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141 Cards in this Set

  • Front
  • Back
What is Diabetes Insipidus?
Hyposecretin of ADH, or decreased renal respone to ADH.
What is Diabetes Insipidus caused by?
Strokes, trauma, idiopathiccauses.
What are the signs and symptoms of Diabetes Insipidus?
polyuria (5-20L a day)
polydipsia
dehydration
low urine specific gravity (less than 1.005)
urine osmolality of less than 100
fatigued from nocturia
generalized weakness
Why is serum osmolality elevated in patients with DI?
as a result of hypernatremia due to pure water loss in the kidney
In a patient with DI, If oral fluid intake cannot keep up with urniary losses, a severe fluid volume deficit results. This deficit is manifested by...
Weight loss, constipation, poor tissue turgor, hypotension, tachycardia, and shock.
A patient with DI will show Central Nervous System manifestations, such as irratibility, mental dullness, and coma. There manifestations are related to..
Increasing serum osmolality and hypernatremia
In a patient with DI, what can occur due to polyuria?
severe dehydration and shock
What is a water deprivation test used for?,
Used to differentiate causes of DI, including central, nephrogenic, and psychogenic polydipsia.
What is administered during a Water Deprivation test?
ADH (vasopression)
In patients with central DI, urine osmolality ________ after ADH.
Increases
In patients with nephrogenic DI, the response to ADH is ______.
Minimal or no response
A patient is getting ready for the water deprivation test when the doctor states her urine osmolality is 350 mOsm/kg. This means that...
She can not take the test. For her to take the test, her serum osmolality needs to be <300mOsm/kg and her serum Na needs to be normal.
How long does a water deprivation test last?
The test lasts 6 hours, usually from 6 a.m. to 12 noon.
What must you obtain before a water deprivation test?
Baseline weight and urine and plasma osmolality.
If a patients weight drops more than 2 kg while taking the water deprivation test, what would you do?
discontinue test and rehydrate the patient with oral fluids. Check orthostatic BP and pulse after rehydration to ensure adequate fluid volume.
What should you assess hourly during a water deprivation test?
Urine, weight, and BP
For a water deprivation test, you should instruct the patient to withold all fluid for how long?
8-16 hours before testing
What is a therapeutic goal of DI?
maintenance of fluid and electrolyte balance
What is mandatory in the assessment of fluid volume status for a patient with DI?
Accurate records of intake and output, urine specific gravity, and daily weights.
What is the hormone replacement of choice in a patient with central DI?
Desmopressin acetate (DDAVP)
What ways can DDAVP be given?
nasal spray, orally, intravenously, or subcutaneously
When assessing the response to DDVAP, what symptoms are you looking for?
weight gain, headache, restlessness, signs of hyponatremia and water intoxication
You should notify the healthcare provider immediatly if what happens while taking DDVAP?
If the patient develops increased urine volume with low specific gravity. This means they need an increased dose of DDVAP.
What is Central DI?
Problem results from an interference with ADH synthesis or release. Multiple causes include brain tumor, head injury, brain surgery, CNS infections.
What is Nephrogenic DI?
Problem results from inadequate renal response to ADH despite presence of adequate ADH. Caused by drug therapy (ESPECIALLY LITHIUM), renal damage, or hereditary renal disease.
What is Primary DI?
Problem results from excessive water intake. Caused by structural lesion in thirst center or psychologic disorder.
What is the treatment for nephrogenic DI?
dietary measures (low sodium diet) and thiazide diuretics. Limit sodium intake to no more then 3 g pre day,
When a low sodium diet and thiazide are not effective, what can be prescribed for nephrogenic DI?
Indomethacin, a non steroidal antiinflammatory agent that helps increase renal responsiveness to ADH.
SIADH occurs when ______ is released despite normal or low ____.
ADH, plasma osmolality
SIADH results from an abonormal production or sustained secretion of ____.
ADH
SIADH is characterized by what manifestations?
fluid RETENTION
serum HYPOosmolality
dilutional HYPOnatremia
HYPOchoremia
concentrated urine in the presence of normal or increased intravascular volume, and normal renal function.
What is the most common cause of SIADH?
A malignancy, usually small cell lung cancer
Excess ADH increases the permeability of the renal distal tubule and collecting duct which leads to what?
The reabsorption of water into the circulation
The reabsorption of water into the circulation consequently causes......
Extracellular fluid volume expands, plasma osmolality declines, glomerular filtration rate increases, and Na levels decline (dilutional hyponatremia)
What does hyponatremia cause?
Muscle cramping, pain, weakness. The patient displays thirst, dyspnea on exertion, and fatigue.
A patient is experiencing low urniary output and increased body weight. What could this patient have?
SIADH
A patients' serum sodium level is falling below 120 mmol/L, what are symptoms that the patient could be experiencing?
vomiting, abdominal cramps, muscle twitching, seizures.
The patients serum sodium level and plasma osmolality is continuing to decline, what are symptoms that can be occuring?
Cerebral edema leading to lethargy, anorexia, confusion, headache, seizures, and coma.
What indicates the patient has dilutional hyponatremia?
serum sodium < 134 mEq/L
serum osmolality < 280 mOsm/kg
urine specific gravity > 1.005
What does a serum osmolality much lower than the urine osmolality indicate?
The inappropriate excretion of concentrated urine in the presence of dilute serum.
What is essential to the assessment of SIADH?
frequent vital signs
frequent measurement of intake & output
frequent measurement of urine specific gravity
daily weights
LOC
observe for signs of hyopnatremia
monitor heart and lung sounds
A patient with SIADH has had 1000mL of fluids today. The patient complains that she is thirsty and would like more to drink. What is the appropriate response?
The total fluid intake has to be restricted to NO MORE then 1000mL/day, including that taken with medications. Provide distractions to decrease the discomfort of thirst related to fluid restrictions.
A patient with ADH is laying supine and wants to sit straight up in bed because he is tired of laying down. Why can't the patient sit up?
The head of bed has to be flat or with no more than 10 degrees of elevation to enhance venous return to heart and increase left atrial filling pressure, reducing ADH release.
The patient with SIADH is wanting to ambulate around the room. What precautions should you take?
Assist the patient and utilize a bed alarm because of potential alterations in mental status to protect from injury.
Once SIADH is diagnosed, treatment is directed at the ____.
Underlying cause
Medications that stimulate the release of ADH should be _________.
Avoided or discontinued
The immediate treatment goal of SIADH is to do what?
restore normal fluid volume and osmolality
A patient is admitted with severe hyponatremia and have seizures, what is should be administered?
IV hypertonic saline solution (3%-5%) This requires a VERY slow infusion rate on an infusion pump to avoid increasing serum sodium too rapidly
What can be to promote diuresis?
a loop diuretic such as furosemide (LASIX) but ONLY if the serum sodium is at LEAST 125 mEq/L because it may promote loss of Na.
With severe hyponatremia , what fluid restriction is implemented?
fluid restriction of 500 mL/day
In chronic SIADH, what water restriction of _____ is recommended.
800-1000 mL/day
What does demeclocycline (Devlomycin) do?
Blocks the effect of ADH on the renal ubules, thereby allowing a more dilute urine.
Because the adrenal glands are highly vascular, the risk for ________ is increased.
Hemorrhage
During an adrenalectomy surgery, manipulation of the glandular tissue occurs. What might this release?
large amounts of hormones into the circulation, producing marked fluctulations in the metabolic processes affected by these hormones.
Because of hormone fluctuations during an adrenalectomy, what should a nurse look out for postoperatively?
BP, fluid balance, and electrolyte levels tend to be unstable
What is administered intravenously during and after an adrenalectomy to ensure adequate responses to the stress of the procedure?
high doses of corticosteroids (hydrocortisone)
If large amounts of endogenous hormone have been released into the systemic circulation during an adrenalectomy, what is the patient likely to develop?
hypertension, which increases the risk of hemorrhage
Susceptibility to infection and delay wound healing are increased after an adrenalectomy do to what?
High levels of corticosteroids
A patient has just come back from an adrenalectomy, what changes should you report to the healthcare provider?
any rapid or significant changes in BP, respirations, or heart rate. 24-48 hrs is a critical period for circulatory instability.
Also monitor intake and output carefully and asses for potential imbalances.
You have a new RN on the post-op floor. What action would indicate that the RN would need further teaching?

a) Monitoring I&O after an adrenalectomy
b) removing the IV line after IV corticosterioids are withdrawn
c) giving a post-op patient an oral dose of corticosterioids
d) obtain morning urine samples at the same time every morning.
B
The IV line is kept in after IV corticosteroids are withdrawn to keep a line open for quick administration of corticosteroids or vasopressors
True or False:
After an adrenalectomy, it is important to obtain morning samples collected at a different time each morning for cortisol measurement to evaluate the effectiveness of the surgery.
False.The sample must be obtained at the SAME time every morning.
True or False:
A patient can quit the corticosteroids right after surgery.
False:
If the corticosteroid dosage is tapered too rapidly after surgery, acute adrenal insufficiency may develop.
Hypocortisolism can be identified by what symptoms?
increased weakness, dehydration, hypotension, painful joints, pruritis, peeling skin, emotional disturbances
What two things should you be alert for following surgery?
subtle signs of postoperative infections because the usual inflammatory responses are supressed and the patient is on bedrest until BP stablizes
True or False.
A patient following an adrenalectomy must wear a Medic Alert bracelet at all times and carry medical identification and instructions in a wallet or purse.
True
Following an adrenalectomy, a patient wants to know if she will be able to go skiing that winter. What would you tell the patient?
Avoid exposure to extremes of temperature, infections, and emotional disturbances (stress may produce or precipitate acute adrenal insufficiency)
You are teaching a patient about their corticosteroid replacement. Further teaching is necessary when the patients states

a) i will require this for the rest of my life
b) i should not change my dosage, no matter what
c) it may take several months to adjust this hormone dose
d) if weakness, fainting, fever, or nausea and vomitting occur i should notify my doctor.
B.
The patient should adjust their corticosteroid replacement therapy in accordance with their stress levels.
After a thyroidectomy, what should the nurse be assessing?
check every 2 hrs for 24 hrs for signs of hemorrhage or tracheal compression such as irregular breathing, neck swelling, frequent swallowing, sensations of fullness at the incision site, choking, and blood on the anterior or posterior dressings.
What position should a patient be in following a thyroidectomy?
semi-Fowlers position with support for the patients head with pillows. Avoid flexion of the neck and ANY tension on the suture lines.
While monitoring vital signs, what else should be assessed following a thyroidectomy?
Tetany secondary to hypoparathyroidism and evaluate difficulty in speaking and hoarseness. Expect hoarseness for 3-4 days after surgery due to edema.
Trousseau's sign and Chvostek's sign should be monitored for ____ hours following a thyroidectomy.
72
A patient is in post-op after a thyroidectomy. She has not had any tetany or other problems related to the thyroidectomy and wants to ambulate around the room. What is the appropriate response?
Since the recovery was uneventful, the patient may ambulate hours after surgery, permitted to take fliud as soon as tolerated, and eats a soft diet the day after surgery
Following a thyroidectomy, a patient is very worried about the scar. What can you do to help reassure the patient?
The scar will fade in color and eventually look like a normal neck wrinkle. A scarf, jewelry, high collar, or other covering can effectively camouflage the scar.
Why is the administration of a thyroid hormone avoided after a thyroidectomy?
exogenous hormone inhibits pituitary production of TSH and delays or prevents the restoration of normal gland function and thyroid tissue regeneration.
Adequate iodine is necessary to promote thyroid function, but excess can inhibit the thyroid gland. What is a sufficient amount of iodine?
Seafood once or twice a week or normal use of iodized salt should provide sufficient intake.
In a patient with hyperparathyroidism, serum calcium levels usually exceed ____.
10 mg/dL (2.50 mmol/L)
In a patient with hyperparathyroidism, serum phosphorus levels are usually less than _____.
3 mg/dL (0.1 mmol/L)
What is the most effective treatment of primary and secondary hyperparathyroidism?
Surgical intervention-- parathyroidectomy
A parathyridectomy can lead to a rapid reduction of what?
high calcium levels
When assessing a patient with hyperparathyroidism, what findings would make her a good candidate for the surgery?
under the age of 50
serum Ca levels > 12mg/dL
hypercalciuria > 400mg/day
markedly reduced bone mineral density
What are major complications following a parathyroidectomy?
hemorrhage and fluid and electrolyte imbalance
What is tetany?
a condition of neuromuscular hyperexcitability associated with sudden decrease in Ca levels, usually apparent early in post op period, but may develop over several days.
What is mild tetany?
unpleasant tingling of the hands and around the mouth

may be present in post-op parathyroidectomy but should decrease over time
If tetany becomes severe following a parathyroidectomy, what should be done by the nurse?
IV Ca may be given. IV Ca gluconate or gluceptate should be readily available for patients following a parathyroidectomy in the event that acute tetany occurs.
Following a parathyroidectomy you should monitor I&O to evaluate fluid status and asses for what levels?
Ca, Ph, K, Mg

chvostek's and trousseaus signs should also be assessed frequently
Why should you encourage mobility after a parathyroidectomy?
to promote bone calcification
What would you instruct a patient to do if they were doing a 24-hour urine collection test?
specimen MUST be kept refrigerated or iced during collection. Deteremine whether preservative is required.
What would you instruct a patient to do regarding a cortisol free test?
24 hour urince collection and avoidance of stressful situations and excessive physical exercise. Ensure that patient is on a LOW-SODIUM diet.
What medication can elevate cortisol free testing?
reserpine, diuretics, phenothazines, amphetamines
When administering an Oral glucose tolerance test, ensure the test is NOT done on patients that:
are malnourished, confined to bed for over 3 days, or severely stressed
What instructions would you give a patient that will be doing and OGTT?
refrain from smoking and caffiene and to fast (except water) for 8-12 hours before the test.
What should a patient's diet for 3 days before an OGTT contain?
150-300mg of carbs, with an intake of at least 1500 cal/day
What may impair glucose intolerance?
estrogens, dilantin (phenytoin, and corticosteriods, *Hyperkalemia
What is the drug of choice to treat hypothyroidism?
Synthroid (levothyroxine)
In older adults and patients with compromised cardiac status, a smaller inital dose of synthroid is recommended because the usual dose may increase __________.
Myocardial oxygen demand, which may cause angina and cardiac dysrhythmias.
What should be reported IMMEDIATLY when a patient starts synthroid?
any chest pain needs to be reported immediatly, then an ECG and serum cardiac enzyme test must be performed. weight loss, nervousness, tremors and insomnia also needs to be promptly reported.
while on synthroid, Monitor heart rate and report a pulse great than ____beats/min
100
In a patient taking synthroid without side effects, the dose is increased at what intervrals?
4-6 week
Individuals using levothyroxine should have their _________ checked _______ weeks after changing a levothyroxine preparation.
TSH level, 4-6 weeks
What is levothyroxines peak?
1-3 weeks
What is Liotrix?
synthetic mix of levothyroxine and liothyronine in a 4:1 combo.
What is Liotrix peak?
2-3 days
In a patient with acromegaly, _____ levels do not fall below _____.
GH levels, 3 ng/mL.
For an OGTT, a patient drinks ____g of glucose and samples are drawn at ____ and __. __,__, and ___ minutes.
75 grams, baseline, 30, 60, 90, 120.
What is aldactone?
aldosterone antagonists and block the harmful neurohormonal effects of aldosterone on the heart blood vessels, also a potassium sparing diuretic that promotes sodium and water exretion while retaining potassium by binding to the receptors at the aldosterone dependent sodium-potassium exchange site in the distal renal tube.
What should you monitor while a patient is taking aldactone?
potassium levels during treatment and orthostatic hypotension
When taking aldactone, use with caution when patient is also taking _____.
digoxin, because hyperkalemia may reduce the effects of digoxin
What foods should a patient avoid while on aldactone?
foods high in potassium such as bananas, oranges, and dried apricots
A common side effect of long term use of aldactone in men is what?
gynecomastia
After a transsphenodial hypopystectomy, what should the patients bed be elevated to and why?
a 30 degree angle AT ALL times, it avoids pressure on the sella turcica and decreases headaches, a frequent problem.
What should an RN tell the patient to avoid after a transsphenoidal hypophysectomy?
vigorous coughing, sneezing, and straining at stool to prevent CSF leakage
Why do you send any clear nasal drainage to the lab to be tested following a transsphenoidal hypophysectomy?
It is to be tested for glucose. A glucose level greater than 30 mg/dL indicates CSF leakage from an open connection to the brain, which increases the risk for meningitis.
If the patient complains of persistant or severe generalized or periorbital headache, what could this indicate?
CSF has leaked into the sinsuses
How long does a CSF usually take to resolve?
72 hours with head elevation and bed rest.
When a CSF leak occures, what is administered?
IV antibiotics to prevent meningitis, if it doesnt resolve in 72 hours, surgery may be required.
When should you perform mouth care on a transsphenoidal hypophystectomy patient?
every 4 hours and NO TOOTHBRUSHING for at LEAST 10 days.
What are the main effects of hyperaldosteronism?
sodium retention and potassium and hydrogen ion excretion
Primary hyperaldosteronism is most commonly caused by what?
a small solitary adrenocortical adenoma. approx 1% of hypertension is caused by this
What is secondary hyperaldosteronism?
occurs in response to a nonadrenal cause of elevated aldosterone levels such as renal artery stenosis, renin-secreting tumors, and chronis kidney disease
Elevated levels of aldosterone are associated with _____ retention and elimination of ______.
sodium, potassium
What does Na retention lead to?
hypernatremia, hypertension, and headache.
Why does edema not usually occur with hyperaldosteronism?
the rate of sodium excretion increase, which prevents more severe sodum retention.
What does hypokalemia due to excessive wasting of potassium cause?
muscle weakness, fatique, cardiac dysrhythmias, glucose intolerance, and metabolic alkaosis that may lead to tetany.
What is pheochromocytoma?
rare condition characterized by a tumor of the adrenal medulla that produces excessive catecholamines (epinephrine, norepinephrine)
What is the most dangerous immediate effect of pheochromocytoma?
secere hypertension
If pheochromocytoma is left untreated, what can it lead to?
hypertensive encephalopathy, diabetes mellitus, cardio myopathy, and death.
What are striking clinical features of pheochromocytoma?
episodic hypertension accompanied by the classic manifestations of severe, pounding headache, tachycardia with palpitations, profuse sweating and unexplained abdominal or chest pain
What can attacks in a patient with pheochromocytoma be provoked by?
medications including antihypertensives, opioids, radiologic contrast media, and tricyclic antidepressants. Attacks may very from few minutes to few hours.
What is the most simple and reliable test to see if a patient has pheocromocytoma?
measurement of urniary fractioned metanephrines as well as a fractionated catecholamines and creatinine usually done as a 24hr urine collection. Values are elevated in 95% of people.
What is graves disease?
an autoimmune disease of unknown etiology marked by diffuse thyroid enlargement and excessive thyroid hormone secretion
What are precipitating factors of graves disease?
insufficent iodine supply, infection, and stressful life events may interact with genetic factors to cause graves disease
In graves disease, this patient develops _____ to the ___ receptor.
antibodies, TSH
A classic finding in graves disease is _______, a protrusion of the eyeballs from the orbitals.
exophthalmos
what are manifestations of graves disease?
palpitations, tremors, weight loss
What is throtoxic crisis?
also known as thyroid storm, all hyperthyroid manifestations are heightened. it is considered a life threatening emergency.
What are manifestations of thyroid storm?
severe tachycardia, heart failure, shock, hyperthermia, restlessness, agitation, seizures, abdominal pain, nausea, vomiting, diarrhea, delirum, and coma.
What are two primary laboratory findings used to confirm the diagnosis of graves disease?
decreased TSH levels, elevated free thyroxine levels
What is the RAIU test used for?
to differentiate between graves disease from other forms of thyroiditis. the patient with graves disease will shown uptake of 35%-95% while a patient with thyroiditis will show an uptake of less than 2%
What types of food should a patient avoid if they have hyperparathyroidism?
highly seasoned or HIGH-FIBER foods because the GI tract is already hyperactive
What is cushing syndrome?
clinical abnormalities caused by an excess of corticosteroids, particularly glucocortocoids
How do you diagnose cushings syndrome?
24hour urine collection for free cortisol, urine cortisol levels beyond normal range of 80-120 in 24 hours indicates cushing syndrome. Pt has marked sodium retention