Genetics and Altered Immune Responses Susan Wise, RNC, Ph

1
Genetics and Altered Immune Responses

• Susan Wise, RNC, PhD

2
Basic Principles of Genetics

• Genes arranged in a specific formation along
  the chromosomes. There are dominant and recessive
  traits that are inherited by offspring.
• Chromosomes 22 pair plus sex chromosomes.
  Females have two X chromosomes and males have one
  X and one Y.
• DNA stores genetic information on double
  strands.
• RNA stores genetic information on single
  strands.

3
DNA Diagrams

4
Inheritance Patterns

• Autosomal dominant disorders
• Autosomal recessive disorders
• X-linked disorders
• Multifactorial inherited conditions

5
Autosomal Dominant

• Autosomal Dominant Conditions   Huntington
  Disease   acondroplasia (short-limbed
  dwarfism)   polycystic kidney disease

6
Autosomal Recessive

•    Cystic fibrosis   Tay-Sachs   hemochromato
  sis
• Sickle Cell Disease   phenylketonuria (PKU)

7
X-linked Dominant Disorders

•    some forms of retinitis pigmentosa   Chondro
  dysplasia Punctata   hypophosphatemic rickets

8
X-linked Recessive Disorders

•    Duchenne muscular dystrophy
•    hemophilia A
•    X-linked severe combined immune disorder
  (SCID)
•   some forms of congenital deafness

9
Conditions with multifactorial inheritance

•    Alzheimers disease   heart disease   some
  cancers   neural tube defects   schizophrenia
     IDDM 

10
Genetic Testing

• May determine a mutation or predisposition to a
  condition
• Blood sample
• Buccal smear
• Amniocentesis
• Chorionic villus sampling
• Advise caution for patients

11
Stem cell research

• Parkinsons disease
• Alzheimers disease
• Heart disease
• Diabetes mellitus
• Spinal cord injuries
• Stroke
• Burns
• Osteoarthritis
• Rheumatoid arthritis

12
(No Transcript)
13
Immune System Overview

• Function major defense against infectious
  organisms and abnormal or damaged cells
• Defends against bacteria, viruses, fungi and
  parasites
• Removes and destroys damaged/dead cells
• Identifies and destroys malignant cells

14
Types of Immunity

• Active (long lasting) body made antibodies
• Natural (innate)
• Chicken pox, measles, mumps
• Artificial
• Immunizations
• Passive (short lived) body did not make
  antibodies
• Natural
• Mother to child
• Artificial
• Injection of serum from immune person - IgG

15
Diagram of Immunities
16
Lymphatic System

• Parts
• Lymph nodes
• Spleen
• Thymus gland
• Tonsils
• Lymphoid tissue
• Bone marrow

17
Cells Involved in Immune Response

• Phagocytes
• Lymphocytes
• B lymphocytes
• T lymphocytes
• T cytotoxic cells
• T helper
• T suppressor
• Natural killer cells

18
Cytokines

• Cytokines act as messengers between T cells, B
  cells, monocytes, and neutrophils.
• At least 100 different cytokines
• Interleukins
• Augments the immune response
• Interferons (Betaseron)
• Multiple sclerosis, leukemia, melanoma, multiple
  myeloma
• Tumor Necrosis
• Kills tumor cells
• Colony-Stimulating Factors (Neupogen)
• Neutropenia
• Erythropoetin (Epogen, Procrit)
• Anemia

19
Immunity

• Humoral
• Cell-Mediated

20
Immunity

• Humoral antibody-mediated, found in plasma
• Pathogen enters body
• B lymphocyte recognizes antigen
• B lymphocyte differentiates into plasma cells
• Mature plasma cells secrete immunoglobulins
  (antibodies)
• Memory cells remain
• Successive exposures trigger memory cells to
  rapidly produce antibodies

21
Immunity

• Cell-mediated
• Antigen recognition by T cells, macrophages
• Immunity against pathogens that live inside cells
  (viruses)
• Fungal infections
• Rejection of transplanted tissues
• Contact hypersensitivity reactions
• Tumor immunity

22
Factors Affecting Immunity

• Age
• Nutrition
• Medications
• Stress
• Virulence of the pathogen

23
Altered Immune Response

• Hypersensitivity Reactions immune response is
  overreactive against foreign antigens or fails to
  maintain self-tolerance
• Type I anaphylaxis, allergic rhinitis, asthma
• Type II cytotoxic (transfusion reaction)
• Type III immune-complex reactions (lupus, RA)
• Type IV delayed hypersensitivity (transplant
  rejection, contact dermatitis)

24
(No Transcript)
25
Care of Patients

• Anaphylaxis
• Patent airway
• Remove allergen if possible
• Epinephrine
• Oxygen
• Elevate legs
• Keep warm
• Histamine blockers Benadryl, Tagamet
• Support BP with fluids, vasopressors

26
Allergic Disorders

• Assessment
• Health history
• Physical assessment
• Diagnostic Studies
• CBC with diff, ESR, CRP
• Skin tests
• Cutaneous scratch or prick
• Intracutaneous injection

27
Care of Patients

• Chronic Allergies
• Recognize and control
• Avoid
• Drug Therapy
• Antihistamines
• Decongestant meds
• Corticosteroids
• Antipruritics
• Immunotherapy
• Rarely needed
• Desensitization SQ, slowly increased, 1-2 years

28
Latex Allergies

• 8 to 17 of health care workers
• Type IV contact dermatitis
• Type I may be mild or up to anaphylaxis

29
Multiple Chemical Sensitivities

• An acquired disorder
• Multiple body systems
• Wide range of symptoms
• Physical evidence may be lacking
• Fatigue
• Headache
• Pain
• Dizziness
• Mouth irritation
• Disorientation
• Cough

30
Autoimmunity

• Inappropriate reaction to self-proteins
• Genetic susceptibility
• Trigger is required
• Apherisis
• Plasmapheresis (plasma exchange)
• Autoimmune diseases
• Systemic lupus erythematosus
• Rheumatoid arthritis
• Scleroderma
• Multiple sclerosis
• Glomerulonephritis
• Guillan-Barré syndrome

31
Rheumatoid Arthritis (RA)

• Chronic
• Inflammatory
• Autoimmune disorder
• Causes the immune system to attack the joints
• Disabling and painful
• Can lead to substantial
• loss of mobility due to
• pain/joint destruction.
• systemic disease
• skin
• blood vessels
• heart
• lungs
• muscles

32
Spondyloarthropathies

• A family of chronic diseases of joints.
• can occur in children and adults.
• inclosing spondylitis
• Reiter's syndrome (reactive arthritis)
• psoriatic arthritis
• joint problems associated with inflammatory bowel
  disease (enteropathic arthritis)
• All of them
• sacroiliac joint
• Affect areas around the joint where your
  ligaments and tendons attach to bone such as at
  the knee, foot, or hip.
• Spondyloarthropathies are different from
  rheumatoid arthritis (RA) in adults and juvenile
  rheumatoid arthritis (JRA) in children

33
(No Transcript)
34
Lyme Disease

• Borrelia burgdorferi
• Bite of infected blacklegged ticks
• Symptoms
• Fever
• Headache
• Fatigue
• Characteristic skin rash called erythema migrans
• If left untreated, infection can spread to
  joints, the heart, and the nervous system
• Most cases of Lyme disease can be treated
  successfully with a few weeks of antibiotics
• Steps to prevent Lyme disease include using
  insect repellent, removing ticks promptly,
  landscaping, and integrated pest management.

35
(No Transcript)
36
Gout

• also called metabolic arthritis
• congenital disorder of uric acid metabolism
• monosodium urate or uric acid crystals are
  deposited on the articular cartilage of joints,
  tendons and surrounding tissues due to elevated
  concentrations of uric acid in the blood stream

37
Gout
38
Systemic Lupus Erythematosus

• body's natural defense system attacks its own
  tissues
• This causes inflammation
• Inflammation causes swelling, pain, and tissue
  damage throughout the body
• Kidneys
• Heart
• Lungs
• nervous system
• blood cells
• Although some people with lupus have only mild
  symptoms, the disease is lifelong and can become
  severe.

39
(No Transcript)
40
Systemic Sclerosis

• Injury to the cells that line blood vessels
  (endothelial cells)
• Excessive activation of the dermal connective
  tissue cells, the fibroblasts
• Fibroblasts normally produce collagen and other
  glycosamine proteins
• Factors that may trigger
• Raynaud phenomenon
• usually the first symptom of systemic sclerosis
• episodes of vasospasm

41
Raynaud Phenomenon
42
Fibromyalgia

• chronic condition
• widespread pain in your muscles, ligaments and
  tendons
• fatigue and multiple tender points
• more common in women than in men
• Other names include fibrositis, chronic muscle
  pain syndrome, psychogenic rheumatism and tension
  myalgias.
• isn't progressive or life-threatening

43
Organ Transplantation

• Allograft - tx from same species
• Autograft tx from self
• Xenograft tx from different animal species
• Domino transplant both lungs and heart. Heart
  to someone else.

44
Major Organs and Tissues Transplanted

• Thoracic organs
• Other organs
• Tissues
• Cells
• Fluids

45
Acute Tissue Rejection

• Most common and treatable
• Recipients T lymphocytes attack organ
• Occurs days to months after transplant
• Prevent - use of antimetabolites or
  anti-inflammatory medications prior to surgery
• Treat with immunosuppressants and steroids
• Elevated BUN, creatinine, liver enzymes,
  bilirubin, and cardiac enzymes.
• Fever, redness, swelling, and tenderness over
  graft site.

46
Chronic Rejection

• Antibody-mediated response
• Occurs months to years post transplant
• Resembles chronic inflammation and scarring.
  Tissue is fibrotic and scar-like tissue.
• Organ in not able to perform function.
• Antibodies and complement are deposited in the
  transplant vessel walls, causing narrowing and
  decreased organ function. Scaring caused by
  chronic ischemia from blood vessel injury.
• Changes are permanent and irreversible.
• Back on the transplant list.

47
Graft-versus-host disease (GVHD)

• Fatal complication not a close match.
• Blood transfusion. Bone marrow transplant
• Occurs within the first 100 days of transplant.
• T cells in graft recognize host as foreign and
  attack.
• Affects skin, liver, and GI. A pruritic rash
  begins on

hands and feet, and it may spread, abdominal
pain, nausea, bloody diarrhea. More organs
involved, poorer prognosis. No adequate treatment
48
Immunosuppressive Therapy

• Calcineurin inhibitors - cyclosporine
  (Sandimmune, Neoral, Gengraf) and tacrolimus
  (Prograf)
• Corticosteroids prednisone, methlprednisolone
  (Solu-Medrol)
• Mycophenolate mofetil (CellCept)
• Sirolimus (Rapamune)
• Often used in combinations

49
Altered Protection

• HANDWASHING
• Reverse isolation
• Monitor vital signs, assess wound, I/O, urine
  output
• Any unusual signs report, immunosuppression can
  delay elevated labs and fever.
• Avoid infection wear mask
• Adequate hydration and nutrition
• Oral hygiene

50
Infections

• Causes of infections
• Bacterial, viral, parasitic
• Emerging infections
• Lyme disease, Ebola hemorrhagic fever
• Reemerging infections
• TB
• Antibiotic-Resistant organisms
• MRSA, VRE
• Nosocomial infections
• 10 of hospital patients
• 35 are preventable

51
Infection Precautions

• Standard precautions
• Airborne precautions
• Contact precautions
• Droplet precautions
• Leukopenic precautions

52
Clinical Management of HIV Disease in Adults

• First recognized 25 years ago.
• First decade - prevention and treatment of the
  infectious complications.
• Second decade - effective antiretroviral
  therapies.
• Lazarus effect - 1996 - highly active
  antiretroviral therapy (HAART).
• 1997 the incidence of many opportunistic diseases
  declined dramatically
• During the last several years in this decade, new
  drugs with less adverse effects and in more
  convenient dosing schedules

53
25,000,000

• More than 25 million people have died of AIDS
  since 1981.
• Africa has 12 million AIDS orphans

54

• HIV/AIDS is 100 preventable

55
Still Many Underserved

• Opportunistic infections and progression to AIDS
  is still occurring among key members of our
  global society, namely
• Undiagnosed or untreated
• Disenfranchised or marginalized
• Under-treated
• Unempowered (e.g., women)
• Impaired (e.g., psychiatric or addicted members
  of society)
• Nonadherent patients
• Patients in third-world countries who do not have
  access to HAART
• Patients not under the care of an HIV-specialist
  or experienced HIV provider
• Patients who are just starting treatment
• People for whom antiretroviral therapy has failed

56
HAART - Highly ActiveAnti-Retroviral Therapy

• Rapid, significant improvement in immune function
  in HIV-infected patients
• Patients lives have been extended substantially
• Dramatic reductions in the incidence of many
  opportunistic diseases
• Pneumocystis jiroveci pneumonia (PCP)
• cytomegalovirus retinitis
• mycobacterium avium complex
• cytomegalovirus infection
• cryptosporidiosis

57
(No Transcript)
58
Primary HIV Infection/Seroconversion

• Two to six weeks after an exposure to HIV, a
  newly infected person will develop a high level
  of viral load (measured by HIV/RNA plasma levels)
• About 50 to 90 of these people will manifest
  as mononucleosis-like.
• Seroconversion illness
• Primary infection manifests in a variety of ways
• Mild fever, myalgia
• Arthralgia, lymphadenopathy
• Anorexia, pharyngitis
• Weight loss
• Rash
• Meningitis

59
Patients are Partners in Care

• Patients need to be considered full partners in
  care.
• Patients must be fully apprised of the risks and
  benefits as well as their responsibilities
• Issues of drug toxicity, pill burden, dosing time
  constraints, drug-nutrient interactions, and the
  unwavering commitment to adhere to complex
  medication schedules

60
Goals of Therapy

• Prolongation of life and improved quality of
  life.
• The greatest possible reduction in viral load
• Immune system reconstitution that is quantitative
  and qualitative
• Rational sequencing of drugs that achieve
  virologic goals but also
• Maintains therapeutic options
• Relatively free of adverse effects
• Realistic with regard to probability of
  adherence.
• The epidemiologic goal is the reduction of HIV
  transmission

61
Adverse Effects of Treatment

• Dyslipidemia and Lipodystrophy
• A syndrome consisting of altered fat distribution
  within the body and metabolic abnormalities, such
  as hyperlipidemia
• First described in 1998

62
(No Transcript)
63
Fat Redistribution

• Changes in the placement of visceral fat to the
• Trunk (truncal obesity)
• Neck (buffalo hump)
• Especially in women, the breasts
• Subcutaneous fat is lost in the
• Face (e.g., facial wasting)
• Extremities
• The buttocks

64
(No Transcript)
65
Nurses - HIV

• CDC has documented 32 cases of occupationally
  transmitted HIV in health care workers, including
  12 nurses. And investigated another 69 cases,
  including 14 nurses.
• These are reported cases. Many exposures go
  unreported for fear of discrimination or loss of
  confidentiality.

66
Nurses - Hepatitis B

• HBV. . . is more readily transmitted 8,700
  health care workers each year contract
  hepatitis-B on the job more than 200 die.
• A safe and effective vaccine is now available
  many employers must provide it for free
• If you are not yet vaccinated, don't wait. Begin
  the series of three shots now, so you can begin
  building immunity to this deadly disease

67
Nurses Hepatitis C

• HCV. . . is a growing threat to nurses. Infection
  with HCV appears to carry a great potential for
  chronic liver disease.
• Antibody tests have been developed to detect the
  virus, but the number of health care workers
  infected is not known.
• No vaccine is currently available.

68
Nursing Care of Clients with Endocrine
Disorders Nursing Assessment

• Susan Wise, RNC, PhD

69
Endocrine System - Review

• Secrete hormones directly into the circulation
  where they bind to specific receptors in target
  tissues
• Nervous system is linked to the endocrine system
• Negative feedback is the most common feedback
  system in hormonal regulation

70
Endocrine System
71
Specific Major Glands

• Pituitary
• Anterior
• Posterior
• Islet cells of the pancreas
• Thyroid
• Parathyroid
• Adrenal
• Gonads (testes and ovaries)

72
Hormones

• Anterior pituitary gland
• Thyroid stimulating hormone (TSH)
• Thyroid gland
• T3 and T4
• Calcitonin
• Adrenocorticotropic (ACTH)
• Adrenal gland
• CORTEX
• Glucocorticoid (cortisol)
• Mineralocorticoid (aldosterone)
• Androgen
• MEDULLA
• Catecholamines

73
Hormones

• CORTEX
• Glucocorticoid (cortisol)
• Mineralocorticoid (aldosterone)
• Androgen
• MEDULLA
• Catecholamines

74
Hormones

• Anterior pituitary
• Growth (GH)
• Prolactin (PRL)
• Luteinizing hormone (LH)
• Follicle-stimulating hormone (FSH)
• Posterior pituitary gland
• Antidiuretic (ADH) and oxytocin

75
Hormones

• Parathyroid glands
• Parathyroid hormones

76
Hormones

• Pancreas
• B (beta cells) secrete insulin
• A (alpha cells) secrete glucagon

77
Physical assessment

• Perform a complete history and physical
  assessment.
• Inspection
• Palpation
• Auscultation
• Percussion
• Specific tests to rule out hypoparathyroidism or
  hypocalcemia
• Chvostek sign
• Trosseau sign

78
Diagnostic Tests

• Direct Tests
• Example - radioimmunoassay
• Indirect Tests
• Example blood glucose
• Provocative Tests
• Stimulation tests (stimulate an underactive
  gland)
• ACTH stimulation test
• Suppression tests (suppress an overactive gland)
• Dexamethasone suppression test

79
Diagnostic Tests

• Thyroid function studies
• MRI, CT, thyroid ultrasound, thyroid scan
• RAI Uptake
• Pituitary structure and function
• Skull x-ray, MRI, CT
• Adrenal gland
• CT, MRI, adrenal venogram, angiography

80
Nursing Care of Clients with Pituitary Problems

• Susan Wise, RNC, PhD

81
ANTERIOR PITUITARY GLAND -

• Excess of Growth Hormone
• Gigantism in children
• Acromegaly in adults
• ACROMEGALY
• Enlarged hands/feet
• Joint pains/arthritis
• Coarse facial features
• HTN/cardiomegaly
• Visual disturbances
• Sleep apnea
• Glucose intolerance

82
Gigantism
83
Acromegaly
84
Acromegaly

• Diagnosis
• Oral glucose tolerance test
• Management
• Hypophysectomy
• Transfrontal approach
• Transsphenoidal approach

85
(No Transcript)
86
Acromegaly

• Radiation
• Drug therapy
• Somatostatin analogs
• Octreotide (Sandostatin)
• Dopamine agonists
• Bromocriptine (Parlodel)
• GH receptor antagonists
• Pegvisomant (Somavert)

87
Nursing Care

• Psychosocial issues
• Physiological needs
• Perioperative care
• Avoid coughing, sneezing, bending, straining,
  brushing teeth
• Surgical dressing
• Clear nasal drainage
• Hormone replacement

88
Prolactinomas

• Prolactin-secreting adenoma or tumor
• Manifestation
• ? (Female)
• Galactorrhea
• Infertility
• Decreased libido
• ? (Male)
• Decreased libido
• Impotence
• Infertility

89
Hypopituitarism

• Hypofunction of the pituitary gland
• Panhypopituitarism
• Deficiency of all pituitary hormones
• Common deficiencies
• Growth hormone
• Gonadotropins (LH FSH)
• Most life-threatening deficiencies
• TSH
• ACTH

90
Hypopituitarism

• Growth hormone deficiency
• Non-specific findings
• LH and FSH deficiency
• ?- loss of libido, testicular failure, decreased
  facial hair
• ?- irregular menstruation, loss of libido, ?
  breast size
• Treatment
• Surgery or radiation for tumor
• Hormone replacement

91
Hormone Replacement

• Hormone replacement
• Growth hormone
• Somatropin (Genotropin, Humatrope)
• Gonadotropins
• Testosterone
• Estrogen and progesterone

92
Posterior Pituitary Gland

• Anti Diuretic Hormone
• Excess
• Syndrome of Inappropriate ADH (SIADH)
• Deficiency
• Diabetes Insipidus (DI)

93
SIADH

• ADH released despite normal plasma osmolarity
• Mostly caused by malignancies
• Manifestations
• Hyponatremia
• Water intoxication
• Weight gain and low output

94
SIADH

• Diagnosis
• serum sodium levels lt 134 mEq/L
• serum osmolality lt 280 mmol/kg
• urine specific gravity gt 1.005
• Treatment
• Fluid restriction
• Hypertonic saline IV
• Demeclocycline (Declomycin)

95

• Diabetes Insipidus

96
Diabetes Insipidus

• Deficiency of ADH (vasopressin)
• Manifestations
• Polyuria (very dilute)
• Polydipsia
• Diagnosis
• Fluid/water deprivation test

97
Diabetes Insipidus

• Treatment
• Replace ADH
• DDAVP
• Fluid replacement
• Correct underlying cause
• Nursing care
• Monitoring hydration
• Administration of hormone replacement
• Teaching

98
Disorders of the Thyroid Gland

• T3 and T4 (thyroid hormones) and calcitonin
• Thyroid Disorders
• Hyperthyroidism
• Hypothyroidism
• Inflammation
• Enlargement (goiter)

99
(No Transcript)
100
Hyperthyroidism

• ? thyroid hormone
• Most common forms
• 1. Graves disease
• Autoimmune
• Presents with thyrotoxicosis
• 2. Toxic nodular goiter
• Manifestations
• See ? ?

101
Thyrotoxicosis
102
Thyrotoxicosis

• Diagnosis
• ? TSH level
• ? free T4 level
• RAI uptake gt 50
• Treatment
• Antithyroid medications
• Radioactive Iodine therapy
• Subtotal thyroidectomy

103
Anti -Thyroid Drug Therapy

• Anti thyroid drug therapy-
• propylthiouracil (PTU)
• methimazole (Tapazole)
• large doses of iodine
• Brand names - SSKI Lugols solution
• IODISM
• Side-effect hypothyroidism
• Interaction with anticoagulants

104
Radioactive Iodine

• Radioactive Iodine (RAI)
• Preferred treatment for non-pregnant adults
• Disadvantages
• Hypothyroidism
• Delayed therapeutic effects
• ? adrenergic blockers
• Propranolol (Inderal)

105
Care of the Hyperthyroid Client

• Nutrition - ? caloric intake
• Eye care
• Rest
• Preventing thyrotoxicosis (thyroid crisis or
  thyroid storm)
• Subtotal thyroidectomy

106
Thyroidectomy

• Perioperative Care
• Supporting head/neck, coughing, and deep
  breathing
• Emergency equipment
• Complications
• Larnygeal nerve damage
• Tracheal compression
• Hemorrhage
• Laryngeal spasms from hypocalcemia

107
Hypothyroidism

• Common causes
• Iodine deficiency (world-wide)
• Atrophy of thyroid gland (US)
• End-result of autoimmune conditions
• Graves disease
• Hashimotos thyroiditis
• Thyroid treatment
• Goitrogenic food

108
Hypothyroidism

• Clinical s/s related to slowing of body processes
• Goiter
• Fluid retention/edema
• Anorexia/weight gain
• Dry skin/coarse hair
• Constipation
• Cold intolerance
• Mental changes
• Slow speech-depression-impaired memory
• Many older adults are misdiagnosed.

109
Hypothyroidism
110
Myxedema
111
Myxedema

• Diagnosis
• Serum TSH and free T4
• Serum T3 and T4
• TRH stimulation test
• Treatment
• Hormone replacement
• Levothyroxine (Synthroid)
• Myxedema coma

112
Patient Teaching

• Thyroid hormone replacement
• When to take it
• Signs and symptoms to report
• Do not change brands
• Life-long therapy
• Skin care
• Constipation
• Avoid cold, sedatives, stressors

113
Other thyroid conditions

• Simple goiter
• Thyroiditis
• Hashimotos
• Viral, bacterial, or fungal
• Thyroid nodules
• Thyroid cancer

114
Disorders of the Parathyroid Glands
115
Disorders of the Parathyroid Glands

• Hyperparathyroidism
• ? secretion of parathyroid hormone (PTH)
• Primary, secondary, or tertiary
• Major manifestations
• Osteoporosis/fractures
• Kidney stones
• Muscle weakness

116
Hyperparathyroidism

• Diagnosis
• ? PTH, ? Ca, ? phosphorous
• Treatment
• Conservative
• Keep active ? fluids moderate calcium
• Drugs (Fosamax), estrogen
• Parathyroidectomy
• http//www.slp3d2.com/launchsiteglobal/previewPlay
  er/previewPlayer.cfm?projectCodetag_1331clientNa
  metghpreviewStatusready

117
Hypoparathyroidism

• ? circulating PTH
• Most common cause is iatrogenic
• Manifestations are related to ? serum calcium
• Tingling of lips, hands, feet
• Muscular spasms
• Chvostek and Trosseau signs

118
Hypoparathyroidism

• Diagnosis
• ? serum Ca and ? serum phosphorous
• Treatment
• IV calcium (emergency)
• Calcium and Vitamin D supplements
• No hormone replacement

119
(No Transcript)
120
DISORDERS OF THE ADRENAL GLANDS (Cortex)

• Hypercortisolism (Cushings Syndrome)
• ? corticosteroids, particularly cortisol
• due to various causes
• Clinical s/s result from cortisol excess

121
Cushings syndrome

• Diagnosis
• Serum and urine cortisol
• Dexamethasone or ACTH suppression test
• Treatment
• Surgery
• Drugs to suppress adrenal activity

122
Cushings syndrome

• Treatment
• If on steroid therapy
• gradually discontinue
• dose reduction
• alternate-day regimen
• Focus of care
• Fluid volume excess
• Risk for injury/fall
• Altered skin integrity
• Risk for infection
• Disturbed body image

123
Adrenalectomy

• Preop
• Check glucose and K levels
• Vitamins and proteins for tissue repair
• Asepsis
• Post-op
• Give IV steroids as prescribed
• Monitor BP, I and O and electrolytes
• Teach
• Steroid replacement
• Adrenal crisis

124
Adrenocortical Insufficiency (Addisons disease)

• Chronic deficiency of adrenal cortex hormones
• Most common cause
• autoimmune.
• Manifestations
• ? aldosterone - hypotension
• ? cortisol - hypoglycemia
• ? androgen - F
• ? pigmentation

125
Addisons disease

• Diagnosis
• ACTH stimulation test using cosyntropin
• cortisol levels
• Treatment
• Steroid replacements
• Glucorticoid (cortisol) replacement
• Hydrocortisone (Cortef)
• Mineralcorticoid (aldosterone)
• Fludrocortisone (Florinef)

126
Steroid Therapy

• Glucocorticoids
• Give 2/3 dose in AM
• Give 1/3 in late PM
• Mineralocorticods
• Give in AM
• Take po steroids with meals.
• Avoid stress, infection, and extremes in
  temperature. If under stress, increase dose.
• Wear Medic-Alert bracelet.
• Carry an emergency kit.

127
Addisonian crisis

• Precipitating factors
• Manifestations
• fever, severe weakness, low BP, vascular
  collapse, lactic acidosis
• Treatment
• rapid IV fluid replacement
• high-dose cortisone

128
Disorder of the Adrenal Medulla-Pheochromocytoma

• Tumor that secretes catecholamines
• Epinephrine and norepinephrine
• Manifestations
• Tachycardia, angina, palpitation
• Hypertension, pallor, epigastric pain
• Diagnosis
• ? catecholamines
• vanillylmandelic acid (VMA)
• Treatment
• adrenalectomy

129
Nursing Images

• The following images were from Memory Notebook of
  Nursing images (2001) by Zerwekh, J. et al.
  Nursing Education Consultants, Inc.
• Volume I
• Hyperthyroidism
• Hypothyroidism
• Addisons disease
• Cushings syndrome
• Volume II
• Corticosteroids