Chapter 66: Thyroid And Parathyroid Flashcards
Hyperthyroidism
Hyper metabolism and increased SNS activity. Stimulate heart:increase HR, CO, BP(systolic) and blood flow.
Negative nitrogen balance (protein metabolized too fast)
Hyperglycemia
Fat metabolism increased>wt loss
Increased libido.
Heat intolerance. Diaphoresis. Tachycardia. Chest pains or palpitations. Vision changes. Fatigue, weakness, insomnia. Irritable or depression. Possible amenorrhea. Stop to silky hair, smooth warm moist skin. Muscle weakness. Hyperactive reflexes. Moodswings.
Thyrotoxicosis
Manifestations of too much thyroid hormone
Graves’ disease
Toxic diffuse goiter
Exophthalmos
Pretibial myxedema (dry waxy swelling front legs)
Autoimmune
Toxic multinodule goiter
Hyperthyroidism caused by thyroid nodules.
Enlarge tissue or benign tumors.
They usually have had a goiter for years.
No exophthalmos or pretibial edema
Exogenous hyperthyroidism
Caused by too many replacement thyroid hormones
Thyroid storm or thyroid crisis
Occurs when it is untreated, poorly controlled, or with severe stress. It can be life-threatening. Most common with Graves’ disease. Manifestations include fever, tachycardia, and systolic hypertension. Possible G.I. problems. Possible anxiety in tremors. They may become psychotic and have seizures leading to coma and even death.
Emergency care includes maintaining the airway, administering thyroid medications, administer sodium iodide, give propranolol slowly over three minutes and monitor with a cardiac monitor. Get glucocorticoids. Monitor for dysrhythmias. Monitor vital signs q30 min. Provide comfort measures such as a cooling blanket. Give nonaspirin antipyretic’s. Correct dehydration with normal saline. Reduce fever
Goiter classification
Zero: no palpable or visible goiter.
One: mass is not visible in normal position. Can be palpated and moves up when the patient swallows.
Two: mass is visible swelling. Goiter is easily palpated and is usually asymmetric
Labs
T3 70-205 or 1.2 - 3.4 units
T4. 4-12 or 51-154 units
Thyroid scan
Iodine is swallowed. Radiation precautions are not needed. Pregnancy should be rule out. The thyroid should take 5 to 35% of the dose within 24 hours. Procedures using iodine die should not be performed for four weeks before the thyroid scan. Any drug containing iodine should be discontinued for one week.
Nonsurgical management for hyperthyroidism
Monitor vital signs closely report an increase of temperature even 1°. Reduce stimulation and encourage rest. Promote comfort. Medication therapy is the initial treatment. PTU (immune supression, report dark urine, notifynif cold and wt gain, q8hrs) and Tapazole preferred trtmnt. They block production of thyroid hormone that their response may be delayed because of the stored amount of the hormone. Lithium may be used if other meds are not tolerated. Radioactive iodine therapy may be given to destroy some cells that produce thyroid hormone.
Surgical treatment of hyperthyroidism
Total or subtotal thyroidectomy. They may need hormone replacement afterwords. Medications are used before surgery to maintain normal levels and decreased the size of the thyroid. Hypertension and dysrhythmias must be controlled. Hoarseness maybe present for a few days.
Post operative care is to monitor for complications. Use sandbags or pillows to support the neck, maintain a semi Fowler’s position, avoid neck extension, humidified air. Respiratory distress can result from swelling or damage causing spasms. Be prepared. Hypocalcemia and Tetany can occur if the parathyroid glands are damaged. Keep calcium gluconate available. Thyroid storm is possible.
Management of exophthalmus
Elevate the head of the bed at night and use artificial tears. Dark glasses for photophobia. Tape lids closed at bedtime. Possible short for steroid therapy. Diuretics maybe used to decrease edema. Possible orbital decompression
Hypothyroidism
Decrease metabolism. Iodide and tyrosine is needed to make thyroid hormones. Possible goiter. Myxedema(edema that is mucinous) appears everywhere. Increase sleeping, weakness, anorexia, muscle aches, constipation, cold intolerance, decrease in libido, impotence and infertility, Decreased heart rate and respiratory rate. Weight gain. Depression.
Myxedema coma
A rare serious complication of untreated or poorly treated hypothyroidism in which decreased metabolism causes the heart muscle to become flabby and the chamber size to increase, resulting in decreased cardiac output and decrease perfusion to the brain and other vital organs. Mortality rate is high and it is a life threatening emergency.
Factors that can cause this includes acute illness, surgery, chemotherapy, discontinuing thyroid replacement therapy, the use of sedatives or opioids. Problems that occur include coma, respiratory failure, hypotension, hyponatremia, hypothermia, hypoglycemia.
Treatment includes maintaining airway, replacing fluids with normal or hypotonic saline. Give levothyroxine IV. Give glucose IV. Give corticosteroids. Take temperature hourly. Blood-pressure hourly. Warm linens. Changes in mental status. Turn every two hours. Aspiration precautions.
Nursing diagnoses for hypothyroidism
Ineffective breathing pattern. Decreased cardiac output. Disturbed thought processes. Additional include imbalance nutrition. Hypothermia. Constipation. Disturbed body image. Deficient knowledge
Nursing diagnoses for hyperthyroidism
In balanced nutrition less than required. Hyperthermia. Fatigue from sleep deprivation. Potential for hypertension and cardiac failure
Thyroid hormone replacement
The most important educational need for hypothyroidism is about hormone replacement therapy and it lifelong need. Where a medical alert bracelet. Over-the-counter drugs may interact with meds. Increase fiber and fluid. The two easiest things to check for treatment effectiveness is sleep pattern and bowel elimination. Constipation or increase need for sleep means the medication may need to be increased.
Thyroiditis
Inflammation of the thyroid gland. Chronic thyroiditis also known as Hashimoto’s disease is the most common. Usually triggered by bacterial or viral infection. Parts of the gland are destroyed resulting in decreased production. Manifestations include dysphagia and painless enlargement. Diagnosis is based on the anti-body and a needle biopsy.
Acute thyroiditis is from bacterial invasion. Pain, neck tenderness, malaise, fever, dysphagia. Treated with antibiotics.
Subacute thyroiditis is from a viral infection after a cold or upper respiratory. Fever, chills, dysphasia, muscle and joint pain that can radiate ears and jaw. Thyroid feels hard and enlarged. It can cause hyper or hypo
Hyperparathyroidism
Parathyroid maintains calcium and phosphate balance. Parathyroid hormone acts directly on the kidney increasing reabsorption of calcium and increased phosphate excretion. This causes hypercalcemia and hypophosphatemia. Stimulates bone to release calcium and reduces bone density.
Bone fractures, weight-loss, arthritis, psychological distress, kidney stones, bone lesions, osteoporosis, anorexia, nausea and vomiting, epigastric pain, constipation, Fatigue, lethargy, if calcium is greater than 12 possible psychosis and Coma.
Diuretic and hydration therapy to reduce calcium levels. Monitor cardiac function. Prevent injury. Mithramycin is a calcium chelation at works great. Only takes 48 hrs, but is toxic, no more than 2-3 doses. Thrombocytopenia.
Parathyroid labs
Serum calcium normal is 9 to 10.5
Serum phosphate is 3.0 to 4.5.
PTH 50-330
Parathyroidectomy
Calcium levels must be decreased before hand. Clotting times needed if on mithramycin. Talking maybe painful for a couple days. Support neck. Respiratory distress from compression of the trachea or swelling. Hypocalcemia crisis can occur. Assessed calcium level frequently such as every four hours. Tingling in twitching in the extremities and face can be a sign. Evaluate voice.
For hyperplasia which is overgrowth 3 1/2 glands are removed. A portion of a gland may be re-implanted in the arm to maintain calcium levels.
Hypoparathyroidism
Hypocalcemia occurs. Iatrogenic hyperparathyroidism, the most common, is from removal of parathyroid tissue. Idiopathic occurs spontaneously and unknown cause. Hypomagnesemia can cause it. This is seen in alcoholics and malabsorption, chronic kidney, malnutrition. Tingling and numbness around the mouth or in the hands and feet reflect mild to moderate hypocalcemia. Severe muscle cramps, spasms of the hands and feet, seizures, reflect a severe hypocalcemia.
Muscle contractions that cause flexion can be seen, checks for chvosteks (tapping facial nerve causes twitch) and trousseaus (inflated BP cuff causes contraction), pits in teeth
Treated with IV calcium over 10 to 15 minutes. Vitamin D is treated with calcipotriol daily. Hypo magnesium is corrected with magnesium sulfate IM or IV. Long-term therapy includes calcium up to 2 g daily in divided doses. Long-term vitamin D deficiency is treated with 50,000 to 400,000 units of ergocalciferol daily.
Eat foods high in calcium the low phosphorus. Milk yogurt in cheeses are avoided because of high phosphorus. Therapy is life wall. Where a medical alert bracelet.
