More endocrine.....review...never ending endo

ADRENALS there are two of these, and each has two parts…the adrenal medulla and the adrenal cortex. The hormone secretion is regulated by the pituitary ACTH. The adrenal medulla is at the center of the gland and it secretes catecholamines. These regulate metabolic pathways to promote the catabolism of stored fuels to meet calorie needs. They increase the blood sugar and increase the metabolic rate. Epinephrine--of course…again is responsible for the fight/flight response. In times of emergency it decreases blood flow to the extremities, GI (not needed) and increase blood supply to the brain and heart. The cortex is the outer portion of the gland. It secretes Steroids and sex hormones (covered last year). Steroids are needed to regulate the body’s response to physical and psychological stress….Glucocorticoids--important to glucose metabolism. Increased secretion leads to increase blood glucose. These are often given to reduce inflammatory response such as allergic reaction, anaphylaxis. Side effects= increase blood glucose, osteoporosis, ulcer, poor wound healing. Mineralcorticoids (Aldosterone) Primary hormone for long term Na+ balance. Act on the kidneys and GI to increase the sodium absorption in exchange for excretion of K+ or Hydrogen ions. Occurs in the presence of angiotensin 2.
(Minimally) Adrenal Sex hormones= Androgens- like male sex hormones. Estrogen--secretes small amounts of this.
DYSFUNCTION OF ADRENAL GLANDS (4)
In the Medulla--PHEOCHROMOCYTOMA--catecholamines are increased. The severity depends on how much epinephrine and norepinephrine are secreted. Causes hypertension (I mean really high) Tumor usually on the adrenal medulla. Clinical s/s= tremor, headache flushing, anxiety, hyperglycemia (remember what epinephrine does) Liver and muscle glycogen turning into glucose. Diagnostics= check urine and plasma levels of catecholamines. The most direct and conclusive test for over activity of the adrenal medulla is t he 24 hour urine for VMA (vanillylmandelic acid) Test.--levels of VMA in the urine will be increased. Diet for this test is no coffee, tea, bananas, chocolate, vanilla, (Oh No!!!) and aspirin prior to the test. ADRENALECTOMY--removal of the tumor. Manipulating the tumor may cause a release of stored epi/norepi….which may increase the heart rate and blood pressure. If both adrenals are removed, Corticosteroids replacement is needed. Hypotension or hypoglycemia may occur because of the sudden withdrawal of catecholamines. Check plasma and urine levels (of catecholamines)! To see if the surgery has been successful.
On to the Cortex…..ADDISONs DISEASE not enough adrenocortical hormones. Caused by TB destroying the gland. Or maybe autoimmune atrophy. Clinical s&s= muscle weakness, fatigue, wasting, anorexia, GI--nausea, vomit, diarrhea leading to dehydration, weight loss. Increased melanocyte hormone causes bronze darkening of mucus membranes, skin, knuckles, knees. Hypotension from hyponatremia--low Na+ craving salt. K+ may be elevated leading to cardiac arrhythmias. *******Hypoglycemia--tired and weak*********
Addisons Crisis---severe hypotension and shock, cyanosis, fever, headache, GI symptoms. On slight overexertions, cold temp, infections or decrease in salt. Leading to shock, circulatory collapse and death. To prevent all this would be Corticosteroids replacement. Labs= low blood sugar, low sodium, high K+, high white blood cells, low levels of adrenocortical hormones, low cortisol levels. Management= fight the shock. Restore blood circulation, fluids, Corticosteroids replacement, treat infections, Provide IV therapy with Na+. Glucose, lytes. Rest. TEACHING= patient should be taught to prevent hyponatremia to increase sodium intake, to prevent illness, stress. Lifelong hormone replacement, to increase CHO and protein.
CUSHINGS SYNDROME has increased production of ACTH. The problem is from to much Corticosteroids being secreted by the adrenal cortex. Caused by adrenocortical tumor or pituitary tumor secreting ACTH which then causes increased secretion of glucocorticoids. If the cause is a pituitary hormone…..treatment of choice is removal of the pit gland. Signs/symptoms= cortisol levels are increased, hypernatremia leading to fluid retention, hypocalcemia, hyperglycemia. Nursing Care= protect from infection, skin care, decrease stress, check edema, accuchecks and insulin as ordered, diet--low calorie, low Na+, high K+, high Ca+, high vit D. daily weights, I&O.
PITUITARY GLAND (covered)
HYPOPITUITARISM disease of pit gland or hypothalamus…tumor, trauma or radiation. Treatment= replace the hormones! Corticosteroids, thyroid hormone, sex hormones, gonadotropins. Diagnose= x ray, CT scan. (to see tumor)
HYPOPHYSECTOMY--partial or complete. 2 approaches. To gain access to the pituitary gland the common approach transsphenoidal. The surgeon makes an incision beneath the upper lip to get inside the nasal cavity. The surgical site is the sella turcica. . Post operative nursing care=Increase head of bed to ease pressure on the sella turcica, and to promote normal drainage. Assess for clear drainage from the nose, constant swallowing, check for glucose in drainage--if positive= CSF Leak. Leak usually resolves in 72hr. May need spinal tap to decrease pressure. Anticipate antibiotics to prevent meningitis. Reduce Cerebral Edema- expect meds to reduce edema- mannitol (draws free water) Decadron may be given IV q6 hours for 24-72 hours….then tapered off. Relieve pain and reduce seizures= Acetaminophen for temp greater than 99.6 F (37.5C) and for pain. Codeine or morphine may be ordered for pain. Monitor the ICP. I&O . Urine specific gravity after each voiding. Check nasal packing frequently for blood and CSF. Oral Care every four hours…they are dry from mouth breathing. Teaching=No bending, no straining, for 2 months post op, no tooth brushing until sutures are out and heal--10days. If whole gland removed patient will have permanent diabetes insipid is.
ABSENCE OF PITUITARY GLAND
Menstruation ceases, Infertility occurs. Need Replacement hormone therapy. Testosterone for me, estrogen for women and HPG may restore fertility in women.
DIABETES INSIPIDIS hypofunction of the posterior pituitary. Leads to deficiency of ADH or Vasopressin. Cause= brain tumor, head trauma, inflammation, removal of the pit gland. S/s= thirst for cold water. Can drink up to 20 Liters a day. Dehydration, polydipsia, low specific gravity of urine ( 1.001-1.005) Large volumes of dilute urine. Diagnosis of DI is the fluid deprivation test. =withhold fluids for 8-12 hours or until 3-5% of body weight is lost. During test= frequent weights, plamsa and osmality of urine, specific gravity of urine. Stop Test if patient becomes tachycardia, weight loss greater than 5 %, If hypotension. Treatment= fluid and lyte replacement. I&O, weights. Administer hormone replacement as ordered= vasopressin (Pitressin) and vasopressin tannate IM, Lypressin nasal spray.
So there it is...I am studying instead of drawing. I have alot more to do.

More and more endocrine....and I am out of my thyroid....

Endocrine Review
some covered elsewhere...ie: islets of langerhans covered in DM...not going beat a dead horse with a stick....I am sick. More and more of endocrine to come.
The Endocrine Glands= pituitary-thyroid-parathyroid-adrenals-islets of langerhans-ovaries-testes
The system works with the nervous system…to maintain homeostasis.
The glands secrete directly into the bloodstream. (as opposed to the exocrine glands.)
This system is a negative feedback system.

Hypothalmus- The link between the nervous and endocrine system. Controls the pituitary.
Pituitary- HYPOPHYSIS= The master gland. Secretes hormones that control secretion of other hormones. (pretty cool.)
Posterior Pituitary--secretes Vasopressin (ADH). This is stimulated in response to…increase in blood osmolality…decrease in blood pressure. To control the excretion of water by the kidney. Secretes Oxytocin. Stimulated by pregnancy, childbirth. Function is to --milk ejection during lactation, increase force of uterine contractions.
Anterior Pituitary--secretes FSH, LH, Prolactin, ACTH, TSH, GH, MSH. (Only covering Growth hormone here, have the others covered elsewhere)--What GH does for you= increases protein synthesis, breakdown of fatty acids, increases the glucose levels in the blood. Secretion of this hormone increases when you: exercise, have stress (like now for exams!…I must be secreting a lot of this hormone) have a low blood sugar, starvation. Decreased secretion with hyperglycemia. If you do not have enough secretion= limited growth and dwarfism. Over secretion during childhood= Gigantism. Over secretion during adult hood leads to Acromegaly (think Abe Lincoln) deformities develop of bone, soft tissue, enlargement of viscera, large broad spade like hands…will not grow taller.

Thyroid Gland--lower neck anterior to trachea. 2 lobes. Highly vascular. Hormones= thyroxin (T4) Triiodothyronine (T3)--these are controlled by TSH. Calcitonin not controlled by TSH. It is controlled by Ca+ levels in the blood. Secreted as a response to high serum Ca+ levels. Reduces Ca+ levels by increasing Ca+ deposition into bone. Need Iodine for hormone synthesis. Functions of the thyroid hormones= control cellular metabolic activity. Influence cell replication, brain development, normal growth.
TRH is secreted by the hypothalamus it influences the release of TSH from the pituitary. The environment….when the environmental temp falls--leads to an increased secretion of TRH which results in an elevated secretion of thyroid hormones.
Labs for the Thyroid function= Serum T4= 5-12ug/dl for normal range. Drugs that decrease T4 levels= Heparin, Lithium, Salicylates. Drugs that increase T4 levels= contraceptives. Serum T3= 110-230mg/dl. Accurate indicator of hyperthyroidism. Greater T3 rise than T4 rise. TSH assay= most useful single test to Dx hypothyroidism.
Radioactive iodine uptake= (not going there today!) elevated levels with hyperthyroidism.
Thyroid ScintiScan= evaluates the size and structure of the thyroid. Areas of hyperactivity are hot spots. Gray or black regions. Areas of hypoactivity are cold spots and will show as white or gray regions. Biopsy= Under general anesthesia, needle biopsy. Detects tumors. Complications= Bleeding (of course) respiratory difficulties coming from Hematoma and edema.
Hypothyroidism
Common women 30-60 years. Causes: autoimmune, surgical removal, over treatment of hyperthyroidism. Assessments=bradycardia, general non pitting edema, anorexia, lethargy, slow mental process, clumsy, Intolerance to cold!!, dry skin, sleep a lot. Everything slows down. Nursing Care= VS. I&O. daily weights, decrease calorie in the diet, increase fluids/fiber, stool softener, keep environment warm, access edema (3rd spacing), thyroid replacement as ordered. Medical Treatment= Synthroid, Proloid, Cytomel. Effects of these: increase blood glucose levels. TH supplements increase the effect of Digitalis Glycosides, (watch for dig toxicity), Anticoagulants (watch for hemorrhage) Indocin. AVOID hypnotics sedatives. May produce profound somnolence. Give ½ to 1/3 dose. Call MD to clarify orders if not ordered this way.
MYXEDEMA= most severe stage of hypothyroidism. Pt. Hypothermic, increased lethargy leading to coma, cardiovascular collapse and shock, thyroid hormone given IV, Mortality rate is high.
HYPERTHYROIDISM or GRAVES DISEASE OR THYROTOXICOSIS
Over secretion of thyroid hormones. Metabolic rate GREATLY increased. Goiter seen with iodine deficiency . Mostly women 30-40s. May appear after emotional shock, stress, infection (unknown reasons) Assessments= nervous, insomnia, can not sit still, exophthalmus (bulging eyes), emotionally hyper excitable, apprehensive…tachycardia, palpitations, elevated systolic reading, flushed warm moist skin, Intolerance to heat!!! No menstrual periods, very thin and active. No weight gain even after eating, eating, eating. Thyroid gland is enlarged, soft and may pulsate. Thrill and Bruit over thyroid arteries. Nursing Care= VS- anti-thyroid meds as ordered, cool environment, decrease stress, increase in diet: CHO, protein, calories, vitamins/minerals. No coffee, tea, cola. Medical Treatment= Antithyroid meds= block synthesis of TH, Propacil, Tapazole. Radiation to destroy the gland, Thyroidectomy, Adrenergic blocking agents such as Inderal to decrease the sympathetic activity and alleviates tachycardia.
THYROIDECTOMY
Pre-Operative Nursing= Antithyroid drugs to suppress function. Iodine prep= Lugols or K iodine to decrease size and vascularity of the gland to reduce the hemorrhage risk.
Post-Operative Nursing= Humidified O2. First fluids to soft diet. Limit talking. Assess voice changes injury to the laryngeal nerve, some hoarseness common. Check for hemorrhage= behind/side neck. If patient complains of fullness or pressure at insertion site call MD stat. Check for Respiratory distress= results of edema of glottis, Hematoma, or injury to the laryngeal nerve, have trach set/airway at bedside, Call MD for extreme hoarseness.
Tetany--from accidental removal of the parathyroid gland during surgery. Disturbs Ca+ metabolism. Assess= hyper irritability of nerves, spasms of hands, feet, muscle twitching. At risk for--Airway obstruction, laryngospasm. Treatment= IV calcium gluconate.
Thyroid Storm= results from release of excessive amounts of TH during surgery. Assess for fever, tachycardia, agitation leading to delirium, heart failure, shock.


Parathyroid glands in the neck posterior to the thyroid (4)
Parathyroid hormone regulates calcium and phosphorous metabolism. Vit D increases the actions of the Parathyroid hormone, (I will abbrev. PTH). PH lowers the phosphorus levels in the blood. An increase exaggerates normal bone function. (Remember osteoblasts and osteoclasts? Building up and Cleaning up. From way back when) PTH has 3 basic effects on the body. 1. To increase bone resorption causes Ca+ loss leading to bone demineralization, bone pain from pathological fractures. 2. Increases renal retention of Ca+. 3. To increase GI absorption of Ca+.
HYPERPARATHYROIDISM is a disorder of calcium, phosphate, and bone metabolism. Hyper secretion of PTH. Clinical signs= elevated Ca+ levels above 10.8mg/dl on 3 tests. Skeletal--easy bone fracture, diffuse bone pain. Kidney-- low urine specific gravity. Decreased filtration leading to stones, and renal failure. GI--constipation, anorexia, nausea, vomit. Cardio--dysrhythmia, hypertension. GOALS= increase the renal excretion of Ca+. Decrease GI absorption and bone resorption of Ca+. high volume isotonic saline IV to increase the glomerular filtration of Ca+. Limit oral Calcium. Nursing Care= walking to put the calcium (Ca+) back into the bones. Low calcium diet. Increase bulk/fiber. Stool softener. Avoid bed rest!!
HYPOPARTHYROIDISM caused by inadequate secretion of PTH, from accidental removal of the parathyroid gland during thyriodectomy leading to hypocalcemia. Diagnostics= low Ca+ levels, increased phosphate levels, x-rays may show increased bone density. Tetany-- A serum calcium below 6.5 and the patient will have symptoms. S/s= tingling of fingers, around lips, painful muscle spasm. Dysphasia, laryngospasm, seizures, cardiac arrhythmias. Chvostek’s sign. Trousseau’s sign. Medical Goal= raise the calcium level. 9-10mg/dl. Calcium gluconate IV for acute. Large doses of Vit. D to increase the absorption of Ca+. Aluminum hydroxide (Amphogel) with or before meals to decrease phosphate levels. Nursing Care= Seizure precautions, quiet, emergency trach and IM Calcium gluconate at the bedside. Check serum Ca+ and phosphate levels.
Not enough color to this.....

Chest Tube review

Chest Tubes
(f)x= to remove air/fluid from the pleural space. To re-expand the lungs.
Simple things to Remember
Normal breathing works on -neg- pressure.
Pressure in the chest cavity is lower than the pressure in the atmosphere--Air moves into the lungs during inspiration.
When the chest is open from surgery or trauma - pressure is lost and the lung can collapse.
Chest tubes drain fluid or gas. Normally 20mL in pleural space.
Pneumothorax= air in the pleural space. Common from surgery.
Hemothorax= blood or serous fluid in the pleural space. Both lead to a decrease in gas exchange.
The chest tube will restore the -neg-pressure needed.
Small bore chest tube--7F to 12F, has a one way valve that prevents the air from moving back to the patient.
Large bore tube--up to 40F. Usually connected to drainage.
Wet Water Seal- amount of suction made by the amount of water instilled in the suction chamber. The amount of bubbling tells how strong the suction is. The water seal prevents the water from being sucked back to the patient on inspiration.
When wall suction is off--must be open to air.
To prevent pneumothorax, tube can be placed in sterile water for a temporary water seal.
Leaks
To check @ insertion site= clamp briefly at site with padded hemostats. If the bubbling stops in the water seal chamber= Leak at insertion site.
To check tubing= pinch rubber connecting tubing. If bubbling stops=leak at connecting site.
The water seal chamber should not be bubbling. Small amount of bubbling when- suction starts, drainage displacement, or a cough displaces air.
Remember
Check q 15min-1 hour first day post operative.
Water Seal chamber should have 2cm tidaling water.
Suction control= 20cm H2O regulates amount of suction
Document the drainage. Do not empty drainage (MD)
Dislodged tube: Have patient exhale. Compress site and provide a tight seal. Apply occlusive dressing. Notify MD
Chest tube disconnected from site: Clamp tube with padded hemostats near the insertion site. Create and underwater seal.
And we know that we will be using a pleur-evac...but since they are still testing us on this old 3 bottle system....anyway good to know the system to understand the concept of the pleur-evac drainage/suction system.