Transcript Unit V * Endocrine Disorders

Unit V – Endocrine Disorders
Case Studies
NSG 203 A
Spring 2015
Case #1 – Mr. Soucy
• You are working for a home care agency are going to see Mr. Soucy, a
60-year-old man who has COPD r/t cigarette smoking. He has used O2
at home for several years (2L) via nasal cannula. Approximately 10
months ago, he was started on chronic oral steroid therapy. His meds
include:
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ipratropium/albuterol inhaler
formoterol inhaler
dexamethasone
digoxin
furosemide
• On the way to see Mr. Soucy, you decide to assess him for s/sx of
Cushing’s syndrome.
Your assessment includes the following findings. Which are
attributable to his COPD or possible Cushing’s disease?
• Barrel chest
• Full-looking face
• BP 180/94
• Pursed-lip breathing
• Striae over trunk and thighs
• Thin extremities
• Bruising on both arms
• Acne
• Diminished breath sounds
bilaterally
• Truncal obesity with
supraclavicular and poster upper
back fat
Case #1
• You inform the MD of the patient’s s/sx. The MD believes Mr. Soucy
has developed Cushing’s syndrome and decides to change his
dexamethasone to prednisone given on alternative days.
• What would be the rationale for this change?
• Identify possible consequences of suddenly stopping the dexamethasone
therapy?
• Cushing’s syndrome can affect memory, and patients can easily forget what
medications have been taken, especially when there are several different
drugs with some taken on alternating days. List three ways you can help the
patient take his pills as prescribed?
Case #1
• Mr. Soucy states that his appetite has increased but he is losing
weight. He says he is trying to eat, but he gets short of breath and
cannot eat any more. How would you address this problem?
• You advise Mr. Soucy to take his prednisone in the morning with food.
You ask him a series of questions r/t possible gastric discomfort,
vision and joint pain. Discuss the rationale for your line of
questioning.
• How would you explain the effect of prednisone to Mr. Soucy? What
side effects would you teach him about?
Case #1
• You review Mr. Soucy’s medications. What are the potential problems
of administering steroids in combination with loop diuretics and
digoxin?
• Is Mr. Soucy at risk for infection? Why or why not? If so, what
guidelines to prevent infection would you give to him?
Case #2 – Mrs. Marshall
• You are working in a community outpatient clinic where you perform
the intake assessment on Mrs. Marshall, a 38-year-old woman who is
attending graduate school and is very sedentary. Her chief complaint
is overwhelming fatigue that is not relieved with rest. She is so
exhausted that she has difficulty walking to classes and trouble
concentrating when studying. Her face looks puffy, and her skin is dry
and pale. She c/o generalized body aches and pains with frequent
muscle cramps and constipation. You notice she is dressed
inappropriately for warm weather.
• VS: 142/84, 52, 12, 96.8F
Case #2
• Compare Mrs. Marshall’s VS with those of a healthy person of her
age.
• List 8 general questions you might ask Mrs. Marshall to get a “ball
park” idea of what is going with her.
• You know that potential causes of her symptoms include depression,
hypothyroidism, anemia, cardiac disease, fluid/electrolyte imbalance,
and allergies. As part of your screening, describe how you would
begin to investigate which of these conditions probably do NOT
account for her symptoms.
• Unnecessary diagnostic tests are expensive. What tests do you think
would be most important for her and why?
Case #2
• Mrs. Marshall is slightly bradycardic, but you find no obvious irregularities
in her cardiopulmonary assessment. Labs are drawn and the TSH comes
back 20.9. The MD diagnoses her with hypothyroidism and places her on
thyroid replacement therapy.
• Mrs. Marshall’s TSH level is increased. Explain the relationship between
these lab results and hypothyroidism.
• The MD prescribes levothyroxine 1.7 mcg/kg/day. At this time, the patient
weighs 130 pounds. What should be her daily dose of levothyroxine in
milligrams?
• What patient teaching will you review with Mrs. Marshall before she
leaves? Why would you want to obtain a complete medication history on
this patient?
Case #2
• What diet teaching will this patient need?
• Mrs. Marshall wonders whether she should take iodine supplements
if she decreases her salt intake. What would you explain to her?
• What should you teach Mrs. Marshall regarding prevention of
myxedema coma?
• Before leaving the clinic, Mrs. Marshall asks how she will know
whether the medication is “doing its job”. What are expected
outcomes for Mrs. Marshall?
Case #2
• Several weeks later, Mrs. Marshall calls the clinic stating she can’t
remember whether she took her thyroid medication. What additional
data should you obtain, and how would you advise her?
• Under what circumstances should Mrs. Marshall hold the drug or the
clinic?
• Further information: http://www.thyroid.org
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http://www.allthyroid.org
Case #3 – Mr. Billings
• Mr. Billings is an 80-year-old man admitted to the hospital following a 5day episode of the “flu” with c/o dyspnea on exertion, palpitations, chest
pain, insomnia, and fatigue. His PMH includes HF, HTN requiring
antihypertensive medications. He admits he has not been taking these
meds on a regular basis.
• Mr. Billings was diagnosed with Grave’s disease 6 months ago and was
placed on methimazole 15 mg po daily.
• Assessment: height 5’8”, wt 130#, anxious and restless, he cries when he
tells you his wife died recently. You notice his belt has several extra holes
punched into it so that he could tighten it.
• VS: 150/90, 104 irreg, 20, 100.2F, 1+ pitting edema in BLE, diminished LS
with fine crackles bilat bases.
Case #3
• Labs: Hgb 11.8, Hct 36%, ESR 48, Na+ 141, K+ 4.7, Cl 101, BUN 33, Creat
1.9, T4 14.9, T3 230
• Of the physical assessment and lab findings, which represent
manifestations of hypermetabolism?
• What additional subjective and objective data would you gather from
someone with Grave’s disease?
• After morning rounds, the MD leaves the following orders:
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Propranolol 20 mg po q6h
Dexamethasone 10 mg IV q6h
Verapamil 120 mg po daily
Diet as tolerated, up ad lib, STAT EKG
• Which of the orders would you question and why?
Case #3
• Develop 4 priority problems related to Mr. Billings care.
• Later on in your shift, you noted that Mr. Billings is extremely restless
and is disoriented to person, place and time. VS are 104/62, 180 and
irregular, 32 and labored, 104F. You request an EKG and this shows
that the patient is in atrial fibrillation (A-fib). What do these findings
indicate?
• What would you do first?
Case #3
• Mr. Billings is in thyroid crisis. The MD orders a STAT ABG and:
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digoxin 0.5 mg IV push now, and 0.250 mg IVP q8h x 2 doses
D5W IV at 100 ml/hr
Increase methimazole to 15 mg po q6h
Lugol’s solution (strong iodine) 10 gtts po tid mixed with H20 or juice to start
1 hour after the first methimazole dose
hydrocortisone 50 mg IVP q6h
Place on cardiac monitor
Strict bed rest
acetaminophen 650 mg po q6h prn temp > 100F
Case #3
• Identify 4 measures that would be essential in caring for Mr. Billings.
• Identify 2 possible factors that may have either preciptated or
contributed to Mr. Billing’s thyroid storm.
• Before discharge, the MD discusses two treatment options with the
patient and his family: radioactive iodine therapy using (131)I and
subtotal thyroidectomy.
• Mr. Billings is fearful of radiation treatment and asks you for your
opinion. How would you respond? How would you explain these
treatments to the patient?
Case #3
• Mr. Billings decides to receive the (131) I therapy. During the
pretreatment instructions, the family asks if he will be radioactive and
what precautions they should take. Outline important guidelines for
instructing Mr. Billings and his family on home precautions.
• Discuss how your discharge teaching instructions will differ from
those you would give to someone following a subtotal thyroidectomy.
Case #4 – Ms. Potter
• You are working on an oncology unit and receive report from the PACU nurse:
Mrs. Potter is a 50-year-old woman with a subtotal thyroidectomy for
multinodular goiter and left superior and right inferior parathyroidectomy
because of adenoma. Estimated blood loss (EBL) is 25 ml.
• PMHx: hysterectomy for fibroids, low-level radiation tx to the neck 38 years ago
for eczema, both parents living – father had MI at age 70, mother had
hypothyroidism but never had thyroid tumors.
• Her meds include: estradiol, lovastatin, and levothyroxine.
• In PACU: peripheral IV D5 ½ NS with 20mEq Kcl and 10mEq calcium gluconate at
100ml/hr, meperidine IV push for pain, total of 50mg
• VS: 130/82, 80 to 90, 20, SpO2 94% on room air. She is awake, A&O x 3
• Pre-op labs: Ca+ 112, Ph 2.4, Cl 106, alk phos 112, elevated PTH and TSH levels,
creatinine 1.4
Case #4
• What additional data should you obtain from the PACU nurse?
• What preparations will you make before Mrs. Potter arrives?
• How will you focus your initial assessment and why?
• During your first assessment, you document negative Chvostek’s and
Trousseau’s signs. Describe data that would support this conclusion.
• Identify the major risk factor that may have contributed to the
development of parathyroid adenoma in Mrs. Potter.
• Identify four actions you should include in the postoperative care of
Mrs. Potter. What signs should you anticipate and monitor for?
• Identify measures that reduce the risk for postoperative swelling.
Case #4
• After surgery, Mrs. Potter’s thyroid hormone levels are elevated and
the MD orders propranolol 80 mg ER (extended release) tabs for
“surgically induced thyrotoxicosis”. Is this reaction expected following
parathyroid surgery or did something go wrong during the surgery?
• 18 hours after surgery, Mrs. Potter calls you into her room and c/o
numbness around her mouth and tingling at the tips of her fingers.
She appears restless but is A&O x 3. You suspect that she is
experiencing hypocalcemia and you notify the MD. What should you
do in the interim before the physician returns your call?
• What orders do you anticipate the MD will give you?
• What is the follow-up care that Mrs. Potter will need?