Exam 2 V2: NSG 4100/ NSG 4100 – Latest 2026/2027 Update – Advanced Medical-Surgical Nursing | Questions and Verified Answers | 100% Elaborated Solutions

Exam 2 V2: NSG 4100/ NSG 4100 – Latest 2026/2027 Update – Advanced Medical-Surgical Nursing | Questions and Verified Answers | 100% Elaborated Solutions 2026 / 2027 Academic Year Q: What does the adrenal gland produce? Answer Cortisol Aldosterone Androgens Q: Helps control the body’s use of fats, proteins and carbohydrates;suppresses Answer Aldosterone inflammation; regulates blood pressure; increases bloodsugar; and can also decrease bone formation Answer Cortisol Q: Tells kidneys to absorb more sodium into the bloodstreamand release potassium into the urine (regulates BP) Q: Assist ovaries produce estrogen and testes produce testosterone Answer Androgen Q: Hypo adrenal gland function Answer Hypoglycemia Q: Salt - hyponatremic and a decrease in salt, causes a decrease in VOLUME and a decrease in BLOOD PRESSURE causes what to happen to bloodpressure Answer HYPERKALEMIA Sex - A decrease in sexual hormones can allow other hormones to bemore easily seen. Ex: a female with low estrogen, may have moretestosterone apparent - thus the facial hair. hyper adrenal gland Sugar- hyperglycemic Salt- hypernatremic and an increase in salt, causes anincrease in VOLUME and an increase in BLOOD PRESSURE causes what to happen to blood pressure Sex - A increase in sexual hormones may be seen Q: What part of the adrenal gland controls adrenaline? Answer Medulla Q: Condition characterized by the shortage (deficiency) or impairedfunction of a hormone called aldosterone. The symptoms of thiscondition include low sodium (hyponatremia), too muchpotassium (hyperkalemia), and a condition where the bodyproduces too much acid (metabolic acidosis) Answer Hypoaldosteronism Q: What is a manifestation of hypoaldosteronism? Answer Dark pigmentation in the mucosa and skin around joints due to high levels of ACTH that binds to melano receptors Q: S/S of hypoaldosteronism Answer HYPOGLYCEMIA • HYPONATREMIA • HYPOVOLEMIA • HYPOTENSION • HYPERKALEMIA Q: How to diagnose Addisons disease Answer Early morning serum cortisol and plasma ACTH & abnormal labs (glucose, sodium, potassium, WBC) Q: CM of Addisons disease Answer Decreased sodium and blood glucose (Chronic: may leadto dehydration) • Increased potassium • Hypotension Increased WBC • Muscle weakness and fatigue • Anorexia • Dark pigmentation: mucous membranes and skin(especially knuckles, knees, elbows) • Apathy: lack of interest Q: Treatment for Addisons disease Corticosteroids: Answer - Infection control - Hyperglycemia - Hypertension - Taper when weaning off. DO not suddenly stop - Moon face, weight gain dose adjustment during times of stress Q: s/s of addisonian crisis Answer Hypotension Cyanosis N/V Shock (low volume) Restlessness confusion Q: Causes of Addisonian Crisis Slight overexertion Answer , cold exposure , acute infection , decrease in salt, emotional stress = lead to circulatory collapse, shock (low volume) death Q: Nursing interventions for addisonian crisis Answer Restore blood circulation IV glucose, Na, and glucose IV corticosteroids Vasopressor Antibiotics Monitor for hyperkalemia Q: Hyperaldosteronism Answer Aldosterone is a minero-corticoid produced in the adrenal cortex.Aldosterone controls sodium and therefore controls water. Q: Overnight low-dose dexamethasone suppressiontests Answer oral dexamthasone given late evening, plasmacortisol in morning. Should see decrease in cortisolbecause ACTH is reduced(neg feedback). If Cortisolstill high= Cushing syndrome Q: CM of hyperaldosteronism Answer • Increase Na, Increase glucose • Decrease K • Hypertension • Round moon face, red face • Buffalo hump, Truncal obesity(not ascites), but generalfluid retention • Striae, petechiae, ecchymosis, acne, thin skin (skinbreakdown) • Decreased immune fx • Menstrual irregularities, facial hair (women) • Personality changes • Osteoporosis Q: Nursing intervention for hyperaldosteronism Answer • Decrease risk of injury • Decrease risk of infection* - good hand washing • Prepare the patient for surgery (possible tumor removal) • Rest and decreased activity • Monitor weight d/t fluid retention • Promote skin integrity * • Monitor electrolytes (Na, K) • Promote positive body image • Diet low in CHO Q: What is needed if your are getting a adrenalectomy Answer cortisone therapy Q: (pituitary tumor) surgeon usually placesthe endoscope through the nose (may be inserted through an incision under theupper lip) Answer Transsphenoidal hypophysectomy Q: Post Transsphenoidal Hypophysectomy Answer • Watch for CSF leakage(pink tinged on nasal packing) and seizures • No blowing nose, straws, sneezing, coughing • HOB elevated • Sinus infection contraindicated • Monitor for DI (not enough ADH):frequenturination and thirst • Excessive ADH secretion from the pituitary gland • Concentrated urine, retain fluids, and develops dilutional hyponatremia. • Water Intoxication Syndrome of Inappropriate Antidiuretic Hormone (SIADH) Q: Most common disorder of the posteriorlobe of the pituitary gland and ischaracterized by a deficiency of ADH Answer Diabetes Insipidus Q: Other causes of DI Answer •Secondary to head trauma, brain tumor, orsurgical ablation or irradiation of the pituitarygland. •Infections of the central nervous system orwith tumors Q: CM of DI Answer • Excessive thirst (polydipsia) • Large amounts of dilute urine • Nocturia Q: Treatment for DI Answer • Replace ADH -Desmopressin (DDAVP) • Ensure adequate fluid replacement • Identify and correct the underlyingintracranial pathology Q: Etiology of SIADH Answer • Tumors - lung malignancies • Non-malignant lung disorders • Drug induced ADH secretion • Hyponatremia Cerebral edema can be caused by Answer SIADH CM of SIADH Answer • Weakness & muscle cramping • N/V • Fluid retention • Weight gain • Pulmonary compromise • Postural BP • Poor skin turgor • Fatigue • Anorexia • Lethargy • Confusion • Hemiparesis • Seizures • Coma Treatment for SIADH Answer • Free water restriction • Furosemide(Lasix) • Hypertonic fluids *BOTH DI & SIADH will present with Answer excessive thirst Bronchocarcinomas are the main reason for Answer SIADH Answer Pheochromocytoma A tumor that is usuallybenign and originatesfrom the chromaffincells of the adrenalmedulla. CM of pheochromocytoma Answer • Abrupt Hypertension (Intermittentor Persistent) • Headache • Palpitations • Blurred Vision • Anxiety • Feeling of Impending Doom Interventions for pheochromocytoma Answer • Monitor for reoccurrence of attacks • Pre/post op care • Monitor and manage any ECGchanges • Arterial pressure • Fluid and electrolyte balance • Blood glucose levels • Administration of fluids and medications Patho of Pheochromocytoma Answer Excess stimulation of alpha and beta adrenergic receptors -- Increased secretion of epinephrine and norepinephrine -- Increased peripheral vascular resistance results in periods of hypertension Medications for pheochromocytoma Answer • Alpha-Adrenergic Blocker (Dibenzyline), (Minipress), (Hytrin),Or (Cardura), • Beta-Adrenergic Blocker (Propranolol), • Calcium Channel Blockers (Procardia) Or (Cardene),Metyrosine, Catecholamine Synthesis Inhibitors (Demser) Cause of thyroid cancer Answer External radiation of the head, neck or chest ininfancy or childhood increases risk Characteristic of thyroid cancer tumor Answer Lesions are single, hard, and fixed Complications for thyroidectomy Answer hemorrhage hematoma edema of the glottis laryngeal nerve injury Answer Take on empty stomach 30-60 mins before eating Levothyroxine teaching Take in the AM s/s of adrenal hyperplasia Answer virilization, masculine feature in women- masculine placement of pubic hair, beard, baldness, masculine build Corticosteroid therapy Answer Suppress inflammation and autoimmune response, control allergic reactions, and reduce transplant rejection Do not stop abruptly Infection control Cushings disease Risk for cushings disease Answer long term corticosteroid use Answer Type 1 DKA is seen is what type of diabetic Hyperglycemic Hyperosmolar State (HHS) Answer *Usually Type 2 DM *Profound dehydration *Glucose may be 600 *Small ketonuria and absent-to-low ketonemia *pH greater than 7.30 *Bicarbonate concentration greater than 15 mEq/L How fast does DKA have an onset more rapid DKA S/S D-ehydration K-etones in the urine and blood, Kussmaul Resp and K+ A-cidosis, Acetone breath, Anorexia d/t nausea Abdominal pain Dark eyes HHS S/S extreme hyperglycemia (600-1200); hyperosmolarity w/ dehydration; NO ketoacidosis; CNS dysfunction Not as a rapid onset Absence of insulin that causes metabolic acidosis Untreated diabetes, missed insulin doses, illness or infection DKA Before you give insulin, always check potassium because once insulin is administered, potassium will start to decrease in the extracellular contents What is the minimum amount of potassium you should have before you start an insulin drip? 3.5 Cerebral edema can occur if your blood sugar drops too rapidly Sick day rules Take insulin as usual Test glucose q3-4Hr Stay hydrated Substitute soft foods if you cannot withstand normal foods Report N/V/D to Dr If unable to retain fluids, go to hospital to avoid DKA What kind of insulin do you use for a insulin drip? Regular Neuropathy CHARACTERIZED BY CAPILLARY BASEMENT MEMBRANE THICKENING. Caused by elevated blood glucose for years Gas exchange occurs in capillaries, causing decreased gas exchanged causing hypoxia Diabetic neuropathy causes demyelination, causing the pain in feet and body or decreased pain reception and the reflexes decrease autonomic neuropathy damage to nerves supplying the internal body structures that regulate functions such as blood pressure, heart rate, bowel and bladder emptying, and digestion neurogenic bladder ---- no control How to diagnose diabetic neuropathy Decreased DTR Deceased vibratory sensation Peripheral neuropathy medications Duloxetine Carbamazepine (Tegretol) Pregabalin (Lyrica) Gabapentin (Neurotin) Autonomic Neuropathy medication Metoclopramide (Reglan) ---- Increase gastric emptying Bethanechol (Urecholine) Diabetic diarrhea ____________________ is a disorder caused by long-standing hyperglycemia causing damage to the autonomic nervous system → results in altered intestinal motility, ↑ intestinal secretions, and ± fecal incontinence. - Manifests as painless, watery diarrhea; secretory-like (persists at night and while fasting). - Laboratory evaluation typically unremarkable. Nephropathy affects more type 1 more than type 2 Nephropathy patho GLOMERULOSCLEROSIS CAUSES INCREASE IN THE GLOMERULAR FLOW RATE,HYPERFILTRATION, GLOMERULUS DAMAGE, MICROALBUMINURIA THAT INCREASES,WHICH LEADS TO CHRONIC KIDNEY DISEASE, AND FURTHER LEADS TO END-STAGEKIDNEY DISEASE In stage one kidney disease you have an increased GFR You go through a hyper filtration due to hyper Nephropathy S/S PROTEINURIA, HEMATURIA, DECREASED GFR, DECREASED EXCRETION OF SODIUM,EDEMA, AND HYPERTENSION Nephropathy treatment • CONTROL HYPERTENSION • PREVENTION OR VIGOROUS TREATMENT OF URINARY TRACT INFECTIONS • AVOIDANCE OF NEPHROTOXIC MEDICATIONS AND CONTRAST DYE • ADJUSTMENT OF MEDICATIONS AS KIDNEY FUNCTION CHANGES • LOW-SODIUM DIET • LOW-PROTEIN DIET • KIDNEY DIALYSIS • TRANSPLANT • SYMPTOM MANAGEMENT • MEDICATION • INSULIN • ACE INHIBITORS, CAPOTEN (CAPTOPRIL) ABNORMAL THICKENING OF THE BASEMENT MEMBRANE IN CAPILLARIES Retinopathy PAINLESS PROCESS OF BLURRY VISION, FLOATERS, COBWEBS IN VISUAL FIELD,SUDDEN VISUAL CHANGES INCLUDING SPOTTY OR HAZY VISION, OR COMPLETELOSS OF VISION S/S of Retinopathy Atherosclerosis is accelerated in diabetic patients S/S of macrovascular complications CHEMICAL REACTIONS BETWEEN BY-PRODUCTS OF SUGARS AND PROTEINS THATOCCUR OVER TIME. THESE REACTIONS CAUSE THICKENING OF COLLAGEN ANDENDOTHELIUM, OVERGROWTH OF ENDOTHELIUM, AND INCREASED VASCULARINFLAMMATION Present at birth Occurs when the enzyme needed for cortisol production is lacking because of a gene defect. Virilization Adrenal Hyperplasia s/s of adrenal hyperplasia Weight loss fatigue Low BP Low blood sugar Abdominal pain darkening of the skin What is the treatment for adrenal hyperplasia? Corticosteroids Is aldosterone under the pituitary control? NO!!! It is a mineralocorticoid which has an effect on fluid balance Hyperaldosteronism excessive output of aldosterone from the adrenal gland, leading to increased sodium and water retention and loss of potassium Hyperaldosteronism S/S Hallmark signs: hypertension and hypokalemia Hyperaldosteronism treatment Spironolactone What is the gold standard for diagnosing cushings disease? Dexamethasone suppression test Mood swings, buffalo hump, moon face, purple striae, sodium retention are S/S of Cushings What medication can you give for after getting an adrenalectomy? Hydrocortisone for a few months until Hypotension, cyanosis, fever, nausea, vomiting, signs of shock, pallor, headache, abdominal pain ,diarrhea, confusion and restlessness S/S of addisonian crisis What can cause an addisonian crisis? If you have Addisons disease and are exposed to stressors like cold exposure, overexertion, infection and or emotional distress What position do you want to place a patient is experiencing addisonian crisis? Recumbent with legs elevated What is included in an emergency kit for addisonian crisis? Prefilled syringes of hydrocortisone (100mg) and 0.9% saline What do patients who are taking steroids become sensitive to? The sun. They become very photosensitive and seen to stay out of the sun. What dietary intake needs to be increased for a patient with Addisons disease if they are experiencing GI/fluid losses? Sodium Lab values for a patient with DI High sodium Low potassium Low urine osmolality When do you know if the DDAVP treatment is working? Patient is urinating less and the specific gravity increases What is the primary cause of SIADH? Lung disorders such as cancer What drugs can induce ADH secretion? Nicotine Morphine Tricyclic antidepressants barbiturates What are S/S of severe hyponatremia? Twitching and seizures Lethargy Cerebral edema Confusion Increased body weight Treatment for SIADH Furosemide ADH antagonist Hypertonic solution What are the s/s of pheochromocytoma? Hypertension Hyperglycemia Hyperhidrosis Hypermetabolism Headache Heart palpitations are also common with Pheochromocytomas What medications can treat post op thyroidectomy Calcium gluconate for tetany (spasms, hyperirritablilty) life long levothyroxine HHS only happens in what type of diabetes? Type 2 What is the cause of HHS Illness accompanied with persistent hyperglycemia which then leads to dehydration What osmolality level indicate HHS? Over 320 Will there be any ketones present with HHS? No What kind of insulin do you give IV for HHS? Regular Mucous membranes will be dry with HHS and you will also have poor skin turgor What will happen to your GCS in HHS? Decrease Causes of DKA Decreased or missed dose of insulin Illness or infection Undiagnosed or untreated diabetes What gland dysfunction occurs in SIADH Posterior pituitary Cortisol is produced by the.. Adrenal cortex Aldosterone is produced by the... Adrenal cortex Androgen is produced by the... Adrenal cortex What does cortisol do to the body? What is cortisol's responsibilities? Helps control the body’s use of fats, proteins and carbohydrates Suppresses inflammation Regulates blood pressure Increases blood sugar Decrease bone formation What does aldosterone do to the body? What are its responsibilities? Tells kidneys to absorb more sodium into the bloodstream - Releases potassium into the urine (regulates BP) What do androgens do for the body? Assists ovaries produce estrogen and testes produce testosterone Congenital Adrenal Hyperplasia occurs when.... the enzyme needed for cortisol production in adrenal gland is lacking because of a gene defect. Primary hyperaldosteronism (Conn syndrome) is caused by... aldosterone-secreting tumors The adrenal medulla controls... adrenaline Secondary hyperaldosteronism is caused by.... Poor kidney perfusion What is hypoaldosteronism? What are symptoms of this condition? Patients with hypoaldosteronism will retain _____ and _____, and have low ________ levels. Salt and water retention Low K+ How is hypoaldosteronism treated? - Mineral corticoids to maintain that salt and water balance, - Glucocorticoids if there is a cortisol deFciency - Potentially diuretics Cushings Syndrome is a condition of hyperadrenalism - High cortisol levels The Pituitary is Located on the.... inferior aspect of the brain and is divided into anterior and posterior lobes. The gland is controlled by the hypothalamus, which is an adjacent area of the brain pituitary gland secretes hormones that... influence growth, metabolism and regeneration the Pituitary signals releases ACTH (adrenocorticotropin hormone), what does ACTH do? tell adrenal glands to release Cortisol (-) fdbck system Hypersecretion of anterior pituitary gland results in Cushings Syndrome ADH (anti diuretic hormone) is also called arginine vasopressin it is a hormone made by the hypothalamus in the brain and is stored in the.... posterior pituitary gland ADH constantly regulates and balances the amount of water in your blood stream. The adrenal glands secretes compounds like cortisone, adrenaline Too much cortisol makes things.... slow down Too little cortisol make things.. speed up If a patient has CONGENTIAL ADRENAL HYPERPLASIA, what happens to their cortisol levels? so less cortisol is being produced if a patient has CONGENTIAL ADRENAL HYPERPLASIA, what are they at risk for? Adrenal crisis bc they have very low levels of cortisol main symptoms of adrenal crisis is .. hypotension or hypovolemic shock If a patient has hyper-aldosteronism, what do you treat them with? we give them spironolactone (k sparing diuretic) this med: o increases sodium excretion and potassium retention these patients are high risk for renal wasting o we want to make sure they are very up to date and compliant with their treatment regimen What is the primary function of aldosterone? facilitates the salt and water retention by the kidney Signs and symptoms of hyper-aldosteronism include.... - HIGH Na, BP - LOWK+ A patient has an their adrenal glands removed due to their hyper-aldosteronism, this puts them at risk for.... insufficient cortisol production Post-Operative Complications for patients who had their adrenal glands removed include... low BP, bleeding infection and blood clots - Adrenal crisis Aldosterone is under the control of the pituitary gland. True or False? False Aldosterone is secreted by the adrenal gland. True or false? True This medication is used to treat heart failure hypertension and fluid retention that prevents your body from absorbing too much salt and keeps your potassium from getting too low? spironolactone Symptoms of Hypoaldosteronism include.... - LOW sodium (Na), Low BP - HIGH K+ - metabolic acidosis Clinical Manifestations of Cushing's Include... - Mood swings - Fatigue - Weight gain - Muscle Weakness - lassitude (A feeling of tiredness, weakness, and lack of interest in daily activities.) A patient presents with muscle weakness dark skin and lupus membranes pigmentation and emotional lability these are clinical manifestations of what? hypoaldosteronism Prednisone in pt with COPD could increase the levels of.... cortisol Your patient, a 35y/o F with emphysema, requests medication to help with her symptoms. What medication do you expect to be ordered? Prednisone When do people with cushing's tend to have high cortisol levels throughout the day? All day Women between the ages of 20 and 40 years are five times more likely than men to develop.... Cushing's Syndrome The main cause of Cushing's syndrome is the pituitary gland producing too much... adrenocorticotropin hormone (ACTH) Cushing's Syndrome is caused by high levels of... cortisol Normal AM Cortisol levels? 10-20 mcg/dl highest in the ___ and lower in the ____? AM PM Normal urine cortisol level is.. 3.5-45mcg/24 hours How is urine collected for cortisol levels? 24hr urine collection (keep urine cold between samples) Indicators of Cushing's aside from cortisol levels include... increased Na and blood GLUCOSE level - decreased K+ - reduction in number of blood eosinophils - disappearance of lymphoid tissue Nursing interventions for Cushing's Disease include... - Rest and decrease the activity - Skin Integrity (Every shift, check skin) - Diet: AVOID LOW CARB diet A patient with Cushing syndrome should be assessed for signs and symptoms of... (due to medications) Addisonian Crisis An Addisonian Crisis is life threatening because the patient could... go into circulatory collapse and shock Patient teachings about Cushing's Disease include... If s/s of an addisonian crisis appear this is an emergency. They need to call 911 or go to the ER immediately Signs and Symptoms of an addisonian crisis include... - life threatening shock  Severe weakness  Confusion  Pain to the lower back and legs  Severe and abdominal pain  Unexplained restlessness  N/V - leading to dehydration  Decreased loc  Decreased BP - they're not perfusing  HIGH K+ and LOW sodium Treatment for Cushing's Disease includes Transsphenoidal Hypophysectomy. What is this? surgical removal of the tumor on pituitary gland - Tx of choice - 80% success rate Patients who undergo a Transsphenoidal Hypophysectomy are at high risk for... losing CSF or cerebral spinal fluid. - observations and assessments by the nurse after the surgery is very important, we have a small amount of CSF circulating at any one time so any loss is significant. How do we know if a patient is losing CSF from a Transsphenoidal Hypophysectomy? If you look at the nasal packing and you see something pinkish and then you see that drainage has this Halo that is CSF this is a medical emergency NOTIFY PCP because they have a CSF leak and they need to go back to surgery immediately. A patient may report "You know I feel like there's something salty, and I and I feel a whole bunch of drainage at the back of my throat” a patient diagnosed with Cushing syndrome may experience these symptoms except: A. Mooning Face B. Weight Loss C. Thin Extremities D. Central-Type Obesity E. HIRITUSIM (excessive growth of hair on face) B Patients with Cushing syndrome are at higher risk for invasive infections what would you teach the patient and caregivers? Wash your hands frequently, and well Addison's disease is a primary... adrenal insufficiency Symptoms of an Addisonian Crisis inlcude... Hypotension, Abd. Pain, Restlessness, N/V/D, dehydration - if patient all of a sudden has restlessness that you cannot find a reason for this is a red flag needs to be assessed A patient with Addison's Disease has a heart rate of 140, what is the priority? Contact the PCP, this patient could be entering an addisonian crisis. Patients who are at risk for Addisonian crisis need to be taught and need to.... carry around an emergency kit at all times. An addisonian crisis Emergency kit contains... - Hydrocortisone 100 million given IM - Dexamethasone it's a pill or milligrams which gives patients with it enough they could swap they could take orally - Saline or D5W The family and the patient may have to be taught how to reconstitute the hydrocortisone properly so they can be given IM. A patient has to use their Emergency Kit for an addisonian crisis. What do they need to do next? Go to ER. They still need to be assessed and treated. Why would you give Hydrocortisone (Solu-Cortef), a steriod, to a patient with addison's disease? give for low BP, N/V if pt hasn't taken their predinisone Does Synthroid or levothyroxine cause photo sensitivity? No. A patient on steroids or with high cortisol levels need to be educated on what, related to being outside? They will have increase photosensitivity. Your patient is prescribed Prednisone 50 milligrams daily and states that when he feels better, he will stop taking them what is your response? you need to be slowly weaned off this type of medication we do not want to push this patient into adrenal crisis. so you were caring for a patient who was status post bilateral adrenalectomy what are signs and symptoms that indicate they are going into Addisonian crisis? A. Pain level of 4/10 B. Severe Abdominal Pain, N/V/D C. Feelings of unease D. blood sugar of 350 mg/dL B Your patient was recently discharged home from being treated for Addison's disease. His wife states she forgot to pick up his Prednisone, and the patient is confused with a BP of 80/45 and he is vomiting what is your priority action? Hydrocortisone (Solu-Cortef) - only be administered via IV so when this patient comes into your ED you need to get the IV in right away Most common disorder of the posterior lobe of the pituitary gland and is characterized by a deficiency of Anti-Diuretic Hormone (ADH) - Diabetes Insipidus Diabetes insipidus (DI) is a disorder of the posterior pituitary that's characterized by a deficiency of.. ADH Secondary Diabetes Insipidus is caused by head trauma brain tumor surgical ablation or irradiation of the pituitary gland In a normal person the hypothalamus produces ADH in relation the the serum osmolarity. What is serum osmolarity? measurement of the concentration of particles dissolved in body fluid In a patient with Diabetes insipidus not enough ADH is being produced. In response the kidneys are being told to filter out as much urine as they want. This results in the #1 symptom of diabetes insipidus.... copious amount of urine. This urine will be pale and watery. Patients with diabetes insipidus need to be monitored frequently during a water deprivation test. Under what circumstances would the test be cancelled/stopped? if tachycardia, excessive weight loss or hypotension develops What is a water deprivation test? Drinking water is withheld from the patient to induce dehydration and to assess urinary water excretion. - Fluids are withheld for 8-12 hrs or until 3-5% of body weight is lost - Pt is weighed freq. during test - Plasma and urine osmolality are done at the beginning and end of the test - Pt is considered as having the DI if they are unable to increase the specific gravity or osmolarity of the urine This definitively diagnoses diabetes insipidus. Clinical Manifestation of Diabetes Insipidus include... Excessive Thirst (polydipsia) Large amts of Dilute urine Nocturia Tachycardia - developing DI A patient with Diabetes Insipidus will have what kind of electrolyte levels? Higher levels of electrolytes due to dehydration. What is the treatment for diabetes insipidus? Desmopressin IV or Nasal Spray (DDAVP) SIADH stands for... syndrome of inappropriate antidiuretic hormone. Too much ADH A patient was just prescribed DDAVP for diabetes insipidus. What do you expect them to report that indicates the medication is working? "I'm peeing less and my urine is getting darker." Normal urine specific gravity? 1.005-1.030 How will a patient's urine look with SIADH? Concentrated If a patient has excessive amount of ADH, what disease do they have? How will they appear? SIADH They will be swollen, with edema. They are retaining fluids. Why will patients with SIADH have low sodium levels? Due to the dilution of the body's fluids, remember they are retaining fluids. SIADH is often non-endocrine in origin often is from.. bronchogenic carcinoma- this Tumor releases a similar form of ADH and tricks the body Endocrine originating SIADH can be caused by medications like morphine, aquavine, phenothiazidesz, antycyclics, antidepressants, thiazides, barbituates diuretics, nicotine Patients with SIADH have fluid retention. This means they will gain water weight. What organ system is important to monitor because of this retention? What are you looking for? Pulmonary. auscultating crackles bilaterally in lower lobes (means =uid has travel to open spaces in lungs) A patient with SIADH must increase their serum sodium levels. How would you encourage sodium intake? DO NOT promote extra dietary sodium intake - ONLY SMALL amts of sodium are needed to increase levels - Encourage fluids high in Na like Broth & Tomato juice In a patient with SIADH If the primary problem is water retention its safer to reduce _________ than to administer ________. Fluids Sodium The treatment for SIADH includes... Water restriction - For water retention - neurological s/s are severe - adm a small amt of hypertonic solu. To alleviate cerebral edema Furosemide (Lasix) - DO NOT GIVE HCTZ (hydrochlorothiazide) it will decrease sodium Hypertonic fluids: - For severe hyponatremia - Give 2% or up to 23%  needs to be given slowly and pt is closely monitored Complications to monitor for in patients with SIADH include... - Hyperkalemia - Crackles in the lungs - Cerebral edem - Heart Attack - Seizure Both Diabetes Insipidus and SIADH patients may present with... excessive thirst What is Pheochromocytoma? A tumor that is usually benign and originates from the chromaffin cells of the adrenal medulla. - Rare tumor of the adrenal gland - Results in the release of too much EPI or NOREPI that control: HR, metabolism, BP - BP affected by the tumor - HTN Intermittent excessive release of catecholamines (Epinephrine and NoEpinephrine) from pheochromocytoma cause periods of... Hypertension What is a major risk factor of pheochromocytoma? Genetics - If a family member has this condition it is important to screen other members of the family. Family members should be alerted & screened if patient has.....? pheochromocytoma pheochromocytoma is diagnosed via... - 24-hour urine, speciFc lab tests (catecholamines and metanephrine) - Clinical Manifestations - CT, MRI, Ultrasound of abdomen/pelvis - Clonidine Suppression Test - for inconclusive catechol. & urine test - Plasma and Urine Catecholamine Levels What should you check before insulin is administered? Why? Potassium Levels Insulin will push potassium into cells, decreasing the serum levels. What orders would you question for a patient with pheochromocytoma? Morning Cortisol Test 3 multiple choice options What is the Clonidine Suppression test? a diagnostic tool used to differentiate between patients with and without paraganglioma (PPGL) and pheochromocytoma. PPGLs are rare tumors that originate from the sympathetic ganglia or adrenal medulla. Clinical Manifestations of pheochromocytoma include... - (Abrupt) Hypertension - Headache - Hyperhidrosis (Excessive Sweating) - Hypermetabolism - Hyperglycemia - Palpitations, Tachycardia - Blurred Vision - Anxiety - Feeling of Impending Doom What should you educate your patient with pheochromocytoma on related to their diet? Avoid foods high int tyramine: - some beers & wines - Aged cheese - Dried or smoked meats, sausages - Soy sauce - Sauerkraut A patient with pheochromocytoma is scheduled for an Adrenalectomy in two weeks. What should you educate them on related to pre-operative care? They will be prescribed antihypertensives approximately two weeks before the surgery to remain as healthy as possible. What medications are expected to be prescribed to a patient with pheochromocytoma? What should you educate the patient on related to these medications? Alpha-Adrenergic Blocker (Dibenzyline), (Minipress), (Hytrin), Or (Cardura) - Teach pt to change positions slowly OT HTN - Monitor salt intake & BP - Report blurred or hazy vision Calcium Channel Blockers (ProCardia or Cardene) - Usually given for spike during surgery to bring down BP A post-operative patient who came back from a thyroidectomy to remove their thyroid cancer reports feeling pressure, trouble breathing, and a 'pulling sensation' at the surgical site. You listen to their lungs and hear stridor. What is the priority? Call the PCP. The airway is about to compromise. What is important to keep at the bedside for post-operative thyroidectomy patients? tracheostomy kit How is Levothyroxine taken? What do you educate the patient on? - Synthroid - Lifelong therapy- - Levels need to be checked Q3 months so med/dose can be adjusted - PO: take 30-60 prior to eating for med to be effective Type 1 DM is characterized by.... the destruction of the pancreatic beta cells Type 2 DM is characterized by.... - insulin resistance and impaired insulin secretion. - In type 2 diabetes, intracellular reactions are diminished, making insulin less effective at stimulating glucose uptake by the tissues and at regulating glucose release by the liver Insulin will prevent ________ breakdown. KETONE (some insulin will work breaking down ketones)- If there's no insulin = ketones are present (DKA) HHS is a metabolic disorder most often of type ____ diabetes resulting from a relative insulin deficiency initiated by an illness that raises the demand for insulin. 2 What does HHS stand for? Hyperglycemic-Hyperosmolar state What is Hyperglycemic-Hyperosmolar state? An acute, life-threatening condition characterized by profound hyperglycemia (above 600) osmolarity that leads to dehydration and an absence of ketosis What is happening to insulin levels in a patient in HHS? Insulin is too low to prevent hyperglycemia (and osmotic diuresis); high enough to prevent fat brkdown. SOME INSULIN is being PRODUCED - insulin present but NOT ENOUGH What is happening to ketone levels in a patient in HHS? KETONES are minimal or ABSENT How does HHS present? - Onset over several days - Normal BiCarbonate (HCO3) - Serum Osmolarity will be greater than 350 - Triggered by stress - Lack of effective insulin (insulin resistance) - Hypernatremia r/t increased osmolarity What is normal serum osmolarity levels? 275 to 295 mOsm/kg What distinguishes HHS from DKA? ketosis and acidosis do not occur in HHS, partly because of differences in insulin levels. A priority Nursing considerations for a patient in HHS is... Put the patient on a cardiac monitor due to low potassium levels. What is DKA? a life-threatening complication of diabetes that occurs when the body doesn't have enough insulin to allow blood sugar into cells for energy. DKA is usually seen in patients with type-1 diabetes, but it can also occur in patients with type-2 diabetes. What are the three main clinical manifestations of DKA? Hyperglycemia Dehydration with Electrolyte loss Acidosis (Metabolic) (Also: Polyuria, Polydipsia, and dehydration, Fruity Breath, Kussmaul Respirations [deep, and rapid], changes in LOC and electrolyte levels) _______ will be present in a patient with DKA. Ketones What are some diabetic keto-acidosis GI symptoms? Why do they occur? Anorexia, Nausea, Vomiting, Abdominal Pain These occur due to the disruption of the enteric nervous system (GI nerves) Why do patients have "fruity breath" when in DKA? Due to the presence of ketones What are kussmuals respirations? Why do patient's in DKA have them? Hyperventilation: Deep, rapid breathes. S/S of Adrenal Hyperplasia Visualization of genitalia during infancy. Males- breast tissue, less to no facial hair Females-facial hair, deep voice, masculine build, baldness, deposition of proteins in the skin Visual disturbances if pituitary tumor is on the optic nerve. What medications are used to treat Adrenal Hyperplasia? Corticosteriods (Glucocticoids, Predisone) What are side effects from corticosteriods use? At increase risk for developing infections, brittle bones, thinning of the skin, moon face and humpback. Muscle wasting, increase BP, thrombophleitis, thromboembolism, accelerated atherosclerosis, glaucoma, corneal lesions. Care plan for Cushing's Disease Risk for impaired cardiac function associated with changes in cardiac function, risk of injury due to weakness, risk for infection due to altered immune system, impaired skin integrity, distributed body image, difficulty. Understand how to prevent addisonian crisis (low blood sugar, low BP, and high potassium) Watch for signs of infection due to possible adrenalectomy which will do transsphenoidal hypophysectomy Complications s/s of post-op transsphenoidal hypophysectomy Clear drainage on nasal drip pad, leukocytosis (increase WBC), urine output 800 ml/hr, visual disturbances, post-op meningitis, pneumocephalus (air in the intracranial cavity). Nutrition needs for Cushing's Patients Foods need to be high in potassium calcium and protein, low in sodium, low in sugar, carbohydrates. Priority Assessment for Cushing's Disease Infection (fever and increase WBC-Leukocytosis), restlessness, N/V, and low BP. Highest risk for Cushing's disease? 20-40 year old women, long term steroid users Priority Assessment for Addison's Disease Heart rate due to dysrhythmias from the increase potassium in the body What needs to be monitored before, during, and after a transsphenodial hypophysectomy? Blood glucose due to possible causing DI after procedure. Addison's Disease Medication's Hydrocortisone (Solu-Cortef), 5% Dextrose in normal saline, vasopressors may be required if hypotension persists, an antibiotics. Clinical Manifestations for Addison's Disease Low sodium, high potassium, low blood pressure, low glucose, high WBC, muscle weakness, anorexia, GI symptoms, fatigue, emaciation, dark pigmentation of the mucous membrane and skin, depression, confusion Chronic- severe dehydration. Teaching plan for Addison's Disease Need a diet high in carb, high in protein, and high in salt. Avoid heat and stress at all cost. Going to be on lifelong steriod use. Need to know about emergency steriod kit (100mg of hydrocortisone or 4mg dexamethasone and 0.9% sterile saline) Wear ID bracelet. Call MD before going to the ER Diabetes Insipidus Medication Desmopressin (DDAVP)- watch on patients with coronary disease AND increase in urine specific gravity. Chlorpropamide (Diabines) and Thiazide Diuretics- watch for high BS. Diabetes Insipidus S/S Polydipsia (excessive thirst), oliguria, highly diluted urine, polyphagia (eating a lot), high HR, high NA, if after surgery will see pink halos on drip pad. Diabetes Insipidus Patho Disorder of the posterior gland that results in an ADH deficiency. Secondary to head trauma, brain tumor, or surgical ablation or irradiation of the pituitary gland, infection of the CNS or with tumors. Teaching plan for DI Knowing the s/s of hyponatremia (CNS dysfunction, malaise/weakness, anorexia, N/V, headache, confusion, leathargy, sz, coma, and cerebral hemiation due to brain swelling or edema) Priority Assessment for SIADH Excessive fluid volume (crackles in the lungs) SIAHA Patho Excessive ADH production from pituitary gland. Cannot excrete a dilute urine, retain fluids, develop a sodium deficiency. Associated with severe pneumonia, pneumothorax, and other disorders in the lungs. Clinical Manifestations of SIADH Increase in ADH, fluid retention, increase body weight, muscle cramps, low NA, fatigue, anorxia, vomiting, abdominal cramps, twitching, sz, confusion, fluid shift from extracellular space to inside the cell Medications for SIADH Furosemide-Lasix, 3% NaCl, restrit fluids to 800 ml/hr, give vasopressin antagonist (Vasostrict, Pitressin), Tolvaptan IV conivaptan hydrochloride What medication should not be used for SIADH? HCTZ (Act on adrenal hormones not renal tubeuls) Complications of SIADH Overhydrated swimming in fluid caused by a increase in ADH which also causes lethargy Pheochromocytoma Patho Tumor that is usually benign and originates from the chromaffin cells of the adrenal medulla. S/S of pheocromocytoma Increase BP, headache, hyperhidrosis (excessive sweating), hypermetabolism, increase glucose, blurred vision, anxiety, shaking feeling of impending doom. Treatment for pheochromocytoma Alpha adrenergic blockers (works by lowering blood pressure). Diagnose for pheocromocytoma Clonidine Suppression test, 24 hour urine for catecholamines and metonephrine, abdominal ultrasound, MRI of pelvis. Priority assessment for pheochromocytoma Control the increase blood pressure, DO NOT percuss or palpate, and assist in signs of nervous system overactivity. Priority assessment and interventions post-op thyroidectomy Will see fullness and tightness at the site and we need to have a trach at bedside. Watch for audible stridor. Best position for post-op thyroidectomy Set patient at Semi-Fowlers with two pillow support. Pheochromocytoma Complications Heart rate is high, and irregular rhythm, high blood sugar, increased anxiety and increase BP Thyroidectomy medication Levothyroxine-lifelong use, levels needs to be checked and adjusted, take in the morning before eating. Priority assessment for Aldosteronism Low potassium and high blood pressure, and polyuria. Levothyroxine S/F Tremors, fast irregular heartbeats, SOB, fever, hot flashes, sweating, headache, leg cramps, muscle aches. After hypohysectomy you see clear nasal drainage what do you test for? Test the drainage for glucose. Aldosteronism (Conn's Syndrome) Excessive aldosterone production usually occurs due to an aldosterone secreting tumor. Treatment for aldosteronism Spironolactone, Na restriction, and K replacement Hyperglycemic-Hyperosmolar State (HHS): Patho Insulin deficiency in a type 2 diabetic with no ketones and severe hydration due to stress, illness and dehydration in older adults. HHS S/S Blood sugar over 300, hypokalemia (risk for dysrhythmias), orthostatic hypotension, profound dehydration, sz. Preparing regular insulin drip Waste 50cc/units to coat the tubing. Priority Assessment for HHS Rehydrate give IV infusion of NS first and restore electrolytes, monitor I's and O's monitor labs, vitals, breath sounds LOC, place patient on regular insulin IV drips. Normal Serum Osmolality 285-295 Normal Specific Gravity 1.005-1.030 Diabetic Ketoacidosis (DKA) Patho Insulin deficiency in a type 1 diabetic which causes metabolic acidosis, undiagnosed diabetes, low or missed insulin doses, absence or marked inadequate insulin, illness, stress and infection DKA S/S Kussmaul respirations, fruity breath, N/V, abdominal pain, polydipsia. polyuria, change on LOC, headache, blurred vision, ortho hypotension, marked fatigue. Regular Insulin Short acting peak 2-3 hour, duration 4-6 hour , onset 30-60 minutes Rapid Acting (Lispro) Onset 10-15 minutes, 1 hour peak, duration 2-4 hours. Must have trays on the floor to give before meals. Treatment for DKA Regular insulin drip, NS TO 1/2 NS to DW5, and electrolyte replacement. Retinopathy Patho Abnormal thickening of the basement membrane in capillaries, hyperglycemia. Sick Day Rules Take insulin and oral antidiabetic agents as usual. Test blood sugar and urine ketones every 3 to 4 hours. Report high blood sugar (greater than 300) and urine ketones and nausea and diarrhea. Take supplemental dose of regular insulin 3 to 4 hours subtitute with soft foods 1/3 jello, 1 cup cream soup, 1 cup of sports drink every 30 minutes to an hour to prevent dehydration. Call MD is unable to keep fluids down. S/S for retinopathy Floaters, sudden visual changes, painless blurry visions. Neuropathy Patho Capillary basement membrane thickening leads to ischemia and nerve death, destruction of myeline sheath. Neuropathy S/S Paresthesia, decreased proprioception, numbness, decrease deep tendon reflexes, decrease vibratory sensation, paresthesia, burning sensation, numbness, decrease gait, decrease to light touch. Treatment for neuropathy Gabapentin, cymbalta, lyrica, tegretol, duloxetine, carbamazepine, metoclopmanide Nephropathy Patho Hardening of glomeruli, capillary basement membrane thickening leads to ischemia and nerve death Nephropathy S/S Microalbuminemia in the urine early indicator. Footcare Education Use mirror to check bottom of the feet, trim nails straight across, wash feet with warm water daily, lotion feet never between the toes, wear good shoes, never soak, use p. stone to smooth corns and calluses. Do not cross legs for a long period of time, put meet up when sitting. What meds be avoided for Nephropathy Gentamycin, contrast dye, nephrotixic drugs. Long-terms complications for diabetes CAD, HTN, PVD, cerebrovascular disease. What is metoclopramide used for? Prescribed to diabetics for GI upset to improve gastric emptying. Macrovascular Disease Blood vessels walls thicken, damage to the large blood vessels providing circulation to the brain, heart and extremities (blocked blood flow) Atherosclerosis is accelerated in diabetic patients. Patients with S/S of macrovascular complications at risk for? MI, PE, stroke