10-day RN/PN Nclex Live Review Course

CONCEPT: ENDOCRINE SYSTEM

A. Posterior Pituitary Gland Disorders

DIABETES INSIPIDUS (DI) SYNDROME OF INAPPROPRIATE ADH

(SIADH)

Problem: _________ ADH Problem: ________ ADH

Assessment: Assessment:

Fluid Fluid

Weight Weight

Hemo___________ Hemo___________

____Sodium ____Sodium

____BUN, ___CREA, ___URIC ACID ____BUN, ___CREA, ___URIC ACID

____BP, ____Fluid volume – can lead to ____ ____BP, ____Fluid volume

Urine output: Urine output:

Urine Specific Gravity: Urine specific gravity:
Meds: WOF: Cerebral Edema – fluid in the brain spaces

Desmopressin (DDAVP, Stimate) Meds:

Lypressin (Diapid) Demeclocycline (Declomycin) – Tetracycline
Vasopressin (Pitressin) antibiotic
IV hypertonic saline (3%) – causes the cells to
shrink
Diuretics – removes excessive fluid
ACTIVITY!!!

ENCIRCLE SIGNS AND SYMPTOMS OF ENCIRCLE SIGNS AND SYMPTOMS OF

DIABETES INSIPIDUS (DI) SYNDROME OF INAPPROPRIATE ADH (SIADH)

Hypotension Weight gain Hypernatremia Weight loss Hypotension Hyponatremia

Fluid retention Hyponatremia WOF: Shock Fluid overload WOF: Shock Hemoconcentration

Neck vein distention Polydypsia Polyphagia Hypertension High urine osmolality WOF: Inc. ICP

Polyuria Hemoconcentration Low urine osmolality Oliguria Hemodilution Weight gain

Dehydration High USG Hemodilution Polydypsia Polyuria Fluid loss

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B. Anterior Pituitary Gland Disorders

Hypopituitarism Hyperpituitarism

Other names: Other names:

Sheehan’s Syndrome – post-partum pituitary gland Gigantism

necrosis due to hypovolemic shock
Acromegaly
Simmonds’ Disease – panhypopituitarism
Causes: Adenoma – benign tumor
Dwarfism – decrease in growth hormone
Hyperplasia – increase in size

Causes: Stress
Tumor MANIFESTATIONS: Depends on which part is affected
Autoimmune
Posterior Pituitary Gland
Trauma
Encephalitis ADH

MANIFESTATIONS: Depends on which part is affected Anterior Pituitary Gland

Anterior Pituitary Gland LH AND FSH – “Precocious Puberty”

( Early onset )
LH AND FSH - L – oss of libido
ADRENOCORTICOTROPIC HORMONE
O-ligomenorrhea/Amenorrhea THYROID STIMULATING HORMONE
GROWTH HORMONE
I -nfertilty
EARLY ONSET happens before the closure of the
D –elayed puberty
epiphyseal plate (growth plate)
GROWTH HORMONE
ADRENOCORTICOTROPIC HORMONE
THYROID STIMULATING HORMONE LATE ONSET happens after the closure of the
epiphyseal plate (growth plate)
Posterior Pituitary Gland

ADH
OXYTOCIN – a) uterine contraction Meds:
b) let down reflex – milk ejection
Manifestation will occur during: Bromocriptine (Parlodel)
Child birth -Dopamine Agonist- Growth hormone
Breast feeding Octreotide (Sandostatin) inhibitor
-Somatostatin Analog-
Meds:

Somatrem (Protropin)
Somatropin (Humatrope, Nutropin)
Hormonal Replacement Therapy

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Surgery: HYPOPHYSECTOMY - Removal of the Pituitary gland (a.k.a. Hypophysis)

1. Craniotomy - Opening the skull - best used if tumor exceed beyond the posterior fossa
2. Trans sphenoidal Surgery
Pituitary gland lies directly behind the nose.
Operative site: upper gingival mucosa between the upper lip and gum
Teaching Prior: Practice breathing through the mouth
Complications Post Transsphenoidal Hypophysectomy:
INCREASED
CSF LEAK (Cerebrospinal
HYPOPITUITARISM INTRACRANIAL MENINGITIS
Fluid Leak)
PRESSURE (ICP)
WOF: WOF: WOF: WOF:
1.Diabetes insipidus ____________________ 1. Severe headache 1. Fever
- leaking of clear fluid from the 2. ___ level of consciousness 2. Nausea and vomiting
nose (e.g., lethargy) 3. Severe headache
4. Stiff neck/nuchal rigidity
Nursing Intervention: Nursing Intervention:
1. Collect sample 1. ___ venous return Nursing Intervention:
2. Test for _____________ - _________________ Start prescribed antibiotic
3. Notify the physician position therapy immediately.
- avoid bending
2. Addisonian/Adrenal crisis
3. Other HYPOpituitarism 2. ___ stimuli
disorders - dimly-lit room
- limit visitors and handling
Nursing Intervention: - avoid
__________________ ____________________
hormone replacement maneuver and straining
therapy
- room assignment: _____
from the Nurses’ station

Prevent Disturbance of the Operative Site

___ Use straw ___ Frequent flossing

___ Commercial mouthwash
___ Gargle with saline solution
___ Frequent tooth brushing
___ Gargle with baking soda solution
___ Sneezing with mouth closed
___ Vigorous flossing
___ Gentle, infrequent flossing
___ Blowing of nose
___ Sneezing with mouth open
___ Toothettes

QUESTION!!!
Patient is post transphenoidal hypophysectomy. What is your nursing intervention after this
operation? Select all that apply:
1.Instruct the patient to use commercial mouth wash for oral care.
2. Position patient flat on bed
3. Instruct patient to avoid straining and coughing.
4. Tell the patient to use toothettes for oral care until suture is removed.
5. Inform patient that hormones replacement therapy is only for 6 months
6. Assess for glucose from clear fluid coming out of the patient’s nose
7. Use straw“Success
when drinking
is a state of mind. If you want success, start thinking of yourself as a success.”
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C. Thyroid Gland Disorders

1. Thyroxine (T4)
2. Triiodothyronine (T3)
3. Calcitonin

THYROXINE TRIIODOTHYRONINE CALCITONIN

T4 T3
MAINTAINS METABOLIC RATE AT A UNSTABLE CALCIUM METABOLISM
STEADY STATE 5X MORE POTENT THAN T4 BRINGS CALCIUM INTO THE BONE

Thyroid function test – To check how the thyroid is working

HYPOTHYROIDISM HYPERTHYROIDISM
PRIMARY
____TSH ____TH ____TSH ____TH
Within the Thyroid
SECONDARY
____TSH ____TH ____TSH ____TH
Anterior Pituitary Gland

QUESTION!!!
Thyroid function test was ordered for a client to identify the cause of Grave’s
Disease. Which of the following laboratory values are indicative of primary Grave’s
Disease?
1.Elevated TSH and elevated thyroid hormone concentrations
2.Decreased TSH and decreased thyroid hormone concentrations
3.Elevated TSH and normal thyroid hormone concentrations
4.Decreased TSH and elevated thyroid hormone concentrations

HYPOTHYROIDISM

Problem: ____ Thyroid Hormone

____ Metabolic Rate
Common Cause:
Hashimoto’s Disease (Thyroiditis) – Inflammation of the thyroid gland / Autoimmune
Types:
1. Myxedema – long standing hypothyroidism - Myxedema coma (severe form) Priority: AIRWAY!
2.Cretinism – thyroid deficiency at birth
MEDICATIONS:
3.Simple Goiter – due to lack of iodine LEVOTHYROXINE (LEVOTHROID,LEVOXYL,SYNTHROID)
LIOTHYRONINE (CYTOMEL)
WOF: CHEST PAIN – CAN LEAD TO

BEST TIME TO TAKE:

1. Morning before breakfast
2. Same time each day
3. Life long compliance

ADVERSE EFFECT: S/SX HYPERTHYROIDISM

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CLINICAL MANIFESTATIONS:

Generally LOW except for: Cholesterol

Weight

Menstruation

P -eristalsis
U – rine output
S - weating
H – eat production
HYPERTHYROIDISM

Problem: ____ Thyroid Hormone

____ Metabolic Rate

Common Type:

Graves Disease – Exophthalmos (bulging of the eyeballs)

Toxic Goiter – contain nodules which increases thyroid hormone concentrations

CLINICAL MANIFESTATIONS:

Generally HIGH except for: Cholesterol

Weight
Menstruation
P – eristalsis
U – rine output
S – weating
H –eat production
Treatment

Propylthiouracil (PTU) Prevents the conversion of t4 to t3

Methimazole (Tapazole)

Adverse Effect:

Beta-Adrenergic Blocker “lol”

SSKI (saturated solution of potassium iodide) , Lugol’s Solution (Strong Iodine Solution)
*** Use straw, causes teeth staining
-decrease the size and vascularity of the thyroid gland
-decrease the thyroid hormone concentrations
-used as pre-op medication: to achieve euthyroid (normal) state – to prevent thyrotoxicosis (thyroid
storm)
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Radioactive Iodine (RAI 131) – to destroy thyroid gland cells - “Medical Thyroidectomy”
Contraindication: Pregnancy and breastfeeding

Surgery: THYROIDECTOMY

2 weeks prior: Hold Anti-clotting medications

COMPLICATIONS:

1. BLEEDING
2. SWELLING/ EDEMA/ HEMATOMA PRIORITY:
3. HYPOCALCEMIA – WOF: SPASMS AND PARESTHESIA
4. LARYNGEAL NERVE DAMAGE
ASSESS:

5. THYROID STORM (Thyrotoxicosis)

Causes: a. infection
b. stress
c. hyperthyroidism
Signs and Symptoms of Thyrotoxicosis:

ACTIVITY!!!

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D. Parathyroid Gland Disorders

1. Parathyroid Hormone (Parathormone) – BRINGS CALCIUM IN THE BLOOD
Controls Calcium and Phosphorus Metabolism

Hypoparathyroidism Hyperparathyroidism

CAUSES: CAUSES:
Autoimmune Adenoma – benign tumor
Thyroidectomy Hyperplasia – increase in size

PROBLEM: PROBLEM
_____PARATHYROID HORMONE _____PARATHYROID HORMONE
_____CALCIUM _____CALCIUM

WOF: *Calcium and Phosphorus Levels WOF:*Calcium and Phosphorus Levels

MEDICATIONS:
CALCIUM SUPPLEMENTS – to increase Calcium
VITAMIN D WITH VITAMIN C – to improve intestinal
absorption of Calcium
PHOSPHATE BINDERS – help to pass excess
phosphorus out of the body in the stool, reducing
the amount of phosphorus that gets in the blood.
MEDICATIONS:
DIURETICS –to eliminate excessive Calcium
PNSS IV - to dilute Calcium
PHOSPHATE IV – to increase phosphorus
CALCITONIN – to bring the Calcium back to the
bones

E. Adrenal Gland Disorders

Adrenal Gland

Adrenal Cortex Adrenal Medulla

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ADDISON’S DISEASE

Problem: ____ Glucocorticoid

Normal Function
____ Mineralocorticoid
“Glucocorticoid” – releases Cortisol
Stress hormone
ASSESSMENT:
Sugar hormone
Decreases the absorption of Calcium

“Mineralocorticoid” - releases Aldosterone

Increases the reabsorption of water and sodium

***___________ salt/sodium substitute!!! Increases urinary potassium excretion
Promotes acid excretion

Priority:

WOF: Addisonian Crisis (Acute Adrenal failure which is caused by Physical Stress: Injury, Infection and
Illness
Clinical Hallmark:

Management:
MINERALOCORTICOID - releases “Aldosterone” - FLUDROCORTISONE (FLORINEF)
Increases the reabsorption of water and sodium
Increases urinary potassium excretion
Promotes acid excretion

GLUCOCORTICOIDS (PREDNISONE, DEXAMETHASONE, BECLOMETHASONE)

***WEAR MEDICAL ALERT BRACELET

-To provide emergency treatment
-To alert people that patient needs steroid replacement

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CUSHING’S DISEASE

Problem: ____ Glucocorticoid

____Mineralocorticoid
Normal Function
“Glucocorticoid” – releases Cortisol
ASSESSMENT:
Stress hormone
Sugar hormone
Decreases the absorption of Calcium

“Mineralocorticoid” - releases Aldosterone

Increases the reabsorption of water and sodium

Increases urinary potassium excretion
Promotes acid excretion

DUE TO STEROIDS USE:

1. SUPPRESS IMMUNE SYSTEM

Avoid exposure to infection and large crowds
2. COMPENSATORY INCREASE WBC – presence of infection
3. PHOTOSENSITIVITY – sensitive to light
4. DECREASE ABSORPTION OF CALCIUM IN GIT - Prone:
5. CATABOLIC TO SKIN (skin breakdown), CONNECTIVE TISSUE AND MUSCLE
WOF: POOR WOUND HEALING

CUSHINGOID APPEARANCE

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Conn’s Syndrome (Hyperaldosteronism)

Problem: ____Mineralocorticoid Management: Diuretics

Anti-hypertensive drugs

Potassium supplements

Pheochromocytoma

Problem: _____Catecholamines Management:

Cause: Anti-hypertensives

H
Diagnostic Test:
1.Vanillylmandelic Acid Test (VMA) – a metabolic by-product of norepinephrine and epinephrine.
Specimen:
Pre-test: Avoid caffeine, tea, alcohol, smoking, aspirin, banana, avocado, vanilla
2.Clonidine Suppression Test – Normally, Clonidine suppresses the release of catecholamines,
the inability of clonidine, to suppress catecholamine secretion is suggestive of a pheochromocytoma.
Specimen:
3.Total Catecholamine Plasma – A test for catecholamines measures the amount of epinephrine and
norepinephrine.
Specimen:

ACTIVITY!!!

ADDISON’S CUSHING’S CONN’S

Glucose
Sodium
Blood Pressure
Potassium
Acid-Base
Imbalance

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F. Pancreas

MODIFIABLE NON MODIFIABLE

Obesity Family History

Hypertension Age
Cholesterol Gestational Diabetes
Ethnicity

TYPE I TYPE II GESTATIONAL DIABETES

Insulin Dependent DM (IDDM) Non-Insulin Dependent DM MELLITUS
(NIDDM)

High blood sugar that starts or is

first diagnosed during pregnancy

Usually happens during 2nd – 3rd

trimester

Diagnostic tests:
1. Fasting Blood Glucose (FBG) 3. Capillary Glucose Monitoring
NPO: No NPO
Done before meals
2. Oral Glucose Tolerance Test (OGTT) 4. Glycosylated Hemoglobin (HbA1C)
Fasting baseline: 70-110mg/dL Normal: 3.5-6%
30-minute sample: 110-170mg/dL Good diabetic control: 7.5% or lower
60-minute sample: 120-170mg/dL Fair diabetic control: 7.6-8.9%
90-minute sample: 100-140mg/dL Poor diabetic control: 9% or higher
120-minute sample: 70-120mg/dL No NPO
Usually for pregnant women Measures the amount of glucose in hemoglobin
NPO: Monitor effectivity of treatment & compliance
Ingestion of glucose concentrate

Acute Complications of DM
1.)HYPOGYLCEMIA
Common Manifestations: Management:
T -remors 10-15 grams of fast acting simple carbohydrates
I -rritability
R -estlessness 2-3 tsp of sugar or honey
E –xcessive hunger 3-4 pcs of glucose tablets
D –iaphoresis 4-6 oz of regular soda / orange juice
6-10 pcs of hard candy

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2.) DKA – Diabetic Ketoacidosis

An absence or markedly inadequate amount of insulin

Management of DKA:
1. Fluid Replacement
2. Insulin Drip
3. Electrolyte Replacement
4. “Sick-Day Rules”
a) Check blood glucose and urine ketones every ___ to ___ hours.
b) Continue taking __________, even if client is too ill to eat.
c) Stay hydrated by drinking ___ ounces of caffeine-free fluids every hours.
d) Contact the physician if blood glucose is over 250 mg/dl for six or more hours or if client has urine
ketones that long.

3.) HHNS - Hyperosmolar Hyperglycemic Nonketotic Syndrome

Extreme hyperglycemia without ketosis and acidosis

Management of HHNS: same with DKA

Chronic Complications Of DM

Macrovascular Microvascular Neuropathy

Coronary Artery Disease NEPHROPATHY PERIPHERAL NEUROPATHY

(CAD) - Damages the kidneys - Damages the nerves
Cerebrovascular Accident RETINOPATHY - Decreased sensation and
(CVA) - Damages small blood vessels numbness
Diabetic Foot in the eyes (retina), which
might lead to blindness Prone: Burns and Injury

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FOOT CARE:

___Manage DM ___Buy shoes half size larger

___Cut toe-nails straight across
___Cross the legs
___Use heating pads
___Wear closed shoes
___Cut toe-nails at angles
___File angles of toe-nails
___Apply lotion in between toes
___Wear cotton socks
___Buy shoes at night
___Break-in new shoes
___Clean & inspect feet daily
___Use chemicals to remove corns & calluses
___Report foot any foot problem to podiatrist

Management of DM:
1. Diet
2. Exercise – recommendation 3 times a week
3. Insulin - for Type 1 DM
4. Oral Hypoglycemic Agents (OHA) - for Type 2 DM

INSULIN
Type Example Peak Nursing Consideration

RA Lispro (Humalog) “SEE FOOD”

Rapid Acting Insulin aspart (Novolog 1 hour Food tray should be available

RE Humulin R “CLEAR”
Regular Acting Novolin R 2-3 MAY BE GIVEN IV
Short Acting hours TREATMENT OF DKA
IN NPH (Humulin N, Novolin N)
Intermediate Lente (Humulin L, Novolin L) 6-12 “CLOUDY”
“LENTE” hours INVERT AND ROLL

LO Ultralente (Humulin U) “CLOUDY”

Long Acting 12-16 INVERT AND ROLL
“Ultralente” hours
VE Insulin glargine (Lantus) None 24-HR DURATION OF ACTION
Very long GIVEN DAILY AT hs
acting

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ORAL HYPOGLYCEMIC AGENTS

CLASSIFICATION MECHANISM OF ACTION NURSING CONSIDERATION

SULFONYLUREAS
First Generation
Tolbutamide (Orinase)
Tolazamide (Tolinase TAKE IT ____________________

Acetohexamide (Dymelor) Disulfiram-like reaction when taken

Chlorpropamide (Diabinase) STIMULATES INSULIN RELEASE with alcohol

Second Generation
Glipizide (Glucotrol)
Glyburide (DiaBeta)
Glimepiride (Amaryl)

NON-SULFONYLUREAS
Alpha Glucosidase Inhibitors
DELAYS THE CONVERSION OF TAKE IT ____________________
Acarbose (Precose) CARBOHYDRATES INTO SIMPLE
SUGAR

Biguanide
Metformin (Glucophage) INHIBITS GLUCONEOGENESIS Assess: ___________

BUN & Creatinine

Meglitinides
TAKE IT ____________________
Nateglinide (Starlix) STIMULATES INSULIN RELEASE
Repaglinide (Prandin)

Thiazolidinediones Assess: ___________

DECREASE INSULIN RESISTANCE
Pioglitazone (Actos) AST & ALT
Rosiglitazone (Avandia)

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POINTS TO REMEMBER!

Complications of DM: PHENOMENA

DAWN PHENOMENON SOMOGYI’S PHENOMENON INSULIN WANING

-results from a nocturnal release of -rebound phenomenon that occurs -progressive rise in blood glucose
growth hormone which may cause during the initial period of blood from bedtime to morning.
blooD glucose to begin to rise at glucose control; develops at peak
around 3am insulin times and during the night.

Rebound phenomenon due to:

counterregulatory
Normal at bed time then
Low at 3am then
High at 7am

MANAGEMENT: MANAGEMENT: MANAGEMENT:

Evening dose of intermediate Decreasing evening dose of Increasing evening dose of

insulin at around 10pm intermediate insulin or increasing intermediate insulin or long acting
bed time snack insulin or giving a dose of insulin
before the evening meal.
PROPER ORDER OF MIXING TWO TYPES OF INSULIN
Invert and roll the bottle of intermediate or long-acting insulin between your hands, to mix the
insulin. Do not shake the bottle.

Clean the top of both insulin vials with alcohol prep pads and allow them to dry.

Measure the same VOLUME OF AIR as you need of the intermediate or long-acting insulin and
inject into the insulin vial. Withdraw the needle.

Measure the same VOLUME OF AIR as you need of the regular insulin and inject into the insulin
vial. Leave the needle in the vial, invert the bottle and WITHDRAW THE CORRECT DOSAGE,
maintaining asepsis. Rapid and short acting insulin are clear in color. Expel any air bubbles,
recheck the volume of insulin for accuracy, then remove the needle from vial.
Turn the bottle of intermediate or long-acting insulin upside down and reinsert the needle into
this vial, maintaining asepsis. Slowly pull the plunger to WITHDRAW THE CORRECT DOSAGE of
insulin. Remove the needle from the vial.

Replace the needle cap on the sterile needle

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