EXAM 4

Med Surg 2
Study Outline
Units 9 – 12
ENDOCRINE SYSTEM
Pituitary and Adrenal Disorders
 Pituitary Gland – Hormones: Anterior Lobe - ACTH, FSH, GH, LH, MSH, PRL, TSH, SGH; Posterior Lobe - Oxytocin, Vasopressin, ADH
o Disorders of the Pituitary Gland
 Hyperpituitarism- Giantism, Acromegaly (from tumors or excess growth hormone), excessive sweat,
A. Arthralgia (joint pain)
B. BP elevated
C. Carpel tunnel
D. Diabetes
E. Enlarged organs (cardiomegaly leads to HF)
F. Field deficit (visual)

 Hypopituitarism – Dwarfism (from tumor, encephalitis, autovirus, Sheenan Syndrome - decreased growth hormone)

 Transphenoidal Hypophysectomy - removal of pituitary tumor through sinus

 Diabetes Insipidus - Causes: TRAUMA, stroke, surgery, or idiopathic (Nephrogenic DI from hypercalcemia or lithium
toxicity)
 Excessive Urination/profound urination 3-20L/day (3000-20000ml)
o High Na+ - body dry/dehydrated, watch other labs as well (elevated)
o low urine osmolality/sp. gravity (diluted)
 Symptoms: thirst, weakness, fatigue, nocturia, FVD = tachycardia, wt. loss, constipation, poor skin turgor
 Give Vasopressin, fluids

 Syndrome of Inappropriate Antidiuretic Hormone – causes stroke, trauma, Cancer (lung or pancreatic), medications,
stress
 Water retention -poof ball
o Low Na+ - blood diluted, all labs can potentially be low – seizure precautions
o Low UOP = high urine osmolality/sp. gravity (super concentrated)
 Symptoms: confusion, seizures, loss of consciousness, muscle cramps, weakness, FVE = edema, wt. gain
 Give diuretics, Na+, fluid restriction, fall & seizure precautions, treat underlying cause

 Hypothyroidism – low and slow: rough & dry skin, cold intolerant, sluggish, constipated, abdominal distention,
flatulent, forgetful, wt. gain, hair loss, non-pitting edema, depression
 Can lead to Myxedema Coma = hypotension,
 hypothermia, respiratory failure, hyponatremia, hypoglycemia
 Hyperthyroidism & Graves disease, fast and furious: wt. loss, nervous/anxious, weakness, heat intolerant, insomnia,
tachycardia, diarrhea, difficulty concentrating (scatter brained), increased thirst & urination
 If not treated early can lead to cardiomyopathy, arrhythmias, HF, & death
 Can lead to Thyroid Storm- sudden and extreme elevation of all body processes
o Elevated HR, BP, Temp, Respirations, anxiety  coma  death
 Hypoparathyroidism – low calcium, high phosphorus
 Hyperparathyroidism – high calcium, low phosphorus
 Adrenal Glands
o Age-related Changes
o Disorders of the Adrenal Glands
 Addison’s Disease: ADD steroids – (low ACTH = Low cortisol)
 low cortisol levels, low BP, low Glucose, Low Na+
 high K+, high Ca+
 S/S: general malaise, muscle weakness, muscle pain, ortho. BP, anorexia, N/V, diarrhea, arrythmias,
anxiety, bronze skin
 Adrenal Crisis/Addisonian Crisis: from infection, stress, surgery, dehydration, steroid withdrawal from
abruptly stopping meds
o IV steroids (tensilon test)– VS Q2, watch BP , Na+, K+, blood sugar
o IVF to prevent shock, see p.855
 EXAM 4
Med Surg 2
Study Outline
Units 9 – 12
ENDOCRINE SYSTEM
 Cushing’s Syndrome: too much steroids (High ACTH = High Cortisol); genetic or drug induced from long term steroid
use (COPD, asthma, etc)
 high cortisol levels, high BP, high Na+, high glucose
 low K+, low Ca+, low albumin
 S/S: buffalo hump, moon face, enlg. Abd, with thin extremities, bruising, HTN, abnormal protein catabolism
resulting in weakness from loss of muscle mass – SEE pic. P. 855
 Remember patient either has high steroid levels or is being given steroids as a treatment – infection, glucose levels,
etc. watch for side effects of
 Pheochromocytoma: rare tumor of adrenal medulla
 Secretes catecholamines (epinephrine, norepinephrine – fight or flight)
 Tachycardia, severe HTN as high as 250/150 (intermittent or persistent)
 Other S/S: profuse diaphoresis, severe HA, palpitations, nausea, weakness, pallor

Diabetes Mellitus
 Review Insulin – rapid, short. Intermediate, long acting…(that’s why we made you do worksheet for clinical)
 Long-term Complications – NO cure for diabetes – treatment is to prevent vascular complications
o Macrovascular Changes = CAD, PVD, HTN, Cardiovascular disease, Cardiomyopathy
o Microvascular Changes = Retinopathy, Neuropathy, Nephropathy
Renal
 Age-related Changes
o Kidney function begins to degrade after age 45
o decreased ability to concentrate urine = more frequent urination & nocturia
o degenerative changes in bladder muscles lead to retention and incontinence – higher risk UTI
o bladder capacity decreases
 Diagnostic Tests and Procedures
o Creatinine Clearance
o Blood Tests
 BUN 10-20
 Creatinine 0.9-1.2, 1.3 or greater is kidney injury
 Electrolytes
 CBC (anemia from decreased production of erythropoietin)
o Arteriogram – assess function and obstructions of blood flow
 Femoral artery – direct pressure 20min post procedure; lie flat 4-12 hours as ordered
 Neurovascular checks: watch S/S bleeding or shock
 drink lots of water post test
o Renal Scan – assess renal perfusion and function – drink 2-3 glasses water before test
o Renal Biopsy – patient teaching
 Prone position for procedure; then bedrest, supine with back roll for 6 to 24hr
 Monitor & report: S/S bleeding, Back pain, Shoulder ache, Dysuria, Infection
 Give 3000ml fluid post procedure unless contraindicated to flush urinary system
 No strenuous activity or heavy lifting x 2 weeks
o Dialysis (who need’s dialysis? AEIOU (Acid-Base problems, Electrolyte problems, Intoxications, Overload of fluids, Uremic
symptoms) 2L a day maximum
 Hemodialysis
 Feel the Thrill, Listen to the Bruit – AV fistula vs AV graft
 4hr, 3 days/week
 Peritoneal Dialysis -put pt on L side for fluid overload
 Daily, but can be done at home
 Protein Loss bc loss of albumin
 Infection Risk: watch for: cloudy solution; C/O abdominal pain rigid board like abdomen,, N/V, general
malaise
 Not great option for diabetics – glucose used in solution
 Disorders of the Urinary System
o Renal Cancer – risk factors: smoking, exposure to lead or phosphate
 S/S: painless hematuria, flank mass, flank pain
 Treatment = Nephrectomy is best, chemo last resort
 EXAM 4
Med Surg 2
Study Outline
Units 9 – 12
ENDOCRINE SYSTEM
o Bladder Cancer
 S/S hematuria, usually painless
o Acute Renal Failure – sudden onset, usually reversible

 Uremic Frost – wash warm, no soap, keep skin clean, moisturized, clip/trim nails
o Renal Calculi drink more water
o Renal Transplant – Immunosuppressants for Life

Trauma, Emergency Care, Disasters

 General Principles
o Calm, Priority, Organized, Efficient
o Me: a dead rescuer rescues nobody
 Nursing Assessment
o A-airway w/cervical spine stabilization
o B-Breathing
o C-Circulation
o D-Disability (neuro)
o E-Exposure
 Specific Emergencies
o Hemorrhage FAST: Focused Abdominal Sonogram for Trauma
o Eye Injury
 Chemicals – irrigate
 Acute Angle Glaucoma – Medical Emergency – sudden onset severe pain, colored halos around lights, blurred vision;
will go blind if not treated immediately
 Retinal Detachment – black spots (blood), curtains closing (blood), painless, gradual or acute
 Penetrating Object – do not remove, cover both eyes
o Ear Injury
 BUG/insect in ear – mineral oil or diluted alcohol to kill bug, then remove
 Meniere’s disease – Dizziness, fail risk - any sudden movement of head or eyes can trigger attack
o Heat and Cold Exposure
 Hyperthermia
 Heat stroke
o Move to cool, shaded area
o Sprinkle with warm water and fan or wipe down
 Hypothermia
 They aren’t dead until they are warm and dead
 Rewarm gradually
 Frostbite: tissue destruction treated like burn
 Initially white, pale, bluish, no pain (frozen!) – don’t massage or rub
 Pain rushes in with blood when warmed back up
 Blister within 24 hours, black eschar within few weeks – need Tetanus shot
o Poisoning
 Call Poison Control
 What, When, How Much, Age & Size, Last meal, Symptoms
 Ipecac, Charcoal, laxative
 Do not promote vomiting
 Carbon Monoxide Poisoning•
 Cherry complexion (pallor more common)
 Remove from environment
 Support respirations
 Hypobaric oxygen
o Bites and Stings – The “Do NOTs”
 Do NOT allow the person to become over-exerted. If necessary, carry the person to safety.
 Do NOT apply a tourniquet.
 Do NOT apply cold compresses to a snake bite.
 Do NOT cut into a snake bite with a knife or razor.
 EXAM 4
Med Surg 2
Study Outline
Units 9 – 12
ENDOCRINE SYSTEM
 Do NOT try to suck out the venom by mouth.
 Do NOT give the person stimulants or pain medications unless a doctor tells you to do so.
 Do NOT give the person anything by mouth.
 Do NOT raise the site of the bite above the level of the person's heart.
Critical thinking includes the nursing process! Assess before you intervene! Then don’t forget to evaluate your care!! How do you
know it worked??? The signs and symptoms improved!

When there seems to be multiple answers for the question or you have the answers narrowed down to 2, reread the question and look for
the key word you missed to tell you which one is correct. When in doubt… follow ABC’s and what’s going to kill them fastest…

GOOD LUCK!

Hyperpituitarism

-Gigantism:

~children

~bones grow upward, very tall

~bone pain

-Acromegaly:

~a in a acro is for ADULTS

~shoes too tight, growing wider

~massive hands

~bone pain

~A. Arthralgia (joint pain)

B. BP elevated

C. Carpel tunnel

D. Diabetes

E. Enlarged organs

F. Field deficit

Transphenoidal Hypophysectomy

-removal of pituitary tumor through sinus

~no tooth rushing

~if mustache bandage has drip, test it for glucose, if positive, report immediately as CSF, watch for s/s meningitis. If leaking, position bed between
30-60 degrees

~prevent ICP

Diabetes Insipidus

-causes ~trauma ~stroke~surgery

~hypercalcemia, lithium toxicity (0.6-1.2)

-excessive urination 3-20L/day

~high Na+ (145+), body dry, dehydration

 EXAM 4
Med Surg 2
Study Outline
Units 9 – 12
ENDOCRINE SYSTEM
~low urine osmolality/sp, gravity diluted (<1.005)

-s/s ~thirst, low BP -give vasopressin, fluids

SIADH-too much antipee (retention)

-causes

~stroke, trauma, cancer (lung or pancreatic ), small cell carcinoma, medications (haldol), stress

-risk for injury -water retention

~low Na+ (<135), initiate seizure precautions

~low UOP= high urine osmolality/sp, gravity super concentrated (>1.030)

-s/s

~confusion, seizures (headache means seizure might come), low consciousness, muscle cramps, weakness, weight gain, edema (NOT PITTING)

-give desmopresin, encourage sodium intake, fluid restriction (most fluid in morning, less at night), fall and seizure precautions, daily weights, low
fluid volumes to prevent seizures

Hypothyroidism

-low and slow

-levothyroxine rest of life, don’t double up on dose.

Hyperthyroidism

-fast and furious

-can lead to thyroid storm

Thyroid Storm

-from hyperthyroidism

-elevated hr, elevated BP, CONFUSION,

-don’t overheat

-v fib= d fib

Addisons Disease (ADD steroids)

-low cortisol levels, low BP (GIVE IVF TO PREVENT SHOCK)

- addisonian episodes come from stressors

-give ivf, iv steroids, steroids, salt, sugar

Cushings Syndrome (cushion of cortisol)

-genetic or drug induced from long term steroid use (copd, asthma)

-trtmnt: hypophysectom (can turn to addisons so ween off steroids and give salt and sugar)

Pheochromocytoma: rare tumor of adrenal medulla

-secretes catechloamines (epinephrine, norepinephrine -fight or flight)

-tachycardia, severe hypertension, diaphoresis, severe headache, weakness, pallor

-DON’T PALPITATE ABDOMEN, give catapres, beta blockers, teach med compliance, REDUCE STRESS
 EXAM 4
Med Surg 2
Study Outline
Units 9 – 12
ENDOCRINE SYSTEM
Diabetes Mellitus

-watch for stroke and retinopathy(can’t draw their own insulin cause they can’t see, shouldn’t be in complete darkness)

-if DKA (type) hydrate immediately and give K+, they’re in metabolic acidosis

-must have leather shoes, cotton diabetic socks

-hypoglycemia- cool and clammy and cranky; give glucagon or dextrose

-increase insulin if active

-crystallized skin

-GIVE GLUCOGON OR DEXTROSE

-if HHNS (sugar over 600, report s/s IMMEDIATELY

-crystallized skin

Renal

-fistula

~needs consent form

~takes about 4-5 months to work

-Peritoneal Dialysis

~watch for s/s infection, REPORT INCREASE IN BODY TEMP IMMEDIATELY

-if natural disaster, let whole hospital know and activate disaster plan

-if eye injury, irrigate and then cover both eyes if if doesn’t come out

-if object penetrating from eye, do not remove object

-if bug in ear, use mineral oil or diluted alcohol to kill, then remove it

-if heat stroke, move to cool area and remove clothing

-if hypothermia, gradually rewarm

-if frostbite, treat like burn. Wrap each finger or whatever individually w gauze dressing. NO OCCLUSIVE, give tetanus shot

-ABC for who to see first

-narcan reverses heroin, rr will go up if working. Give more when rr decreases

-Thiamine for alcohol abuse for brain degeneration, implement seizure precautions and give benzos to prevent stroke

-compress femoral artery if glass in thigh

-pulmonary anthrax is the worst and will most likely kill, mostly highest priority

-if choking and making sound, leave alone. Once no longer making sounds, hiemlich

-sulfanorea TEACH NO ALCOHOL

-Pyelonephritis comes from UTI, flank pain

 EXAM 4
Med Surg 2
Study Outline
Units 9 – 12
ENDOCRINE SYSTEM
CANDLELIGHT SESSION 1

Role of ADH?

2 disorders covered by ADH- DI SIADH (RETAINS WATER, so sodium decreases at risk for seizures, 1 priority is COACH seizure precautions )

If patient is assessed, move on to next step in nursing process

Sodium 135-145

Seizure precautions, no lights in eyes, calm setting, no flickering lights or loud family members.

SIADH treatment is fluid restriction, finding causative agent and then treating it

LOOK AT WEIGHT for fluid overload

Most water in the morning, least water at night

SIADH is working when the patient has baseline BP, urine output, electrolyte balance, resolution of thirst, and no generalized edema. NO PITTING
EDEMA.

Causes of SIADH is head injury, infection, stroke, hemorrhage, pulmonary disorders

First sign of impending seizure is a headache

SIADH encourage foods with sodium

Dripping fluid, check if glucose positive. CSF.. MED EMERGENCY, OPEN SITE in meninges

Put pt at risk for meningitis, burdinkis sign, nuchal rigidity. No walking around, HOB neutral positions, no lower than 30-60.

Treat nausea/coughing right away. Don’t add extra intracranial pressure

SAIDH Redflag for complication development headache, Altered mental status, pupils no light exposures, nausea, airway problem, intubate pt, neck
vein distention (means fluid overload, R side heart failure). Listen to lung sounds for L sided heart failure.

Developing complication secondary to Diabetes insipidus, dry brain, headache and seizure, circum oral paresthesia (tingling), dehydrated and dry,
thirsty cant get enough, increased urine output (LITERS!)

SIADH weight gain of 3lbs or more in a few days is concerning, weigh patient daily in the morning after peeing. 3kg=6.6lbs CALCULATIONS

-----Pituitary Disorders –

Giantism (children) Acromegaly (adults) - sudden increase in weight, are your shoes tight? FOOT GROWTH. Growth hormone is too high, bones
grow in girth not length (adults),

CUSHINGS and ADDISONIAN- Adrenal gland (cortex cortisone and aldosterone are made)

Do not palpate abdomen

Cushing’s- cortisol is high (cushion, high!) cortisol is a form of natural steroid. Steroids impairs immune system causes risk for infection, bones
cause osteoporosis which puts at risk for breaking and falls, skin will be slow healing… too much cortisol, remove it cortisolsectomy, can turn into
addisons patient if too low cortisol

Threat with addisons BP CRASHES 30/10….need salt and sugar while tapering off steroids

First thing for addisons 50/30 (ex) steroids and IV push, prevent hypovolemic shock, perfuse brain and kidneys

Determine what patient to see first by ABCs

Phenocytocroma no palp of abdomen, reduce stress. HR drugs to control HR are Alfa adrenergic drugs catopress, beta blockers -olol, be compliant
with meds. Stress Increases stress hormones epinephrine and norepinephrine

Hyperthyroidism biggest threat is thyroid storm will kill them BP. Presents thyroid storm with confused agitated, PROFUSE DIPHORESIS, High HR,
dysarrthymia, severely hypertensive (beta blockers). Do not overheat. Skinny, talk fast, friend then foe quick, issues w relationships,
 EXAM 4
Med Surg 2
Study Outline
Units 9 – 12
ENDOCRINE SYSTEM
treat hypothyroidism with levothyroxine.. can turn into hyperthyroidism. MONITOR do not double dose med

sunshine for psoriasis, no aesthetic food like tomatoes avoid food

hypothyroidism no heating blanket! If cold, tell them to bundle up with gloves and socks, hat. Sensors for body temperature is in feet soles and
palm of hands

Diabetes 1 – insulin dependent form for life, genetic or virus or autoimmune disease, protein snacks pt is cool and clammy.. 1 st sign of hypoglycemia
is

Diabetes 2- noncompliant pt, BMI complex crabs like sweet potatoes and meat NO breads, conchas. Glucoagone

Liver - insulin and glucagon

After amplodine 50 you must GIVE FOOD, therputic when sugar is normal

Long term effects of diabetes- atherosclerosis, retinopathy (take meds in well lit area, night lights, do not draw up own insulin), peak time in regular
insulin 2 ½ hrs check insulin Q15min,

Peak in long term (NONE) sugar will

Cloudy to clear

clear to cloudy

Diabetes closed toed shoes, not tight, leather shoes cotton socks (diabetic socks) if blister teach pt to monitor site daily for infection care for by
keeping clean, putting dressing to protect

If diabetes not taken care of, renal disease

Surgery needs consent form

AV fistula takes 3-4 months, feel the thrill

If pt is noncompliant and is in DKA (type 1 metabolic) first thing to do is HYDRATE!! Normal Saline.

Diabetes type 2- HHNS (HYDRATE PRIORITY, antibiotic) number 1 cause is infection leads to sepsis will kill patient

Hydration - glucose and potassium

DKA pt imbalance of metabolic acidosis (respiratory should help) KUSSMAL RESP.

Type 2 diabetics that aren’t on insulin, are put on insulin in the hospital because of stress.

Type 2 diabetes failure, uric acid – take cold baths, clip elderly nails

Pt cant cope, drug to reverse heroin is Narcan, we should see respirations going up ,Narcan goes away when rep goes down.

Pt cant cope downs alcohol, brain alcohol abuse is treated by thymine, protects brain.

Know alchol withdrawl symp and withdrawl causes vasoconstriction, ends up severely hypertensive, give benzos , risk for having a seizure and
injury and stroke INJURY PRECAUTIONS

DI is treated with vasopressin

SIADH is treated with fluid restriction and diuretics NORMAL SALINE

CHECK DRAINAGE FROM THE NOSE for glucose CSF BRUDINSKIS CHEST TO NECK AND KNEES FLEX, nuchal rigidty

Ss of hypogly tremor, jerk, agitated,confused, cool, clammy ,weaty give glucagone or sugar right into vein

Hemodialysis- bleeding and infection will kill you first

If allowed 900ml in 24 hrs….. give majority of fluid in the morning, less in evening, least at night
 EXAM 4
Med Surg 2
Study Outline
Units 9 – 12
ENDOCRINE SYSTEM
Bladder cancer painless hematuria, if painful sign of UTI

BPH cardinal sign is cant urinate, forced urination

Substance abuse reverse stub abuse w Narcan observe for 4 hours for respiratory rate

Eye injuries if eyes still hurt, cover both eyes

If someone is choking.. assess.. keep items that are choking hazards where children cant reach

Hypovolemic shock treat is fluids

Hemm shcok give blod

Anaphylactic shick give epi followed by antihistamine

Cardio genic shock treat w digoxin

Treat frostbite like a burn, remove threat like gloves, warm hands with room temp water, never massage

Control hemmorrage (do not remove) close off artery

Treat heat exhaustion , remove from heat safety priority

Glipizide, glypride, flagil tell pt cant drink alcohol dysphramatic reaction

Who will die first SAIDH or DI? DIABETES INSIPIDUS

ADD or cush? ADDISONS (steroid inj of hydrocortisone EPI)

If double dose on insulin, give ACCUCHECK ASSESS FIRST

Med errors

Hyperthyroidism-tigger

HYpothy-egore if trying to reverse can cause hyper and concern is thyroid, do not double dose levothyroxine,

NO HEATED BLANKETS