Genetics and Altered Immune
Responses
Susan Wise, RNC, PhD
Basic Principles of Genetics
Genes – arranged in a specific formation
along the chromosomes. There are
dominant and recessive traits that are
inherited by offspring.
Chromosomes – 22 pair plus sex
chromosomes. Females have two X
chromosomes and males have one X and
one Y.
DNA – stores genetic information on double
strands.
RNA – stores genetic information on single
strands.
DNA Diagrams
Inheritance Patterns
Autosomal dominant disorders
Autosomal recessive disorders
X-linked disorders
Multifactorial inherited conditions
Autosomal Dominant
Autosomal Dominant Conditions:
• Huntington Disease
• acondroplasia (short-limbed
dwarfism)
• polycystic kidney disease
Autosomal Recessive
• Cystic fibrosis
• Tay-Sachs
• hemochromatosis
Sickle Cell Disease
• phenylketonuria (PKU)
X-linked Dominant
Disorders
• some forms of retinitis pigmentosa
• Chondrodysplasia Punctata
• hypophosphatemic rickets
X-linked Recessive
Disorders
• Duchenne muscular dystrophy
• hemophilia A
• X-linked severe combined immune
disorder (SCID)
• some forms of congenital deafness
Conditions with
multifactorial inheritance:
• Alzheimers disease
• heart disease
• some cancers
• neural tube defects
• schizophrenia
• IDDM
Genetic Testing
May determine a mutation or
predisposition to a condition
Blood sample
Buccal smear
Amniocentesis
Chorionic villus sampling
Advise caution for patients
Stem cell research
Parkinson’s disease
Alzheimer’s disease
Heart disease
Diabetes mellitus
Spinal cord injuries
Stroke
Burns
Osteoarthritis
Rheumatoid arthritis
Immune System Overview
Function – major defense against
infectious organisms and abnormal or
damaged cells
Defends against bacteria, viruses,
fungi and parasites
Removes and destroys
damaged/dead cells
Identifies and destroys malignant
cells
Types of Immunity
Active (long lasting) body made antibodies
Natural (innate)
Chicken pox, measles, mumps
Artificial
Immunizations
Passive (short lived) body did not make antibodies
Natural
Mother to child
Artificial
Injection of serum from immune person - IgG
Diagram of Immunities
Lymphatic System
Parts:
Lymph nodes
Spleen
Thymus gland
Tonsils
Lymphoid tissue
Bone marrow
Cells Involved in
Immune Response
Phagocytes
Lymphocytes
B lymphocytes
T lymphocytes
T cytotoxic cells
T helper
T suppressor
Natural killer cells
Cytokines
Cytokines act as messengers between T cells, B cells,
monocytes, and neutrophils.
At least 100 different cytokines
Interleukins
Augments the immune response
Interferons (Betaseron)
Multiple sclerosis, leukemia, melanoma, multiple
myeloma
Tumor Necrosis
Kills tumor cells
Colony-Stimulating Factors (Neupogen)
Neutropenia
Erythropoetin (Epogen, Procrit)
Anemia
Immunity
Humoral
Cell-Mediated
Immunity
Humoral – antibody-mediated, found in
plasma
Pathogen enters body
B lymphocyte recognizes antigen
B lymphocyte differentiates into plasma cells
Mature plasma cells secrete immunoglobulins
(antibodies)
Memory cells remain
Successive exposures trigger memory cells to
rapidly produce antibodies
Immunity
Cell-mediated
Antigen recognition by T cells,
macrophages
Immunity against pathogens that live inside
cells (viruses)
Fungal infections
Rejection of transplanted tissues
Contact hypersensitivity reactions
Tumor immunity
Factors Affecting Immunity
Age
Nutrition
Medications
Stress
Virulence of the pathogen
Altered Immune Response
Hypersensitivity Reactions – immune response
is overreactive against foreign antigens or fails
to maintain self-tolerance
Type I – anaphylaxis, allergic rhinitis,
asthma
Type II – cytotoxic (transfusion reaction)
Type III – immune-complex reactions
(lupus, RA)
Type IV – delayed hypersensitivity
(transplant rejection, contact dermatitis)
Care of Patients
Anaphylaxis
Patent airway
Remove allergen if possible
Epinephrine
Oxygen
Elevate legs
Keep warm
Histamine blockers – Benadryl, Tagamet
Support BP with fluids, vasopressors
Allergic Disorders
Assessment
Health history
Physical assessment
Diagnostic Studies
CBC with diff, ESR,
CRP
Skin tests
Cutaneous scratch or
prick
Intracutaneous
injection
Care of Patients
Chronic Allergies
Recognize and control
Avoid
Drug Therapy
Antihistamines
Decongestant meds
Corticosteroids
Antipruritics
Immunotherapy
Rarely needed
Desensitization SQ, slowly increased, 1-2 years
Latex Allergies
8% to 17% of
health care
workers
Type IV –
contact
dermatitis
Type I – may
be mild or up
to anaphylaxis
Multiple Chemical Sensitivities
An acquired disorder
Multiple body systems
Wide range of symptoms
Physical evidence may be lacking
Fatigue
Headache
Pain
Dizziness
Mouth irritation
Disorientation
Cough
Autoimmunity
Inappropriate reaction to self-proteins
Genetic susceptibility
Trigger is required
Apherisis
Plasmapheresis (plasma exchange)
Autoimmune diseases
Systemic lupus erythematosus
Rheumatoid arthritis
Scleroderma
Multiple sclerosis
Glomerulonephritis
Guillan-Barré syndrome
Rheumatoid Arthritis (RA)
Chronic
Inflammatory
Autoimmune disorder
Causes the immune system to attack the joints
Disabling and painful
Can lead to substantial
loss of mobility due to
pain/joint destruction.
systemic disease
skin
blood vessels
heart
lungs
muscles
Spondyloarthropathies
A family of chronic diseases of joints.
can occur in children and adults.
inclosing spondylitis
Reiter's syndrome (reactive arthritis)
psoriatic arthritis
joint problems associated with inflammatory bowel disease
(enteropathic arthritis)
All of them:
sacroiliac joint
Affect areas around the joint where your ligaments and
tendons attach to bone such as at the knee, foot, or hip.
Spondyloarthropathies are different from rheumatoid
arthritis (RA) in adults and juvenile rheumatoid arthritis
(JRA) in children
Lyme Disease
Borrelia burgdorferi
Bite of infected blacklegged ticks
Symptoms
Fever
Headache
Fatigue
Characteristic skin rash called erythema migrans
If left untreated, infection can spread to joints, the
heart, and the nervous system
Most cases of Lyme disease can be treated
successfully with a few weeks of antibiotics
Steps to prevent Lyme disease include using insect
repellent, removing ticks promptly, landscaping, and
integrated pest management.
Gout
also called metabolic arthritis
congenital disorder of uric acid
metabolism
monosodium urate or uric acid
crystals are deposited on the
articular cartilage of joints, tendons
and surrounding tissues due to
elevated concentrations of uric acid
in the blood stream
Gout
Systemic Lupus Erythematosus
body's natural defense system attacks its own tissues
This causes inflammation
Inflammation causes swelling, pain, and tissue
damage throughout the body
Kidneys
Heart
Lungs
nervous system
blood cells
Although some people with lupus have only mild
symptoms, the disease is lifelong and can become
severe.
Systemic Sclerosis
Injury to the cells that line blood vessels
(endothelial cells)
Excessive activation of the dermal
connective tissue cells, the fibroblasts
Fibroblasts normally produce collagen and
other glycosamine proteins
Factors that may trigger
Raynaud phenomenon
usually the first symptom of systemic sclerosis
episodes of vasospasm
Raynaud Phenomenon
Fibromyalgia
chronic condition
widespread pain in your muscles, ligaments
and tendons
fatigue and multiple tender points
more common in women than in men
Other names include fibrositis, chronic
muscle pain syndrome, psychogenic
rheumatism and tension myalgias.
isn't progressive or life-threatening
Organ Transplantation
Allograft - tx from same species
Autograft – tx from self
Xenograft – tx from different
animal species
Domino transplant – both lungs
and heart. Heart to someone else.
Major Organs and Tissues
Transplanted
Thoracic organs
Other organs
Tissues
Cells
Fluids
Acute Tissue Rejection
Most common and treatable
Recipient’s T lymphocytes attack organ
Occurs days to months after transplant
Prevent - use of antimetabolites or anti-inflammatory
medications prior to surgery
Treat with immunosuppressants and steroids
Elevated BUN, creatinine, liver enzymes, bilirubin, and
cardiac enzymes.
Fever, redness, swelling, and tenderness over graft site.
Chronic Rejection
Antibody-mediated response
Occurs months to years post transplant
Resembles chronic inflammation and scarring. Tissue is
fibrotic and scar-like tissue.
Organ in not able to perform function.
Antibodies and complement are deposited in the
transplant vessel walls, causing narrowing and decreased
organ function. Scaring caused by chronic ischemia from
blood vessel injury.
Changes are permanent and irreversible.
Back on the transplant list.
Graft-versus-host disease (GVHD)
Fatal complication; not a close match.
Blood transfusion. Bone marrow transplant
Occurs within the first 100 days of transplant.
T cells in graft recognize host as foreign and attack.
Affects skin, liver, and GI. A pruritic rash begins on
hands and feet, and it may
spread, abdominal pain,
nausea, bloody diarrhea.
More organs involved, poorer
prognosis.
No adequate treatment
Immunosuppressive Therapy
Calcineurin inhibitors - cyclosporine
(Sandimmune, Neoral, Gengraf) and
tacrolimus (Prograf)
Corticosteroids – prednisone,
methlprednisolone (Solu-Medrol)
Mycophenolate mofetil (CellCept)
Sirolimus (Rapamune)
Often used in combinations
Altered Protection
HANDWASHING
Reverse isolation
Monitor vital signs, assess wound, I/O, * urine
output
Any unusual signs report, immunosuppression
can delay elevated labs and fever.
Avoid infection – wear mask
Adequate hydration and nutrition
Oral hygiene
Infections
Causes of infections
Bacterial, viral, parasitic
Emerging infections
Lyme disease, Ebola hemorrhagic fever
Reemerging infections
TB
Antibiotic-Resistant organisms
MRSA, VRE
Nosocomial infections
10% of hospital patients
35% are preventable
Infection Precautions
Standard precautions
Airborne precautions
Contact precautions
Droplet precautions
Leukopenic precautions
Clinical Management of HIV
Disease in Adults
First recognized 25 years ago.
First decade - prevention and treatment of the
infectious complications.
Second decade - effective antiretroviral therapies.
“Lazarus effect” - 1996 - highly active antiretroviral
therapy (HAART).
1997 the incidence of many opportunistic diseases
declined dramatically
During the last several years in this decade, new
drugs with less adverse effects and in more
convenient dosing schedules
25,000,000
More than 25
million
people have
died of AIDS
since 1981.
Africa has 12
million AIDS
orphans
HIV/AIDS is
100%
preventable
Still Many Underserved
Opportunistic infections and progression to AIDS is still
occurring among key members of our global society,
namely
Undiagnosed or untreated
Disenfranchised or marginalized
Under-treated
Unempowered (e.g., women)
Impaired (e.g., psychiatric or addicted members of society)
Nonadherent patients
Patients in third-world countries who do not have access to
HAART
Patients not under the care of an HIV-specialist or experienced
HIV provider
Patients who are just starting treatment
People for whom antiretroviral therapy has failed
HAART - Highly Active
Anti-Retroviral Therapy
Rapid, significant improvement in immune function in HIV-
infected patients
Patient’s lives have been extended substantially
Dramatic reductions in the incidence of many opportunistic
diseases
Pneumocystis jiroveci pneumonia (PCP)
cytomegalovirus retinitis
mycobacterium avium complex
cytomegalovirus infection
cryptosporidiosis
Primary HIV
Infection/Seroconversion
• Two to six weeks after an exposure to HIV, a newly infected person
will develop a high level of viral load (measured by HIV/RNA plasma
levels)
• About 50% to 90% of these people will manifest as “mononucleosis-
like.”
• “Seroconversion” illness”
• Primary infection manifests in a variety of ways
•Mild fever, myalgia
•Arthralgia, lymphadenopathy
•Anorexia, pharyngitis
•Weight loss
•Rash
•Meningitis
Patients are Partners in Care
Patients need to be considered full partners
in care.
Patients must be fully apprised of the risks
and benefits as well as their
responsibilities
Issues of drug toxicity, pill burden, dosing
time constraints, drug-nutrient
interactions, and the unwavering
commitment to adhere to complex
medication schedules
Goals of Therapy
Prolongation of life and improved quality of life.
The greatest possible reduction in viral load
Immune system reconstitution that is quantitative and
qualitative
Rational sequencing of drugs that achieve virologic goals
but also:
Maintains therapeutic options
Relatively free of adverse effects
Realistic with regard to probability of
adherence.
The epidemiologic goal is the reduction of HIV
transmission
Adverse Effects of Treatment
Dyslipidemia and Lipodystrophy
A syndrome consisting of altered fat
distribution within the body and
metabolic abnormalities, such as
hyperlipidemia
First described in 1998
Fat Redistribution
Changes in the placement of visceral
fat to the
Trunk (truncal obesity)
Neck (buffalo hump)
Especially in women, the breasts
Subcutaneous fat is lost in the
Face (e.g., “facial wasting”)
Extremities
The buttocks
Nurses - HIV
CDC has documented 32 cases of
occupationally transmitted HIV in health
care workers, including 12 nurses. And
investigated another 69 cases, including
14 nurses.
These are reported cases. Many
exposures go unreported for fear of
discrimination or loss of confidentiality.
Nurses - Hepatitis B
HBV. . . is more readily transmitted: 8,700
health care workers each year contract
hepatitis-B on the job; more than 200 die.
A safe and effective vaccine is now available;
many employers must provide it for free
If you are not yet vaccinated, don't wait. Begin
the series of three shots now, so you can begin
building immunity to this deadly disease
Nurses – Hepatitis C
HCV. . . is a growing threat to nurses.
Infection with HCV appears to carry a
great potential for chronic liver disease.
Antibody tests have been developed to
detect the virus, but the number of
health care workers infected is not
known.
No vaccine is currently available.
Nursing Care of Clients with
Endocrine Disorders
Nursing Assessment
Susan Wise, RNC, PhD
Endocrine System - Review
Secrete hormones directly into the
circulation where they bind to specific
receptors in target tissues
Nervous system is linked to the endocrine
system
Negative feedback is the most common
feedback system in hormonal regulation
Endocrine
System
Specific Major Glands
Pituitary
Anterior
Posterior
Islet cells of the pancreas
Thyroid
Parathyroid
Adrenal
Gonads (testes and ovaries)
Hormones
Anterior pituitary gland
Thyroid stimulating hormone (TSH)
Thyroid gland
T3 and T4
Calcitonin
Adrenocorticotropic (ACTH)
Adrenal gland
CORTEX
Glucocorticoid (cortisol)
Mineralocorticoid (aldosterone)
Androgen
MEDULLA
Catecholamines
Hormones
CORTEX
Glucocorticoid
(cortisol)
Mineralocorticoid
(aldosterone)
Androgen
MEDULLA
Catecholamines
Hormones
Anterior pituitary
Growth (GH)
Prolactin (PRL)
Luteinizing hormone (LH)
Follicle-stimulating hormone (FSH)
Posterior pituitary gland
Antidiuretic (ADH) and oxytocin
Hormones
Parathyroid glands
Parathyroid
hormones
Hormones
Pancreas
B (beta cells)
secrete insulin
A (alpha cells)
secrete
glucagon
Physical assessment
Perform a complete history and
physical assessment.
Inspection
Palpation
Auscultation
Percussion
Specific tests to rule out
hypoparathyroidism or hypocalcemia
Chvostek sign
Trosseau sign
Diagnostic Tests
Direct Tests
Example - radioimmunoassay
Indirect Tests
Example – blood glucose
Provocative Tests
Stimulation tests (stimulate an underactive
gland)
ACTH stimulation test
Suppression tests (suppress an overactive gland)
Dexamethasone suppression test
Diagnostic Tests
Thyroid function studies
MRI, CT, thyroid ultrasound, thyroid scan
RAI Uptake
Pituitary structure and function
Skull x-ray, MRI, CT
Adrenal gland
CT, MRI, adrenal venogram, angiography
Nursing Care of Clients with
Pituitary Problems
Susan Wise, RNC, PhD
ANTERIOR PITUITARY GLAND -
Excess of Growth
Hormone
Gigantism in children
Acromegaly in adults
ACROMEGALY
Enlarged hands/feet
Joint pains/arthritis
Coarse facial features
HTN/cardiomegaly
Visual disturbances
Sleep apnea
Glucose intolerance
Gigantism
Acromegaly
Acromegaly
Diagnosis
Oral glucose tolerance test
Management
Hypophysectomy
Transfrontal approach
Transsphenoidal approach
Acromegaly
Radiation
Drug therapy
Somatostatin analogs
Octreotide (Sandostatin)
Dopamine agonists
Bromocriptine (Parlodel)
GH receptor antagonists
Pegvisomant (Somavert)
Nursing Care
Psychosocial issues
Physiological needs
Perioperative care
Avoid coughing, sneezing, bending,
straining, brushing teeth
Surgical dressing
Clear nasal drainage
Hormone replacement
Prolactinomas
Prolactin-secreting adenoma or tumor
Manifestation
♀ (Female)
Galactorrhea
Infertility
Decreased libido
♂ (Male)
Decreased libido
Impotence
Infertility
Hypopituitarism
Hypofunction of the pituitary gland
Panhypopituitarism
Deficiency of all pituitary hormones
Common deficiencies
Growth hormone
Gonadotropins (LH & FSH)
Most life-threatening deficiencies
TSH
ACTH
Hypopituitarism
Growth hormone deficiency
Non-specific findings
LH and FSH deficiency
♂- loss of libido, testicular failure, decreased facial hair
♀- irregular menstruation, loss of libido, breast size
Treatment
Surgery or radiation for tumor
Hormone replacement
Hormone Replacement
Hormone replacement
Growth hormone
Somatropin (Genotropin, Humatrope)
Gonadotropins
Testosterone
Estrogen and progesterone
Posterior Pituitary Gland
Anti Diuretic Hormone
Excess
Syndrome of Inappropriate ADH (SIADH)
Deficiency
Diabetes Insipidus (DI)
SIADH
ADH released despite normal plasma
osmolarity
Mostly caused by malignancies
Manifestations
Hyponatremia
Water intoxication
Weight gain and low output
SIADH
Diagnosis
serum sodium levels 1.005
Treatment
Fluid restriction
Hypertonic saline IV
Demeclocycline (Declomycin)
Diabetes Insipidus
Diabetes Insipidus
Deficiency of ADH (vasopressin)
Manifestations
Polyuria (very dilute)
Polydipsia
Diagnosis
Fluid/water deprivation test
Diabetes Insipidus
Treatment
Replace ADH
DDAVP
Fluid replacement
Correct underlying cause
Nursing care
Monitoring hydration
Administration of hormone replacement
Teaching
Disorders of the Thyroid Gland
T3 and T4 (thyroid
hormones) and calcitonin
Thyroid Disorders
Hyperthyroidism
Hypothyroidism
Inflammation
Enlargement (goiter)
Hyperthyroidism
thyroid hormone
Most common
forms
1. Grave’s disease
Autoimmune
Presents with
thyrotoxicosis
2. Toxic nodular
goiter
Manifestations
See
Thyrotoxicosis
Thyrotoxicosis
Diagnosis
TSH level
free T4 level
RAI uptake > 50%
Treatment
Antithyroid medications
Radioactive Iodine therapy
Subtotal thyroidectomy
Anti -Thyroid Drug Therapy
Anti thyroid drug therapy-
propylthiouracil (PTU)
methimazole (Tapazole)
large doses of iodine
Brand names - SSKI; Lugol’s solution
IODISM
Side-effect: hypothyroidism
Interaction with anticoagulants
Radioactive Iodine
Radioactive Iodine (RAI)
Preferred treatment for non-pregnant
adults
Disadvantages
Hypothyroidism
Delayed therapeutic effects
adrenergic blockers
Propranolol (Inderal)
Care of the Hyperthyroid Client
Nutrition - caloric intake
Eye care
Rest
Preventing thyrotoxicosis (thyroid
crisis or thyroid storm)
Subtotal thyroidectomy
Thyroidectomy
Perioperative Care
Supporting head/neck, coughing, and
deep breathing
Emergency equipment
Complications
Larnygeal nerve damage
Tracheal compression
Hemorrhage
Laryngeal spasms from hypocalcemia
Hypothyroidism
Common causes
Iodine deficiency (world-wide)
Atrophy of thyroid gland (US)
End-result of autoimmune conditions
Grave’s disease
Hashimoto’s thyroiditis
Thyroid treatment
Goitrogenic food
Hypothyroidism
Clinical s/s related to
slowing of body
processes
Goiter
Fluid retention/edema
Anorexia/weight gain
Dry skin/coarse hair
Constipation
Cold intolerance
Mental changes
Slow speech-
depression-
impaired memory
Many older adults are
misdiagnosed.
Hypothyroidism
Myxedema
Myxedema
Diagnosis
Serum TSH and free T4
Serum T3 and T4
TRH stimulation test
Treatment
Hormone replacement
Levothyroxine (Synthroid)
Myxedema coma
Patient Teaching
Thyroid hormone replacement
When to take it
Signs and symptoms to report
Do not change brands
Life-long therapy
Skin care
Constipation
Avoid cold, sedatives, stressors
Other thyroid conditions
Simple goiter
Thyroiditis
Hashimoto’s
Viral, bacterial, or fungal
Thyroid nodules
Thyroid cancer
Disorders of the Parathyroid Glands
Disorders of the Parathyroid Glands
Hyperparathyroidism
secretion of parathyroid hormone
(PTH)
Primary, secondary, or tertiary
Major manifestations
Osteoporosis/fractures
Kidney stones
Muscle weakness
Hyperparathyroidism
Diagnosis
PTH, Ca+, phosphorous
Treatment
Conservative
Keep active; fluids; moderate calcium
Drugs (Fosamax), estrogen
Parathyroidectomy
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Hypoparathyroidism
circulating PTH
Most common cause is iatrogenic
Manifestations are related to serum
calcium
Tingling of lips, hands, feet
Muscular spasms
+ Chvostek and Trosseau signs
Hypoparathyroidism
Diagnosis
serum Ca++ and serum phosphorous
Treatment
IV calcium (emergency)
Calcium and Vitamin D supplements
No hormone replacement
DISORDERS OF THE ADRENAL
GLANDS (Cortex)
Hypercortisolism
(Cushing’s
Syndrome)
corticosteroids,
particularly
cortisol
due to various
causes
Clinical s/s result
from cortisol
excess
Cushing’s syndrome
Diagnosis
Serum and urine cortisol
Dexamethasone or ACTH suppression
test
Treatment
Surgery
Drugs to suppress adrenal activity
Cushing’s syndrome
Treatment
If on steroid therapy
gradually discontinue
dose reduction
alternate-day regimen
Focus of care
Fluid volume excess
Risk for injury/fall
Altered skin integrity
Risk for infection
Disturbed body image
Adrenalectomy
Preop
Check glucose and K+ levels
Vitamins and proteins for tissue repair
Asepsis
Post-op
Give IV steroids as prescribed
Monitor BP, I and O and electrolytes
Teach
Steroid replacement
Adrenal crisis
Adrenocortical Insufficiency
(Addison’s disease)
Chronic deficiency of
adrenal cortex
hormones
Most common cause
autoimmune.
Manifestations
aldosterone -
hypotension
cortisol -
hypoglycemia
androgen - Φ
pigmentation
Addison’s disease
Diagnosis
ACTH stimulation test using cosyntropin
cortisol levels
Treatment
Steroid replacements
Glucorticoid (cortisol) replacement
Hydrocortisone (Cortef)
Mineralcorticoid (aldosterone)
Fludrocortisone (Florinef)
Steroid Therapy
Glucocorticoids
Give 2/3 dose in AM
Give 1/3 in late PM
Mineralocorticods
Give in AM
Take po steroids with
meals.
Avoid stress, infection,
and extremes in
temperature. If under
stress, increase dose.
Wear Medic-Alert
bracelet.
Carry an emergency kit.
Addisonian crisis
Precipitating factors
Manifestations
fever, severe weakness, low BP, vascular
collapse, lactic acidosis
Treatment
rapid IV fluid replacement
high-dose cortisone
Disorder of the Adrenal Medulla-
Pheochromocytoma
Tumor that secretes catecholamines
Epinephrine and norepinephrine
Manifestations
Tachycardia, angina, palpitation
Hypertension, pallor, epigastric pain
Diagnosis
catecholamines
+ vanillylmandelic acid (VMA)
Treatment
adrenalectomy
Nursing Images
The following images were from Memory
Notebook of Nursing images (2001) by
Zerwekh, J. et al. Nursing Education
Consultants, Inc.
Volume I
Hyperthyroidism
Hypothyroidism
Addison’s disease
Cushing’s syndrome
Volume II
Corticosteroids