Mark Klimek NCLEX Review: Thyroid, Adrenal Cortex (Addison Disease, Cushing), Laminectomy
Mark Klimek NCLEX Review: Thyroid (Hyper-, Hypo-), Adrenal Cortex (Addison Disease, Cushing), Toys, Laminectomy
Thyroid and Adrenals
Since the thyroid gland regulate metabolism, whenever you see the word “thyroid,” change it to “metabolism”
Hyperthyroidism
- Hypermetabolism
So, what are the S/Sx of hypermetabolism?
- Weight loss
- HR up, BP up
- Hyperpersonality
- They have heat intolerance … Can tolerate cold because body is like a furnace
- Exophthalmos (bulging eyes) … Think Susan Sarandon, or Don Knotts
Exophthalmos is seen in Graves disease
Run yourself into the Graves disease
Hyperthyroidism—3 Treatment Modalities
1. Nuke it with radioactive iodine
- Patient must flush three times after urinating
- Call hazmat team if urine is spilled on the floor
- Patient needs a private room in the first 24hrs
- Visitors restriction in hospital, at home in first 24 hours
2. PTU (Propylthiouracil)
- PTU “Puts Thyroid Under”
- PTU’s primary use is for cancer—Monitor WBC b/c patient is immunosuppress
3. Thyroidectomy
- Surgical removal of the thyroid is the most common treatment
- To answer questions on the Board correctly, pay attention whether it is a Total, Sub (a.k.a. Partial) thyroidectomy
- Total thyroidectomy needs lifelong hormone replacement, and patient is risk for hypocalcemia due to difficulty to spare the parathyroid glands
Question
What are the symptoms of hypocalcemia?
Paresthesia, tetany, twitching, spasm, clonus, seizure, jitteriness, tremor (all UP!). also, Chvostek and Trousseau signs
Treatment of Sub-thyroidectomy
- Do not need lifelong hormone replacement
- May need to supplement at first
- HOWEVER, they are at risk for thyroid storm
S/Sx of thyroid storm — A medical emergency
- Temps of 105 or above
- Get temp down, bring oxygen up
- Bring body temperature down using ice packs/cooling blankets
- Oxygen per mask at 10L
- Stay with patient
- High BP, stroke level — about 210/180
- Severe tachycardia 180 as high as 200
- Psychotically delirious
Lowering body temperature in thyroid storm
- First step is ice pack
- Best step is cooling blanket
Postop Risks in total thyroidectomy and subtotal thyroidectomy
- First 12 hours—risks are the same for both total and subtotal
1. Top priority is airway, due to edema
2. Next is hemorrhage because it is an endocrine gland—very vascular
- Next 12 to 48 hours—It matters what kind of surgery you’ve had now
1. Total: big danger is tetany due to low calcium
TOTAL = TETANY … Can close off airway with an irreversible spasm
2. Subtotal: big danger is thyroid storm
SUBTOTAL = STORM (Severe)
- After 48 hours—risk is infection
Note: For any type of procedure, the risk of infection significantly increases after 72 hours.
Hypothyroidism
- Hypometabolism
So, what are the S/Sx of hypomatabolism?
- Obesity
- HR down, BP down
- Personality: Flat, boring, dull
- They have cold intolerance … Can tolerate heat
- Academically challenged
Myxedema:
This is when a patient with severe hypothyroidism presents with skin involvement
Myxedema coma
- Severe hypothyroidism leading to decreased mental status, hypothermia, and other symptoms related to slowing of function in multiple organs
- Medical emergency
Treatment of Hypothyroidism
- Levothyroxine (Synthroid)
- Taken in the morning 30 minutes to 1 hour before breakfast
- Taken alone on an empty stomach with water
Do not sedate these patients
- They’re already super slow. They can go into a coma.
Question
What pre-op order from the physician would you question?
- Ambien (zolpidem) at hs [at bedtime]
Question
A patient dx with hypothyroidism will be undergoing surgery the next morning. The physician ordered the patient NPO at 12:00 am. Patient is on Synthroid and multivitamin pills. What should the nurse question?
- Clarify the NPO order for the Synthroid … Why?
The patient needs the Synthroid medication to get through surgery. Otherwise, the condition may potentiate the suppressing effects of the anesthesia during surgery
Therefore, don’t hold thyroid pills unless explicitly orders
Adrenal Cortex Disease
Interestingly, all adrenal cortex diseases either start with an “A” or a “C”
- Addison Disease (a.k.a. hypoadrenalism or adrenal insufficiency), Cushing
Addison disease
- Under secretion of steroids (they are a time bomb!)
- S/Sx: patients are Hyperpigmented (very tan)
- They do NOT adapt to stress
Question
What is the purpose of the stress response in an individual?
- To maintain:
- A normal blood pressure to perfuse the brain and other organs
- An adequate level of glucose to feed the body
Question
What could happen if these patients can’t adapt to stress?
- Under stress, patients with Addison disease will go into shock and have a hypoglycemic episode (Addisonian crisis)
Treatment
- Give steroids
- Glucocorticoids drugs that end in -SONE
- Prednisone
- Methylprednisone
- “In Addison, you ADD-a-SONE”
Cushing’s Syndrome
- If you have a cushy touchie … You got more
- Oversecretion of adrenal cortex (steroids)
All the S/Sx of Cushings are the S/E of Steroid medications
- Draw picture of a little man
- Give man a MOON FACE
- Give him a beard—hirsutism
- Draw a big body—truncal or central obesity
- Arms and legs are skinny—muscle atrophy
- Bump on front—gynecomastia (big breast)
- Bump on back—buffalo hump
- Fill him full of water (he is retaining Na+ and water) He is losing K+ out the back
- Give him some striae—stretch marks
- Most important one of all—high serum glucose
- Do Accu-Checks q6h. They look like diabetics
- Easy bruising—put bruises all over him
- Make him say something in a speech balloon …
“I’M MAD, BECAUSE I HAVE AN INFECTION”
- Grouchy (“Roid rage”)
- Immunosuppressed
Question
A patient comes in with an acute exacerbation of COPD. The patient is being treated with Solu-Medrol (methylprednisolone) IV push q8 hours to reduce the inflammation in the airway. What nursing action needs to be taken while the patient is on the medication?
- Do an Accu-Checks q6 hours
- Since patient is on steroid, his condition is similar to diabetes even though he is not diabetics
- The complications are worse if patient is diabetic
Treatment for Cushing’s
- Adrenalectomy
- What happens with a bilateral adrenalectomy?
- Now patient has Addison disease
- Now give steroids (ending in SONE) to treat.
- Patient will start looking like Cushman (Cushinoid-like)
- It takes about a year or so—after a lot of titration—for the patient to start looking normal
Kids Toys
When you select toys and play activities for children, there are three things to consider
1. Is it safe?
2. Is it age appropriate?
3. Is it feasible?
- Is it possible to do easily or conveniently?
- For instance, swimming in hospital with body cast
Safety
- Size (no small toys for kids under 4)
- Over 4 small pieces are fine
- NO Metal (or dye-cast) if oxygen is in use
- Think of a flint-sparks!
- Beware of fomites
- A fomite is a non-living object that harbors microorganisms, such as stuffed animals—the worst type of fomites
- Hard plastic toys are fine … They can easily be disinfected
Note
If you have a child who is immunosuppressed … Give them a hard plastic action figure. It can easily be disinfected
Age-appropriate toys (See Piaget’s Theory of Cognitive Development on page 94)
Infants
0 to 6 months:
Sensorimotor. Best toy is a musical mobile (Best choice)
Toy should be large but soft (2nd best choice)
6 to 9 months:
Object permanence. Best toy teach them to Cover/Uncover
This is to teach them that the object is still there even if they can’t see it
Examples are: Jack-in-the-Box and Peek-a-Boo
Toy should be large but firm
Worse toy after 6 months is the Musical Mobile because of the risk of strangulation
9 to 12 months
Vocalization. Best toys are speaking or verbal toys
Good list of toys are: Tickle me Elmo, Woody Cowboy, See and
Say-Barnyard Friends, Talking books
For purposeful play, the infant should be at least 9 months or older
- These words mean purposeful play: build, sort, stack, make, and
construct
- Baby in womb for 9 months, another 9 months for purposeful play
Toddlers
1 to 3 years
Work on Gross Motor skills, which is running, jumping
Best toys for this age group are Push/Pull toys
Examples are: Lawn mowers, Wagon, dog with floppy feet
They can paint (They use the hand to paint)
They are characterized Parallel Play (think terrible two)
Preschoolers
3 to 6 years
Work on fine motor skills
Therefore, preschoolers have finger dexterity.
hence, can write, draw, use colored pencils, scissors
Work on balance—Dance, ice skates, tricycles, tumbling
They are characterized by Cooperative Play
- Need to cooperate in Preschool (= Pretend)
- You’d be the sheriff, I’ll be robber …
Highly imaginative
School age
7 to 11 years
Concrete
Characterized by the “3 Cs”
1. Creative—Give them blank paper to draw, they like to
get involved …Toys: Legos, Transformers
2. Collective—Baseball cards, Webkinz, Barbies, Beanie Babies
3. Competitive—Winner/losers
Adolescents
12 to 18 years
Peer group association
Allow adolescents to be in each other’s rooms
unless one of them has been/is
1. Recently post-op for <12 hours
2. Immunosuppressed
3. Contagious
Note: When given a variety of ages to choose from, always go younger because children regress, when sick you want to give them time to grow
Laminectomy
Lamina: the vertebral spinous process (bumpy bones along backbone)
Ectomy: removal
Laminectomy is the removal of the vertebral spinous process
Question
Why perform a laminectomy?
To relieve nerve root compression … In other words, cutting away the bony prominence gives the nerve more room
Question
What the S/Sx of nerve root compression?
The 3 “Ps”
1. Pain
2. Paresthesia (tingly)
3. Paresis (muscle weakness)
When you get a laminectomy question, pay attention to location, location, location
There are 3 different locations where laminectomy is performed:
1. Cervical
2. Thoracic
3. Lumbar
1. Cervical - neck
What is the most important pre-op assessment for cervical?
- Cervical innervates the diaphragm and the arms
- First, assess for breathing
- Next, check functions of arms/hands
Post-op complication
- Watch for pneumonia
2. Thoracic - upper back
What is most important pre-op for thoracic?
- Thoracic innervates gut/abdominal muscles … Assess cough and bowels (cannot cough when you cannot contract abs)
Post-op complication
- Pneumonia and paralytic ileus
3. Lumbar - lower back
What is most important pre-op for lumbar?
- Lumbar innervates Bladder and legs … Assess for urinary retention or last time patient voided or is the bladder empty
- Next best answer is to evaluate leg functions
Post-op complication
- Urinary retention and Leg problems
Lumbar = Legs, Urinary retention
Postop Laminectomy
- Number 1 answer for postop laminectomy, including spinal surgery, is log roll
- Better pick log roll
Mobilizing patient after laminectomy or spinal surgery
- Do not dangle these patients—have them seat at the edge of the bed
- They should go from supine to walking as soon as possible
- Can they sit on bed long enough to overcome orthostatic hypotension?
- Yes, but not for 10 to 15 minutes
- Do not allow patient to sit for more than 30 minutes
- So, what post-op order would you question for a laminectomy?
- Up in chair for 1 hour TID
- These patients may:
- Walk, stand, lie down without restriction
- Sitting is bad
Question
You are caring for a patient with a lumbar oligodendroglioma. What is the #1 problem?
a. Airway
b. Ileus
c. Cardiac arrhythmia
d. Urinary retention
Answer:
Who cares what oligodendroglioma is. The lesion is in the lumbar spine. Therefore, we should assess for urinary retention, then for leg problems
- If the question instead mentions lumbar abscess or lumbar surgery, lumbar ependymoma, the answer would be the same.
Note
Typically, there are no chest tubes with Laminectomy. However, the anterior thoracic will have chest tubes
What does anterior thoracic means?
- From the front through the chest to the spine
Laminectomy with fusion
- This involves taking a bone graft from (1) the iliac crest and (2) the spine
- Bone from your hip is taken and put it in place so no bone-to-bone
Questions
Of the two incisions, which site has the most Pain?
- THE HIP
Of the 2, which one will have/need the most Bleeding/Drainage?
- THE HIP
- This is where the HEMOVAC, JP will be
Of the 2, which one has the higher risk of infection?
- They are equal
Of the 2, which one has the higher risk for rejection?
- The spine
Since the hip gives more problems, surgeons want to get rid of hip incision. Why?
- Because, it is shorter recovery … It cuts the infection in half … It decreases the drainage by 80% … Decreases the pain by 80%
- That is why surgeons are using cadaver bone from banks because the risk of rejection is very low
- Bone are not protein and protein is what triggers the antigen-antibody response
Discharge Teaching?
There are 4 temporary restrictions and 3 permanents
- Temporary restrictions … (6 weeks)
1. Do not sit for >30 minutes
2. Lie flat, log roll for 6 weeks
3. Don’t drive for 6 weeks
4. Don’t lift more than 5 lbs for 6 weeks (gallon of milk) Permanent restrictions
- Permanent restrictions
1. Laminectomy patients will never be allowed to lift by bending at waist (use knees)
2. Cervical laminectomy should never be allowed to lift anything over the head
3. No horseback riding, off trail biking, jerky amusement park rides, etc. …
Note
This Unit on laminectomy can be used to get any spinal cord question correct … Pay attention to location