12. Spinal shock: temporary flaccid paralysis and areflexia following a severe injury to the spinal cord.
    1. Pathophysiology: squeezing or shearing of the spinal cord due to fractures or dislocation of vertebrae; interruption of sensory tracts; loss of conscious sensation; interruption of motor tracts; loss of voluntary movement; loss of facilitation; loss of reflex activity; loss of muscle tone; loss of stretch reflexes, leading to bowel and bladder retention. If injury between T-l and L-2, leads to loss of sympathetic tone and decrease in blood pressure. Afferent impulses are unable to ascend from below the injured site to the brain, and efferent impulses are unable to descend to points below the site.
    2. Risk factors:
       1. Automobile/motorcycle accidents.
       2. Athletic accidents, e.g., diving in shallow water.
       3. Gunshot wounds.
    3. Assessment:
       1. Subjective data:
          1. Loss of sensation below level of injury.
          2. Inability to move extremities.
          3. Pain at level of injury.
       2. Objective data:
          1. Neurological exam:
             1. Absent: pinprick, pressure, and vibratory sensations below level of injury; reflexes below level of injury.
             2. Muscles: flaccid.
          2. Vital signs:
             1. BP decreased (loss of vasomotor tone below level of injury).
             2. Bradycardia.
             3. Elevated temperature.
             4. Respirations: may be depressed; possible respiratory failure if diaphragm involved.
          3. Absence of sweating below level of injury.
          4. Urinary retention.
          5. Abdominal distention: retention of feces, paralytic ileus.
          6. Skin: cold, clammy.
    4. Analysis/nursing diagnosis:
       1. Decreased cardiac output related to loss of vasomotor tone below level of injury.
       2. Ineffective breathing pattern related to injuries involving diaphragm.
       3. Improved physical mobility related to loss of voluntary movement of limbs.
       4. Urinary retention related to loss of stretch reflexes.
       5. Fear related to serious physical condition.
       6. Risk for injury related to potential organ damage if shock continues.
    5. Nursing care plan/implementation:
       1. Goal: prevent injury related to shock.
          1. Maintain patent airway: intubation and mechanical ventilation may be necessary with cervical spinal injuries due to involvement of diaphragm.
          2. Monitor vital signs; profound hypotension and bradycardia are most dangerous aspects of spinal shock.
          3. Administer blood/IV fluids as ordered.
          4. Nutrition and hydration:
             1. NPO in acute stage: maintain nutrition by IV infusions as ordered.
             2. When allowed to eat: high-protein, high-calorie, high-vitamin diet.
          5. Maintain proper position to prevent further injury.
             1. Backboard is necessary to transport from place of injury.
             2. Support head in neutral alignment and prevent flexion.
             3. Skeletal traction will be applied once diagnosis is made.
          6. Monitor urinary output qlh; may have Foley catheter while in shock; later intermittent catheterization will be used as needed.
          7. Relieve bowel distention; use lubricant containing anesthetic, as necessary, when checking for or removing impaction.
    6. Evaluation/outcome criteria:
       1. Complications are avoided.
       2. Body functions are maintained.


13. Autonomic dysreflexia (autonomic hyperreflexia): a group of symptoms in which many spinal cord autonomic responses are activated simultaneously. This may occur when cord lesions are above the sixth thoracic vertebra; it is most commonly seen with cervical and high thoracic cord injuries; may occur up to 6 years after injury.
    1. Pathophysiology: pathological reflex condition, which is an acute medical emergency characterized by extreme hypertension and exaggerated autonomic responses to stimuli.
    2. Risk factors:
       1. Distention of bladder or rectum.
       2. Stimulation of skin, , decubitus ulcers, wrinkled clothing.
       3. Stimulation of pain receptors.
    3. Assessment:
       1. Subjective data:
          1. Severe, pounding headache.
          2. Blurred vision; sees spots in front of eyes.
          3. Nausea.
          4. Restlessness.
          5. Feels flushes.
       2. Objective data:
          1. Severe hypertension (systolic BP may reach 300 mm Hg).
          2. Bradycardia (30-40/minutes); fever.
          3. Profiise diaphoresis, above level of injury, Flushing of skin above level of injury.
          4. Pale skin below level of injury.
          5. Pilomotor spasm (goose flesh); chills.
          6. Nasal congestion.
          7. Distended bladder, bowel.
          8. Skin breakdown.
          9. Seizures.
    4. Analysis/nursing diagnosis:
       1. Dysreflexia related to high spinal cord injury.
       2. Risk for injury related to complications of hypertension, CVA.
       3. Visual sensory/perceptual alteration related to blurred vision.
       4. Urinary retention related to inability to empty bladder due to spinal injury.
       5. Constipation related to inability to establish successful bowel training program.
       6. Impaired skin integrity related to immobility.
    5. Nursing plan/implementation:
       1. Goal: decrease symptoms to prevent serious side effects.
          1. Elevate head of bed; this lowers BP in persons with high spinal cord injuries.
          2. Identify and correct source of stimulation if possible; notify physician.
          3. Monitor vital signs (BP) ql 5 minutes and pm; uncontrolled hypertension can lead to stroke, blindness, death.
          4. Give medications as ordered: nitrates, nifedipine (Procardia), or hydralazine (Apresoline).
       2. Goal: maintain patency of catheter.
          1. Monitor output; palpate for distended bladder.
          2. Check for tubing kinks; irrigate catheter prn.
          3. Insert new catheter immediately if blocked. Do not Credè or tap the bladder; it could exacerbate the response.
          4. Culture if infection suspected.
       3. Goal: promote regular bowel elimination.
          1. Bowel training program.
          2. Administer suppository/enemas/laxatives as ordered and prn.
          3. When checking for and removing impaction, first use anesthetic ointment (dibucaine [Nupercainai] ointment) to decrease irritation.
       4. Goal: prevent decubitus ulcers.
          1. Meticulous skin care.
          2. Position change ql-2.
          3. Flotation pads, alternating pressure mattress on bed and wheelchair.
       5. Goal: health teaching.
          1. How to recognize risk factors that could initiate this condition.
          2. Methods to prevent situations that increase risk, bowel program, bladder program, skin care, position change schedul
    6. Evaluation/outcome criteria:
    1. BP remains wihin normal limits.
    2. No complications occur


14. Hyperthyroidism (also called thyrotoxicosis; Graves’ disease): spectrum of symptoms of accelerated metabolism caused by excessive amounts of circulating thyroid hormon Graves’ disease is most common cause of hyperthyroidism. The three components of Graves’ disease are hyperthyroidism, ophthalmopathy (protrusion of the eyes), and skin lesions (dermopathy). Graves’ disease is triggered by: stress, smoking, radiation of the neck, some medications (interleukin-2), and infections. Treatment of hyperthyroidism is accomplished by antithyroid medications, radioactive iodine administration (capsule given once), or surgery. Patients may need to take supplemental thyroid hormone (levothyroxine) after treatment.
    1. Pathophysiology: diffuse hyperplasia of thyroid gland—> overproduction of thyroid hormone and increased blood serum levels. Hormone stimulates mitochondria to increase energy for cellular activities and heat production. As metabolic rate increases, fat reserves are utilized, despite increased appetite and food intak Cardiac output is increased to meet increased tissue metabolic needs, and peripheral vasodilation occurs in response to increased heat production. Neuromuscular hyperactivity —» accentuation of reflexes, anxiety, and increased alimentary tract mobility. Graves’ disease is caused by stimulation of the gland by immunoglobulins of the IgG class.
    2. Risk factors:
       1. Possible autoimmune response resulting in increase of a gamma globulin called longacting thyroid stimulator (LATS).
       2. Occurs in third and fourth decade.
       3. Affects women more than men.
       4. Emotional trauma, infection, increased stress.
       5. Overdose of medications used to treat hypothyroidism.
       6. Use of certain weight-loss products.
    3. Assessment:
       1. Subjective data:
          1. Nervousness, mood swings.
          2. Palpitations.
          3. Heat intolerance.
          4. Dyspnea.
          5. Weakness.
       2. Objective data:
          1. Eyes: exophthalmos, characteristic stare, lid lag.
          2. Skin:
             1. Warm, moist, velvety.
             2. Increased sweating; increased melanin pigmentation.
             3. Prétibial edema with thickened skin and hyperpigmentation.
          3. Weight loss despite increased appetite.
          4. Muscle: weakness, tremors, hyperkinesia.
          5. Vital signs: BP-increased systolic pressure, widened pulse pressure; tachycardia.
          6. Goiter: thyroid gland noticeable and palpable.
          7. Gynecological: abnormal menstruation.
          8. GI: frequent bowel movements.
          9. Activity pattern: overactivity leads to fatigue, which leads to depression, which stimulates patient into overactivity, and pattern continues. Danger: total exhaustion.
          10. Lab data:
              1. Elevated: serum T₄ (>11 μg/100 mL), free T₄ or free T₄ index, T₃ level (>35%) and free T₃ level.
              2. Elevated: thyroid uptake of radioiodine (RAIU).
              3. Elevated: metabolic rate (BMR).
              4. Decreased: WBC caused by decreased granulocytosis (<4500).
    4. Analysis/nursing diagnosis:
       1. Altered nutrition, less than body requirements, related to elevated basal metabolic rate.
       2. Risk for injury related to exophthalmos and tremors.
       3. Activity intolerance related to fatigue from overactivity.
       4. Fatigue related to overactivity.
       5. Anxiety related to tachycardia.
       6. Sleep pattern disturbance related to excessive amounts of circulating thyroid hormone.
    5. Nursing care plan/implementation:
    1. Goal: protect from stress: private room, restrict visitors, quiet environment.
    2. Goal: promote physical and emotional equilibrium.
    1. Environment: quiet, cool, well ventilate.
    2. Eyecare:
       1. Sunglasses to protect from photophobia, dust, wind
       2. Protective drops (methylcellulose) to soothe exposed corner
    3. Diet
       1. High: calorie, protein, vitamin
       2. 6 meals/day, as needed
       3. Weigh daily.
       4. Avoid stimulants (coffee, tea, colas, tobacco).
    3. Goal: prevent complications.
       1. Medications as ordered:
          1. Propylthiouracil to block thyroid synthesis; hyperthyroidism returns when therapy is stoppe
          2. Methimazole (Tapazole) to inhibit synthesis of thyroid hormone
          3. Iodine preparations: used in combination with other medications when hyperthyroidism not well controlled; saturated solution of potassium iodide (SSKI) or Lugol’s solution; more palatable if diluted with water, milk, or juice; give through a straw to prevent staining teet Takes 2-4 weeks before results are evident.
          4. Propranolol (Inderal), atenolol (Tenormin), metoprolol (Lopressor) given to counteract the increased metabolic effect of thyroid hormones, but do not alter their levels. Relieve the symptoms of tachycardia, tremors, and anxiety.
       2. Monitor for thyroid storm (crisis)- medical emergency: acute episode of thyroid overactivity caused when increased amounts of thyroid hormone are released into the bloodstream and metabolism is markedly increased
          1. Risk factors for thyroid storm: patient with uncontrolled hyperthyroidism (usually Graves’ disease) who undergoes severe sudden stress, such as:
             1. Infection.
             2. Surgery.
             3. Beginning labor to give birt
             4. Taking inadequate antithyroid medications before thyroidectomy.
          2. Assessment:
             1. Subjective data- thyroid storm:
                1. Apprehension.
                2. Restlessness.
             2. Objective data- thyroid storm:
                1. Vital signs: elevated temperature (106°F), hypotension, extreme tachycardi
                2. Marked respiratory distress, pulmonary edema
                3. Weakness and delirium.
                4. If untreated, patient could die of heart failure
          3. Medications-thyroid storm:
             1. Propylthiouracil or methimazole (Tapazole) to decrease synthesis of thyroid hormone
             2. Sodium iodide IV; Lugol’s solution orally to facilitate thyroid hormone synthesis.
             3. Propranolol (Inderal) to slow heart rate
             4. Aspirin to decrease temperature
             5. Steroids to combat crisis.
             6. Diuretics, digitalis to treat heart failure
    4. Goal: health teaching.
       1. Stress-reduction techniques.
       2. Importance of medications, their desired effects and side effects.
       3. Methods to protect eyes from environmental damage.
       4. Signs and symptoms of thyroid storm.
    5. Goal: prepare for additional treatment as needed.
       1. Radioactive iodine therapy:
          1. Radioactive isotope of iodine to decrease thyroid activity.
          2. Dissolved in water and given by mouth.
          3. Hospitalization necessary only when large dose is administered.
          4. Minimal precautions needed for usual dose.
             1. Sleep alone for several nights.
             2. Flush toilet several times after use.
          5. Effectiveness of therapy seen in 2-3 weeks; single dose controls 90% of patients.
          6. Monitor for signs of hypothyroidism.
    6. Evaluation/outcome criteria:
    1. Complications avoided.
    2. Compliance with medical regimen.
    3. No further weight loss.
    4. Able to obtain adequate sleep.


15. Thyroidectomy: partial removal of thyroid gland (for hyperthyroidism) or total removal (for malignancy of thyroid).
1. Risk factor: unsuccessful medical treatment of hyperthyroidism.
2. Analysis/nursing diagnosis:
   1. Risk for injury related to possible trauma to parathyroid gland during surgery.
   2. Ineffective breathing pattern related to neck incision.
   3. Pain related to surgical incision.
   4. Altered nutrition, less than body requirements, related to difficulty in swallowing because of neck incision.
   5. Impaired verbal communication related to possible trauma to nerve during surgery.
   6. Risk for altered body temperature related to thyroid storm.
3. Nursing care plan/implementation: Prepare for surgery . Postoperative:
   1. Goal: promote physical and emotional equilibrium.
      1. Position: semi-Fowler’s to reduce edema.
      2. Immobilize head with pillows/sandbags.
      3. Support head during position changes to avoid stress on sutures, prevent flexion or hyperextension of neck.
   2. Goal: prevent complications of hypocalcemia and tetany, due to accidental trauma to parathyroid gland during surgery; signs of tetany indicate necessity of calcium gluconate IV
      1. Check Chvostek’s sign - tapping face in front of ear produces spasm of facial muscles.
      2. Check Trousseau’s sign - compression of upper arm (usually with BP cuff) elicits carpal (wrist) spasm.
      3. Monitor for respiratory distress (due to laryngeal nerve injury, edema, bleeding); keep tracheostomy set/suction equipment at bedside.
      4. Monitor for elevated temperature, indicative of thyroid storm .
      5. Monitor vital signs, check dressing and beneath head, shoulders for bleeding qlh and pm for 24 hours; hemorrhage is possible complication; if swallowing is difficult, loosen dressin If patient still complains of tightness when dressing is loosened, look for further signs of hemorrhage.
      6. Check voice postoperatively as soon as responsive after anesthesia and every hour (assess for possible laryngeal nerve damage)-, crowing voice sound indicates laryngeal nerves on both sides have been injured; respiratory distress possible from swelling.
         1. Avoid unnecessary talking to lessen hoarseness.
         2. Provide alternative means of communication.
   3. Goal: promote comfort measures.
      1. Narcotics as ordered.
      2. Offer iced fluids.
      3. Ambulation and soft diet, as tolerated.
   4. Goal: health teaching.
      1. How to support neck to prevent pressure on suture line: place both hands behind neck when moving head or coughing.
      2. Signs of hypothyroidism; needs supplemental thyroid hormone if total thyroidectomy.
      3. Signs and symptoms of hemorrhage and respiratory distress.
      4. Importance of adequate rest and nutritious diet.
      5. Importance of voice rest in early recuperative period.
4. Evaluation/outcome criteria:
   1. No respiratory distress, hemorrhage, laryngeal damage, tetany.
   2. Preoperative symptoms relieved.
   3. Normal range of neck motion obtained.
   4. States signs and symptoms of possible complications.


16. Hypothyroidism (myxedema): deficiency of circulating thyroid hormone; often a final consequence of Hashimoto’s thyroiditis and Graves’ disease.
1. Pathophysiology: atrophy, destruction of gland by endogenous antibodies or inadequate pituitary thyrotropin production —> insidious slowing of body processes, personality changes, and generalized, interstitial nonpitting (mucinous) edema - myxedema; pronounced involvement in systems with high protein turnover (e.g., cardiac, GI, reproductive, hematopoietic).
2. Risk factors:
1. Total thyroidectomy; inadequate replacement therapy.
2. Inherited autosomal recessive gene coding for disorder.
3. Hypophyseal failure.
4. Dietary iodine deficiencies.
5. Irradiation of thyroid gland.
6. Overtreatment of hyperthyroidism.
7. Chronic lymphocytic thyroiditis.
8. Postpartum thyroiditis.
9. Viral thyroiditis.
10. Medications, such as amiodarone HC1 (Cordarone), used to treat abnormal heart rhythms.
3. Assessment:
1. Subjective data:
1. Weakness, fatigue, lethargy.
2. Headache.
3. Slow memory, psychotic behavior.
4. Loss of interest in sexual activity.
2. Objective data:
1. Depressed basal metabolism rate (BMR).
2. Cardiomegaly, bradycardia, hypotension, anemia.
3. Menorrhagia, amenorrhea, infertility.
4. Dry skin, brittle nails, coarse hair, hair loss.
5. Slow speech, hoarseness, thickened tongue, Weight gain: edema, generalized interstitial; peripheral nonpitting; periorbital puffiness.
6. Intolerance to cold.
7. Hypersensitive to narcotics and barbiturates.
8. Lab data:
1. Elevated: thyroid-releasing hormone (TRH), thyroid-stimulating hormone (TSH), cholesterol (>220 mg/dL), lipids (>850 mg/dL), protein (>8g/dL).
2. Normal-low: serum thyroxine (T₄), serum triiodothyrinine (T₃).
3. Decreased: radioactive iodine up take (RAIU).
4. Analysis/nursing diagnosis:
1. Risk for injury related to hypersensitivity to drugs.
2. Altered nutrition, more than body requirements, related to decreased BMR.
3. Activity intolerance related to fatigue.
4. Constipation related to decreased peristalsis.
5. Decreased cardiac output related to hypotension and bradycardia.
6. Risk for impaired skin integrity related to dry skin and edema.
7. Social isolation related to lethargy.
5. Nursing care plan/implementation:
   1. Goal: provide for comfort and safety.
      1. Monitor for infection or trauma; may precipitate myxedema coma, which is manifested by: unresponsiveness, bradycardia, hypoventilation, hypothermia, and hypotension.
      2. Provide warmth; prevent heat loss and vascular collapse.
      3. Administer thyroid medications as ordered: levothyroxine (Synthroid) - most common drug used; liothyronine sodium (Cytomel); dosage adjusted according to symptoms.
   2. Goal: health teaching.
   1. Diet: low calorie, high protein.
   2. Signs and symptoms of hypothyroidism and hyperthyrodism.
   3. Lifelong medications, dosage, desired effects and side effects.
   4. Medication dosage adjustment: take onethird to one-half the usual dose of narcotics and barbiturates.
   5. Stress-management techniques.
   6. Exercise program.
6. Evaluation/outcome criteria:
1. No complications note Most common complications: atherosclerotic coronary heart disease, acute organic psychosis, and myxedema coma.
2. Dietary instructions followed.
3. Medication regimen followed.
4. Thyroid hormone balance obtained and maintained.


17. Cushing’s disease: an endogenous overproduction of adrenocorticotropic hormone (ACTH) that can be caused by pituitary-dependent adenomas. Cushing’s syndrome: condition marked by chronic excessive circulating cortisol with or without pituitary involvement. One of the most common causes of Cushing’s syndrome is the administration of cortisone-like medications for treatment of a variety of conditions.
1. Pathophysiology:
1. Excess glucocorticoid production, leading to:
1. Increased gluconeogenesis —> raised serumglucose levels —> glucose in urine, increased fat deposits in face and trunk.
2. Decreased amino acids —> protein deficiencies, muscle wasting, poor antibody response, and lack of collagen.
2. Risk factors:
1. Adrenal hyperplasia.
2. Excessive hypothalamic stimulation.
3. Tumors: adrenal, hypophyseal, pituitary, bronchogenic, or gallbladder.
4. Excessive steroid therapy.
3. Assessment:
1. Subjective data:
1. Headache, backache.
2. Weakness, decreased work capacity.
3. Mood swings.
2. Objective data:
1. Hypertension, weight gain, pitting edema.
2. Characteristic fat deposits, truncal and cervical obesity (buffalo hump).
3. Pendulous abdomen, purple striae, easy bruising.
4. Moon face, acne.
5. Hyperpigmentation.
6. Impotence.
7. Virilization in women: hirsutism, breast atrophy, and amenorrhea.
8. Pathological fractures, reduced height.
9. Slow wound healing
10. Lab data:
1. Urine: elevated 17-ketosteroids (>12 mg/24 hours) and glucose (>120 mg/dL).
2. Plasma: elevated 17-hydroxycorticosteroids, cortisol (> 10 >p.g/dL). Cortisol does not decrease during the day as it should.
3. Serum: elevated - glucose, RBC, WBC; diminished - potassium, chlorides, eosinophils, lymphocytes.
11. X-rays and scans to determine tumors/ metastasis.
4. Analysis/nursing diagnosis:
1. Body image disturbance related to changes in physical appearance.
2. Activity intolerance related to backache and weakness.
3. Risk for injury related to infection and bleeding.
4. Knowledge deficit related to management of disease.
5. Pain related to headache.
5. Nursing care plan/implementation.
1. Goal: promote comfort.
1. Assist with preparation of diagnostic workup.
2. Explain procedures.
3. Protect from trauma.
2. Goal: prevent complications; monitor for:
1. Fluid balance - I&O, daily weights.
2. Glucose metabolism - blood, urine for sugar and acetone.
3. Hypertension - vital signs.
4. Infection - skin care, urinary tract; check temperature.
5. Mood swings - observe behavior.
3. Goal: health teaching.
1. Diet: increased protein, potassium; decreased calories, sodium.
2. Medications:
   1. Cytotoxic agents: aminoglutethimide (Cytadren), trilostane (Modrastane), mitotane (Lysodren) - decrease cortisol production.
   2. Replacement hormones as needed.
3. Signs and symptoms of progression of disease as noted in assessment.
4. Preparation for adrenalectomy if medical regimen unsuccessful.
6. Evaluation/outcome criteria:
   1. Symptoms controlled by medication.
   2. No complications - adrenal steroids within normal limits.
   3. If adrenalectomy necessary.