THYROID DISORDERS HYPERTHYROIDISM HYPOTHYROIDISM

1
THYROID DISORDERS

• HYPERTHYROIDISM
• HYPOTHYROIDISM

2
PATHOPHYSIOLOGY

• thyroid hormone secretion leads to
  hyperthyroidism
• What you see in this is called thyrotoxicosis

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WHAT DO THYROID HORMONES AFFECT?

• Metabolism in all body organs
• Stimulate the heart
• heart rate
• stroke volume
• cardiac output
• blood flow

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HYPERTHYROIDISM

• INCREASED THYROID HORMONES
• Hypermetabolism
• sympathetic nervous system activity
• Effects protein, lipid and carbohydrate
  metabolism

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EFFECTS ON PROTEIN METABOLISM

• Protein synthesis and degradation
• More breakdown than buildup
• Leads to loss of protein
• Called negative nitrogen balance

6
EFFECTS ON GLUCOSE

• Glucose tolerance decreased
• Leads to hyperglycemia

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EFFECTS ON FAT METABOLISM

• fat metabolism
• body fat
• appetite
• food intake food intake does not meet energy
  demands
• weight
• nutritional deficiencies with prolonged
  disease

8
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)

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ADDITIONAL CAUSES OF HYPERTHYROIDISM

• TOXIC MULTINODULAR GOITER multiple thyroid
  nodules, milder disease
• EXOGENOUS HYPERTHYROIDISM excessive use of
  thyroid replacement hormones
• THYROID STORM untreated or poorly controlled
  hyperthyroidism life threatening

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WHO GETS IT

• Most often women between 20-40 yrs

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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

12
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)

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GOITER

• Thyroid gland may be 4 X normal
• Bruits (turbulence from increased blood flow)
  heard with stethoscope

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CARDIAC PROBLEMS

• systolic BP
• tachycardia
• dysrhythmia

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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

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LABORATORY ASSESSMENT

• IN HYPERTHYROIDISM
• T3
• T4
• TSH in Graves disease
• Radioactive Thyroid Scan
• Ultrasonography used to determine goiter or
  nodules
• EKG note tachycardia

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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)

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DRUG THERAPY

• Iodine preparations
• Lugols 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

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DRUG THERAPY

• Lithium Carbonate
• ACTION inhibits thyroid hormone release
• NOT USED OFTEN BECAUSE OF SIDE EFFECTS
  depressions, diabetes insipidus, tremors, NV

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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

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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
• Total thyroidectomy (must take lifelong thyroid
  hormone replacement)
• Subtotal thyroidectomy

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PREOPERATIVE CARE

• Low weight
• Hi protein, hi CHO diet for days/weeks before
  surgery

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PRE-OPERATIVE CARE

• Antithyroid drugs to suppress function of the
  thyroid
• 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
• Tachycardia, BP, dysrhythmias must be controlled
  preop

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PREOPERATIVE TEACHING

• Teach CDB
• Teach support neck when CDB
• Support neck when moving reduces strain on suture
  line
• Expect hoarseness for few days (endotracheal tube)

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POST-OP THYROIDECTOMY NURSING CARE

• VS, IO, IV
• Semifowlers
• Support head
• Avoid tension on sutures
• 5. Pain meds, analgesic lozengers

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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

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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

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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

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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

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HYPOTHYROIDISM

• Decreased levels
• of
• Thyroid Hormone

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CAUSES

• Cells damaged no longer function
• Cells might be normal, person doesnt ingest
  enough iodide tyrosine needed to make thyroid
  hormones

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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

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MYXEDEMA DEVELOPS

• With low metabolism metabolites build up inside
  the cells which increases mucous and water
  leading to cellular edema
• Edema changes clients appearance
• Nonpitting edema appears everywhere especially
  around the eyes, hands, feet, between shoulder
  blades
• Tongue thickens, edema forms in larynx, voice
  husky

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INCIDENCE OF HYPOTHYROIDISM

• 30-60 yrs of age
• Mostly women

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ASSESSMENT

• Increased sleeping (14-16 hours daily)
• Generalized weakness
• Anorexia
• Muscle aches
• Paresthesias
• Constipation
• Cold intolerance
• Decreased libido, womandifficulty becoming
  pregnant, changes in mensesmen/impotence

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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

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LABORATORY ASSESSMENT

• T3
• T4
• TSH

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DRUGS THAT IMPAIR THYROID FUNCTION

• lithium carbonate (Lithane)
• Aminoglutethimide
• Sodium or potassium perchlorate
• Thiocyanates
• cobalt

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NURSING DIAGNOSES
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NURSING INTERVENTIONS

• EXPECTED OUTCOMES
• Maintains HR greater than 60/min
• Maintains BP within normal limits
• No dysrhythmia, peripheral edema, neck vein
  distension

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TREATMENT

• LIFELONG THYROID HORMONE REPLACEMENT
• levothyroxine sodium (Synthroid, T4, Eltroxin)
• IMPORTANT start at low does, to avoid
  hypertension, heart failure and MI
• Teach about SS of hyperthyroidism with
  replacement therapy

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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

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PROBLEMS SEEN WITH MYXEDEMA COMA

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

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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

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PARATHYROID DISORDERS

• HYPERPARATHYROIDISM
• HYPOPARATHYROIDISM

46
RESPONSIBILITY OF GLANDS

• Maintain calcium and phosphate balance

47
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

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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

49
CHRONIC CALCIUM EXCESS

• Calcium is deposited in soft tissues

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CAUSES OF HYPERPARATHYROIDISM

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

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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

52
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

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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

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INTERVENTIONS

• Assess cardiac function and IO 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

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DRUG THERAPY

• PHOSPHATES
• oral phosphates inhibit bone resorption and
  interfere with calcium absorption
• IV only used when serum calcium levels need rapid
  lowering

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DRUG THERAPY

• CALCITONIN
• Decreases the release of calcium and increases
  the kidney excretion of calcium
• Best effect when combined with glucocorticoids

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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)

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SURGICAL REMOVAL OF PARATHYROID GLAND

• Used to manage hyperparathyroidism
• Surgery similar to that of removal of thyroid
  gland

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HYPOPARATHYROIDISM
60
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

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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)

62
ASSESSMENT

• Positive signs indicating potential tetany
• CHVOSTEKS SIGN sharp tapping over facial nerve
  causes twitching of mouth, nose and eye
• TROUSSEAUS SIGN carpopedal spasm induced by
  application of BP cuff

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LABORATORY ASSESSMENT

• EEG
• CT scan (shows brain cacifications from chronic
  hypocalcemia)
• Serum calcium
• Serum phosphate
• Serum magnesium
• Serum vitamin D

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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

65
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

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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