Transcript Pharmacology and Pathophysiology II

Pharmacology and
Pathophysiology II
The Endocrine System
Pharmacology Test
• Log Into Engrade
– Med – Surg II
What is the peak time for Humulin R?
15 Minutes
30 Minutes
60 Minutes
120 Minutes
What is the duration of Humalog?
3 – 4 Hours
5 – 7 Hours
18 – 24 Hours
10 – 24 Hours
You are caring for a patient who has an order for Avandia for DMII.
Which of the following is a finding that you should monitor for?
Urinary Retention
Palpitations
Seizures
Edema
Which of the following is a S/S of levothyroxine toxicity?
Hair Loss
Lethargy
Weight Loss
Cold Intolerance
Which endocrine gland excretes oxytocin?
Ovaries
Posterior Pituitary
Anterior Pituitary
Thyroid
What hormone stimulates the adrenal cortex to produce
cortisol and androgens?
TSH
ADH
ACTH
PTH
Which endocrine gland excretes epinepherine?
Adrenal Medulla
Adrenal Cortex
Anterior Pituitary
Posterior Pituitary
Anatomy and Physiology
Hormones
• Cortisol
– Help the body respond to stress
– Regulates use of protein, carbohydrates and fat
– Maintain BP and cardiovascular function
– Controls Inflammation
• Aldosterone
– Regulates sodium and water (assists kidneys)
Hormones
• Epinephrine
– Increase BP
– Increase HR
– Activates cells influenced by Sympathetic Nervous
System
• Growth Hormone
– Promotes growth in all body tissues
• TSH
– Stimulates thyroid to produce thyroid hormones
Hormones
• ACTH
– Stimulates adrenal cortex to produce cortisol and
androgens
• PRL
– Stimulates milk production by mammary glands
• FSH
– Stimulates growth and hormonal activity of ovarian
follicles
– Stimulates growth of testes
– Promotes sperm cell development
Hormones
• LH
– Initiates ovulation, corpus luteum formation and
progesterone production (female)
– Stimulates testosterone secretion (male)
• ADH
– Promotes water reabsorption in kidneys
– Stimulates constriction of blood vessels (high level)
• Oxytocin
– Causes uterine contraction and milk ejection
Hormones
• T4 and T3
– Increase metabolic rate
– Required for normal growth
• PTH
– Regulates exchange of CA- between blood and bones
– Increases CA- levels in blood
• Cortisol
– Increase blood glucose concentration in response to
stress
Hormones
• Aldosterone
– Promotes sodium retention and postassium
excretion
• Insulin
– Reduces blood glucose levels by promoting
glucose uptake into cells and storage
– Promotes fat and protein synthesis
• Glucagon
– Stimulates liver to release glucose
Hormones
• Testosterone
– Stimulates growth and development of sexual
organs
– Develops secondary sexual characteristics
• Estrogen
– Stimulates growth and development of sexual
organs
– Develops secondary sexual characteristics
What causes pathophysiological
changes to the Endocrine System?
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Hormone Imbalance
Disease
Feedback System Problem
Glandular failure
Genetic Disorder
Infection
Injury
Pathophysiology
• Adrenal Insufficiency
– Adrenal gland releases too little of cortisol or
aldosterone
– Fatigue, Upset Stomach, Dehydration, Skin
Changes
Pathophysiology
– Addison’s Disease
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1 / 100,000
Can lead a normal life as long as pt. is taking medication
Autoimmune Disease (70%)
Long lasting infections and cancer
Prolonged use of steroid hormones (prednisone)
Chronic Fatigue
Muscle Weakness
Loss of Appetite
Weight Loss
Hypotension
Skin Changes
Hypoglycemia
N/V/D
Changes in Mood
Inability to cope with stress
Heat and Cold Intolerance
Increase in cravings of salty foods
Pathophysiology
• Addisonian Crisis
– Sudden penetrating pain in lower back, abdomen
and legs
– Severe V/D
– Dehydration
– Hypotension
– LOC
– Renal failure (shutdown)
Pathophysiology
• Cushing’s Disease
– Overproduction of cortisol
– Most common is the long term use of oral
corticosteroids
– Hallmark sign:
• Fatty hump between shoulders
• Moon Face
– Progressive obesity
– Pink or purple striae
– Thinning and fragile skin
– Slow healing of cuts and infections
Pathophysiology
• Cushing’s Disease
– Females
• Hirsutism (thicker / more visible body and facial hair)
• Irregular and absent menstrual periods
– Males
• Decreased Libido
• Decreased Fertility
• Erectile Dysfunction
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Fatigue and Muscle Weakness
Depression / Anxiety / Irritability
Loss of Emotional Control
Cognitive Difficulties
Hypertension
Glucose Intolerance
HA
Bone Loss
Pathophysiology
• Acromegaly
– “Gigantism”
– Increase in GH in adults and children
• Usually middle –aged if in adults
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Enlarged hands and feet
Coarsened and Enlarged Facial Features
Excessive Sweating and body Order
Fatigue and Muscle Weakness
Small outgrowths of skin tissue (skin tags)
Severe Snoring (obstruction)
Enlarged tongue
Joint pain and decreased mobility
ED in men; menstrual cycle irregularities in women
Enlarged liver, heart, kidneys, spleen
Increased chest
Pathophysiology
• Hyperthyroidism
– Increase in TH
– Most common cause if Grave’s Disease
• Autoimmune disorder
– Tachycardia
– Sweating
– Nervousness
– Weight loss
Pathophysiology
• Hypothyroidism
– Decrease in TH
– Some types present at birth
– Can slow development in children
– Women more likely (especially over 60)
– Obesity
– Joint Pain
– Fatigue
Pathophysiology
• Hypothyroidism
– Puffy Face
– Constipation
– Cold intolerance
– Hypercholesterolemia
– Depression
– Slowed heart rate / Bradycardia
– Depression
– Impaired Memory
– Thinning Hair
Pathophysiology
• Diabetes Mellitus
– Type I and Type II
– Symptoms
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Often develop quickly
Polyuria
Increase Thirst
Weight Loss
Blurred Vision
Fatigue
HA
Increased Hunger
Diabetic Ketoacidosis
• Diabetic Ketoacidosis
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Excessive Thirst
Frequent Urination
N/V
Abdominal Pain
Weakness and Fatigue
SOB
Fruity Breath (acetone)
Hyperventilation
Confusion
Hyperglycemia
High ketone levels in urine
Pathophysiology
• Diabetic Ketoacidosis
– Caused by
• Illness or infection
– Increase in adrenaline or cortisol
» Both act against insulin
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Poor Insulin Therapy
Stress
High Fever
MI
ETOH and Drug Abuse
– Particularly cocaine
Pathophysiology
• Diabetes Insipidus
– Intense thirst, regardless of polydipsia
– Polyuria
– Result of the body not producing, storing or
releasing ADH
– Urine output can range from 2 liters per day to 20
liters per day
• Healthy output is between 1.5 – 2.5 liters per day
Pathophysiology
• Diabetes Insipidus
– Delayed Growth
– Weight Loss
– Fever
– Vomiting
– Dry Skin with Cool Extremeties
– Unexplained Fussiness / Inconsolable crying
(children)
– Unusually wet diapers (children)
Pathophysiology
• Diabetes Insipidus
– Nephrogenic DI
• Defect in kidney tubules
– Unable to respond to ADH
• May be genetic or a chronic disorder
– Medications (lithium and demeclocycline)
– Gestational DI
• Ennzyme in placenta destroys maternal ADH
– Primary Polydipsia
• Prolonged excessive water intake
Pathophysiology
• Diabetes Insipidus
– Complications
• Dehydration
• Electrolyte Imbalance
Pharmacology
Category
TYPE OF
INSULIN
TRADE
NAME
ONSET
PEAK
DURATION
Rapid Acting
Regular
Insulin
Humulin R
Novolin R
30 – 60
Minutes
2 – 4 Hours
2 – 8 Hours
Rapid Acting
Insulin
Lispro
Humalog
5 – 10
Minutes
0.5 – 1.5
Hours
2 – 5 Hours
Rapid Acting
Insulin
Aspart
Novolog
5 – 10
Minutes
1 – 3 Hours
3 – 5 Hours
Rapid Acting
Insulin
Glulisine
Apidra
10 – 20
minutes
0.5 – 2.5
Hours
1 – 2.5
Hours
Pharmacology
Category
TYPE OF
INSULIN
TRADE
NAME
ONSET
PEAK
DURATION
Intermediate NPH
Acting
Humulin N
Novolin N
1.5 Hours
4 – 12 Hours
24 Hours
Intermediate Lente
Acting
Humulin L
1 – 2.5
Hours
7 – 15 Hours
24 Hours
Long Acting
Glargine
Lantus
1 Hour
5 Hours
(virtually
none)
24 Hours
Long Acting
Ultralente
Humulin U
4 – 8 Hours
10 – 30
Hours
20 – 36
Hours
Long Acting
Detemir
Levemir
2 Hours
3 – 14 Hours
24 Hours
Pharmacology
• Insulin
• Adverse Reactions
• Hypoglycemia
– Sympathetic Nervous System (SMS) Symptoms if
abrupt onset
– Parasympathetic Nervous System (PNS) Symptoms if
gradual onset
• Lipohytrophy
– Rotate sites
– Allow 1 inch between sites
• Hypoglycemia
– Administer Glucose
• 15 g of carbs
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4 oz orange juice
2 oz of grape juice
8 oz of milk
Glucose tablets
IV (emergencies)
• Glucagon
– SC or IM
– Use in patients that are not fully conscious
Pharmacology
• Insulin
– Interactions
• Sulfonylureas, meglitidines, ETOH
– Additive Hypoglycemic Effects
• Thiazide Diuretics and Glucocorticoids
– Counteract insulin (increase glucose levels)
• Beta Blockers
– Additive Hypoglycemic Effect
– May mask SNS response
Pharmacology
• Oral Hypoglycemics
– Sulfonylureas
• Glipizde
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Glucotrol, Glucotrol XL
Diabinese
Glyburide
Glimeperide (Amaryl)
Causes insulin to be released from the pancreas
Take 30 Minutes before a meal
– Meglitinides
• Prandin (repaglinide)
– Causes insulin to be released from the pancreas
– Eat within 30 minutes of taking medication
Pharmacology
• Oral Hypoglycemics
– Biguanides
• Metformin (glucophage)
• Reduces the production of glucose within the liver by
suppressing glucogenesis
• Increases muscular glucose uptake and use
• IR tablets with breakfast and dinner
• SR tablets with dinner
– Thiazolidinediones (Glitazones)
• Rosiglitazone (Avandia)
• Pioglitazone (Actos)
• Increases cellular response to insulin by decreasing insulin
resistance
• Increases glucose uptake and decreases glucose production
• Take with or without food
Pharmacology
• Oral Hypoglycemics
– Thiazolidinediones (Glitazones)
• Rosiglitazone (Avandia)
• Pioglitazone (Actos)
• Increases cellular response to insulin by decreasing
insulin resistance
• Increases glucose uptake and decreases glucose
production
Pharmacology
• Oral Hypoglycemics
– Gliptins
• Sitagliptin (Januvia)
• Augments naturally ocurring incretin hormones
– Promotes insulin release and decreases secretion of glucagon
• Lowers fasting and postprandial (2 hours after starting to eat
a meal) blood glucose levels
• Take with or without food
– Alpha Glycosidase Inhibitor
• Acarbose (Precose)
– Slows CHO absorption and digestion
– Take with first bite of food
Pharmacology
• Oral Hypoglycemics
– Adverse Reactions
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GI Effects
Weight Loss
Vitamin B12 Deficiency
Lactic Acidosis
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Hyperventilation, myalgia, sluggishness, somnolence
50% mortality rate
D/C medication and notify physician
Hemodialysis (severe lactic acidosis)
Pharmacology
• Oral Hypoglycemics
– Adverse Reactions
• Fluid Retention (Avandia and Actos)
– Watch for S/S HF
• Elevation in LDL (Avandia and Actos)
• Hepatoxicity (Acarbose)
– Jaundice
– Dark urine
Pharmacology
• Thyroid Hormone
– Levothyroxine
• Synthroid, Levothroid
– Synthetic form of T4
– Increases
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Metabolic rate
Protein synthesis
Cardiac Output
Growth Process
– PO and IV form
• IV used for myxedema coma
– Administer on empty stomach
– Monitor T4 and TSH levels
Pharmacology
• Thyroid Hormone
– Adverse Effects
• Hyperthyroidism
• Use caution with patients with cardiovascular problems
• Do not use after MI
Pharmacology
• Thyroid Hormone
– Interactions
• Antacids, Iron and Calcium Supplements
– Reduce levothyroxine absorption
• Tegretol, Dilantin, phenobarbital, Zoloft
– Increase levothyroxine metabolism
• Increase effects of warfarin
– Breaks down vitamin K
Pharmacology
• Antithyroid Medications
– Propylthiouracil (Propyl-Thyryracil)
– Methimazole (Tapazole)
– Blocks synthesis of thyroid hormones and conversion
of T4 into T3
– Graves’ Disease, adjunct to irradiation of thyroid,
euthyroid state prior to surgery
– Emergency treatment of thyrotoxicosis
– May take 1 – 2 weeks for therapeutic level
– Take with food
Pharmacology
• Antithyroid Medications
– Adverse Reactions
• Hypothyroidism
• Agranulocytosis (sore throat and fever)
– Treat with Neupogen
– Interactions
• Increase anticoagulation with anticoagulants
• Increase glycoside level with Digoxin
Pharmacology
• Radioactive Iodine
– Antithyroid
– Absorbed by the thyroid
– Used for hyperthyroid and thyroid cancer (high
doses)
– Used for thyroid function studies (low dose)
– Oral route
Pharmacology
• Radioactive Iodine
– Nursing Consideration
• Void Frequently
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Avoid irradiation of gonads
Limit contact with people to 30 minutes / day
Increase fluid intake to 2 – 3 liters / day
Dispose of body waste per protocol
Avoid coughing and expectoration
– Adverse Reactions
• Radiation sickness
• Bone Marrow Depression
• Hypothroidism
Pharmacology
• Anterior Pituitary Hormones and Growth
Hormones
– Somatropin
• Genotropin, Nutropin
– Somatrem
• Protropin
– Stimulation of overall growth and the production
of protein and decrease the use of glucose
– IM or SQ Injection
Pharmacology
• Anterior Pituitary Hormones and Growth
Hormones
– Adverse Reactions
• Hyperglycemia
• Hypothyroidism
– Contraindicated with severe obesity or severe
respiratory impairment
– Interactions
• Glucocorticoids
– Counteraction of growth – promoting effects
– Medication is discontinued prior to epiphyseal
closure
Pharmacology
• Posterior Pituitary Hormones and Antidiuretic
Hormones
– Vasopressin
– Desmopressin
• DDAVP
• Stimate
– Promotion of water reabsorption within kidneys
– Cause vasoconstriction
• Contraction of vascular smooth muscle
Pharmacology
• Posterior Pituitary Hormones and Antidiuretic
Hormones
– Used for Diabetes Insipus
– Used during Cardiac Arrest (Vasopressin)
– Vasopressin
• SQ, IM, IV, Intranasal
– Desmopressin
• Oral, Intranasal, SQ, IV
Pharmacology
• Posterior Pituitary Hormones and Antidiuretic
Hormones
– Adverse Effects
• Water Intoxication
– Drowsiness, lethargy, pounding headache, confusion
• Myocardial Ischemia
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EKG and BP Changes
Chest Pain
Diaphoresis
– Vasopressin is contraindicated for CAD patients and
those with decreased peripheral circulation (risk for
gangrene) and those with chronic nephritis
Pharmacology
• Posterior Pituitary Hormones and Antidiuretic
Hormones
– Interactions
• Tegretol and tricyclic antidepressants
– Increase in antidiuretic action
– Monitor
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I&O
Specific Gravity
BUN / Creatinine
Electrolytes
Vitals
Central Venous Pressure (ICU)
Pharmacology
• Adrenal Hormone Replacement
– Hydrocortisone
• Hydrocortone, Solu-Cortef
– Prednisone
– Decadron
– Mineral Corticoids
• Florinef
– Mimic the effect of natural hormones
– Used for Addison’s Disease
– Also used for nonendocrine disorders
• Cancer, Inflammation and Allergic Reactions
– Route – Oral or IV
Pharmacology
• Adrenal Hormone Replacement
– Adverse Effects
• Osteoporosis
• Adrenal Suppression
– Hyperpigmentation, weakness and fatigue, N/V, orthostatic
hypotension, dehydration, hyponatremia, hyperkalemia,
hypolglycemia and hypercalcemia
• Peptic Ulcer
• GI Discomfort
– Coffee – Ground Emesis, Bloody or Tarry Stools, Abdominal
Pain
• Infection
• Retention of sodium and Water (Mineralocorticoid)
Pharmacology
• Adrenal Hormone Replacement
– Interactions
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Oral Anticoagulants
Potassium Depleting Agents
Vaccines and Toxoids
– Reduction in antibody response
– Considerations
• Give with food
• Do not stop suddenly
– TAPER THE DOSAGE
Pharmacology
• Male Hormones
– Androgens
• Promote tissue building (anabolism) and reverse tissue
depletion (catobolism)
• Testosterone
– Androgel, Androderm, Testim
• Fluoxymesterone
– Also used for inoperable breast cancer in women
Pharmacology
• Male Hormones
– Androgens
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Adverse Effects
N/V
Acne
Hair Thinning
Libido Changes
Mood Changes
Erectile Dysfunction (males)
Amenorrhea or virilization (females)
Pharmacology
• Female Hormones
– Estrogens
• Used in conjunction with progesterone
– Birth control
• ERT estrogen replacement therapy
• Atrophic vaginitis
• Osteoporosis
Pharmacology
• Estrogens
– Conjugated Estrogen
• Premarin
– Esterified Estrogen
• Menest
– Topical Estrogen
• Estrogel
Pharmacology
• Estrogens
– Adverse Reactions
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HA
Dizziness
DVT
Vaginal irritation
Weight Changes
Vaginal Changes
A patient is prescribed Radioactive Iodine for thyroid treatment. Which of the
following findings would cause the nurse to stop treatment and notify the MD?
Mild Nausea
Intolerance to Heat
Epitaxis
Elevated HR
A patient is receiving levothyroxine 112 mcg PO Daily, Lasix 20 mg PO Daily, Cardizem 80 mg
PO Daily, Coumadin 2.5 mg PO Daily, and Zoloft 50 mg PO Daily. Which of the following
would alert the nurse to a problem?
TSH 3.4
INR 3.5
Troponin 0.01
BUN 18
The nurse understands that which medication increases
muscular uptake of glucose and increases its use?
Metformin
Januvia
Actos
Amaryl
The nurse understands that which supplement may be
prescribed for a patient taking Metformin?
Vitamin D
Potassium
Calcium
Vitamin B12
You enter a patient’s room after administering insulin and find them lethargic,
diaphoretic with cool clammy skin. Which of the following will you administer?
15 grams of carbs (Orange Juice)
Glucagon SQ
Glucose Tablets
5 units of Lantus
You enter a patient’s room and find she is lethargic, delirious and has had a history
of fatigue, constipation and dry skin since her diagnosis of Graves’ Disease. You
identify this condition and anticipate what order from the physician?
Levothyroxine 500 mcg IV
Radioactive Iodine
Narcan 1 mg IV
Prednisone 5 mg PO