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MedSurg - 341 > MedSurg 3 - Thyroid, Parathyroid Glands' Problem (Chap 66) > Flashcards

MedSurg 3 - Thyroid, Parathyroid Glands' Problem (Chap 66) Flashcards

1
Q

Hyperthyroidism

= a common endocrine disorder.

A

= 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.
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2
Q

Hyperthyroidism

- Pathophysiology

A
  • 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

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3
Q

Hyperthyroidism

- Etiology

A
  • 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)
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4
Q

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.
A
  • 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).
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5
Q

Hyperthyroidism caused by Graves’ disease

- Manifestation

A
  • 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

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6
Q

Hyperthyroidism caused by Toxic Multinodular Goiter
- Manifestation

  • Toxic Multinodular Goiter usually occurs after age 50.
  • Affects women 4X more than men.
A
  • 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
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7
Q

Hyperthyroidism

- Assessment & Clinical Manifestation

A
  • 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
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8
Q

Hyperthyroidism

- Assessment & Clinical Manifestation (con’t)

A
  • 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
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9
Q

Hyperthyroidism

- Assessment & Clinical Manifestation (con’t)

A
  • 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)
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10
Q

Hyperthyroidism

- Assessment & Clinical Manifestation (con’t)

A

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.

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11
Q

Hyperthyroidism

- Assessment & Clinical Manifestation (con’t)

A
  • 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
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12
Q

Hyperthyroidism

- Assessment & Clinical Manifestation (con’t)

A
  • 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
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13
Q

Hyperthyroidism

- Psychosocial Assessment

A
  • 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
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14
Q

Hyperthyroidism

- Laboratory Assessment & Diagnosis

A

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)

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15
Q

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.
A
  • 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.
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16
Q

Hyperthyroidism

- ULTRASONOGRAPHY

A
  • ULTRASONOGRAPHY can determine its size and the general composition of the masses or nodules.

– takes 30 min to perform and painless

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17
Q

Hyperthyroidism

- Electrocardiography (ECG)

A
  • Electrocardiography (ECG) usually shows tachycardia.
  • Atrial Fibrillation may be seen
  • Dysrythmia
  • P and T waveform changes
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18
Q

Hyperthyroidism

- Interventions

A
  • 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
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19
Q

Hyperthyroidism

  • Non-surgical Management
    • Prevent THYROID STORM **
A
  • 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
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20
Q

Hyperthyroidism

  • Non-surgical Management
    • REDUCE STIMULATION **
A
  • 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.

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21
Q

Hyperthyroidism

  • Non-surgical Management
    • PROMOTE COMFORT **
A
  • 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
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22
Q

Hyperthyroidism

  • Non-surgical Management
    • DRUG TREATMENT – Thionamides **
A
  • 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
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23
Q

Hyperthyroidism

  • Non-surgical Management
    • DRUG TREATMENT – Lithium **
A
  • 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.

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24
Q

Hyperthyroidism

  • Non-surgical Management
    • DRUG TREATMENT – Beta Blockers **
A
  • 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.
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25
Q

Hyperthyroidism

  • Non-surgical Management
    • Radioactive Iodine (RAI) Therapy **
A
    • 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.
26
Q

Hyperthyroidism

  • Non-surgical Management
    • Radioactive Iodine (RAI) Therapy **
A
    • 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.
27
Q

Hyperthyroidism

  • Non-surgical Management
    • Radioactive Iodine (RAI) Therapy **
A

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.

28
Q

Hyperthyroidism

  • Surgical Management -
    • Total or Subtotal Thyroidectomy – under general anesthesia**
A

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.
29
Q

Hyperthyroidism

- Pre-operative Care -

A
    • 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.
30
Q

Hyperthyroidism

- Pre-operative Care - (con’t)

A
    • 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.
31
Q

Hyperthyroidism

- Post-Op Teaching

A
  • 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.
32
Q

Hyperthyroidism

- Post-Op Care

A
    • 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
33
Q

Hyperthyroidism

- Post-Op Care - Preventing Complications

A

– 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

34
Q

Hyperthyroidism

  • Post-Op Care - Preventing Complications
  • ** Hemorrhage ***
A
    • 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

35
Q

Hyperthyroidism

  • Post-Op Care - Preventing Complications
  • ** Respiratory Distress ***
A
  • 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
36
Q

Hyperthyroidism

  • Post-Op Care - Preventing Complications
  • ** Hypocalcemia and Tetany ***
A
    • 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
37
Q

Hyperthyroidism

  • Post-Op Care - Preventing Complications
  • ** Laryngeal Nerve Damage ***
A
    • Hoarseness & Weak Voice
    • Assess voice EVERY 2 HRS

*Reassure patient that hoarseness is usually Temporarry.

38
Q

Hyperthyroidism

  • Post-Op Care - Preventing Complications
  • ** THYROID STORM or thyroid Crisis ***
A

– 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.

39
Q

THYROID STORM

- Signs and Symptoms

A
  • 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
40
Q

THYROID STORM

- Intervention

A
  • Focus on:
  • Airway
  • Ventilation
  • Reduce Fever
  • Stabilize hemodynamically
41
Q

Eye & Vision Problem of GRAVEs’ Disease

– Intervention

A

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.

42
Q

HYPERTHYROIDISM

– Teaching

A
    • 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)
43
Q

HYPOTHYROIDISM

– Pathophysiology

A
  • 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
44
Q

HYPOTHYROIDISM

– Pathophysiology (con’t)

A
  • 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
45
Q

HYPOTHYROIDISM
– Pathophysiology (con’t)

** MYXEDEMA COMA **

A
  • 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.
46
Q

Hypothyroidism: Etiology

A
  • 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
47
Q

Hypothyroidism: Incidence/Prevalence

A
  • Women b/w 30 & 60
  • Women 7 to 10 X more often than men
  • Association b/w hypothyroidism and diabetes mellitus
    Increases with age
48
Q

Hypothyroidism:

- Assess HISTORY

A
  • 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
49
Q

HYPOTHYROIDISM:

– Physical Assessment/Clinical Manifestations

A
  • 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
50
Q

HYPOTHYROIDISM:

– Psychosocial Assessment

A
  • Depression
  • Lethargic, apathetic, or drowsy – unable to recognize changes in own condition
  • Withdrawn
  • Reduced mental function
  • Impaired attention span & memory
  • Social isolation
51
Q

HYPOTHYROIDISM:

– Laboratory Assessment

A
  • 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
52
Q

HYPOTHYROIDISM:

– Goal / Interventions

A
  • Improving oxygenation
  • Preventing hypotension
  • Supporting cognition
  • Preventing myxedema coma
53
Q

HYPOTHYROIDISM: Intervention

– Improving Oxygenation

A
  • 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
54
Q

HYPOTHYROIDISM: Intervention

– Preventing hypotension

A

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)

55
Q

HYPOTHYROIDISM: Intervention

– Preventing hypotension (con’t)

A
  • 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
56
Q

HYPOTHYROIDISM: Intervention

– Supporting cognition

A

-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

57
Q

HYPOTHYROIDISM: Intervention

– Preventing myxedema coma

A
  • 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
58
Q

HYPOTHYROIDISM: Intervention
– Preventing myxedema coma
(Emergency Care of the Patient During Myxedema Coma)

A
  • 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
59
Q

HYPOTHYROIDISM: Intervention

- Community Based Care

A
  • 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
60
Q

HYPOTHYROIDISM: Intervention

- Community Based Care

A
  • 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

MedSurg - 341 (7 decks)

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