Everyone needs a little therapy (IV that is)
What are the 3 types of crystalloid IV solutions, and why are they called crystalloid?
Isotonic, hypotonic, hypertonic
"an aqueous solution of mineral salts and other small, water-soluble molecules"- National Institute of Health; Solutions with small molecules that flow easily from blood into cells and tissues
How can you see SIADH in a blood test?
hyponatremia, increased ADH, fluid overload
What hormones are secreted by the thyroid and which ones are measured to determine hyper-hypo-thyroidism?
T3, T4- measured
Calcitonin
What is the parathyroid?
What is the difference between type 1 and type 2 diabetes mellitus?
Type 1 is an absolute lack of insulin (non-reversible)
Type 2 is insulin resistant (reversible)
B. ketones present in urine
What medications are used for hyperthyroidism and why are those used? (what does it do to the thyroid?)
propylthiouracil (PTU)
methimazole- safe for pregnancy, most common
radioctive iodine- permanent cure
These medications are essentially "killing" the thyroid to reduce T3 and T4 production
What is the goal of fluid resuscitation and when do you use it?
goal- patient and organ rescue
-pressure bag for shock, hypovolemia, and dehydration
water diabetes- kidneys cant conserve water
What is an important patient teaching if they get a thyroidectomy?
They will be on life long medication to compensate for no thyroid
What foods contain phosphurous?
dairy, red meat, poultry, seafood, legumes, and nuts
If a patient's glucose is 60, and they are awake, what would be the first intervention to get their sugar up?
4 oz OJ- 15 g glucose
3-4 glucose tabs
glucose gell
regular soda- 6 oz
honey- 1 tbs
sugar- 1 tbs
A client with the recent diagnosis of MI and impaired renal function is recuperating on the step-down cardiac unit. The client's blood pressure has been borderline low and IV fluids have been infusing at 100 mL /hr via a central line catheter in the right internal jugular for approx 24 hours to increase renal output and maintain the blood pressure. Upon entering the client's room, the nurse notes that the client is breathing rapidly and is coughing. The nurse determines that the client is most likely experiencing which complication of IV therapy.
1. Hematoma
2. Air embolism
3. Systemic infection
4. Circulatory overload
Circulatory overload
What two meds are used for hypothyroidism and what does it replace?
levothyroxine- T4
liothyronine- T3
What are the differences between osmalality and osmolarity and what is the normal serum range?
Osmolality- is weight based
osmolarity- is volume based
275-295 mOsm/kg or liter
What are some S/S of an Addisonian crisis?
weakness, N/V, abdominal pain, severe hypotension, severe hypoglycemia, hyperkalemia
What can hypothyroidism be caused by and what is happening with the thyroid hormones?
Hashimoto’s disease, Pituitary gland tumor, Hypothalamus dysfunction, Hyperthyroid treatment, Inadequate iodine intake, Thyroidectomy
low T3 T4 and free T4
What causes hyperparathyroidism?
low calcium absorption, decreased Ca, vitamin D intake, low absorption in bowels, parathyroid adenoma, renal failure
When is a lower blood sugar reading concerning?
If Glucose is LESS than 70, the workload may get HEAVY!!!
The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The nurse notes that a client's IV site is cool, pale, and swollen, and the solution is not infusing. The nurse concludes that which of the following complications has occurred.
1. Infection
2. Phlebitis
3. Infiltration
4. Thrombosis
infiltration
what medications can treat DI?
ADH administration, Vasopressin (but not preferred because of vasoconstriction), desmopressin, thiazide diuretics, chlorpropamide, carbamazepine
What are the 3 main types of solutions that are considered isotonic?
5% dextrose (D5W)
0.9% normal saline
Lactated Ringers- contains lactate, so be careful with liver disease patients
With Cushing's there could be cardiovascular symptoms such as S/S HF and hypertension, why?
Preload is increased which puts stress on the heart and too much aldosterone and increased fluid retention due to hypernatremia
What electrolyte do you need to monitor after a thyroidectomy, and what needs to be in place?
hypocalcemia- seizure precautions
What foods are high in calcium?
seeds, dairy, leafy greens, sardines, whey protein
What is considered a positive test for A1C and how is it calculated?
Anything greater than 6.5%
it is calculated by the average glucose levels over time
Following surgery, the nurse has administered albumin to a client. The nurse would evaluate this intervention to be effective if which of the following assessments was obtained?
A. Heart rate 96
B. Temperature 98.8
C. Respirations 24
D. Blood pressure 140/80
blood pressure 140/80
Hyperparathyroid meds
Sensipar (kidney disease)- tricks parathyroid to think there is enough Ca or PTH
calcitonin- lowers Ca by suppressing osteoclasts
loop diuretic- inhibits Ca absorption
alendronate- slow osteoclast activity
When would you give a hypertonic solution?
cerebral edema and severe hyponatremia
What is the difference between Cushing syndrome and crushing disease?
Syndrome- excess cortisol
Disease- ACTH producing tumor- pituitary adenoma
What disease causes hyperthyroidism, and what happens with hormone production and what does that look like?
Graves Disease
T3, T4 are being overproduced, TSH is low
overheated- weight loss, tachycardia, hypertension, exopthalmos (bulging eyes), palpitations
What are S/S of hypocalcemia
Hypo- numbness, tingling, muscle twitching, trousseaus sign, chvosteks sign, seizures, tetany
Why don't you hold long-acting insulin even if a patient has lower blood sugar?
it does not have a peak and will not drastically change sugars
A patient arrives to the ER and is unable to give you a health history due to altered mental status. The family reports the patient has gained over 10 lbs in 1 week and says it is mainly “water” weight. In addition, they report the patient hasn’t been able to urinate or eat within the past week as well and was recently diagnosed with small cell lung cancer. On assessment, you note the patient’s HR is 115 and BP 180/92. Patient sodium level is 90. Which of the following conditions do you suspect the patient is most likely presenting with?
SIADH
What medications can treat Addison's and what class are they?
prednisone, hydrocortisone- glucocorticoids and mineralocorticoids (steroids)
When would you give fluids through a central line?
If the serum osmolality is over 900 mOsm/kg because it increases vein irritation and chance of phlebitis/ thrombophlebitis
What is Nephrogenic DI?
kidneys are not responding to ADH that may be caused by renal disease/tumor, nephrotoxic drugs, or infections
What kind of diet does somebody need to utilize for hypothyroidism?
low calorie- high fiber (constipation)
what are S/S of hyperparathyroidism?
groans, stones, bones, psychiatric moans
For T1 and T2, what are treatments that are the same for both?
nutrition management, patient and family education, detection and prevention of complications, insulin
With a patient diagnosed with SIADH what drug do you anticipate the patient will be started on per doctor’s order?
Declomycin
What medications are used for Cushing's disease?
ketoconazole, osilodrostat- decrease cortisol levels
mifepristone- block effects of cortisol on tissues
Pasireotide- decrease amount of ACTH
What is a colloid and when would you give them?
contain large insoluble molecules such as protein
to increase blood volume and is usually given in adjunct for hypovolemic fluids
What are the differences between SIADH and DI
SIADH- high ADH, fluid overload, seizure risk, hyponatremia
DI- too little or insensitivity to ADH, water diabetes not sugar diabetes, hypernatremia
What are some signs and symptoms of a Thyroid storm and what is the treatment?
S/S: anxiety, heat intolerance, mood swings, diaphoresis, tachycardia, palpitations, dyspnea, delirium, coma, HF
Treatment- beta blockers, antithyroid meds, antipyretics
how is hypoparathyroid diagnosed?
low Ca and PTH, high phosphorous
albumin may be low
vitamin D low
What are the differences between diabetic ketoacidosis(DKA) and Hyperosmolar hyperglycemic state (HHS)?
DKA is a complication of Type 1, sugars between 200-300, ketones in blood, affects younger more than older, life threatening, hydration is key, frequent blood sugars, patient may have kussmal respirations.
HHS is a complication of Type 2, sugars over 600, no ketones, depressed immune system, neuropathy, vascular issues
A patient is admitted with thyroid storm. Which sign and symptoms are NOT present with this condition-SELECT ALL THAT APPLY?*
D- HR of 20 bpm
E- intolerance to cold
What kind of medications are used to treat SIADH
loop diuretics- furosemide
hypertonic IV- to increase sodium
salt supplements
ADH antagonist- Declomycin, lithium
What is a hypotonic solution used for? (<250 mOsm/kg) and when would you not give it?
DKA
hyperosmolar hyperglycemia
provides free water for kidneys
do not give for ICP, burns, Trauma
What are the differences between Addison's and Cushings?
Addisons- too little cortisol, aldosterone and androgens, ACTH is not being adequately produced, hypoglycemia, bronze skin, weakness, weight loss
Cushings- too much cortisol, aldosterone, androgens, caused by adrenal/pituitary tumors, weight gain but thin arms and legs, delay in wound healing, moon face, buffalo hump
Why can't you stop hypothyroid meds abruptly and when should you take them?
it can cause a life-threatening myxedema coma
Take in the morning before breakfast
How is hyperparathyroidism diagnosed?
increased PTH and Ca for primary
Increased PTH and phosphorus, decreased Ca for secondary (check albumin to ensure it is normal)
What are the 4 types of insulin and how are they administered/ what is their peak?
Rapid- subcu, onset: 10-30 min, 30-90 min peak, deadliest
short acting- subcu, onset: 30min-hr, peak 2-5 hr
regular- only one that can be given IV, or subcu, onset: 1.5-4hr, 4-12 hr peak
long acting- subcu, onset: .8-4hr, no pronounced peak
A patient with Addison’s Disease should consume which of the following diets?
C. high protein, carbs, and adequate sodium
What are some other medications you can use for diabetes and their MOA?
Insulin secretagogues Action: increase pancreatic insulin secretion (First generation examples: sulfonylureas, tolazamide, tolbutamide; Second generation examples: glyburide, glipizide, glimepiride; Quicker acting: repaglinide, nateglinide)
Biguanides Action: prevents inappropriate hepatic gluconeogenesis (Glucophage (metformin) Note: often a first try medication)
•Alpha-glucosidase inhibitors Action: delay intestinal absorption of carbs (acarbose, miglitol)
•Thiazolidinedione insulin sensitizers Enhance sensitivity of peripheral cells to insulin (pioglitazone (subclasses- empagliflozin, sitagliptin))
Glucagon-like peptide-1 (GLP-1agonists) Action: slows absorption in the gut and increases secretion of insulin from pancreas in response to hyperglycemia, reduces glucagon levels and reduces appetite (exenatide, liraglutide (Victoza), dulaglutide (Trulicity))
What is a febrile nonhemolytic reaction and what does it look like?
happens shortly after blood transfusion
temp increases by 1 degree celsius or more, chills or mild dyspnea, is usually benign
Central Neurogenic DI is caused by what?
not enough production of ADH
What is the difference in hormones between hypothyroidism caused by an autoimmune disease and a tumor?
autoimmune- increased TSH, and decreased T4, free T4, and T3
Tumor- everything is decreased
What can you administer for a patient experiences hyperparathyroidism to prevent kidney stones?
IV fluids
decrease calcium antacids and vitamin D
How does Continuous glucose monitoring work?
Tests interstitial fluid instead of blood which helps monitor non-critical patients (do not use for DKA or HHS)
What statement or statements are INCORRECT regarding Diabetic Ketoacidosis?*
E. Cheyne stokes breathing will always be present in DKA and severe hypoglycemia is a hallmark sign in DKA
how does declomycin work for SIADH?
it is an antibiotic that will decrease the effectiveness of collecting tubule cells in the kidney to decrease responsiveness to ADH.
What is acute hemolytic reaction and what does it look like?
wrong blood was given
medical emergency- DIC, shock, acute renal failure, dyspnea, fever, chills, hypotension, nausea, tachycardia, red urine
Treatment- fluid resuscitation to offset renal failure
What can cause SIADH? (name 3)
medications (chlorpropamide, carbamazepine), cancer, trauma to hypothalmus or pituitary, infection
What is a myxedema Coma and what are the S/S and treatment?
causes- untreated hypothyroidism, meds abruptly stopped, infection, illness
S/S- bradycardia, decreased cardiac output, decreased level of consciousness, hypothermic, hypotensice
Tx- warm, maintain BP, IV levothyroxine
What are some precautions you need to take as the nurse for hyperparathyroidism?
monitor calcium and phosphate levels, airway (have trach kit, O2, and suction at bedside); seizure precautions, cardiac monitoring, neuro checks
What is the rule of 15?
Need to raise glucose level as quickly as possible
If conscious and able to swallow and glucose < 70 mg/dL 15 g carbohydrate à recheck glucose à repeat if needed If unable to swallow and IV access 25 g D50W à recheck glucose à repeat if needed If unable to swallow and no IV access get access I g IM or IV glucagon à recheck and repeat if needed If glucose still < 70 after one repeat of treatment follow policy
Which of the following foods below should a patient experiencing a thyroid storm avoid? Select all that apply:
A. shrimp
b. milk
c. hardboiled eggs
D. seaweed (kelp)
Reasoning: limit foods with iodine
Hypoparathyroidism Meds
calcium and vitamin D supplements
phosphate binders- aluminum hydroxide, sucroferic oxyhydroxide, calcium carbonate - decreases phosphorous by increasing excretion
Calcium gluconate/ calcium chloride- increases calcium levels
Natara- parathyroid hormone replacement (injection)