THYROID DISORDERS

HYPERTHYROIDISMHYPOTHYROIDISM

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 – 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

• 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

• 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

• systolic BP• tachycardia• dysrhythmia

FURTHER SYMPTOMS

• 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 syrupACTION: – 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 drugsTWO 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. VS, I&O, IV2. Semifowlers3. Support head4. Avoid tension on sutures5. 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 CARECHECK 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

• 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

• 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

• 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

• Coma• Respiratory failure• Hypotension• Hyponatremia• Hypothermia• hypoglycemia

TREATMENT OF MYEXEDEMA COMA

• 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

HYPERPARATHYROIDISMHYPOPARATHYROIDISM

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

• Tumors• Trauma• Radiation• Vit D deficiency• Chronic renal failure with hypocalcemia

ASSESSMENT

High levels of PTH:• Cause renal calculi• Pathologic fractures• OsteoporosisHigh 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/dLSerum phosphate decreased:• Normal 3.0-4.5mg/dLSerum 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 THERAPYCALCIUM 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: hypocalcemiaCaused 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 tetanyCHVOSTEK’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 gluconateCalcium lactateCalcium 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