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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? • • • • • • • 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 • • • • • • • • • • • • • • • • • 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 – – – – – – – – 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 – – – – – – – – – – – 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 • • • • • • • • Often develop quickly Polyuria Increase Thirst Weight Loss Blurred Vision Fatigue HA Increased Hunger Diabetic Ketoacidosis • Diabetic Ketoacidosis – – – – – – – – – – – 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 • • • • • 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 – – – – – 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 – – – – – – 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 • • • • GI Effects Weight Loss Vitamin B12 Deficiency Lactic Acidosis – – – – 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 • • • • 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 – – – – – 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 – – – – From vasoconstriction 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 • • • • • • 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 • • • • NSAIDS and ETOH (increased GI distress or bleed) 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 • • • • • • • • 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 • • • • • • 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