MedSurg 3 - Thyroid, Parathyroid Glands' Problem (Chap 66) Flashcards
Hyperthyroidism
= a common endocrine disorder.
= excessive thyroid hormone secretion.
Signs of hyperthyroidism is called thyrotoxicosis, regardless of the cause.
- stimulates most body system:
- causing hypermetabolism
- increased sympathetic nervous system (SNS) activity
- Thyroid hormone stimulates the heart, increasing both HR and Stroke volume. – these response increase CO, Systolic BP, and blood flow.
Hyperthyroidism
- Pathophysiology
- Affects Protein, Lipid, and Carbohydrate metabolism.
== With hyperthyroidism, protein synthesis and degradation (breakdown) are increased, but breakdown exceeds buildup, causing a net loss of body protein known as a NEGATIVE NITROGEN BALANCE.
== Glucose tolerance is decreased, and the patient has hyperglycemia.
== Fat metabolism is increased, and body fat decreases.
** Although the patient has an increased appetite, the increased metabolism causes weight loss and nutritional deficiency
== Has increased libido
Hyperthyroidism
- Etiology
- GRAVES’ DISEASE aka Toxic Diffuse Goiter – most common cause of hyperthyroidism.
- TOXIC Multinodular Goiter is another cause.
- Exogenous Hyperthyroidism (excessive use of thyroid replacing hormone)
Hyperthyroidism and Graves’ disease
- Pathophysiology
- Graves disease can occur at any age but is diagnosed more often in women between 20 to 40 yrs-old.
- Women is affected 10X more than men.
- Graves’ Disease is an autoimmune disorder in which antibodies Thyroid-stimulating Immunoglobulins (TSIs) are made and attach to the Thyroid-stimulating hormone (TSH) receptors on the thyroid tissue.
- The thyroid gland responds by increasing the number and size of the glandular cells, which enlarge the gland, forming a GOITER, and overproduces thyroid hormones (Thyrotoxicosis).
Hyperthyroidism caused by Graves’ disease
- Manifestation
- EXOPHTHALMOS – abnormal protrusion of the eyes
- PRETIBIAL MYXEDEMA - dry, waxy swelling of the front surfaces of the lower leg
** Not all patients with goiter has hyperthyroidism
Hyperthyroidism caused by Toxic Multinodular Goiter
- Manifestation
- Toxic Multinodular Goiter usually occurs after age 50.
- Affects women 4X more than men.
- The nodules may be enlarged thyroid tissues or benign tumors (ADENOMAS).
- These patients usually have had the goiter for years.
- The overproduction of thyroid hormones is milder than that seen in Graves’ disease
- NO Exophthalmos nor Pretibial edema
Hyperthyroidism
- Assessment & Clinical Manifestation
- record age, gender, & usual weight
- assess unplanned weight loss
- Increased appetite and increased number of bowel movements per day
- Heat intolerance (hallmark of hyperthyroidism)
- Diaphoresis (even when temp is comfortable for others)
- Palpitations or Chest Pain may be reported
- Breathing pattern (dyspnea w/out exertion is common)
- Change is vision (blurring or double vision and tiring of the eyes)
- Change in energy level to perform ADL
- Fatigue, Weakness & Insomnia are common
Hyperthyroidism
- Assessment & Clinical Manifestation (con’t)
- Irritable or depressed
- Changes is menses (AMENORRHEA, decrease in menstrual flow is common)
- Increased in LIBIDO, but this changes as patient becomes more fatigued
- Ask about patient’s medical history (previous thyroid surgery) or radiation therapy to the neck because some people remain hyperthyroid after surgery or are resistant to radiation therapy
- Ask about past and current drugs, esp thyroid hormone replacement or anti-thyroid drugs
Hyperthyroidism
- Assessment & Clinical Manifestation (con’t)
- Exophthalmos (Only with Graves’ disease)
- The wide eyed or “startled” look is due to edema in the extraocular muscles and increased fatty tissue behind the eye, which pushes the eyeball forward.
- Pressure on the optic nerve may impair vision
- Swelling and shortening of the muscles may cause problems with focusing.
- if the eyelid fails to close completely and the eye is unprotected, the eye may become overly dry and develop corneal ulcers or infection.
- Observe patient’s eyes for excessive tearing and a bloodshot appearance.
- Ask about sensitivity to light (PHOTOPHOBIA)
Hyperthyroidism
- Assessment & Clinical Manifestation (con’t)
Two other eye problems common in all types of hyperthyroidism:
- EYELID TRACTION (Eyelid lag)
- Upper eyelid fails to descend when the patient gazes slowly downward.
- GLOBE (Eyeball) Lag
- Upper eyelid pulls back faster than the eyeball when the patient gazes upward.
** Ask patient to look down and then up, and document the response.
Hyperthyroidism
- Assessment & Clinical Manifestation (con’t)
- In goiter, thyroid gland may increase 4X its normal size.
- Goiter is common in Graves’ disease.
- BRUITS (turbulence from increase blood flow) may be heard in the neck.
- Cardiovascular Problem:
- Increased Systolic BP
- Tachycardia
- Dysrythmia
- Diastolic BP is usually decreased, causing a widened pulse pressure
Hyperthyroidism
- Assessment & Clinical Manifestation (con’t)
- Hair and Skin
- Fine, soft, silky hair, and smooth
- Warm, Moist Skin are common
- Muscle weakness and hyperactive deep tendon reflexes are common
- Tremors of the hands
- Restless, Irritable and Fatigued
Hyperthyroidism
- Psychosocial Assessment
- Wide mood swings
- Irritability
- Decreased attention span
- Manic behavior
- Insomnia
- Hyperactivity often leads to fatigue because of the inability to sleep. “Two Modes” – either “Full Speed Ahead” or “Completely Stopped”
- Ask if patient cries or laughs without cause
- Difficulty concentrating
Hyperthyroidism
- Laboratory Assessment & Diagnosis
Testing for hyperthyroidism:
- Triiodothyronine (T3)
- Thyroxine (T4)
- T3 Resin Uptake (T3RU)
- Thyroid Stimulating Hormone (TSH)
Testing for Graves’ Disease Diagnosis:
– Antibodies to TSH (TSH-RAb)
Hyperthyroidism
** THYROID SCAN **
- Assess if the patient has undergone procedures that might affect the result of the scan.
- Procedures that use iodine-containing dye (Ex. renography) should NOT be performed for at least 4 weeks before a thyroid scan is done.
- Any drug that contains iodine should be discontinued for 1 week before the scan.
- Thyroid Scan
- evaluates position, size, and functioning of the thyroid gland
- Radioactive Iodine (RAI) is given by mouth, and the uptake of the iodine by the thyroid gland (Radioactive Iodine Uptake- RAIU) is measured.
- The half-life of RAI is short (radiation precaution is NOT needed)
- Pregnancy should be ruled out before scan is performed
- Normal thyroid has an uptake of 5% to 35% of the given dose in 24 hrs. RAIU is INCREASED in hyperthyroidism.
Hyperthyroidism
- ULTRASONOGRAPHY
- ULTRASONOGRAPHY can determine its size and the general composition of the masses or nodules.
– takes 30 min to perform and painless
Hyperthyroidism
- Electrocardiography (ECG)
- Electrocardiography (ECG) usually shows tachycardia.
- Atrial Fibrillation may be seen
- Dysrythmia
- P and T waveform changes
Hyperthyroidism
- Interventions
- To decrease the effect of thyroid hormone on Cardiac Function and to reduce thyroid secretions
- Focus on:
- monitoring for complications
- reducing stimulation
- promoting comfort
- teaching patient and family about drugs and procedures
Hyperthyroidism
- Non-surgical Management
- Prevent THYROID STORM **
- Monitor Apical Pulse, BP, Temperature at least Q4H.
- Increase in temperature may indicate a rapid worsening of the patient’s condition and the onset of a THYROID STORM, a life threatening event that occurs with uncontrolled hyperthyroidism.
- THYROID STORM is characterized by high fever and severe hypertension
- Keep patient’s room at risk for thyroid storm COOL, DARK, & QUIET
- Immediately report a temperature increase of even 1 degree Fahrenheit !!!
- If a temperature elevation is reported, immediately assess CARDIAC STATUS.
- If patient has cardiac monitor, check for DYSRYTHMIAS
- Instruct patient to report ASAP any Palpitations, Dyspnea, Vertigo, Chest Pain
Hyperthyroidism
- Non-surgical Management
- REDUCE STIMULATION **
- Reducing Stimulation
- Encourage rest
- keep room quiet
- limit visitors
- postpone nonessential care or treatments.
** Noisy or stressful environment can increase the manifestations of hyperthyroidism and increase the risk for cardiac complications.
Hyperthyroidism
- Non-surgical Management
- PROMOTE COMFORT **
- PROMOTE COMFORT
- reduce room temperature
- Fresh pitcher of Ice water
- Change bed linen whenever damped from diaphoresis
- Cool Shower or sponge bath several times a day
- Prevent eye dryness == use artificial tears and tape eyelids for sleep
Hyperthyroidism
- Non-surgical Management
- DRUG TREATMENT – Thionamides **
- DRUG TREATMENT is the initial treatment for hyperthyroidism.
- THIONAMIDES (preferred drug):
- Blocks TH production by preventing iodide binding in the thyroid gland.
- PTU also inhibits conversion of T4 to T3
- Response is delayed bec patient may have large amounts of stored TH that continue to be released.
- Improvement seen within 2 weeks, but take weeks before metabolism returns to normal
- can result to HYPOthyroidism, close monitoring for dose adjustment
- (Propylthiouracil or PTU)
- Methimazole (Tapazole) – lower than PTU doses but response is delayed
Hyperthyroidism
- Non-surgical Management
- DRUG TREATMENT – Lithium **
- Lithium also inhibits thyroid hormone release.
- Use of Lithium is limited because of side effects:
- Depression
- Diabetes Insipidus
- tremors
- Nausea & Vomiting
** Lithium may be used for a patient who cannot tolerate other antithyroid drugs.
Hyperthyroidism
- Non-surgical Management
- DRUG TREATMENT – Beta Blockers **
- Beta Adrenergic Blockers such as Propanolol (Inderal) may be used as supportive therapy
- Beta Blockers relieve diaphoresis, anxiety, tachycardia, and palpitations BUT DO NOT inhibit thyroid hormone production.
Hyperthyroidism
- Non-surgical Management
- Radioactive Iodine (RAI) Therapy **
- Radioactive Iodine (RAI) Therapy not used in pregnant women bec it can cross the placenta and can damage the fetal thyroid gland.
- The dosage depends on the size and sensitivity to radiation
- The thyroid gland picks up the RAI, and some of the cells that produce thyroid hormone are destroyed by the local radiation.
- Because the thyroid gland stores thyroid hormones to some degree, the patient may not have complete symptom relief until 6 to 8 weeks after RAI therapy, so additional drug therapy is still needed during the first few weeks after RAI treatment.
Hyperthyroidism
- Non-surgical Management
- Radioactive Iodine (RAI) Therapy **
- RAI therapy is performed on outpatient basis.
- One dose may be sufficient, but some may need 2nd or 3rd dose.
- The radiation is Low and usually completely eliminated within a month, however, some radioactivity is present in the patient’s body fluids and stool for a few weeks after therapy.
- Radiation precautions are needed to prevent exposure to family members and other people.
Hyperthyroidism
- Non-surgical Management
- Radioactive Iodine (RAI) Therapy **
The degree of thyroid destruction varies. Some patients become hypothyroid as a result of a treatment. This problem may occur within a few weeks, or it may take several years to develop. The patient then needs LIFELONG thyroid hormone replacement.
** All patients who have undergone RAI therapy should be monitored regularly for changes in thyroid function.
Hyperthyroidism
- Surgical Management -
- Total or Subtotal Thyroidectomy – under general anesthesia**
Antithyroid drugs & RAI therapy are the most common treatments of hyperthyroidism.
- Surgery to remove all or part of the thyroid gland may be needed for patients who have a large goiter causing tracheal or esophageal compression or who do not have a good response to antithyroid drugs.
- Total or Subtotal Thyroidectomy of the thyroid tissue decreases the production of thyroid hormones.
- After a Total Thyroidectomy, patient must take lifelong thyroid hormone replacement.
Hyperthyroidism
- Pre-operative Care -
- If possible, patient is treated with a drug therapy (using antithyroid drugs) first to have a near-normal thyroid function (EUTHYROID) before thyroid surgery.
- Also, give iodine preparations to decrease thyroid size and vascularity, thereby reducing the risk for hemorrhage and the potential for thyroid storm during surgery.
Hyperthyroidism
- Pre-operative Care - (con’t)
- Hypertension, tachycardia, and dysrhythmias must be controlled before surgery.
- Patient is often not in optimal weight and may need to follow a high-protein, high carbohydrate diet for days or weeks before surgery.
Hyperthyroidism
- Post-Op Teaching
- Cough and breathing exercises
- Importance of supporting the neck when coughing or moving by placing both hands behind the neck to reduce the strain on the suture line.
- Explain that hoarseness may be present for a few days as a result of endotracheal tube placement during surgery.
- Explain that a drain and dressing may be in place after surgery.
Hyperthyroidism
- Post-Op Care
- Monitor VS every 15 min until stable then every 30 min for 24 hrs.
- Semi-fowler position when patient is awake
- Avoid neck extension
- Humidify air to promote easier respiration and thins respiratory secretions
- Assist in cough and deep breathe every 30 min to 1 hr.
- Suction oral and tracheal secretions if needed
Hyperthyroidism
- Post-Op Care - Preventing Complications
– Thyroid surgery can cause hemorrhage, respiratory distress, parathyroid gland injury (resulting in hypocalcemia and tetany, damage to the laryngeal nerves, and thyroid storm.
** remain alert on potential complications and identify manifestation early
Hyperthyroidism
- Post-Op Care - Preventing Complications
- ** Hemorrhage ***
- inspect dressing & behind the neck for signs of bleeding
- Drain and moderate amt of serosangueneous drainage is ok
** Hemorrhage is seen in incision site or as respiratory distress caused by tracheal compression
Hyperthyroidism
- Post-Op Care - Preventing Complications
- ** Respiratory Distress ***
- due to tracheal compression, swelling, tetany, or damage to the laryngeal nerve
- STRIDOR - heard in acute respiratory obstruction
- Notify Rapid Response Team
- tracheostomy equipment must be kept in the room
- Make sure Oxygen and Suctioning equip are available in the room and are functioning
Hyperthyroidism
- Post-Op Care - Preventing Complications
- ** Hypocalcemia and Tetany ***
- Assess TINGLING around mouth, toes, & fingers HOURLY
- Muscle Twitching is a sign of hypocalcemia
- Rx of calcium Gluconate or Calcium Chloride IV for emergency situation
Hyperthyroidism
- Post-Op Care - Preventing Complications
- ** Laryngeal Nerve Damage ***
- Hoarseness & Weak Voice
- Assess voice EVERY 2 HRS
*Reassure patient that hoarseness is usually Temporarry.
Hyperthyroidism
- Post-Op Care - Preventing Complications
- ** THYROID STORM or thyroid Crisis ***
– a Life threatening event occurs with uncontrolled hyperthyroidism ( most often in Graves’ dz.)
– Triggered by TRAUMA, INFECTION, DKA, & PREGNANCY
* Other Triggers:
= Vigorous palpation of the goiter
= Exposure to iodine
= RAI therapy
** Although Thyroid Storm after surgery is less common bec patients receive antithyroid drugs, beta blockers, and iodides before thyroid surgery, it can still occur.
THYROID STORM
- Signs and Symptoms
- KEY S/S:
- Fever
- Tachycardia
- Systolic Hypertension
- May have GI sypmtoms:
- abdominal pain,
- N & V,
- Diarrhea
- Anxious & Tremors
- Restless, Confusion, Psychotic
- Seizures, Coma & may lead to Death
THYROID STORM
- Intervention
- Focus on:
- Airway
- Ventilation
- Reduce Fever
- Stabilize hemodynamically
Eye & Vision Problem of GRAVEs’ Disease
– Intervention
Note that Eye/Vision problem is NOT corrected by treatment of Graves’ Disease !!
- Elevate HOD at night
- Use artificial Tears
- For Photophobia, wear sunglasses, or eye patches
- For those who cannot close eyes, tape the lids with non-allergenic tapes at bedtime to prevent injury
- Short term steroid - Prednisone (Deltasone)
- Diuretics for edema
- Orbital decompression (surgery)
** If pressure behind the eye continues and forces the eyes forward, blood supply to the eye can be compromised, leading to ISCHEMIA and BLINDNESS.
HYPERTHYROIDISM
– Teaching
- Teach for S/S
- Report increase or re-occurrence of symptoms
- Teach need for TH replacement for the rest of life if Total Thyroidectomy is done
- Importance of regular Follow Up
- Teach S/S of HYPOThyroidism ( may occur even years after RAI therapy)
HYPOTHYROIDISM
– Pathophysiology
- S/S result from Decreased metabolism from low levels of THs.
- Thyroid Cells fail to produce sufficient levels of THs
– Cells may be damaged & no longer function
– Cells may function but not enough iodine and tyrosine are ingested to make THs
Low TH levels in blood – decreased metabolic rate
Hypothalamus and anterior pituitary make stimulating hormones, esp TSH – body tries to trigger hormone release from the poorly responsive thyroid gland
TSH binds to thyroid cells – causes gland to enlarge – forms a goiter- TH production does NOT increase
HYPOTHYROIDISM
– Pathophysiology (con’t)
- Most tissues & organs affected by low metabolism
- Build up of metabolites inside cells – glycosaminoglycans – increases mucus & water – forms cellular edema & changes cellular organ texture
- Myxedema – changes the person’s appearance
- Nonpitting edema everywhere – voice husky
HYPOTHYROIDISM
– Pathophysiology (con’t)
** MYXEDEMA COMA **
- MYXEDEMA COMA – rare serious complication of untreated or poorly treated hypothyroidism
- Heart flabby - decreased CO - decreased perfusion of vital organs
- Leads to tissue & organ failure
- Mortality rate for myxedema coma very high considered a life-threatening emergency
- Myxedema coma – caused by a number of events, drugs, & conditions.
Hypothyroidism: Etiology
- Due to thyroid surgery for hyperthyroidism
- RAI therapy for hyperthyroidism
- Common in areas with little iodide in soil & water – endemic goiter
- Iodide added to table salt
Hypothyroidism: Incidence/Prevalence
- Women b/w 30 & 60
- Women 7 to 10 X more often than men
- Association b/w hypothyroidism and diabetes mellitus
Increases with age
Hypothyroidism:
- Assess HISTORY
- Activity level reduced
- More time sleeping
- Generalized weakness, anorexia, muscle aches, & paresthesias
- Constipation
- Cold intolerance
- Decrease in libido
- Women - changes in menses; may have infertility
- Men may have impotence & fertility
- Current & past drug use esp amiodarone (Cordarone)
- Prior Rx for hyperthyroidism
HYPOTHYROIDISM:
– Physical Assessment/Clinical Manifestations
- Change facial features – coarse features, edema around eyes and face, blank expression, & thick tongue
- Slow muscle movement
- Speech not clear
- Longer to respond to questions
- Reduced cardiac & respiratory functions; P < 60; R slow
Temp < 97° F - Weight gain
- May have goiter = can have goiter + hypothyroidism
HYPOTHYROIDISM:
– Psychosocial Assessment
- Depression
- Lethargic, apathetic, or drowsy – unable to recognize changes in own condition
- Withdrawn
- Reduced mental function
- Impaired attention span & memory
- Social isolation
HYPOTHYROIDISM:
– Laboratory Assessment
- Triiodothyronine (T3)
& thyroxine (T4) are
decreased - TSH high in primary hypothyroidism but decreased or near NL in secondary hypothyroidism
- Over 80 – may have lower THs without S & S
HYPOTHYROIDISM:
– Goal / Interventions
- Improving oxygenation
- Preventing hypotension
- Supporting cognition
- Preventing myxedema coma
HYPOTHYROIDISM: Intervention
– Improving Oxygenation
- Observe & record respiratory rate & rhythm
- Pulse oximetry – check for hypoxemia
- Auscultate lung sounds
- Severe hypothyroidism – may have severe respiratory distress & may need ventilatory support
- Respiratory distress often occurs with myxedema coma
- Sedation, if needed, with reduced dose as more sensitive to these drugs
HYPOTHYROIDISM: Intervention
– Preventing hypotension
Monitor for changes in BP, heart rate & rhythm
Monitor for signs of shock, such as BP, urinary output, and ∆ LOC
Teach patient to report chest pain STAT
Started on synthetic hormone replacement Levothyroxine (Synthroid)
HYPOTHYROIDISM: Intervention
– Preventing hypotension (con’t)
- Levothyroxine (Synthroid)
- Started in low doses
- Gradually increased over a few weeks
- If dose too high – can cause severe HTN, HF, and MI
- Take the drug exactly as prescribed; do NOT change the dose or schedule without consulting the HCP
- Ask about CP & dyspnea with initial doses
HYPOTHYROIDISM: Intervention
– Supporting cognition
-Observe for and document lethargy, drowsiness, memory deficit, poor attention span, & difficulty communicating
- Mental awareness usually returns in 2 weeks
- Orient to person, place, & time and explain all procedures
Safe environment
- Family may have difficulty coping with patient ‘s behavior
HYPOTHYROIDISM: Intervention
– Preventing myxedema coma
- Increased Risk:
- Newly diagnosed hypothyroidism
- Any other health problem
- Factors that may lead to myxedema
- Acute illness
- Surgery
- Chemotherapy
- D/C thyroid replacement therapy
- Use of sedatives or opioids
- Rx instituted quickly
HYPOTHYROIDISM: Intervention
– Preventing myxedema coma
(Emergency Care of the Patient During Myxedema Coma)
- Maintain patent airway
- Replace fluids w/ IV normal or hypertonic saline
- Give Levothyroxine Sodium IV
- Give Glucose IV
- Give Corticosteroids
- Check pt’s temperature hourly
- Monitor BP hourly
- Cover pt w/ warm blanket
- Monitor for changes in mental status
- Turn every 2 hrs
- Institute aspiration precaution
HYPOTHYROIDISM: Intervention
- Community Based Care
- Home Care Management
- One-floor living is fatigue & activity intolerance
- Discuss how to handle cold intolerance
- Help with drug regimen; may need plan & person to take responsibility for meds
HYPOTHYROIDISM: Intervention
- Community Based Care
- Teaching for Self-Management
- Need for lifelong drugs
- S & S of hypo and hyperthyroidism
- Medic alert bracelet
- Need to follow-up care – dosage adjustment; periodic blood tests
- No OTC drugs due to interactions
- Diet to prevent constipation; no fiber supplements as interfere with absorption of TH
- Adequate rest
- Take TH on empty stomach
- Time required for resolution of hypothyroid S & S varies
- Self-monitoring of therapy effectiveness – esp sleep and constipation
