruptly stop meds Cortisol replacement: ↑ Report stress levels (may need adjustment) Carry injection of cortisol for emergency Hydrocortisone (divided doses each day) Wear med alert bracelet Prednisone Dexamethasone ↑ Diet Prot/carbs, include Na Avoid undue stress and strenuous exercise Aldosterone replacement: Watch for Addisonian Crisis (see next page) Fludrocortisone  Disorders of the Adrenal Glands Secondary Adrenal Insufficiency Decrease in cortisol due to lack of ACTH from pituitary gland Causes: Signs/Symptoms: Chronic steroid use *Most common Similar to Addison's Disease, except: Pituitary tumor No dark patches of skin Removal of pituitary gland No dehydration Head injury Na & K levels normal Treatment: Corticotropin level is LOW Prednisone or hydrocortisone Addisonian Crisis (Adrenal Crisis) Extremely low cortisol levels. Life-threatening emergency! Causes: Signs/Symptoms: Intervention: Pt has Addison's Dz and: Severe Ab/low back/leg pain Monitor for: Not treated properly Sudden, extreme weakness Infection Experiencing extreme stress, accident, ↓ Extremely BP Neuro status injury, surgery, severe infection Dehydration Electrolyte status Adrenalectomy Severe vomiting/diarrhea (Na, K, BG) Pituitary gland not producing ACTH May lead to Treatment: Kidney failure; shock IV Solu-Cortef/IV fluids (D5NS) **STAT!** Loss of consciousness Pheochromocytoma Tumor in the adrenal medulla that produces excessive amounts of catecholamines Normally, the adrenal medulla secretes catecholamines (epinephrine, norepinephrine, Diagnosis Treatment dopamine) in response to stress. They cause: 24 hr urinary ↑ ↑ ↑ ↑ HR, BP, BG, BMR catecholamines & Tumor removal or ↑ Fat metabolism metanephrines complete adrenalectomy ↓ ↑ Thermogenesis (breakdown products) Until surgery, catecholamines and BP Feelings of anxiety/fear Serum catecholamines with meds: However, in pheochromocytoma, the tumor MRI/CT to look for Alpha-adrenergic causes these reactions without stress. tumor blockers: Cardura, Tumors are mostly benign Usually in one gland Intervention Minipress, Hyrtin Beta-adrenergic Affect mostly adults (20-40 yrs) Monitor: blockers: Labetalol or BP, HR, BG Signs and Symptoms Inderal Look for hypertensive crisis: ↑ Severe HTN, BG; headaches >180 systolic or >120 diastolic Educate pt: Tachycardia; excess sweating S/S: Headache, changes in High cal diet N/V; back/Ab/chest pain vision or neuro, seizures, SOB No stimulants Tremors in hands; anxiety/fear Chest pain and/or EKG changes Hormone therapy Heat intolerance; flushed face Meds as ordered post-surgery  DI vs SIADH Diabetes Insipidus vs Syndrome of Inappropriate Antidiuretic Hormone It's all about Antidiuretic Hormone (ADH)-- AKA Vasopressin ADH is produced in the hypothalamus and stored/secreted in pituitary gland. ADH is secreted or withheld due to changes in hydration status ADH function: to cause the body to retain water and constrict blood vessels. How? By causing the renal tubules to retain water. Diabetes Insipidus SIADH D = DRY S = Soaked Too little ADH Too much ADH ↓ADH ↑ADH Cannot retain water Retains too much water ↑urine output ↓ urine output ↑Na ↓Na Dehydrated Overhydrated Diabetes Insipidus Condition in which the kidneys are unable to retain water. Types/Causes: Too little ADH Central DI - Pituitary gland does not secrete ADH - Most common ↓ADH Cannot retain water Damage to hypothalamus or pituitary gland Brain damage: Head trauma, stroke ↑urine output Brain tumor ↑Na Dehydrated Aneurysm Certain drugs: Declomycin (tx. for SIADH) Nephrogenic DI - Kidneys do not respond to ADH Diagnosis Hereditary Acquired Water deprivation test - 12 hours no fluid Certain drugs: Lithium, Declomycin Measure urine , electrolytes, wts regularly Polycystic Kidney Disease, Sickle Cell Disease Then inject ADH after 12 hrs Gestational - Rare ↓ If urination, urine concentrated, BP Placenta produces vasopressinase which can cause rises, HR normal = Central DI ADH to breakdown If not = Nephrogenic DI  DI vs SIADH Diabetes Insipidus, cont. Signs and Symptoms Intervention Polyuria - LOTS of urine - 4-24L/day Strict I/Os, daily wts Polydipsia - crave water/ice ↓ Monitor electrolytes (Na, K); Na diet ↓ Dehydrated - dry mucous membranes/skin; skin turgor Meds as prescribed ↓ Urine diluted ( spec gravity) Avoid caffeine: tea, coffee, energy drinks ↑ ↓ Na - due to water levels Hypotension - due to severe dehydration and vessels Medications dilated Chlorpropamide (Diabinese) Extreme fatigue ↑ ADH hormone Muscle pain/weakness ↓ May cause BG, photosensitivity Treatment Desmopression (DDAVP, Stimate) Nasal spray/tablet/injection/or IV No cure ↓ Na diet ↓ May cause Na Give adequate water Meds Thiazide diuretics Syndrome of Inappropriate Antidiuretic Hormone (SIADH) Condition in which the body makes too much ADH Causes: Too much ADH Diagnosis Lung cancer (ADH produced outside the ↑ADH Blood and urine tests pituitary) Retains too much (Na & K) Damage to hypothalamus or pituitary gland water Infection/germs ↓ urine output Difficult to diagnose - need Pneumonia ↓ Na to rule out other conditions CNS disorder - stroke, hemorrhage, trauma Overhydrated Intervention HIV Certain drugs Treatment