1.

Differentiate between Type 1 and Type 2

diabetes: the causes, clinical manifestation,
management, and nursing intervention. Describe
the relationships between diet, exercise, and
medication of the diabetic patient.
Type 1 diabetes, formerly known as juvenile diabetes is
an autoimmune disorder in which the body’s T cells
attack and destroy the pancreatic beta cells which is the
source of the body’s insulin. The pancreas is no longer
making insulin and manifestations usually occur at this
time. Onset is usually rapid and seen more commonly in
the young but can occur at any age.
In Type 2 diabetes the onset is gradual and the
pancreas may be making insulin but the amount is
usually insufficient for the body’s needs or is poorly
utilized by the tissues. Type 2 is usually seen in
overweight individuals and those around age 35 or
younger.
Clinical manifestations
Type 1 diabetes is rapid and acute and includes:
polydipsia, polyuria, and polyphagia, weight loss due to
the body breaking down fat and protein to restore energy
source, malaise and fatigue due to a decrease in energy
and blurred vision due to swelling of lenses from osmotic
effects.
Type 2 diabetes can also have the symptoms polydipsia,
polyuria, and polyphagia as well as fatigue, recurrent
infections, recurrent vaginal yeast or monila infections,
prolonged wound healing, and visual changes.
Management for patients with Type 1 or Type 2
diabetes include calorie controlled diet, exercise and
medications (either oral or insulin) to control blood
glucose levels. In patients with Type 1 diabetes insulin
is required. Also for patients with Type 1 diabetes, a
consistency in timing and amount of food eaten is
important for those who take insulin. Reduction of total
fat, especially saturated fat and simple sugars are
important for those with Type 2 diabetes and
maintenance of a more desirable body weight. Patients
should also be taught to self-monitor their blood glucose
levels.
Nursing interventions for the patient with Type 1 or
Type 2 diabetes include monitoring of blood glucose
levels, encourage oral fluid intake, regular bathing and
oral care with daily foot inspection because patients with
diabetes are prone to foot ulcers, proper administration,
and assessment of use and response to medications and
educating the patient and family about diabetes. Also
make sure nutritional needs are met and monitor intake
and output especially in the hospital setting. Know the
onset, peak, and duration of administered insulin, plan for
administration of prescribed insulin, and monitor client for
signs of hypoglycemia. When mixing insulin never mix
Lantus with anything and always mix clear to cloudy,
rotate sites and the abdomen is most commonly because
absorption is faster. Lastly, education about the disease,
treatment, and encouraging compliance should be
maintained.
Describe the relationships between diet, exercise,
and medication of the diabetic patient.
Exercise is essential because it reduces blood glucose
levels by increasing glucose use by the muscles. This
potentially decreases the need for insulin. The
frequency, intensity, and time should all be taken into
consideration.
Nutritional intake is a balanced healthy diet with an
appropriate mixture of carbohydrates, proteins and fat.
This will also create an even release of glucose into the
blood of a diabetes patient. The goals are to keep blood
glucose as near as possible to that of a normal person.
Count grams of carbohydrates consumed. Dosage of
insulin is determined by carbohydrate consumption.
Medications taken depend on the type of diabetes.
People with type 1 diabetes must have insulin to keep
their blood glucose levels low along with diet and
exercise. Those with type 2 diabetes will perhaps need
oral or insulin medications along with proper nutrition,
regular physical activity, and maintaining a desirable
body weight which can help them attain an optimal level
of blood glucose control.
Diabetes management requires a careful balance
between nutrient intake, daily energy needs, and the
dose and timing of insulin or oral medications.

2. Differentiate between hyperglycemia, diabetic

ketoacidosis, and hyperosmolar nonketonic
syndrome. Identify the diagnostic and clinical
significance of blood glucose test results.
Hyperglycemia- High blood glucose (sugar) that occurs
when the body has too little insulin or when the body
can't use insulin properly. Usually extreme thirst and
frequent urination are symptoms and they may not be
noticed until the blood glucose levels are extremely high.
Treatment with insulin and exercise should be restricted
when blood glucose levels are > 250 mg/dl. Also
remember to check blood glucose levels regularly and
have your urine checked for ketones because
hyperglycemia can lead to diabetic ketoacidosis.
Encourage oral fluid intake. If symptoms progress a
doctor should be notified.

Diabetic ketoacidosis-Caused by a profound deficiency

of insulin and is characterized by hyperglycemia, ketosis,
acidosis, and dehydration. Most common in those with
Type 1 diabetes. Initial management includes
administering fluids and electrolytes. Insulin therapy may
be withheld until fluids are replaced. Laboratory
findings include a blood glucose level above 300
mg/dl, arterial blood pH below 7.30 and serum
bicarbonate levels less than 15 meq, and ketones in the
blood and urine. This is significant of DKA.
Hyperosmolar Nontectonic Syndrome-Occurs in the
patient with diabetes who is able to produce enough
insulin to prevent DKA but not enough to prevent severe
hyperglycemia, osmotic diuresis, and extracellular fluid
depletion. Management includes immediate IV
administration of either 0.9% or 0.45% NaCl and regular
insulin. Electrolytes are monitored and replaced as
needed. Laboratory values include blood glucose >400
mg/dl and a marked increase in serum osmolality.
Ketone bodies are absent or minimal in both blood and
urine.
Blood tests that are used as a diagnostic tool for diabetes
include:
Fasting blood sugar (fasting for at least 8 hrs.) >
126mg/dl, which is confirmed by repeat testing on a
different day. If FBS is greater than 100 mg/dl but less
126 mg/dl the person is said to have impaired fasting
glucose.
Casual or random glucose > 200 mg/dl plus polyuria,
polydipsia, and polyphagia are indicated in diabetes.
Oral glucose tolerance test > 200mg/dl using a
glucose load of 75 g.
When symptoms of hyperglycemia exist with fasting
blood glucose levels of 126 mg/dl or greater further
testing using the OGTT may not be necessary to make a
diagnosis.

An A1C test can also be done to check for chronic

hyperglycemia. This test will identify the plasma glucose
level over a long period of time. All patients with
diabetes should have regular assessments of A1C done to
monitor treatment.

3. Diabetes is a chronic illness that requires a

lifetime of special self-management behaviors:
develop a teaching plan for a newly diagnosed
diabetic patient.
• First ask if the patient if they would like to include
family members into their care.
• Assess the patient’s knowledge and lifestyle
preferences. This can serve as a useful tool to see
what knowledge the patient has and allow you to
correct incorrect or inaccurate statements.

• Patient should be taught how to accurately monitor

 blood glucose levels with a self-monitoring kit.
Results should be recorded in a log with date and
time and teach patients to test before meals and
possibly after meals.
• Patients should be taught how to take their oral or
injectable medications properly and to not skip
doses. Instruct them not to rub the area where the
insulin was administered. Follow up assessments
should be done on patients using insulin. If the
patient cannot self-inject, family members should be
instructed in the administration of insulin injections.
• Teach them to exercise regularly and not to start an
exercise regimen without first checking with their
doctor. Let them know that exercise will lower blood
glucose levels so be cautious. Also let them know
that they should not exercise when glucose levels
are high because it may lead to a worsening of the
blood glucose levels.
• Next teach them about diet. An individualized meal
plan should be tailored to their specific needs by a
dietitian and should be following regularly at regular
times. Emphasis should also be placed on
maintaining a consistent day-to-day carbohydrate
intake at meals and snacks. Fiber should also be
included and alcohol should not be used in excess
because a low blood glucose reaction may occur.
Also try and eat foods low in saturated fats.
• Teach the patient about complications from diabetes,
including hyperglycemia, hypoglycemia and diabetic
foot ulcers. Instruct them on the importance of
keeping the feet clean, dry and free from injury. Any
abnormalities should be reported to their physician
 immediately. Also, they should carry some form of
glucose at all times to treat hypoglycemia quickly.
• The patient needs to understand that diabetes is a
lifelong disease process that requires a lifetime
commitment and lifestyle changes. Books,
pamphlets, and magazines should be provided for
additional information.
4. Develop a plan of nursing care for the patient
preopt and postopt undergoing a thyroidectomy.
• Preopt---First you have to make sure you obtain the
signed consent form and answered any questions the
patient may have. Next, preoperative teaching
should include comfort and safety measures that
they patient can participate in. Coughing, turning,
deep breathing and leg exercises should be taught.
Patient should also be taught how to support the
head manually while turning in bed because this
minimizes stress on the suture line after surgery.
ROM exercises of the neck should be practiced.
Teach about routine post-operative care such as IV
infusions post op and the patient should be told that
talking may be difficult after surgery. Hospital room
should contain oxygen, suction equipment, and a
tracheostomy tray. This is incase airway obstruction
occurs.

• Postop—Assess patient every 2 hours for 24 hours for

signs of hemorrhage or tracheal compression. Place
patient in semi fowlers and support the head with
pillows and avoid neck flexion. Monitor vitals, assess
pain and give postop medications and check for signs
 of tetany secondary to hyperparathyroidism.
Trousseau’s sign and Chvostek’s signs should be
monitored for 72 hours. Let patient know that they
may be hoarse for 3-4 days after surgery because of
edema.
• If surgery is well tolerated, patient may ambulate
within hours after surgery can fluids as soon as
tolerated and can eat a soft diet the day after
surgery.
• Other postoperative care includes discharge teaching
about monitoring thyroid hormone balance to ensure
that normal function has returned.
• Caloric intake must be reduced to prevent weight
gain. Iodine may be necessary to promote thyroid
function.
• Regular exercise should be included to help stimulate
the thyroid gland and high environmental
temperature should be avoided because it inhibits
thyroid regeneration.
• Regular follow up care is necessary and includes
seeing their doctor biweekly for a month and then at
least semiannually.
• If compete thyroidectomy has been performed, the
patient needs instruction in lifelong thyroid
replacement.
5. Identify the teaching needs of patients requiring
corticosteriod therapy.
• A diet high in protein, calcium and potassium but low
in fat, and concentrated simple sugars should be
 maintained.
• Adequate rest and restriction of caffeine late in the
day.
• Develop an exercise plan to maintain bone integrity.
• Restrict sodium intake to < 2000 mg/day if edema
occurs.
• Monitor glucose levels and recognize S/S of
hyperglycemia (polyuria, polydipsia, blurred vision)
and glucose in the urine. Report hyperglycemic
symptoms or capillary glucose levels > 120 mg/dl or
urine positive of glucose.
• Notify physician of post prandial heartburn or
epigastric pain that is not relieved by antacids.
• Have an eye exam yearly to assess for cataracts.
• Use safety measures to prevent injury from getting
up (get up slowly) from bed or chair and use good
lighting.
• Maintain good hygiene and try to stay away from
those who are sick to avoid infection.
• Inform all health care providers about use of
corticosteroids.
• Inform patient that their dosage may be increased in
times of physical or emotional stress.
• Corticosteroids should never be abruptly stopped
because it can lead to addisonian crisis and possible
death.
• For the patient taking steroids as non-replacement
 therapies, they should be taken once a day or once
every other day. They should also be taken early in
the morning with food to decrease gastric irritation.
• Teach patient about therapies to reduce the
resorption of bone including increasing their intake of
calcium, vitamin D supplementation,
bisphosphonates and institution of a low impact
exercise plan.
Additional Teaching
When teaching a patient about corticosteroid therapy, I
also felt that patients should be taught about some of the
possible side effects of taking corticosteroids including:
hypertension, hypokalemia, predisposition to peptic ulcer
disease, hypocalcemia, protein depletion which may
predispose them to pathological fractures, skeletal
muscle atrophy and weakness, delayed would healing,
mood and behavior changes, redistribution of fat from the
extremities to the trunk and face, increased susceptibility
to infection, and glucose intolerance which may
predispose them to diabetes.

6. Compare hypothyrodism and hyperthyroidism:

the causes, clinical manifestation, management of
the disease process and nursing interventions. (Be
sure to include meds with specifics for
administration and maintenance).
Hyperthyroidism—Hyperactivity of the thyroid gland
with sustained increase in synthesis and release of
thyroid hormones (T3 and T4).
Causes:
A. Grave’s Disease which is an autoimmune disease
which cause the thyroid to enlarge and excessively
secrete thyroid hormones.
B. Toxic nodular goiters--These nodules sometimes
produce excessive amounts of thyroid hormones and
when associated with hyperthyroidism they are termed
toxic.
C. Thyroiditis--Inflammation of the thyroid gland that can
lead to the release of excess amounts of thyroid
hormones which can be due to bacterial, viral or fungal
infections.
Clinical manifestations:
• Possible goiter
• Tachycardia
• Exophthalmos
• Intolerance to heat
• Weight loss
• Muscle wasting
• Fine straight hair
• Finger clubbing
• Tremors
• Increased diarrhea
• Localized edema
• Increases systolic blood pressure
• Facial flushing
• Fatigue
Signs in the elderly patient may include: anorexia,
apathy, lassitude, depression, weight loss, atrial
fibrillation, and confusion.
Management of the disease: The disease is treated by
blocking the adverse effects of thyroid hormones and
their oversecretion. This can achieved with Drug therapy,
radioactive iodine therapy, or surgical therapy.
Drug Therapy—propylthiouracil (PTU) and methimazole
(Tapazole). These drugs inhibit the synthesis of thyroid
hormone. Improvement of hyperthyroidism usually
begins 1-2 weeks after start of medication therapy and
good results are seen within 4-8 weeks. Therapy is
usually continued for 6 -15 months for spontaneous
remission.
Patient Teaching: Patients need to know that use of
these medications is not a cure and that recurrence of
hyperthyroidism may occur when drugs are discontinued.
Also, since PTU lowers hormone levels more quickly, it
has to bed taken three times per day. Tapazole is
administered in a single daily dose.
B-Adrenergic blockers—Used for symptomatic relief of
thyrotoxicosis. Propranolol (Inderal) is usually
administered with other antiythroid agents and rapidly
provides symptomatic relief. Atenolol (Tenormin) is the
preferred B-adrenergic blocker for use with a patient with
asthma or heart disease.
Radioactive Iodine Therapy (RAI)—Treatment of
choice for most nonpregnant individuals. RAI damages or
destroys thyroid tissue limiting hormone secretion.
Patient Teaching: Patients should know that maximum
effectiveness may not be seen for 2-3 months due to
delayed response time and that they may be treated with
antithyroid drugs and propranolol before and during the
first 3 months after RAI initiation until effects become
apparent. Patient should also know that lifelong thyroid
hormone replacement may be needed due to high
incidence of posttreatment hypothyroidism.
Surgical Therapy—Thyroidectomy is indicated for
individuals who have been unresponsive to antithyroid
therapy, those with very large goiters causing tracheal
compression and for those with possible malignancy. An
advantage is that it more rapidly decreases T3 and T4
levels than RAI. Subtotal thyroidectomy is the preferred
procedure.
Nursing responsibilities preop: Before surgery,
antithyroid drugs, iodine, and B-adrenergic blockers may
be administered to achieve a euthyroid state and to
control symptoms. Iodine reduces the risk of hemorrhage
during surgery.
Postop complications to monitor for:
hypothyroidism, damage to or accidental removal of
parathyroid glands causing hypoparathyroidism and
hypocalcemia, hemorrhage, injury to the recurrent or
superior laryngeal nerve, thyrotoxic crisis and infection.
Nutritional Therapy
A high calorie diet (4000 to 5000 kcal/day) may be
ordered to satisfy hunger and prevent tissue breakdown.
This can be accomplished with 6 full meals a day and
snacks high in protein, carbohydrates, minerals and
vitamins, especially vitamin A, thiamine, vitamin B6, and
vitamin C.
Increased carbohydrates should compensate for an
altered metabolism while providing energy and lessening
the use of body stored protein.
Highly seasoned and high fiber foods should be avoided.
Consult a dietitian for guidance.
Nursing interventions:
Clients receiving antithyroid medications should be
monitored for signs of hypothyroidism, which can occur
with overmedication.
• A calm quiet cool room should be provided so that
sleep will not be disturbed.
• Minimize the client’s energy usage by assisting with
activities as necessary.
• Encouraging the client to alternate periods of activity
with rest.
• Monitor nutritional status. Provide increased calories,
protein, and other nutritional support as necessary.
• Assess the client’s mental status and decision-
making ability. Intervene as needed to ensure safety.
• Provide eye protection (patches, eye lubricant,
taping eyelids closed) for a client with exophthalmos.
• Monitor vital signs and cardiorespiratory response to
activity.
• Use light bed covers and change linen frequently if
patient is diaphoretic.
• Prepare the client for total/subtotal thyroidectomy, if
the client is unresponsive to antithyroid medications
or has an airway-obstructing goiter. (see # 4 for
preop and postop teaching)
• Discharge teaching for the patient after surgery and
make them aware that thyroid hormone balance
should be monitored periodically to ensure that
 normal function has returned.
• Regular follow up care is necessary.

Hypothyroidism—Insufficient circulating thyroid

hormone as a result of a variety of abnormalities.
Cause:
Iodine insufficiency is the most common cause worldwide.
Other causes include atrophy of the thyroid gland and
drugs like Amiodarone and lithium.
Hypothyroidism can also develop in infancy and is called
Cretinism. It is caused by thyroid hormone deficiencies
during fetal or early neonatal life.
Clinical Manifestations:
• Hair loss
• Apathy
• Lethargy
• Dry skin
• Muscle aches and weakness
• Constipation
• Cold intolerance
• Receding hairline
• Facial and eyelid edema
• Dull blank expression
• Thick tongue—slow speech
• Anorexia
• Brittle nails and hair
• Menstrual disturbances
• Anemia
Late clinical manifestations include: subnormal temp,
bradycardia, weight gain, decreased LOC, thickened skin,
and cardiac complications.

Management:
Overall treatment includes hormone replacement therapy
and a low calorie diet is indicated promote weight loss.

Drug of choice includes levothyroxine (Synthroid). In

the young and healthy patient the maintenance dose is
adjusted according to the patient’s response and
laboratory findings.
Older adult patient with cardiac compromised
status: Initial dose is smaller because the usual dose
may increase myocardial oxygen demand and may cause
angina and cardiac dysrhythmias.

Liotrix is a synthetic mix of levothyroxine and

liothyronine and it may be used in acutely ill individuals
with hypothyroidism. It has a faster onset of action with
a peak of 2 to 3 days, as opposed to levothyroxine with a
peak of 1 to 3 weeks.

Nursing responsibility/Patient teaching regarding

medications:

• Any chest pain experienced by a patient starting

thyroid replacement should be reported immediately
and an EKG and serum cardiac enzyme tests must be
performed.

• When taking Synthroid, carefully monitor patients

with cardiovascular disease. Monitor heart rate and
report pulse of 100 beats/min or greater and
 promptly report chest pain, weight loss, nervousness,
tremors, and insomnia.

• Multiple levothyroxine preparations are available and

patients taking levothyroxine should have serum TSH
levels checked 4 to 6 weeks after changing a
levothyroxine preparation.

• Patients with no side effects may have their dosage

increased at 4 to 6 week intervals.

• Medications should be taken regularly and lifelong

replacement therapy is usually required.

Nursing Interventions

• Client needs to be monitored for cardiovascular

compromise (palpitations, chest pain, shortness of
breath, rapid heart rate)
during early thyroid therapy.

• Clients receiving thyroid replacement therapy must

be monitored for and taught regarding signs and
symptoms of hyperthyroidism, which can occur with
overmedication. Signs include: irritability, tremors,
tachycardia, palpitations, and heat intolerance.

• Increase the client’s activity level gradually, and

provide frequent rest periods to avoid fatigue and
decrease myocardial oxygen demand.

• Provide a high-bulk, low-calorie diet and encourage

activity to combat constipation and promote weight
loss.
 • Encourage increased fluid intake, monitor body core
temperature and provide warm blankets if they are
cold.

• Patient with diabetes should monitor blood glucose

levels.

• Weigh patients at appropriate intervals and monitor

intake and output.

• Thyroid preparations potentiate the effects of

anticoagulants and decrease the effect of digitalis
compounds, therefore, patients should be taught the
toxic signs and symptoms of these medications and
should remain under close medical observations until
stable.

7. Compare hyperparathyroidism and

hypoparathyroidism: their causes, clinical
manifestation, management of disease processes,
and nursing interventions.
Hyperparathyroidism:
Condition involving an increased secretion of parathyroid
hormone. PTH helps regulate calcium and phosphate
levels by stimulating bone resorption of calcium, renal
tubular reabsorption of calcium and activation of vitamin
D. Can be classified as either primary, secondary, or
tertiary.
Primary hyperparathyroidism:
Primary is due to an increased secretion of PTH. The most
common cause is a benign tumor (adenoma) in the
parathyroid gland. Usually occurs between 30 and 70
years of age with peak incidence in the 40’s and 50’s.
Patients who have recently undergone head and neck
radiation may have an increased risk of developing a
parathyroid adenoma.
Secondary hyperparathyroidism:
Usually a compensatory response to a condition that
induces or causes hypocalcemia such as vitamin D
deficiency, malabsorption, chronic renal failure, and
hyperphosphatemia.
Tertiary hyperparathyroidism:
Occurs when there is hyperplasia of the parathyroid
glands and a loss of negative feedback from circulating
calcium levels. This causes autonomous secretion of PTH
even with normal calcium levels.
Major Clinical Manifestations:
• Weakness
• Loss of appetite
• Constipation
• Increased need for sleep
• Emotional disorders
• Shortened attention span
• Loss of calcium from bones (major sign)
 • Fractures (major sign)
• Kidney stones (major sign)
• Muscle weakness (neuromuscular abnormality)
• Hypertension

Management of disease
Surgical therapy—Most effective treatment for both
hyper and hypoparathyroidism. Leads to a rapid
reduction of chronically high calcium levels.
Criteria for surgery
• Serum calcium levels >12 mg/dl)
• Hypercalciuria (> 400 mg/dl)
• Markedly reduced bone mineral density
• Overt symptoms (neuromuscular effects,
nephrolithiasis)
• Those over age 50
*If autotransplantation of normal parathyroid tissue in the
forearm is done, the patient will be able to maintain
normal PTH secretion and calcium levels. If not then the
patient will need to take calcium supplements for life.
Nonsurgical therapy
Annual exam for tests for serum PTH, calcium,
phosphorus, and alkaline phosphatase levels; renal
function; x-rays to assess for metabolic bones loss and
measurement of urinary calcium excretion.
Continued ambulation and avoidance of immobility
Drugs that are helpful in lowering calcium levels include:
• Bisphosphonates (alendronate[Fosamax])—Inhibit
bone resorption and normalize serum calcium levels.
• Estrogen or progesterone can reduce serum and
urinary calcium levels in the premenopausal woman.
• Oral phosphates may be used to inhibit calcium
absorbing effects of vitamin D in the intestine.
ALERT: Phosphates should only be used if the
patient has normal renal function and low serum
phosphate levels.
• Diuretics may also be used to increase urination and
aid in excretion of calcium.
• Calcimimetic agents (cinacalcet [Sensipar]) are a
new class of drugs that increase the sensitivity of the
calcium receptor on the parathyroid gland, resulting
in decreased PTH secretion and calcium blood levels
and sparing calcium stores in the bone.
NURSING INTERVENTIONS:
• Monitor for postop (parathyroidectomy)
complications including hemorrhage, and fluid and
electrolyte imbalances.
• Monitor for tetany which is due to a sudden
decrease in calcium levels.
• Mild S/S of tetany includes tingling of hands and
around the mouth. More severe S/S includes
muscular spasms or laryngospasms. IV calcium
gluconate or gluceptate can be given for acute
 tetany.
• Monitor intake and output. Monitor calcium,
phosphate, potassium, and magnesium levels
frequently. Also monitor for Chvostek’s and
Trousseau’s signs. Mobility is also encouraged.
• If surgery is not performed the nurse should relieve
the symptoms and prevent complications.
• Adapting a meal plan to the patient’s lifestyle,
referral to a dietitian and an exercise program should
be included.
• Encourage patient to keep appointments and explain
all tests being performed.
• Patients should also be taught the S/S of
hypocalcemia and hypercalcemia and report these
symptoms if noticed.

Hypoparathyroidism
Condition associated with inadequate circulating PTH. It
is characterized by hypocalcemia resulting from a lack of
PTH to maintain serum calcium levels.
Cause
Most common cause is iatrogenic. This may include
accidental removal of the parathyroid glands or damage
to the vascular supply of the glands during neck surgery.
Severe hypomagnesemia can also lead to a suppression
of PTH secretion.
Clinical Manifestations
 • Sudden decrease in calcium can cause tetany. This
causes tingling of the lips, fingertips, and feet and
increased muscle tension leading to paresthesias and
stiffness.
• Painful tonic spasms of smooth and skeletal muscles,
dysphagia, laryngospasms.
• Chavostek’s sign and Trousseau’s sign are usually
positive.
• Respiratory function may be compromised and
patients are usually anxious and apprehensive.
• Abnormal lab values include decreased serum
calcium and PTH levels and increased serum
phosphate levels.
Management
• Management is to treat the acute complications of
tetany, maintain normal serum calcium levels, and
prevent long-term complications. Emergency
treatment of tetany requires calcium IV.
• Rebreathing may partially alleviate acute
neuromuscular symptoms associate d with
hypocalcemia such a as generalized muscle cramps
or mild tetany.
• Vitamin D is used in chronic and resistant
hypocalcemia to enhance intestinal calcium
absorption and bone resorption.
• With vitamin D therapy, preferred preparations are
dihydrotachysterol (Hytakerol) and 1,25-
dihydroxycholecalciferol (calcitrol [Rocaltrol]). These
drugs raise calcium levels and are quickly
 metabolized.
• Ergocalciferol (Calciferol) is the least expensive of
the vitamin D preparations and may also be
prescribed.
• A lower pH enhances the degree of ionization of
calcium causing an increase in the proportion of total
body calcium available in the active form. This will
temporarily relieve the manifestations of
hypocalcemia.
• PTH replacement is not usually recommended
because of the expense and the need for parenteral
administration. Oral calcium supplement of at least
1.5-3 g/day in divided doses are usually prescribed.
Nursing Interventions
• IV calcium chloride, calcium gluconate, or calcium
gluceptate should be given slowly. Calcium is
infused slowly because blood levels can cause
hypotension, serious cardiac dysrhythmia, or cardiac
arrest.
• EKG monitoring is necessary when infusing calcium.
• IV patency should be assessed and monitored
throughout infusion because IV calcium can cause
venous irritation and inflammation. Extravasation
may cause cellulitis, necrosis, and tissue sloughing
so monitor.
• Instruct patient in management of long term drug
therapy and nutrition.
• Patients should include a high calcium meal plan in
their diet. This includes foods such as dark green
 vegetables, soybeans, and tofu
• Patients should be told that foods containing oxalic
acid (spinach, rhubarb), phytic acid (bran, whole
grains), and phosphorous reduce calcium absorption.
• Teach patients about the need for lifelong treatment
and follow up care including the monitoring of
calcium levels there to four times a year.

8. Use the nursing process as a framework for care

of a patient with Cushing syndrome.
Assessment
The patient with Cushing’s will have weight gain,
especially in the trunk, face (moon face) and cervical
spine area. Hyperglycemia may be present due to
glucose intolerance as well as hypertension. Extremities
may be thin and the patient may complain of fatigue,
irritability, and anxiety. Sodium levels may be increased
and potassium levels decreased. Patient will also have
increased susceptibility to infection. Patient will have
fluid retention and purple striae may be seen.
According to some of the symptoms contained, the
following nursing diagnosis will help me with planning
care for this patient.
• Fluid volume excess R/T sodium and fluid retention
• Activity Intolerance R/T weight gain
• Disturbed body image R/T change in body
appearance
• Risk for infection D/T increase in susceptibility to
 infection secondary to excess use of corticosteroids
Goals for this patient will be:
• Maintain normal fluid volume
• Maintain normal weight through diet and exercise to
limit fatigue
• Accept the physical characteristics of Cushing’s
syndrome and the characteristics of it and maintain a
positive self-image.
• No infection
• Experience relief of symptoms
• Actively participate in their plan of care
Implementation
• Patient will need to have intake and output
monitored and weighed daily.
• Allow for adequate rest periods
• Provide education about Cushing’s syndrome and the
clinical manifestations of the disease and provide
emotional support because the changes in
appearance may make them feel unattractive or
unwanted.
• Refer patient to a dietitian and talk with physician
about implementation of an exercise program.
• Monitor blood glucose levels regularly and monitor
electrolytes (potassium, sodium).
• Ongoing assessment of vital signs, possible
infections, S/S of inflammation and sudden chest
 pain dyspnea, or tachypnea should all be monitored
and checked for daily.
• Also monitor for hormone and drug toxicity and
complicating conditions (cardiovascular disease,
diabetes mellitus, and infection).
• Teach the patient not to abruptly stop taking the
corticosteroid. The medication will have to be
gradually discontinued.
• Evaluation should be ongoing.