DEALING WITH
HYPOTHYROID
HYPOTHYROID
The drugs in this category, including the one on our unit, help to raise the level of thyroid hormones in all the various conditions where it may be low/insufficient, as well as conditions producing a goiter. The common name for "primary hypothyroidism" (think: everything being slow/cold) comes from the name of this JAPANESE doctor
who first described it in 1912
HASHIMOTO'S DISEASE
The more recent drug in this category, methimazone (Tapazole), which is NOT a part of this unit but was mentioned in lecture because it is more commonly seen today, can be used long-term for the treatment of primary hyperthyroidism which is most commonly known by the name _________ Disease.
BONUS: Name the earlier prototype of the drug in this category that IS on our unit
GRAVE'S DISEASE
BONUS: The name of the early prototype that is on our unit is propylthiouracil (PTU)
The prototype somatropin (Genotropin) whose primary use is to treat either Pediatric Growth Hormone (GH) deficiency or Non-GH-Deficient Short Stature, essentially provides these pediatric patients with a supplemental form of GH that normally is released by the anterior pituitary gland
to do WHAT in the child's body?
(1) Promote the growth of almost all their organs/tissues
(2) Increases the length of their bones
(prior to closure of epiphyseal plates)
(3) Increase lean muscle mass
(4) Increase protein synthesis
(d/t increased amino acid reuptake)
(5) Increase glucose levels (d/t reduced utilization)
The primary net effect of receiving the synthetic form of ADH/
desmopressin (DDAVP) intranasally, IV, subQ, or PO,
is to do what exactly?
DECREASE URINE OUTPUT [VOLUME].
By holding on to more "water," as a consequence the osmolality (think concentration, relative amount of a solid in a liquid) in blood goes DOWN (for there is now a greater amount of liquid relative to the solids in blood) and the osmolality of urine goes UP (for there is now more solid relative to the decreased amount of liquid in urine, i.e. the urine is more "concentrated," and it takes on a darker shade of yellow)
The main endocrine-related reason a patient may be given a corticosteroid is for "replacement therapy," because for whatever reason their body produces a deficient amount of CORTISOL, such as in the condition known as "Primary Adrenal Insufficiency," otherwise known as
___________ Disease
BONUS: Name some of s/s of this condition
ADDISON'S DISEASE
BONUS: fatigue, weight loss, hyperpigmentation, hyponatremia and salt craving, hypotension, hypoglycemia, hyperkalemia; amenorrhea for patients with a uterus
This is the name of the prototype drug (give both the generic and Trade version) that is structurally identical to the thyroid hormone T4, and therefore serves as a replacement or supplementation to the body's endogenous (self-produced) thyroid hormones
levothyroxine (SYNTHROID)
TRUE OR FALSE: When a patient ingests the PO capsules of Iodine-131, a radioactive isotope of stable iodine that emits beta particles and gamma rays, one major concern is that this radioactivity will cause cancerous cells to appear in the GI and GU tracts as the iodine moves through these systems
FALSE
Just like stable iodine, radioactive Iodine-131 gets quickly concentrated in the thyroid gland, which is destroyed by the beta particles. They have a limited ability to penetrate physical barriers, so they do not travel outside the thyroid, and have little chance of damaging other organs
when taken in therapeutic doses
TRUE OR FALSE: Not only children but also ADULTS can receive the bioengineered form of GH that is made by recombinent DNA technology in order to grow their bones longer/bigger
FALSE
Once a person's bones' epiphyses are closed, they CANNOT reopen and continue growing. That being said, still some adults who have GH-deficiency can still benefit from this drug therapy, for that condition reduces their muscle mass, and taking this supplemental form of GH will help raise their exercise capacity and lower their risk for
CV-related mortality
FILL IN THE BLANKS: A person with Diabetes Insipidus is "______-Inside" (Dry or Wet?) because of their _______ (increased or decreased?) Urine Output as a result of deficiency in the hormone ADH, which stands for _____-________ ______.
Another name for this same hormone,
whether natural or synthetic, is D_____.
A person with Diabetes Insipidus (D.I.) is _DRY-Inside (D.I.)_ because of their _[substantially] INCREASED_ UO as a result of deficiency in the hormone ADH, which stands for _Anti-Diuretic Hormone_ (i.e. it works AGAINST diuresis, diuresis being the production of urine by the kidneys. ADH's function is to help the body hold onto fluid, the opposite of a diuretic), aka DESMOPRESSIN
TRUE OR FALSE: In low doses, and especially if not taken long term, corticosteroids / glucocorticoids
DO NOT produce adverse effects
TRUE
The large number of potential side effects listed -- and be sure to study that list, for these drugs are fairly common ones -- are often caused by toxicity due to either high doses or long-term therapy (that can push a person's body into the s/s associated with HYPER-cortisolism or "Cushing Syndrome")
The prototype drug in this category can in an emergency be given IV (e.g. to treat extreme thyroid hormone insufficiency causing a "Myxedema Coma"), but is most commonly given PO. What KEY PATIENT TEACHING must you give to patients taking the oral version of the drug, related to the time they take it and the condition of their stomach (empty or full?) when they do.
TAKE IN THE MORNING ON AN EMPTY STOMACH
Ideally it is taken each day 60 minutes before breakfast. Why? Taking it together with foods, drugs, or other supplements may bind up this drug (it is 99% protein bound), preventing the drug from being absorbed completely and limiting its effectiveness.
In addition to being used for long-term treatment of primary hyperthyroid, propylthiouracil (PTU) has
at least TWO other SHORT-term uses.
NAME AT LEAST ONE OF THEM
(1) Used as an adjunct alongside radioactive iodine-131 therapy, since the full effects of that therapy take 2-3 months to appear
(2) used to suppress thyroid hormone synthesis temporarily as a preparation for thyroidectomy surgery
What special instructions should be given to a patient with Diabetes who is taking
somatropin (Genotropin)?
Since this drug will likely raise their blood glucose due to its effect of decreasing glucose utilization, patients with Diabetes may need to adjust their insulin intake and/or dose of DM-medications. Aside from adjusting doses, they should be instructed to monitor their CBGs closely and regularly while on this drug
A secondary function of increasing the levels of ADH / desmopressin in the body is to affect the __________ cascade, shortening bleeding times.
BONUS: Name the specific FACTORS affected to help achieve this effect
_CLOTTING_ CASCADE
BONUS: ADH/desmopressin increases blood plasma levels of von Willebrand Factor, and of clotting
factor VIII (8), and of tissue plasminogen activator,
all which play a role in the clotting cascade.
By increasing these factors, clotting happens more quickly, thus decreasing bleeding times
Name the TWO drugs in this unit that both contain a corticosteroid/glucocorticoid that has the very same structure as the body's own naturally-made steroid called cortisol (okay to list the two drugs with either their generic or their Trade names)
prednisone (DELTASONE) containing a glucocorticoid (cortisol);
hydrocortisone (SOLU-CORTEF) which is a combo drug: a short-acting glucocorticoid (cortisol) together with a mineralocorticoid (aldosterone)
Excessive doses of the prototype drug used to treat hypothyroid conditions can sent a patient to the other extreme, into thyrotoxicosis / hyperthyroid symptoms. List some of the Adverse Reactions that one might see as a result of such excessive doses
TACHYCARDIA, HYPERTHERMIA,
HEAT INTOLERANCE, NERVOUSNESS, INSOMNIA, SWEATING, TREMORS
There are SIXTEEN bullet points for Patient Education for Radioactive Iodine-131 (131-I). You don't have to memorize them all, but familiarize yourself with at least some of them to understand their purpose. A number of these teachings are not about protecting the patient taking the drug but about PROTECTING OTHERS AROUND THEM FROM EFFECTS OF 131-I --
List AT LEAST FOUR such teachings
*Avoid close contact with other for several days after the procedure, esp. children or pregnant women
*Sleep alone& avoid prolonged intimate contact for 3-4 days
*Avoid public places for at least 3 days
*Use private toilet facilities; flush twice
*Separately launder your linens, towels, and clothes daily at home
*Use disposable eating utensils or wash separately
*Do not prepare food for others with your bare hands
*Stop breast feeding several days before taking
(the notes also say "Contraindicated in pregnancy... and lactation"
but apparently that is not absolute)
The drug somatropin (Genotropin) has MANY potential Adverse Reactions. Name as many of them as you are able
(AT LEAST FOUR to receive points)
*HA, trouble sleeping
*fatigue, back pain, muscle pain, joint pain, muscle stiffness
*GI disturbances: n/v/d, stomach pain
*symptoms of "common cold" or "flu-like" symptoms
*hair loss and/or enlarged breasts
*hyperglycemia in patients with Diabetes
*increased RF death in pts with severe respiratory impairment
*increase RF intracranial pressure (ICP) in patients with
chronic renal (kidney) failure
*Hypothyroidism OR injection site reaction
Aside from the possibility of shortness of breath, nasal congestion/irritation, gastric irritation/heartburn, a person taking desmopressin may experience water intoxication leading to THIS electrolyte imbalance (begins with the prefix "hypo-" or "hyper-"), many of whose s/s are also potential ARs of
this drug treatment in general
HYPONATREMIA (low blood serum SODIUM, not caused by having not enough Na+ in the blood, but instead because the amount of Na+ gets so diluted in all the extra water retained in the blood)
Among its s/s: DIZZINESS, DROWSINESS, CONFUSION, LETHARGY, POUNDING HEADACHE. It may also cause weight gain, severe convulsions, and coma.
Aside from the endocrine cortisol hormone replacement therapy that is the focus of this unit, the two drugs in this category also have nearly a dozen NON-endocrine applications due to the way the drug works to suppress the body's normal immune and inflammation responses.
LIST AT LEAST FOUR NON-ENDOCRINE USES
*Rheumatoid Arthritis (RA)
*Systemic Lupus Erythematosis (SLE or "Lupus")
*Inflammatory Bowel Disease (IBD)
*Allergic conditions
*Asthma/COPD (but not for emergency exacerbation)
*Dermatologic diseases: Psoriasis, Seborrheic and Contact dermatitis
*Cancerous Neoplasms
*Suppression of Organ Transplant (Allograft) Rx
*Suppression of Nausea/Vomiting caused by other meds
*Suppression of Respiratory Distress Syndrome (RDS) in preterm infants
List AT LEAST FIVE elements that should be included in the Patient Education for someone taking the drug that is the synthetic form of T4 that replaces or supplements a person's natural thyroid hormones
PT TEACHING for levothyroxine (SYNTHROID):
(1) Take on an empty stomach at the same time each day
(2) Do not take within 2 hrs of taking an antacid, iron,
magnesium, zinc, calcium, or a cholestyramine or sucralfate
(3) Don't stop taking abruptly without MD consult
(4) Report s/s of thyrotoxicosis to MD
(5) Report if taking OTC meds that raise HR or cause nervousness
(6) Get periodic labs to check your hormone levels: T3, T4, TSH, TRH
(7) Get period physical exams to assess reversal of s/s of hypothyroidism
Among the Patient Education for propylthiouracil (PTU), aside from the general instruction to "take as directed/do not DC early without consulting the provider," and the importance of regular lab and exam checkups, and the instruction to consult with the provider before taking any OTC drug that contains Iodine,
explain the purpose of 4 OTHER teachings:
(1) Monitor WEIGHT 2-3 times/wk
(2) Take your pulse; report if >100 or <60
(3) Report sore throat, fever, chills, HA, malaise
(4) Report yellowing of eyes/skin, unusual bruising or bleeding
(1) Monitor weight, report significant changes: follow the effects of the drug, which should cause some gradual weight gain
(2) If pulse is regularly >100 the dose may not be high enough; if pulse <60 it may be too high.
(3) Sore throat, etc., may be a s/s of infection that could be caused by agranulocytosis (d/t toxic drug levels)
(4) Yellowing of eyes and/or skin, i.e. jaundice, as well as bruising or bleeding, may be s/s of liver damage
(due to the drug causing "hepatotoxicity")
Name the typical ROUTE OF ADMINISTRATION of somatropin (Genotropin) and also list a potential AR that is associated with its
route of administration
BONUS: What nursing instructions/considerations are related to the administration of this drug?
Normally it is given IM or SubQ ;
either way the injection is given, a potential AR is
"irritation where the shot is given,"
i.e. injection site reaction
BONUS: Swirl, do not shake (i.e. do the opposite of the method of making James Bond's martinis), to mix with dilutent or sterile water as indicated. When injecting,
rotate injection sites (d/t risk for site irritation)
Aside from assessing the patient's hydration status (by observing their skin turgor and mucus membranes, and by analyzing their UO, Na+ and K+ levels), the nurse should be sure to provide THESE FOUR ELEMENTS OF PATIENT EDUCATION that all have something to do with
some type of fluids / body fluid levels
(1) Teach pt. strictly to monitor/record daily I/O
(2) Teach pt. to avoid drinking alcohol
(3) Decrease overall fluid intake at the start of the treatment to avoid water intoxication
(4) Teach the patient to recognize and report the early s/s of water intoxication --> hyponatremia
Aside from hydrocortisone (Solu-Cortef) being a combo drug that contains not only the equivalent of cortisol but also of aldosterone, what did the lecture mention as one main ADVANTAGE of this later corticosteroid / glucocorticoid drug over the other prototype in this same category, prednisone (Deltasone)?
The original form of prednisone (Deltasone) is taken orally (PO) q 8 hours, while hydrocortisone (Solu-Cortef) can be taken just one time a day,
generally taken PO in the AM
"to mimic normal cortisol release"