THYROID DISORDERS
HYPERTHYROIDISM
HYPOTHYROIDISM
PATHOPHYSIOLOGY
• thyroid hormone secretion leads to
hyperthyroidism
• What you see in this is called: thyrotoxicosis
WHAT DO THYROID HORMONES
AFFECT?
• Metabolism in all body organs
• Stimulate the heart
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heart rate
stroke volume
cardiac output
blood flow
HYPERTHYROIDISM
INCREASED THYROID HORMONES:
• Hypermetabolism
• sympathetic nervous system activity
• Effects protein, lipid and carbohydrate
metabolism
EFFECTS ON PROTEIN METABOLISM
• Protein synthesis and degradation
• More breakdown than buildup
• Leads to loss of protein
• Called negative nitrogen balance
EFFECTS ON GLUCOSE
• Glucose tolerance decreased
• Leads to hyperglycemia
EFFECTS ON FAT METABOLISM
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fat metabolism
body fat
appetite
food intake; food intake does not meet energy
demands
•
weight
•
nutritional deficiencies with prolonged disease
CAUSES
GRAVES DISEASE:
• Client has a goiter (enlarged thyroid gland (p1484)
• Autoimmune problem
• Antibodies attach to gland causing it to enlarge
• SYMPTOMS:
– exophthalmos (protrusion of the eyes) p1484)
– Pretibial myxedema (dry, waxy swelling of the frontal
surfaces of the lower legs)
•
ADDITIONAL CAUSES OF
HYPERTHYROIDISM
1. TOXIC MULTINODULAR GOITER: multiple thyroid
nodules, milder disease
2. EXOGENOUS HYPERTHYROIDISM: excessive use of
thyroid replacement hormones
3. THYROID STORM: untreated or poorly controlled
hyperthyroidism; life threatening
WHO GETS IT
• Most often women between 20-40 yrs
ASSESSMENT
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Recent wgt loss
Increased appetite
Increase in # BM/day
****heat intolerance
Diaphoresis even when temperatures comfortable
for others
• Palpitations/chest pain
• Dyspnea with or without exertion
ASSESSMENT
VISUAL PROBLEMS MAY BE EARLIEST PROBLEM:
• Infiltrative Exophthalmopathy (abnormal eye
appearance or function)
• Blurring/double vision/tiring of eyes
• Increased tears
• Photophobia
• Eyelid retraction(eyelid lag) (p1483)
• Globe lag (eyeball lag) (p1483)
GOITER
• Thyroid gland may be 4 X normal
• Bruits (turbulence from increased blood flow)
heard with stethoscope
CARDIAC PROBLEMS
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systolic BP
tachycardia
dysrhythmia
FURTHER SYMPTOMS
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Fine, soft, silky hair
Smooth, moist skin
Muscle weakness
Hyperactive deep tendon reflexes
Tremors of hands
Restless, irritable, mood swings
Decreased attention span
Fatigued, inability to sleep
LABORATORY ASSESSMENT
IN HYPERTHYROIDISM:
• T3
• T4
• TSH in Graves disease
•
Radioactive Thyroid Scan
• Ultrasonography: used to determine goiter or
nodules
• EKG: note tachycardia
DRUG THERAPY
• ***antithyroid drugs: thioamides
– propylthiouracil (PTU)
– methimazole (Tapazole)
– carbimazole (Neo-Mercazole)
• ACTION: blocks thyroid hormone production; takes
time
Need to control cardiac manifestations (tachycardia,
palpitations, diaphoresis, anxiety) until hormone
production reduced: use beta-adrenergic blocking
drugs: propranolol (Inderal, Detensol)
DRUG THERAPY
Iodine preparations:
• Lugol’s Solution
• SSKI (saturated solution of potassium iodide)
• Potassium iodide tablets, solution, and syrup
ACTION:
– decreases blood flow through the thyroid gland
– This reduces the production and release of thyroid
hormone
– Takes about 2 wks for improvement
– Leads to hypothyroidism
DRUG THERAPY
• Lithium Carbonate
• ACTION: inhibits thyroid hormone release
• NOT USED OFTEN BECAUSE OF SIDE EFFECTS:
depressions, diabetes insipidus, tremors, N&V
DRUG THERAPY
RADIOACTIVE IODINE THERAPY:
• Receives RAI in form of oral iodine
• Takes 6-8 Weeks for symptomatic relief
• Additional drug therapy used during this type
of treatment
• Not used on pregnant women
SURGICAL MANAGEMENT
Why use surgery?
• Used to remove large goiter causing tracheal or
esophageal compression
• Used for pts who do not have good response to
antithyroid drugs
TWO TYPES OF SURGERIES:
1. Total thyroidectomy (must take lifelong thyroid
hormone replacement)
2. Subtotal thyroidectomy
PREOPERATIVE CARE
Low weight:
• Hi protein, hi CHO diet for days/weeks before
surgery
PRE-OPERATIVE CARE
1. Antithyroid drugs to suppress function of the
thyroid
2. Iodine prep (Lugols or K iodide solution) to
decrease size and vascularity of gland to minimize
risk of hemorrhage, reduces risk of thyroid storm
during surgery
3. Tachycardia, BP, dysrhythmias must be controlled
preop
PREOPERATIVE TEACHING
• Teach C&DB
• Teach support neck when C&DB
• Support neck when moving reduces strain on
suture line
• Expect hoarseness for few days (endotracheal
tube)
POST-OP THYROIDECTOMY NURSING
CARE
1.
2.
3.
4.
5.
VS, I&O, IV
Semifowlers
Support head
Avoid tension on sutures
Pain meds, analgesic lozengers
POSTOP THYROIDECTOMY NURSING CARE
• Humidified oxygen, suction
• First fluids: cold/ice, tolerated best, then soft
diet
• Limited talking , hoarseness common
• Assess for voice changes: injury to the
recurrent laryngeal nerve
POSTOP THYROIDECTOMY NURSING CARE
• CHECK FOR
HEMORRHAGE 1st 24 hrs:
• Look behind neck and
sides of neck
• Check for c/o pressure or
fullness at incision site
• Check drain
• REPORT TO MD
• CHECK FOR RESPIRATORY
DISTRESS
• Laryngeal stridor (harsh hi
pitched resp sounds)
• Result of edema of glottis,
hematoma,or tetany
• Trach set/airway/ O2,
suction
• CALL MD for extreme
hoarseness
TETANY
• accidental removal of the parathyroid gland during
surgery can happen
• This disturbs the Ca metabolism
• low blood calcium: see hyper-irritability of the
nerves, spasms of the hands and feet, muscle
twitchings occur, tingling, around mouth/toes/fingers
• RISK: laryngospasm, airway obstruction
• TREAT: IV calcium gluconate or calcium chloride
POSTOP NURSING CARE
CHECK FOR THYROID STORM: 25% mortality rate
• result of release of TH during surgery
• Observe for fever, tachycardia, systolic hypertension,
agitation leading to seizures, delirium and coma, heart
failure and shock
TREAT:
• Patent airway, cardiac monitor
• Antithyroid drugs IV: PTU, propyl-Thyracil, Tapazole,
sodium iodide solution
• Inderal, Detensol for cardiac symptoms
• Glucocorticoids (hydrocortisone IV)
• Antipyretics and cooling blanket for fever
HYPOTHYROIDISM
Decreased levels
of
Thyroid Hormone
CAUSES
• Cells damaged; no longer function
• Cells might be normal, person doesn’t ingest
enough iodide & tyrosine needed to make
thyroid hormones
SYMPTOMS
• Blood levels of thyroid hormones are low
• Decreased metabolic rate
• Hypothalamus and anterior pituitary gland
make stimulatory hormones (TSH) as
compensation
• Thyroid gland enlarges forming goiter
MYXEDEMA DEVELOPS
• With low metabolism metabolites build up inside the
cells which increases mucous and water leading to
cellular edema
• Edema changes client’s appearance
• Nonpitting edema appears everywhere especially
around the eyes, hands, feet, between shoulder
blades
• Tongue thickens, edema forms in larynx, voice husky
INCIDENCE OF HYPOTHYROIDISM
• 30-60 yrs of age
• Mostly women
ASSESSMENT
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Increased sleeping (14-16 hours daily)
Generalized weakness
Anorexia
Muscle aches
Paresthesias
Constipation
Cold intolerance
Decreased libido, woman:difficulty becoming
pregnant, changes in menses;men/impotence
ASSESSMENT
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Coarse features
Edema around eyes and face
Blank expression
Thick tongue
Overall muscle movement is slow
Lethargic, apathetic, drowsy, poor attention
span, poor memory
LABORATORY ASSESSMENT
• T3
• T4
• TSH
DRUGS THAT IMPAIR THYROID
FUNCTION
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lithium carbonate (Lithane)
Aminoglutethimide
Sodium or potassium perchlorate
Thiocyanates
cobalt
NURSING DIAGNOSES
NURSING INTERVENTIONS
• EXPECTED OUTCOMES:
– Maintains HR greater than 60/min
– Maintains BP within normal limits
– No dysrhythmia, peripheral edema, neck vein
distension
TREATMENT
LIFELONG THYROID HORMONE REPLACEMENT
• levothyroxine sodium (Synthroid, T4, Eltroxin)
• IMPORTANT: start at low does, to avoid
hypertension, heart failure and MI
• Teach about S&S of hyperthyroidism with
replacement therapy
MYEXEDEMA COMA
• Rare serious complication of untreated
hypothyroidism
• Decreased metabolism causes the heart muscle
to become flabby
• Leads to decreased cardiac output
• Leads to decreased perfusion to brain and other
vital organs
• Leads to tissue and organ failure
• LIFE THREATENING EMERGENCY WITH HIGH
MORTALITY RATE
PROBLEMS SEEN WITH MYXEDEMA
COMA
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Coma
Respiratory failure
Hypotension
Hyponatremia
Hypothermia
hypoglycemia
TREATMENT OF MYEXEDEMA COMA
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Patent airway
Replace fluids with IV NSSS
Give levothyroxine sodium IV
Give glucose IV
Give corticosteroids
Check temp, BP hourly
Monitor changes LOC hourly
Aspiration precautions, keep warm
PARATHYROID DISORDERS
HYPERPARATHYROIDISM
HYPOPARATHYROIDISM
RESPONSIBILITY OF GLANDS
• Maintain calcium and phosphate balance
INCREASED PTH
EFFECTS ON KIDNEY
• acts directly on the kidney causing increased
kidney reabsorption of calcium and increased
phosphate excretion
• Leads to hypercalcemia and
hypophosphatemia
INCREASED PTH
EFFECTS ON BONE
• Increase bone resorption (bone loss of
calcium)
• by decreasing osteoblastic (bone production)
activity and increasing osteoclastic (bone
destruction activity)
• This process releases Ca and phosphate into
the blood and reduces bone density
CHRONIC CALCIUM EXCESS
• Calcium is deposited in soft tissues
CAUSES OF HYPERPARATHYROIDISM
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Tumors
Trauma
Radiation
Vit D deficiency
Chronic renal failure with hypocalcemia
ASSESSMENT
High levels of PTH:
• Cause renal calculi
• Pathologic fractures
• Osteoporosis
High levels of Calcium:
• Anorexia, N/V, constipation, wgt loss, peptic
ulcers
• Fatigue/lethargy
• Mental confusion, psychosis, coma, death if
serum Ca greater than 12 mg/dL
LABORATORY ASSESSMENT
Serum calcium elevated:
• normal range: 9-10.5mg/dL
Serum phosphate decreased:
• Normal 3.0-4.5mg/dL
Serum parathyroid hormone increased:
• Normal 50-330 pg/ml
NONSURGICAL MANAGEMENT
GOAL: reduce serum calcium levels
• Hydration: IV saline in large volumes promotes
renal excretion of calcium
• Diuretics: furosemide (Lasix, Uritol) - increases
kidney excretion of calcium
INTERVENTIONS
• Assess cardiac function and I&O q2-4 hrs
during hydration therapy
• Continuous cardiac monitoring
• Close monitoring of serum calcium levels
reporting precipitous drops to MD
• Sudden drops may lead to tingling/numbness
in muscles
DRUG THERAPY
PHOSPHATES:
• oral phosphates inhibit bone resorption and
interfere with calcium absorption
• IV only used when serum calcium levels need
rapid lowering
DRUG THERAPY
CALCITONIN:
• Decreases the release of calcium and
increases the kidney excretion of calcium
• Best effect when combined with
glucocorticoids
DRUG THERAPY
CALCIUM CHELATORS:
• Lower calcium levels by binding (chelating) calcium which
reduces the levels of free calcium
FIRST EXAMPLE: mithramycin (cytotoxic agent), one IV dose
can lower serum calcium in 48 hrs
• DANGER: THROMBOCYTOPENIA, increased tendency to
bleed, kidney and liver toxicity
SECOND CALCIUM CHELATOR: penicillamine (Cuprimine,
Pendramine)
SURGICAL REMOVAL OF PARATHYROID
GLAND
• Used to manage hyperparathyroidism
• Surgery similar to that of removal of thyroid
gland
HYPOPARATHYROIDISM
PATHO
• Rare disorder
• Parathyroid function decreased
• Either lack of PTH secretion or lack of
effectiveness of PTH secretion
• End Result: hypocalcemia
Caused by:
• removal of glands during thyroidectomy,
• or hypomagnesemia (seen in alcoholics or chronic
renal disease, or malnutrition); causes
impairment of PTH secretion
ASSESSMENT
• Mild tingling and numbness due to tetany
• Tingling and numbness around the mouth or in the
hands and feet reflect mild to moderate
hypocalcemia
• Severe muscle cramps, carpopedal spasms, and
seizures (with no loss of consciousness or
incontinence), mental changes from irritability to
psychosis reflect a more severe hypocalcemia)
ASSESSMENT
• Positive signs indicating potential tetany
CHVOSTEK’S SIGN: sharp tapping over facial
nerve causes twitching of mouth, nose and
eye
TROUSSEAU’S SIGN: carpopedal spasm induced
by application of BP cuff
LABORATORY ASSESSMENT
• EEG
• CT scan (shows brain cacifications from
chronic hypocalcemia)
• Serum calcium:
• Serum phosphate:
• Serum magnesium:
• Serum vitamin D:
INTERVENTIONS
• CORRECT HYPOCALCEMIA: IV calcium with 10%
solution of calcium chloride or calcium gluconate
over 10-15 minutes;
• then long term oral therapy Calcium 0.5-2G daily
• Oral calcium: OSCAL
Calcium gluconate
Calcium lactate
Calcium carbonate
INTERVENTIONS
CORRECT VITAMIN D DEFICIENCY: large doses of vit D to
increase absorption of Calcium; acute treated with
calcitriol (Rocaltrol)
CORRECT HYPOMAGNESEMIA: acute is treated with
50% magnesium sulfate either IM or IV
• Then long term is treated with 50,000 to 400,000
Units of ergocalciferol daily
INTERVENTIONS
• DIET: high in calcium, low in phosphorus
• Avoid milk, yogurt and processed cheeses because of
high phosphorus content
• aluminun hydroxide (Amphogel) with or before
meals to decrease phosphate levels
• THERAPY FOR HYPOCALCEMIA IS LIFELONG
• WEAR MEDIC ALERT