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Parathyroid hormone regulates
calcium and phosphorous levels
All types of hyperparathyroidism leads to
hypercalcemia and hypophosphatemia
Target organs of the parathyroid
Normals for calcium and phospherous
What are your calcium levels for severe hyperparathyroidism?
Clinical manifestations of hyperparathyroidism
- all have to do with hypercalcemia:
- osteoporosis-drawing of ca out of bone, making them brittle
- nephrolithiasis-kidney stones
- memory change
Little mnemonic for hyperparathyroidism
- Moans-feel cruddy from n/v
- Groans-pain from kidney stones
How do you diagnose hyperparathyroidism?
- PTH and serum CA levels
- MRI, CT for possible tumor
Bone density test done as preventative and notice osteoporosis and do further tests of calcium levels
When does a person get a parathyroidectomy?
when the person has primary hyperparathyroidism that is affecting the kidneys, has peptic ulcers, pancreatitis
How does the parathyroidectomy get performed?
removal of 3 parathyroid glands and replacement of the 4th (resection) in the forearm or sternoclidomastoid.....
still allows for calcium levels to be regulated.
What is a drug to decrease serum calcium levels? How does it work?
decreases rate of bone resorption, decreasing serum calcium levels
Potential post op complications from parathyroidectomy
- respiratory distress...secondary to tracheal edema
- hemorrhage....vascular area around this gland
- transient hypoparathryoidism
How can you tell a person post op from parathyroidectomy may be starting to have issues with respiratory distress?
- hoarse voice
- loss of voice
- difficulty swallowing
laryngeal paralysis is a problem post op
s/s of hypocalcemia
Chovteks tests.....and how
tape cheek...if it twitches, then hypocalcemia
Trouseaus tests...and how?
inflate BP cuff on patient and hold it there for 3 minutes....
will make the hand point in if have hypocalcemia
Post op care after parathyroidectomy
- watch for tetany
- admin calcium gluconate prn
- monitor I&O
TEACH importance of exercise and dietary intake of CA and low phospherous
If a person is getting calcium gluconate I need to watch for....
hypotension and arrhythmias
All types of hypoparathryroidism leads to
hypocalcemia and hyperphosphatemia
A person who has hypoparathryoidism will have signs of
- muscle cramps
Clinical manifestations of hypoparathyroidism
- All related to hypocalcemia
- decreased co
- paresthesia of lips, hands, feet
- chronic spasms
How do you prevent tetany?
check PTH levels and admin calcium gluconate as needed
How much calcium should we have a day? Taken with?
- 1.5-3 grams/day
- V. D, helps with absorption in GI tract
Characteristics of hyperparathyroidism
- increased bone resorption
- elevated serum ca levels
- decreased serum phos levels
- decreased neuromuscular irritability
What are you at risk for getting when you hyperparathyroidism? Why?
you have hypercalciuria and hyperphosphaturia....which causes causes kidney stones
Characteristics of hypoparathyroidism
- decreased bone resorption
- depressed serum calcium levels
- elevated serum phosphate levels
- increased neuromuscular activity that may progress to tetany
Can you get kidney stones with Hypoparthyroidism too? Why?
yes cuz have hypercalciuria too
Calcium containing foods....phosphorous containing foods?
calcium-dairy, green leafy, whole grains
phosphorous-dark sodas, pumpkin seeds, romano cheese, salmon, scallops, veal, tofu, beans, lentils
3 drugs to treat hyperparathyroidism....and how do they work?
bone resorption inhibitor
3 meds for hypoparathyroidism....and how do they work?
Increases intestinal absorption of calcium
What is Cushings Syndrome
excessive corticosteroids...partically glucocorticoids/cortisol
People at risk to get Cushings Syndrome? Why?
COPD and people with auto immune diseases
cuz they are on high doses and long term treatments with corticosteroids
S/S of Cushings Syndrome
- Buffalo hump
- thin extremities
- thin/fragile skin
- sick lots...leukocytosis
- hyperpigmentation of skin
With Cushings Syndrome the person has a lot of......, causing......
- sodium and water retention
Key labs for Cushings syndrome....
everything is too high, but K is low
extra blood sugar, blood volume, sodium
Dx studies for Cushings syndrome/hypercortisolism
- 24 hr urine for free cortisol
- plasma cortisol, ACTH
- lab of electrolytes (increased glucose, decreased K)
- CT/MRI for tumors
Goal of collaborative management for cushings syndrome
normalize hormone secretion
Pre operative care for a person with Cushings having hypophysectomy or adrenalectomy
- Correct F&E Imbalances-na, k, glucose
- watch for dysrhythmias from hypokalemia
- prevent infection using aseptic technique
- Start glucocorticoid therapy
If a person has Cushings, they have too much cortisol. But prior to surgery we are going to admin cortisol....why?
When we remove the adrenal gland they will have experience an adrenal crisis if we don't....so give ACTH so this doesn't happen
Post op care for a person after an adrenalectomy
- watch for symptoms indicating cardiovascular collapse from insufficient glucocorticoids
- watch for hypotension
- decreased UO
- weak/rapid pulse
- *teach life long corticosteroid treatment
Nursing management for a person with Cushings
- H & P...asking if they have had a pit. tumor, adrenal tumor or long term steroid treatment
- teach about dose adjustments with stress/sick
- wear medic alert bracelet
What is the problem with adrenocortical insufficiency?
- inadequate secretion of ACTH
- dysfunction of hypothalamic-pituitary control mechanism
- complete or partial destruction of adrenal glands
Primary adrenal insufficiency's AKA-
Describe Addison's Crisis
stressful event-surgery, trauma or severe infection
the major problem is profound hypotension and shock
When a person with Addisons is describing how they feel what will they say?
- GI problems
- menstrual problems
- weight loss
What assessment findings will I see in a person who has Addisons disease?
Low everything, but high K
- skin changes
ACTH Stimulation test?
measures how well the adrenal glands respond to ACTH
- draw blood and check cortisol levels
- give injection of cosyntropin
- after 30 - 60 min draw blood and check cortisol levels
increase in ACTH is normal...18-20 higher
Goal for treatment of Addison's/Adrenalcortical insufficiency
Interventions for Addison's
- monitor and replace gluco and mineralcorticoids
- teach patient side effects and long term treatment problems of corticosteroids
- add sugar, volume, salt
Problems with taking steroids long term
- risk for infection
- increased bp
- mood swings
- weight gain
- high blood sugar
If a person with Addisons is going to have surgery or is under a lot of stress....what do they do?
increase dose by 50%
How do you take your hydrocortisone/prednisone orally?
- with meals/food...watch for GI irritation
- 2/3 in am
- 1/3 in pm
If a persons on cortisone/hydrocortisone/prednisone they need to call the doctor if....
- rapid weight gain
- round face
- fluid retention
with...severe diarrhea, vomiting, fever
If a patient is on Fludrocortisone for Addisons/hypofunction of the adrenal gland what needs to be monitored?
- watch for hypertension
- report weight gain/edema...cuz sodium related fluid retention is possible
Hyperaldosteronism is usually from?
- Adrenal Tumor
- Conn's Tumor
S/S of Conn's Syndrome
- muscle weakness
How do you treat Conn's syndrome?
- carefully monitor VS
- Watch electrolytes
What is commonly given to a person with Conn's Syndrome?
K sparing diuretic....it will decrease K and increase na
Is this right?
tumor of the adrenal medulla producing excess epinephrine and norepinephrine
S/S of pheocromocytoma
- severe episodic HTN
- profuse sweating
How is pheocromocytoma treated?
- CT/MRI to locate tumor....and surgery
- Calcium channel blockers...correct cardio complications
- 24 hour urine collection
What in the urine is a positive ID for pheocromocytoma
- vanillamandelic acid
Why is an injury to the occipital lobe bad?
It encases the brain stem and is the vasomotor center....it controls
#1 watch ABC!!
Which area of the brain is the most fragile and requires attention the fastest?
Where are lumbar punctures done?
What lines the interior of the skull?
dura mater....tough mother
Where does the outer layer of the brain dura terminate?
What is the innermost layer of the brain....it covers the entire surface of the brain?
What lies above the dura, between the skull and the dura mater
What lies below the dura, between the dura mater and the arachnoid space?
What is below the arachnoid layer, between the arachnoid layer and the pia mater?
What space does the CSF flow in?
Left hemisphere vs. Right hemisphere....most people are???
- Language ....left
most are left
What connects the 2 hemispheres of the brain?
Corpus Collasum....important for seizure control
What is a Corpuscalistotomy?
its a surgery to stop a person seizures from going from focal to generalized
We live in our......? why do we say this?
it controls HR, BP and RR
When it doesnt function we die....or need interventions fast
Which cranial nerves are in the mid brain? What do they control?
What cranial nerves are in the PONS?
If this area of the brain isnt functioning you will need mechanical support
medulla....controls respirations and BP
3 parts of the brain stem
What part of the brains vasculature provides blood to the brain?
- internal carotid
- anterior and cerebral arteries
What does the Circle of Willis do?
it is at the base of the skull and is a protective mechanism that insures the brain has adequate blood flow
it is where the arteries meet...anterior and posterior arteries
What part of the brain will be responsible for shunting blood if there is a problem with circulation?
Circle of Willis
How much CSF do we make an hr?
What part of the brain absorbs CSF?
What can cross the blood brain barrier?
Venous circulation is emptied by....
gravity....it doesnt have valves
Why dont people lie flat when we know they have ICP?
cuz venous return isnt allowed to use gravity then to empty....therefore increasing ICP
When a person is deteriorating neurologically, how will we see their orientation change....what order?
- #1 Event
- #2 Time
- #3 Place
- #4 Person
can only be aroused by vigorous and continuous external stimuli
duller indifference to external stimuli, and response is minimally maintained
Lowest score for glascow coma....highest?
What kind of light do you use to assess pupil size?
ambient light....low key
If pupils are in the midposition this means....
CN #3 is ok
This change in the pupils signifies an increase of ICP
ovoid pupil shape
If a person has a keyhole shaped pupil, what does this mean? What do I do?
CT of orbit
Sluggish pupils means?
increase in ICP...CN #3 is compromised
Non reactive pupils means....
when pupils constrict then bound right back....increased ICP
when eyes dont track together
Sum up Broca's area
cant find words on their own, but can repeat stuff perfectly
Sum up Wenicke's area
cant understand messages, they babble about nothing I am asking them about.
words dont have meaning
What's the problem with dysarthria?
problem with oral control of the tongue....CN #12
person sounds drunk
3 primitive reflexes
How can you tell if it is a reflex or the person means to do it?
- finger squeeze
tell them to let go of your finger....if they do it, then it is not a reflex and they have neuro function
Rule for increase in temp and increase in ICP
for every 1 c increase in temp, the ICP increases 10%
With an increase in ICP what happens to the BP?
- increased systolic....not diastolic
- widened pulse pressure
seen in advanced stages of ICP
What is the sign of advanced ICP?
How do you describe respirations?
abnormal respirations with 20 seconds of apnea
NOT RR of 9
Cranial Nerves saying....
Oh, oh, oh, to touch and feel a gross, veiny, slimy heart
12 cranial nerves
- spinal accessory
Which CN are tested together to look at eyes?
Which CN are tested together to test swallowing?
9 and 10
Which CN tells you about smell?
How do you test CN #V...Trigeminal?
flick fingers in front of their eyes and they should twitch
How do you test the facial CN #7
make sure face is symmetrical....make them make a smile
How do you know the auditory CN #8 is working?
the person is following commands
How do you test the optic CN #2?
How many fingers am I holding up?
Which CN is important to test when a person has a suspected spinal cord injury? How?
#11, spinal accessory
turn head, shrug shoulders
How do you test CN #12, hypoglossal?
listen to see if they ares slurring their speech, watch them eat and have them do tongue tricks
How do you test CN 3, 4, and 6?
Occulomotor, Trochlear, Abducens
PERRLA and make an "H" with finger in the air and make sure they track your drawing
What happens with the eyes with increased ICP
dilated, sluggish pupils
sluggish pupil with droopy eye lid....increased ICP
When there is increased ICP, what is shunted first? Then????
Modified Monro-Kelly Hypothesis
the skull is a rigid compartment. If one component increases in volume, another must decrease in volume or intracranial pressure will rise
Normal ICP with a lumbar puncture and with a transducer
0-15 with transducer
the ability of the brain to adapt to increasing pressure without increasing ICP
Hypertension and the brain
increased systemic arterial pressure causes vasoconstriction in the vessels of the brain
Hypotension and the brain
decreased systemic arterial pressure causes vasodilation in the vessels of the brain
Describe chemical autoregulation of ICP
PaCO2 >45 and PaO2 <50 (hypoxemia) cause vasodilation and increased ICP
When do auto regulatory mechanisms fail when it comes to managing intracranial pressures?
- when ICP >40
- Cerebral injury
- Profoundly elevated BP....a MAP >130
Whats CPP and what level is normal?
Cerebral Perfusion Pressure
How do you calculate Cerebral Perfusion Pressure?
Mean Arterial Blood Pressure - ICP
MAP=1 systolic + 2 Diastolic/3