Lecture 7 Endocrine

LECTURE 7 ENDOCRINE • focus on the thyroid & adrenal glands -> what you need to know most for the test • Hint: change the word ‘thyroid’ to ‘metabolism’ (the thyroid regulates metabolism) THYROID Hyperthyroidism: • a.k.a. hypermetabolism • think of all the S & S that you would see in a high metabolism such as:! - weight loss, high BP & heart rate, anxious & irritable, ! hyper, heat intolerance (cold tolerance), exophthalmus! -> think Don Knotts! - called Grave’s disease (run yourself into the grave) • 3 treatment options for too much hormone:! a) radioactive iodine! i. PT should be in a room by themselves for 24 hrs. ! -> no visits for the first 24 hrs.! ii. after that, PT needs to be extra careful with their ! urine (i.e. flush 3 times after voiding, if urine spills ! on the floor the hazmat team must be called)! -> radioactive material is excreted via urine! -> biggest risk to nurse is the urine! b) PTU -> Propylthiouracil! - “puts thyroid under” = slows thyroid down! - primary use as a cancer drug BUT is used ! specially for hyperT! - nursing role:! -> be aware that it is an immunosuppresent so ! WBC count needs to be monitored! c) Thyroidectomy (most common way)! - partial or total removal -> PAY ATTENTION TO ! THIS IN THE TEST (most important)! - total = need lifelong hormone replacement! -> at risk for hypocalcemia (because of ! parathyroid, hard to save it in a total)! -> check Trousseau’s & Chvostek’s! - sub-total = don’t need lifelong replacement ! because but may need it for a bit before the ! leftover thyroid starts “kicking in”! -> less risk for hypocalcemia! -> at risk for thyroid storm/crisis; ! thyrotoxicosis (total’s never get this) • Thyroid Storm:! 1. super high temps. (105 & up)! 2. extremely high BP’s (stroke category; ex. 210/180)! 3. severe tachycardia (ex. could be in the 180’s)! 4. have psychotic delirium! —> MEDICAL EMERGENCY!!! can cause brain ! damage (can fry the brain to death)! - immediate treatment = get the temperature down & ! get the O2 up ! -> first way - ice packs! -> best way - cooling blanket! -> O2 per mask at 10L (BUT, remember they are ! psychotic so good luck keeping that mask on)! ** maybe pick this first if picking between O2 & ! ice packs! - will come out of it themselves or die -> self-limiting! - don’t medicate! - 2 on 1 (need 2 people to care for these PT’s)! Post-Op Risks:! —> depends on type of surgery & timeframe (HAVE ! TO KNOW THIS) • 1st 12 hours:! a) does not matter if total or partial; priority is airway! - thyroid is in the neck! - any edema can cause constriction of airway! b) hemorrhage! - endocrine gland -> has a lot of blood vessels • 12-48 hours:! - need to pay attention to the type of thyroidectomy! a) Total = tetany due to the low Ca! - can cause constriction of airway! b) Sub-total/Partial = thyroid storm • after 48 hrs:! - big risk is infection! *** but never pick infection in the first 72 hours Hypothyroidism: • a.k.a. hypometabolism • think of all the S & S seen in low metabolism:! - obese (weight gain), flat/boring personality, cold ! intolerance (heat tolerance), low BP & heart rate! - called Myxedema • treatment option for not enough hormone:! - give thyroid hormones -> Synthroid (levothyroxine) • DO NOT SEDATE THESE PT’S - because they’re body is already super slow & you could put them into a coma = myxedema coma! - question any pre-op orders that have sedation (i.e. ! Ambien before surgery)! - if PT is NPO before surgery you need to call the MD ! because they need to be able to take their morning ! thyroid hormone PO (never hold thyroid pills pre-! op without express order to do so)! -> if no hormone replacement they will be ! hypothyroid & that will cause issues when being ! given sedative agents (anesthetics) for surgery ADRENAL CORTEX • coincidentally, these diseases start with the letter A or C (like the initials of adrenal cortex)! - ex. Grave’s would not be one, Cushing’s would Addison’s Disease: • under-secretion of the adrenal cortex! - one of the rarest endocrine disorders • S & S:! a) hyper-pigmented! - very tanned (look healthy)! b) do not adapt to stress (don’t have regulation of ! stress response)! - when stressed, BP will go down & glucose will ! down which will put them into shock! ** the purpose of the stress response is perfuse ! the brain w/ blood (raise BP) & give the brain ! glucose (raise glucose) • Treatment:! - steroids (because they’re low in steroids)! -> glucocorticoids! ** all steroids end in ‘-sone’! -> in Addison’s you “add a -sone” Cushing’s Syndrome: • over-secretion of the adrenal cortex! - “cushy” sounds like you have more of something • S & S:! ** HAVE TO KNOW THIS! ** gives you 2 things: the S&S of Cushing’s & the ! side-effects of steroids! ** draw a picture of a little man (a.k.a. Cushman)! - moon face with a beard! - big big body w/ a bump on the front & the back! - skinny arms & legs! - fill him full of water & write ‘Na’ inside (put K+ ! outside of the body)! - draw striae on his abdomen (stretch marks)! - write ‘high glucose’ (MOST IMPORTANT)! - draw bruises! - word bubble = “I’m mad. I have an infection.”! a) moon face! b) hirsutism (lots of excess hair)! c) central obesity! d) bumps = gynecomastia & kyphosis (buffalo hump)! e) atrophy of extremity muscles! f) retains Na & water (thus, losing K+)! g) stretch marks! h) hyperglycemia (look like diabetics)! i) easily bruised! j) easily irritable! k) immunosuppressed • ex. If you’re on a steroid and you’re a diabetic, what do you do?! - need a lot more insulin (because steroids increase ! the blood glucose) • ex. PT w/ acute COPD exacerbation on Solu-Medrol (a steroid) IV push Q8 to reduce inflammation in the airway. What nursing action needs to be taken on this PT? = Accu-Chek’s Q6 because of the high glucose!! -> steroids make glucose go up EVEN IF you’re not ! a diabetic • Treatment:! - adrenalectomy (classic treatment for hyper-! secretory glands is to cut it out)! -> bilateral adrenalectomy (remove all)! -> but then this causes you to have Addison’s which ! means you have to have steroid treatment ! (which makes you look like “Cushman” all over ! again which is the reason you got the adrenals ! removed in the first place)! -> takes about 1-2 yrs. just to get equilibrated back ! to feeling normal • endocrine surgery creates the opposite problem ! CHILDHOOD DEVELOPMENT • children’s toys -> how to select the appropriate play activity/toy given the age of the child • 3 things to consider:! - Is it safe?! - Is it age appropriate?! - Is it feasible? Safety Considerations: • a) no small toys for children under 4! - no small parts that can be aspirated for under 4 • b) no metal toys if oxygen is in use! - because of sparks! - might use the word “dye-cast” instead of metal (ex. ! hot wheels car) • c) beware of fomites! - fomite = non-living object that harbours microorganisms ! ** vector/host is the name for living! - toys are notorious fomites on a pediatric unit (kids ! stick them in their mouths)! - worst fomite = stuffed animals! - best kinds of toys -> hard plastic toys (because you ! can terminally disinfect them)! - ex. If you have a child who is immunosuppressed, ! what would be the best toy for them? -> a hard ! plastic action figure Feasibility: • “could you do it” in a certain situation • ex. Is swimming a good/safe activity for a 13 yr. old? YES! ex. Is swimming an age appropriate activity for a 13 yr. old? YES! ex. Is swimming feasible for a 13 yr. old in a body cast? NO • use common sense Age Appropriateness: • this is what mostly gets tested! -> if the test gives you a certain age, you need to ! know what toy/activity to give them • 0 - 6 months:! - children at this age are sensory-motor! - best toy = musical mobile! -> something that stimulates BOTH sensory & motor! - if they don’t have mobile as a choice, look for ! something that is large & soft • 6 - 9 months:! - working on skills of object permanence (the idea ! that something is still there even if you can’t see it)! -> play at this age should be teaching them this! - best toy = “cover-uncover toy”! -> choose something easy to cover & uncover (i.e. ! jack-in-a-box, pop up toys, books with movable ! parts that cover/uncover)! - peek-a-boo, putting blanket on head & pulling off! - 2nd-best toy = something large & hard! - worst toy for this age is the musical mobile (because ! they can pull themselves up, pull the mobile and ! strangle themselves) • 9 - 12 months:! - working on vocalization! - best toy = speaking/talking toys! -> ex. tickle me Elmo, talking books! - purposeful activity w/ objects (at least 9 months)! -> ex. building w/ blocks! -> Hint: Never pick an answer w/ the following ! words if the kid is under 9 months = build, sort, ! stack, make, construct (because they are ! “purpose words”) • Toddlers -> 1 - 3 years:! - working on gross-motor skills! -> running, jumping! - best toy = push-pull toys! -> ex. wagons, lawnmowers, little strollers! - if it takes finger dexterity, then DO NOT choose it for ! the toddler! -> ex. no colored pencils, no blunt scissors! - finger-painting is appropriate (should be called ! “hand” painting) -> is not a dextrous activity, it is ! gross motor! - parallel play = play alongside others but not with • Preschoolers: ! a) working on fine-motor skills! -> things that use finger dexterity! b) working on balance! -> ex. tricycles, tumbling, skating, dance class! -> swimming is more of a gross motor skill because it ! doesn’t take balance (can start this w/ infants)! - co-operative play = play w/ others! - pretend play = highly imaginative at this stage • School-aged:! - characterized by the 3 C’s! a) creative = let them make it (don’t make it & give it ! to them)! -> better to give them blank paper & crayons ! instead of coloring book so that they can create ! their own pictures! -> LEGO age! (let them create the trucks and cars ! instead of giving them toy cars)! b) collective = they like collecting things! -> etc. beanie babies, pokemon, barbies! c) competitive = like to play games where there is a ! winner & a loser! -> preschoolers want games where everyone is the ! winner & everyone gets the same prize • Adolescents:! - peer-group association = they want to hang out ! with their friends and fit in! - if you have a question stating that there are a group ! of teenagers hanging out in one teenager’s room you ! let them unless 1 of 3 things is happening:! a) if anyone is fresh post-op (under 12 hrs.)! b) if anyone is immunosuppressed! c) if anyone has a contagious disease NEURO LAMINECTOMY • lamina = the vertebral spinous processes! -> the bumpy bones you feel on the spine! ectomy = removal • removing posterior processes of the vertebral bones • reason -> to relieve nerve root compression! - cut away some of the bone to relieve the pressure ! on nerves (give nerves more room to exit) • a.k.a. decompression surgery S & S of Nerve Root Compression (3 P’s): • Pain • Paresthesia = numbness & tingling • Paresis = muscle weakness • For Laminectomy questions, the most important thing to pay attention to in any neuro question is LOCATION, LOCATION, LOCATION!!! - will determine symptoms, prognosis, & treatment! - LOCATION IS EVERYTHING IN NEURO • 3 locations in Laminectomies:! - cervical = neck! -> innervates the diaphragm (breathing) & arms! - thoracic = upper back! -> innervates abdominal muscles (cough ! mechanism) & gut muscles (bowels)! - lumbar = lower back! -> innervates the bladder & the legs! Pre-Op Laminectomy: • when you change the location, you change the answer • ex. What is the most important pre-op assessment for a cervical laminectomy?! = breathing & if it’s not one of the choices, pick the ! one that checks the function of the arms & hands • ex. What is the most important pre-op assessment for a thoracic laminectomy?! = coughing & bowel sounds! -> if abdominal muscle function is affected, PT won’t ! be able to contract enough to cough properly • ex. What is the most important pre-op assessment for a lumbar laminectomy?! = bladder function (voiding, distention), or function ! of legs and feet Post-Op Laminectomy: • #1 post-op laminectomy answer on N-CLEX is log-roll! -> for any spinal injury • 3 other things to know about mobilizing PT’s after surgery:! a) Do not dangle these PT’s! - go from lying to immediate standing/walking! - they can sit on the edge of the bed long enough to ! avoid orthostatic hypoTN but not more than that! b) Do not let PT sit for longer than 30 mins! - question this typical post-op order: up in chair for ! 1 hr TID! -> in chair for meals is ok because usually meals ! only last for 30 mins! c) PT may walk, stand & lie down w/o restrictions! - restrictions only on sitting! -> jobs w/ sitting all day (i.e. admitting clerk) has ! shown to have the most occurrence of back ! issues/pain Post-Op Complications: • they depend on location! • cervical:! - # 1 complication is pneumonia (because breathing ! is affected) • thoracic:! - pneumonia -> can’t cough properly! - ileus -> affected bowel function • lumbar:! - urinary retention -> affected bladder function! - issues w/ the legs • ex. You are caring for a PT w/ a lumbar oligodendrogliocytoma. What’s the #1 problem?! a) airway c) cardiac arrhythmia! b) ileus d) urinary retention -> it’s lumbar! *** LOCATION LOCATION LOCATION • typically, don’t have chest tubes w/ laminectomies BUT the anterior thoracic will have chest tubes! - means the surgery goes through the front of the ! thorax to get to the spine so you need tubes in order ! to address pneumo/hemathorax Laminectomy WITH FUSION: • “with fusion” -> key word; means that a bone graft is taken from the iliac crest! - take some bone from your hip to fuse in between the ! bones from where the disc was taken out (to keep ! from grinding) • most laminectomies don’t have fusion! - because usually it’s just the “wing thing” being taken ! out BUT if the disc is also removed, you need fusion • PT will have 2 incisions:! a) hip! -> has the most pain, most bleeding & drainage (will ! have the JP/Hemovac drain)! -> post-op, this one causes the most problems! ** surgeons want to get rid of this incision because it ! costs more, has more risks, want to cut recovery ! time/hospital stay in half, less drainage if gone -> ! surgeons are using cadaver bones from bone banks ! (no more 2nd incision; risk for rejection is low)! b) spine! -> highest risk for rejection! ** both have equal risk for infections Discharge Teaching for Laminectomies: • very important! • 4 Temporary Restrictions:! a) Do not sit for longer than 30 mins! - applies for 6 weeks! - Hint: if you have to guess long a restriction ! applies for something, you should pick 6 weeks ! (otherwise if you know what it is pick the it)! b) Lie flat & log roll for 6 weeks! c) No driving for 6 weeks! d) Do not lift more than 5 pounds for 6 weeks! - ex. gallon on milk • 3 Permanent Restrictions:! a) Will never be allowed to lift objects by bending ! at the waist! - should lift with the knees (everyone should)! b) Cervical lam’s are not allowed to lift anything ! over their head! - for the rest of their life! - get step stools! c) No jerky amusement rides, off-roading, horse-! back riding etc. ! • the Laminectomy info can be used to get any spinal cord questions right! - pay attention to the locations