Somatomedin C (Insulin-like growth factor or IGF-1)

Test for which gland?

Magnetic resonance imaging (MRI)

Test for which gland?

Water deprivation test

Test for which gland?

Magnetic resonance imaging (MRI) — thyroid

Test for which gland?

Radioactive iodine uptake (RIA)

Test for which gland?

Calcium (Ca)

Test for which gland?

Magnetic resonance imaging (MRI) – parathyroid glands

Test for which gland?

C-peptide

Test for which gland?

Computed tomography (CT) of the abdomen

Test for which gland?

Fasting blood sugar (FBS)

Test for which gland?

Oral glucose tolerance test (OGTT)

Test for which gland?

Glycosylated haemoglobin (HbA1C)

Test for which gland?

Magnetic resonance imaging (MRI)—pancreas

Test for which gland?

Urine tests for glucose and ketone

Test for which gland?

ACTH suppression

Test for which gland?

Dexamethasone suppression test

Test for which gland?

Related nursing interventions

• Tell client not to eat or drink 8-10 hours prior to blood test.

• Rest client for 30-60 mins before blood taking.

Related nursing interventions

• Overnight fasting is preferred but not necessary.

Related nursing interventions

• Assess for any metallic implants (e.g. pacemaker, clips on brain aneurysms, body piercings).

• Remove transdermal medication patches unless otherwise ordered, replace the patches after the procedure.

• Ask if client is pregnancy.

• Ask about claustrophobia (instruct the client to take relaxing medication prior to the procedure).

Related nursing interventions

• Instruct client not to smoke, eat, or drink.

• The test takes up to 8 hours.

• Assess weight, take postural BP.

• Assess urine volume and specific gravity, send samples of urine to the lab for osmolality hourly during test.

• Blood samples for osmolality are taken when urine sample are collected and when client demonstrate orthostatic hypotension.

Related nursing interventions

• Client should not eat or drink for 6-8 hours before the test.

• Instruct client not to take supplemental iodine several weeks before the test and thyroid medications should be discontinued.

• Check for any history of allergy to drug or food.

• Encourage client to increase fluid intake as radionuclide takes 6 – 24 hours to be eliminated from the body.

Related nursing interventions

• Assess for family history of thyroid disease and assess about recent viral infection (which could trigger autoimmune disease).

Related nursing interventions

• Instruct client to avoid eating shellfish for several days prior to the test.

• Assess medication: value may be increased by aspirin, steroids; and decreased by lithium and potassium iodide

Related nursing interventions

• Assess medications as some medications may decreased the level e.g. cortisone, phenytoin, heparin. Values may be increased by oral contraceptives.

Related nursing interventions

• Assess medications as some medications may decreased the level e.g. Inderal, lithium, phenytoin. Values may be increased by oral contraceptives and methadone.

Related nursing interventions

• Assess for manifestations of tetany, including positive Chvostek’s and Trousseau’s signs, if hypocalcemia is present.

Related nursing interventions

• Educate client to fast for 8 hours before the test.

Related nursing interventions

• Assess for allergy to contrast media.

Related nursing interventions

• Not to eat or drink anything other than water for 6 – 8 hours before the test

• Do not administer insulin until blood specimen is taken

• Assess medications: can be increased by cortisone, diuretics, levodopa, epinephrine

Related nursing interventions

• Instruct the client to fast for 6-8 hours before the test.

• Assess medications: drugs that increase OGTT level are steroids, oral contraceptives and salicylates

• Explain to the client that he/she may feel weak and may perspire during the test and should report to the nurse.

Related nursing interventions

• Encourage patient to take dexamethasone with milk to avoid gastric irritation.

Related nursing interventions

• administrated orally at 11pm, as it suppresses ACTH.

• Serum cortisol is collected at 8am the next morning.

Thyroid scan

Nonfunctional nodules (malignant lesions) do not take up radioiodine, usually malignant

Thyroid scan

Hyperfunctioning nodules (Benign lesions) take up radioiodine

Helps to differentiate between type 1 and type 2 diabetes

a clinical condition that results from increased thyroid hormone production

Over-activity of the thyroid gland with sustained increase in synthesis and release of TH

Laboratory Test

decreased TSH

Laboratory Test

increased TSH

Laboratory Test

thyrotropin-receptor antibodies (TRAb): highly sensitive and specific, positive in 95% of patients with?

Management of Hyperthyroidism

⚪ Thionamides : carbimazole, methimazole/thiamazole, levothyroxine, propylthiouracil (PTU)--> Inhibit synthesis of TH

⚪ Do not affect the release or activity of TH that has been formed--> treatment should continue for 12 to 18 months

⚪ Initially at higher doses and titrated to lower maintenance doses

⚪ Methimazole is contraindicated in pregnancy (cross placenta)

Management of Hyperthyroidism

⚪ Symptomatic therapy

⚪ Competitively block β-adrenergic receptors

⚪ Controls tachycardia and other cardiac symptoms of thyrotoxicosis (e.g. palpitation) that results from -> β -adrenergic receptor stimulation caused by excessive TH

⚪ Primary options: propranolol or atenolol

⚪ Secondary options: diltiazem or verapamil

⚪ Propranolol may also inhibits peripheral conversion of T4 to T3

⚪ Not indicated if there is history of asthma, bradycardia, or heart block

⚪ Calcium-channel blockers are an alternative if this are contraindicated

Postoperative Complications of Hyperthyroidism

Nursing Responsibilities:

⚫ Closely monitor vital signs including blood pressure and pulse hourly to monitor for manifestations of hypovolemic shock

⚫ Elevate the head of bed with pillows to reduce oedema

⚫ Assess dressing and the area under the client’s neck and shoulders for early detection of haemorrhage

⚫ Monitor the drainage volume, consistency and colour for signs of increased bleeding

⚫ Ensure patency of wound drainage system

⚫ Monitor for neck swelling, sensation of fullness at neck for early detection of respiratory difficulty

Postoperative Complications of Hyperthyroidism

Nursing Responsibilities:

⚫ Position client at a semi-Fowler’s position to minimize oedema at surgical site and facilitate breathing

⚫ Prepare the suction equipment, oxygen, and a tracheostomy set available for emergency use

⚫ Assess for:

⚪ Respiratory rate , rhythm, effort and SpO2

⚪ Manifestations of airway obstruction: swelling/ sensation of pressure or fullness at neck, laryngeal stridor and difficulty in swallowing

⚪ Signs of hypoxia: dyspnoea, tachypnoea, altered mental state, cyanosis

⚪ Wound drain for the amount and consistency of drainage for excessive collection of blood

⚪ Wound dressing for bleeding and neck swelling/tightness indicative of oedema, internal bleeding or haematoma

Postoperative Complications of Hyperthyroidism

Nursing Responsibilities:

● Assess voice quality, tone, ability to speak aloud and difficulty in breathing to detect RLN injury

● Keep communication with client simple to minimize demand for response and promote voice rest

• Anticipate needs as much as possible to reduce anxiety and client's needs to communicate

• Maintain quiet environment to enhance ability to hear whispered communication

● Provide alternative methods of communication (e.g. writing) to facilitate expression of needs

● Inform doctor immediately for breathing difficulty and intervene promptly

● If there is an obvious respiratory distress with vocal cord paralysis confirmed, emergency tracheostomy may be done to create an open airway

● If there is functional palsy, the condition may recover within 3 - 6 months

● If there is structural damage, plastic repair of vocal cords will be required, then followed with speech therapy

Postoperative Complications of Hyperthyroidism

Nursing Responsibilities:

● Assess for any complaints of numbness or tingling in fingers and toes and muscular twitches

● Observe for laryngeal stridor for early recognition and prompt intervention

● Monitor client for positive Trousseau’s sign and Chvostek’s sign suggestive of hypocalcaemia

● Monitor postoperative serum calcium level to detect hypocalcaemia

● Keep calcium gluconate or calcium chloride available for immediate IV use to reverse hypocalcaemia

Postoperative Complications of Hyperthyroidism

Nursing Responsibilities:

● Monitor client’s vital signs for increase body temperature, blood pressure and pulse, respiratory rate which may be indicative of thyroid storm

● Observe for complaints of feeling hot, palpitation

● Observe client’s mental state and any periods of agitation, confusion to detect signs of thyroid storm

● Report to surgeon immediately if these symptoms occurs and implement interventions promptly

Haemorrhage and Haematoma

Can be evacuated by needle aspiration

Haemorrhage and Haematoma

⚪ Difficulty in breathing, pressure in the neck, voice change and obvious collection in wound

⚪ Requires emergent surgical intervention

Clinical Manifestations

● Unilateral injury: weak, hoarseness of voice

● Bilateral injury: aphonia, respiratory distress with increasing dyspnoea and stridor

Clinical Manifestations

⚫ Restlessness

⚫ Numbness and tingling sensation over face, hands and feet

⚫ Spasm of facial muscle, carpopedal spasm

⚫ Spasm of vocal cords and bronchus : high-pitch voice, airway obstruction, suffocation

⚫ Positive Chvostek’s sign

⚫ Positive Trousseau’s sign

⚫ Hypocalcaemia (< 8 mg/dL)

Clinical Manifestations

● Abrupt onset of extreme agitation, confusion, tachycardia or other arrhythmia

Tetany (Hypoparathyroidism)

⚪ Impaired blood supply to the parathyroid glands after surgery

Tetany (Hypoparathyroidism)

⚪ Compromise of all parathyroid glands (accidental removal of parathyroid glands)

Structure of the Parathyroid Glands

PTH secretion (?) when plasma calcium level fall

Structure of the Parathyroid Glands

By increasing renal excretion of phosphate in urine, (?) excretion of calcium, (?) bone reabsorption to cause release of calcium from bones.

• parathyroid adenoma (95%)

• parathyroid hyperplasia, parathyroid carcinoma, external neck irradiation, Lithium therapy

• A reaction of parathyroid glands (compensatory oversecretion of PTH) to hypocalcaemia, e.g. chronic kidney (CKD) disease, pregnancy, vitamin D deficiency etc.

⚪ It results from hyperplasia of parathyroid glands and a loss of response to serum calcium level, commonly seen in chronic kidney disease.

ECG 1 small box or 1mm = (?) second

ECG 1 large box or 5mm = (?) second

ECG

Time and voltage measurements on ECG paper at a recording speed of (?) mm/second

Descriptions: indicates atrial depolarization and contraction.

Normal value: Round and upright

What is the wave form

Descriptions: indicates ventricular depolarization and contraction.

Normal value: 0.06-0.10 second

What is the wave form

Descriptions: indicate ventricular repolarization following contraction.

Normal value: Less than 10mm tall

What is the wave form

Descriptions: Signify repolarization of the terminal Purkinje fibers.

Normal value: Not normally seen

What is the wave form

Descriptions: indicates the time for sinus impulse transmitting to AV node and Purkinje fibers.

Normal value: 0.12-0.20 second

What is the wave form

Descriptions: signifies the beginning of ventricular repolarization.

Normal value: Isoelectric line

What is the wave form

Descriptions: Indicates the total time of ventricular depolarization and repolarization.

Normal value: 0.21-0.44 second

What is the wave form

Ambulatory Cardiac Monitoring:

Clients are instructed to keep the electrodes in place and record any cardiac symptoms and events during the prescribed period, usually (?) hours for analysis.

To evaluate the response of the cardiovascular system to the stress induced by exercise or drugs.

A transducer is used to record the high- frequency sound waves bounced off the heart to assess direction and flow of blood through heart in audio and graphic data.

Allows visualization of adjacent cardiac and extracardiac structure to identify or monitor mitral

and aortic valve pathology, left atrium intracardiac thrombus, acute dissection of the aorta,

endocarditis, perioperative left-ventricular function and intracardiac repairs during surgery

Use computer-processed combinations of many X- ray images to visualize the heart anatomy,

coronary circulation, or to quantify early calcium deposits in coronary arteries (calcium score)

Use for evaluation of myocardium as risk of infarction and to determine infarction size

Intravenous administer radioisotopes and detected by gamma or scintillation camera

For evaluation of pumping function:

◦ cardiac status following MI and congestive heart failure

◦ effectiveness of cardiac medications

◦ left ventricular function during rest and exercise

◦ The resulting images are compared for myocardial perfusion and myocardial metabolic function

◦ Use magnetic field and computer-generated pictures to image the heart and great vessels so as to identify the areas of MI, perfusion of the heart and patency of coronary arteries after coronary grafts and to evaluate pericarditis and cardiac tumors

◦ Assess for any metallic implant such as pacemaker, prosthetic joints, or clips.

QRS < 120ms

QRS > 120ms

• Rhythm: Regular

• Rate: 60-100/min

• P wave: 0.08-0.10s

• P:QRS : 1:1

• PR interval: 0.12-0.20s (< 0.20 sec)

• QRS complex: 0.06-0.10s

• Rhythm: Regular

• Rate: < 60/min

• P:QRS : 1:1

• PR interval : 0.12- 0.20 sec

• QRS complex: 0.06-0.10s

• Rhythm: Regular

• Rate: 101-150/min

• P:QRS : 1:1 (with very fast rates, P wave may be hidden in preceding T waves)

• PR interval: 0.12-0.2s

• QRS complex: 0.06-0.10s

Atrial dysrhythmias:

• Rate: Variable

• Rhythm: irregular, normal rhythm interrupted by early beats arising from atrial, P waves are premature and differ from normal sinus P

wave

• P:QRS : 1:1

• PR interval: 0.12-0.2s, but may be prolonged

• QRS complex: 0.06-0.10s

Atrial dysrhythmias:

• Atrial rate: 240-360/min (Intra-atrial reentry mechanism)

• Rhythm: atrial regular; ventricular usually irregular;

• Identical recurring regular sawtooth flutter waves

• P:QRS : 2:1, 3:1 or 4:1 (ratio between flutter wave and QRS complex)

• QRS complex: 0.06-0.10s

• Commonly occurs in association with

– Chronic obstructive pulmonary disease (COPD)

– Pulmonary hypertension

– Coronary artery disease (CAD)

– Valvular disease

– Thyrotoxicosis

Atrial dysrhythmias:

• Rate: atrial rate 350-600/min, absent of P wave

• Multifocal ectopic foci in atria without effective atrial contraction

• Rhythm: Irregular

• P:QRS : Variable, ventricular rhythm is very irregular ranges from 100-180/min

• QRS complex: 0.06-0.10s

• Rhythm: Regular

• Rate: fast, 100-280/min; usually >150/min

• Absent of P wave

• umbrella term for rhythms originate above ventricles. P wave usually not measurable, and mechanism not known

• PR interval difficult to detect

• QRS present, narrow, unifocal

– P wave is inverted, absent, buried, retrograde in some of the ECG leads

– PR interval < normal (<0.12 sec)

– QRS complex is typically narrow

• Sinus node dysfunction influences impulse formation, transmission, conduction

• Common in older adults

• Sinus bradycardia, sinus arrhythmia, sinus pauses or arrest and atrial tachyarrhythmias

• Bradycardia-tachycardia syndrome

• Impulse conduction through the AV node is slowed, but all impulses are conducted

• Benign condition → asymptomatic → treatment not required

• May be a result of digitalis or structural abnormalities

• Prolonged PR interval (PRI) but constant

• A block in AV node

• QRS are “grouped” into twos, threes, fours

• Repeating pattern of increasing AV conduction delays until an impulse fails to conduct to the ventricles

• Ventricle rate remains adequate

➢Progressive lengthening of PR interval until an entire cycle is dropped

• Intermittent failure of the AV node to conduct an impulse to the ventricles without preceding delays in conduction.

• PR interval remains constant, but not all P followed by QRS complex

• Ratio of P:QRS → e.g. 2:1, 3:1, 4:1

• Associated with MI, drug toxicity, congenital, valvular disease, hyperkalemia

• Treatment: pharmacological and electrical therapy

• It occurs when atrial impulses are completely blocked at the AV node and fail to reach the ventricles.

• Complete dissociation of impulse between atria and ventricles

➢(No relationship between P waves and QRS complexes)

• Beats arise from the same focus all QRSs look alike

• Regular

• Fast

• No P

• Wide-complex

• Beats arise from the same focus therefore all QRS look alike

• Rapid, disorganized ventricular rhythm that causes ineffective quivering of the ventricles due to extremely chaotic ventricular depolarization → no CO.

• Cardiac conduction impulses occur in an organised pattern but ineffective contractions

• Looks like NSR

• no CO and no pulse

· Predictable and caused by similar precipitating factors each time, e.g., exercise, emotional upset, being in very cold temperature, smoking, heavy meals and tachycardia.

· Relieved by rest and Nitrates (sublingual TNG)

· Atypical angina and unpredictable and often at night

· Caused by coronary artery spasm

· Unpredictable increasing frequency, severity, and duration of pain, may occur at rest

· May not relieved by rest and Nitrate (3 sublingual TNG tablets)

· Affects the smallest coronary artery blood vessels

· Usually lasts more than 15 – 20 minutes

· long-term chest pain doesn’t get better with medication and surgery

Types of AMI:

Subendocardial infarction

Types of AMI:

Transmural infarction

GENERAL MANAGEMENT, Unstable angina/NSTEMI/NSTE-ACS:

- Aspirin,

- P2Y12 inhibitors include prasugrel (Effient), ticagrelor (Brilinta) and clopidogrel (Plavix)

- Low-Molecular-Weight-Heparin (LMWH) e.g. Enoxaparine (Clexane)

GENERAL MANAGEMENT, Unstable angina/NSTEMI/NSTE-ACS:

I. Nitrates

II. Beta-blockers

III.Calcium Antagonists

Rhythms for Tachycardia:

• Narrow-QRS complex (SVT) tachycardias (QRS less than 0.12 s) in order of frequency (≥150bpm)

Rhythms for Tachycardia:

• Wide-QRS complex tachycardia (QRS 0.12 s or more)

Stable Tachycardia:

QRS <0.12 (Narrow) and Regular

Attempt?

Bradycardia Management:

Unstable bradycardia

Administrate?

ACLS related pharmacological therapy:

Mechanisms of action: Binds with alpha- and beta- adrenergic receptors, increasing heart rate and force of contraction, causing vasoconstriction and relaxing bronchial smooth muscle

Dosage: Cardiac arrest:

• IV/IO: 1mg (in 10 mL) of 1:10000 solution IV push, follow with 20 mL fluid flush, may repeat 1 mg dose every 3 to 5 min

• Tracheal: 2 to 2.5 mg diluted in 5 to 10 mL of sterile water or normal saline

Considerations: available in different concentrations

ACLS related pharmacological therapy:

Action:

· Causes increased cardiac output

· Acts on beta 1 and alpha receptors causing vasoconstriction in blood vessels

· Low dose causes renal and mesenteric vasodilation

· Beta 1 stimulation produces inotropic effects with increased cardiac output

Uses: Shock, increase perfusion, hypotension, bradycardia

Dosages & Route: IV infusion, 5-10 mcg/kg/min, maximum 50 mcg/kg/min

ACLS related pharmacological therapy:

Action:

• Blocks acetylcholine at parasympathetic neuroeffector sites

• Increases cardiac output and heart rate and blocking vagal stimulation

Uses: Bradycardia, bradyarrhythmia, cardiac vagal reflexes

LABORATORY STUDIES

Examination of the client’s (?) and (?) can provide information about a primary musculoskeletal problem

LABORATORY STUDIES

• This enzyme, produced by osteoblasts of bone, is needed for mineralization of organic bone matrix

• Increased in bone cancer, healing fractures, rheumatoid arthritis and osteoporosis

• Normal value: 42-136 U/L

LABORATORY STUDIES

• is one of a group of enzymes located primarily in the prostate gland and prostatic secretions.

Smaller amounts are found in bone marrow

• Increased in bone fracture, cancer with bone metastasis

• Normal value: 0.5 -2.0 U/L

LABORATORY STUDIES

■ To monitor calcium levels and detect calcium imbalances

■ provides bone with rigid structure

■ decrease serum level is found in osteomalacia, renal disease, and hypoparathyroidism

■ increase in bone cancer and multiple fractures

■ Normal value: 4.5- 5.5 mEq/L

LABORATORY STUDIES

■ is formed as the purines adenine and guanine are continuously metabolized during the formation and degradation of RNA and DNA and from metabolism of dietary purines

■ increase in gout

■ Normal value: 2.8- 6.8 mg/dL (females)

3.5– 8.0 mg/dL (males)

LABORATORY STUDIES

■ is an immunoglobulin present in the serum of 50%-95% of adults with rheumatoid arthritis (RA)

■ Also increased in lupus erythematosus and scleroderma

■ Normal value: < 1:20 titer

LABORATORY STUDIES

■ are glycoproteins found on all nucleated cells

■ The presence of B-27 antigen is highly correlated with ankylosing spondylitis and rheumatoid arthritis

■ Normal value: negative

LABORATORY STUDIES

■ A low-molecular-weight, light-chain immunoglobulin synthesized by malignant plasma cells in the bone marrow and

initially broken down and reabsorbed by the kidneys

■ Positive: in osteomalacia

■ Normal value: negative

The common bacteria in septic arthritis includes:

1. Staphylococcus aureus

2. Neisseria gonorrhoeae

The common bacteria in osteomyelitis includes:

1. Staphylococcus aureus

2. Neisseria gonorrhoeae

Classification of Necrotizing Fasciitis

■ Polymicrobial, usually combinations of anaerobes and Enterobacteriaceae species

■ Usually in occurs in immunocompromised individuals, such as clients with DM, peripheral vascular disease, post surgery or trauma, intravenous drug users

■ More likely to be present on the trunk, abdomen, perineum, or perianal

Classification of Necrotizing Fasciitis

■ Monomicrobial and caused by Group A β-hemolytic streptococci (GABHS) related ± Staphylococci (Meticillin- Sensitive Staphylococcus aureus (MSSA) or methicillin– resistant Staphylococcus aureus (MRSA))

■ Usually in clients with surgery, minor trauma or varicella; 50% do not have an obvious portal of entry

■ Common on the head and neck, and limbs

Classification of Necrotizing Fasciitis

■ Caused by Clostridium perfringen, C. septicum or C histolyticum (gas- producing organisms)

■ Always have an obvious portal of entry

■ Usually in patients with surgery, trauma or colonic cancer or leukemia

Classification of Necrotizing Fasciitis

■ Also called saltwater NF

■ Caused by Vibrionaceae, including Vibrio (e.g. Vibrio vulnificus), Aeromonas (e.g. Aeromonas hydrophilia) and Plesiomonas

■ Usually in clients with minor trauma and exposure to river or sea water

■ Vibrio vulnificus infection is considered as one of the “communicable diseases of topical public health concern” should be notified to the Centre for Health Protection (CHP)

Clinical Manifestations of Necrotizing Fasciitis

• Warm on palpation

• Erythema

• Tenderness to palpitation (extending beyond apparent areas of skin involvement)

• Swelling

• Pain out of proportion to the swelling or erythema

• Fever

• Tachycardia

Clinical Manifestations of Necrotizing Fasciitis

• Vesicle or bullae formation

• Skin fluctuance

• Skin induration

• Pus or foul smell discharge

• Crepitus

• Skin necrosis with dusky discolouration progressing to frank gangrene

• Severe pain or skin anaesthesia due to cutaneous infarct

• Hypotension

• Shock

• Multiple organs failure