Thyroid and Parathyroid, Ch. 58 (Iggy) Flashcards
-Triiodothyronine (T3)
-Thyroxine (T4)
-Calcitonin.
The body takes iodine from food and converts it into T3 and T4. Calcitonin is produced by C cells and is released based on serum calcium levels.
The 3 hormones the Thyroid secretes
–Thyroid PATHO
What kind of relationship do TSH and T3/T4 have?
-Introverted
If TSH is LOW, then T3/T4 ^ (Hyperthyroidism)
Same for hypothyroidism TSH ^, T3/T4 is LOW
-Has 4 glands
- Secrete PTH to regulate CALCIUM levels
-PTH affects bones, kidneys, and GI tract
-impaired gland fxn causes Hyperparathyroidism (to much PTH) and Hypoparathyroidism (to little PTH)
Parathyroid PATHO
- T3/T4 ^, TSH Low
CAUSES:
-Graves DZ (autoimmune disorder that leads to an overactive thyroid gland)=accounts for 80% of cases
-Thyroiditis, ^Iodine Intake, Pituitary Tumors, and Thyroid Cancer
–The ^T3/T4 causes HYPERMETABOLISM
Hyperthyroidism
(a.k.a. Thyrotoxicosis)
If need to decrease Iodine intake what is a phrase from 1st Semester that makes it easy to remember? (May need to decrease due to gland impairment or meds)
“If it is from the sea, It is not for me”
An autoimmune disorder, often occurring after an episode of thyroid inflammation.
–Causes the production of autoantibodies (thyroid-stimulating hormone- TSI) that attach to thyroid-stimulating hormone (TSH) receptors on the thyroid gland GREATLY ^ production of TSH
Graves’ Disease
An autoimmune disorder that experiences acute flare-ups
–pt.s will often also have other autoimmune disorders like…
Rheumatoid Arthritis (usually attacks joints), Systemic Lupus Erythematosus, and Celiac DZ
Graves’ Disease
What autoimmune disorder could lead to thyroid tissue destruction (atrophy), which leads to hypothyroidism?
**
Graves’ Disease
Do you need precautions for a Radioactive Iodine Uptake (RAIU) thyroid scan? Why?
No
Because the radioactive capsule has a very short half life
-TSH LOW=Grave’s Disease.
-TSH ^ = non-Graves hyperthyroidism.
-T3 and T4 HIGH
—Thyroid SCAN with radioactive iodine uptake (RAIU) helps determine whether the patient has Graves’ disease/ thyroiditis or Hypo/Hyper
–>Iodine is admin. PO or IV. Usually by a capsule containing a radioactive substance the day before the scan. The substance is targeted for absorption by the thyroid gland.
Hyperthyroidism Diagnostics
**Graves’ or Thyroiditis?
S/SX: plus all other possible sx of hyperthyroidism
-Possible GOITER
-EXOPHTHALMOS
—>abnormal protrusion of the eyes; ^ fat deposits and edema in the periorbital area.
–>Permanent
-PRETIBIAL MYXEDEMA
—>dry, waxy swelling of the front surfaces of the lower legs; resembles benign tumors or Keloids
CLINICAL MANIFESTATIONS: Hyperthyroidism due to Graves’
Visibly enlarged thyroid gland
NEVER PALPATE if pt. has sx of HYPERthyroidism; it will stimulate production of TSH/T3/T4 causing Thyroid Storm
-Auscultation reveals BRUIT r/t ^ blood flow to the gland
-CAUSE: TSH binds to thyroid cells=enlargement of gland; TSH does not ^
–Common for many thyroid problems; doesn’t strictly mean Hypo and Hyperthyroidism
Goiter
S/SX: Hypermetabolism
–^ body temp. ; ^ appetite and thirst; N/V ; Weight LOSS; thin hair;
–HTN ; Tachypnea and Dyspnea
Rapid, bounding HR; Dysrhythmias
–Fatigue, weakness
–Insomnia, restlessness, tremors, Muscle Fatigue/Wasting; Finger clubbing
–Heat intolerance (Often 1st sx noticed always hot); Facial flushing
–Hyperglycemia, Diaphoresis
–Manic behaviors (Laugh w/out cause); Increased libido (decreases w/ exhaustion)
–^ Peristalsis=Diarrhea/ ^ BM; Amenorrhea
CLINICAL MANIFESTATION:
Hyperthyroidism
**TSH affects most body systems–>Hypermetabolism and ^ Sympathetic Nervous sx
**Cognitive: either full speed or stopped
Severe overproduction of T3 and/or T4
A life-threatening COMPLICATION.
S/SX:
–critically ^ ,^ BP, and ^body temp.
–Insomnia, delirium, and restlessness.
RISK: Cardiac Dysrhythmias
Com. w/ AID NEED TO KNOW IF TEMP GOES UP BY 1 DEGREE
Thyroid Crisis (Thyroid Storm)
Key S/SX: fever, tachy, and systolic HTN
-Contact provider; do all below while waiting for doc.
-Assess for ^ body temp. by 1
-Lower external stimulation to help prevent ^ in sx
-Lower body with ice packs or cooling blanket
-ADMIN Beta Blocker
“-olol” med
-IF TEMP RISE IMMEDIATELY assess cardiac status and check for dysrhythmias
INTERVENTIONS: Thyroid Crisis (Thyroid Storm)
PropylThioUracil (PTU)
**Antithyroid Agent
*DOC for thyroid crisis/storm
REPORT: darkening of the urine or SX of Jaundice = possible liver toxicity or failure, a serious side effect
REPORT: fever or sore throat
TEACH: s/sx of hypoTH= ^wt., low HR, Cold intolerance=> lower dose needed
MED: Hyperthyroidism
Propylthiouracil (PTU)
THINK: “Put the Thyroid Underground”
THERAPY: Results in Hypothyroidism
—Limits thyroid hormone production by destroying thyroid tissue. Prevents T3 and T4 production and decreases thyroid vascularity to make it safe for surgery.
–For GOITER surgery=Lowers vascularity to limit Risk of hemorrhage
**3 months for the effects to be seen.
Requires precautions: Pt. is Radioactive for >2wk. Toxic to other humans; all body fluids must be contained and cleaned, NO gel fem. pads. or Tamps
INTERVENTION:
Radioactive Iodine Therapy
Need Pregnancy Test Prior
Methimazole—Antithyroid
–Prevents production of thyroid hormones
–AVOID crowds and people who are ill because med is an immune suppressant & ^ RISK of infection
TEACH patients s/sx of infection
CONTRAINDICATED for pregnancy r/t birth defects; women must wear gloves
MED: Hyperthyroidism
METHIMAZOLE
Lowers immunity/causes Birth Defects
Propranolol
Beta-adrenergic blockers
—> (end in –olol)
ACTION: block sympathetic nervous system stimulation. Used to alleviate cardiac sx of hyperthyroidism (^HR, ^BP)
REPORT dizziness
TX: Relieve diaphoresis, anxiety, tachy, and palpations
Med: Hyperthyroidism
PROPRANOLOL
*Supportive Therapy
Iodine (Inorganic)
–Prevents T3 and T4 production and decreases thyroid vascularity to make it SAFE FOR SURGERY (goiters are ^ vascular)
—> Potassium iodide (SSKI) is also used
Med: Hyperthyroidism
*Surgery Prep
IODINE or SSKI
(inorganic, so is therapeutic)
Lugol Solution
Saturated solution of potassium iodide (SSKI)
REPORT: GI distress, *metallic taste/ Sour, or mouth sores, as these are indications of iodism (HIGH RISK of toxicity)
Surgery Prep Solution
Med: Hyperthyroidism
Lugol Solution
Metalic taste; High Risk of Toxicity; Surgery Prep
–^ caloric intake to compensate for the higher metabolic demands.
–Low-sodium diet
–Six full meals with snacks
–AVOID spicy and high-fiber foods and High-Iodine (Seafood) “If it is from the sea it is not for me”
TEACH: Hyperthyroidism
ASSESS: for laryngeal stridor, dyspnea, ^ swallowing, or bloody dressings. (RESP.)
–>MUST keep tracheostomy kit at the bedside r/t pos. obstruction
BLEEDING: ^ IV fluid and notify RR team.
THYROID STORM:
Apply cooling blanket, decrease stimuli, admin. beta blocker, and call doc ASAP.
–MONITOR: q2hr VS and CA levels for pos. Parathyroid injury. Admin Calcium Gluconate if needed.
ASSESS for Chvostek’s and Trousseau’s signs.
–Temporary laryngitis: r/t laryngeal nerve damage; EDU. pt. pre-op of horse voice
–Place pt. in semi-Fowler’s position with pillows behind the head/neck.DON’T overextend neck
*Thyroid hormone replacement therapy for life (Levothyroxine)
SURGICAL MANAGEMENT: Thyroidectomy
For Hypo or Hyper
for Goiter, Mass, or Tumor
What is the Nursing Priority for a thyroidectomy?
Respiratory Distress
Inflammation of the thyroid gland
Thyroiditis
–Subacute granulomatous thyroiditis is caused by a virus.
–Acute thyroiditis r/t bacteria or fungi.
–Hashimoto’s thyroiditis is an autoimmune response.
The 3 types of Thyroiditis
Caucasian
Relative (Family Hx)
Age (increased)
Women
Hashimoto’s Thyroiditis RISK FACTORS think “CRAW”
Short hyperthyroidism then develops into Hypothyroidism
S/SX:
–Radiating Thyroid Pain to throat, ears, or jaw.
–Fever, chills, sweats, heart palpitations, and fatigue.
–Prominent goiter (trouble swallowing)
–Change in voice or breathing pattern if thyroid obstructs trachea.
Hashimoto’s Thyroiditis
Regardless of the cause=thyroid is not functioning.
– ^ T3 /T4 levels (w/ inflamed goiter) HYPER at first but decrease as inflammation decreases HYPO
– ^ TSH in an attempt to produce more T3 and T4. (Intervention)
Hashimoto’s Thyroiditis
–>Nonsteroidal anti-inflammatory Meds (NSAIDs) = TX Pain and Decease Inflammation
–>Corticosteroids = Decrease inflammation
–>Beta-Blockers = TX Cardiovascular Complications
–>Thyroid Hormone Replacement = replace thyroid hormones (USED after T3/T4 dec. & NEVER in the beginning stages)
MEDS: Thyroiditis
Inflammation, Pain, Cardiac, Hormones
-PRIMARY: thyroid tissue is destroyed or inadequate amount of hormone is produced.
-SECONDARY: pituitary or hypothalamic (brain area that controls hunger, thirst, and temp) dysfxn= inadequate hormone production.
***The worldwide leading cause is iodine deficiency.
**In US leading cause is thyroid atrophy related Hashimoto’s thyroiditis.
OTHER CAUSES: thyroidectomy and medications.
PATHO: Hypothyroidism
*Primary and Secondary
–Fatigue; Lethargy; ^ sleep
–Personality changes;
Impaired memory; Depression; Apathy; Forgetfulness, Slow speech (r/t Thick tongue)
–Cold intolerance
–Amenorrhea (no period)
–Bradycardia; Dyspnea
–Constipation
–Weight ^, Anorexia (decreased appetite); Husky voice
–Hair loss; Brittle hair and nails; Thickened Skin
Decreased Metabolic Rate
CLINICAL MANIFESTATION:
Hypothyroidism
Serious COMPLICATION
S/SX: periorbital and facial edema and a mask-like appearance. Loss of Expression
CAUSE: From lowered metabolic rate Protein, Sugar, and Water retention in cells=nonpitting Generalized Edema
—> Long-standing/ untreated Hypothyroidism
ASSESS: VS, Wt., I&O’s, Mental Status, and Edema; PROVIDE skin care
Myxedema
Hypothyroidism Complication
Myxedema => Hypothyroid Crisis=> (untreated) Death
–Emergency
–LOW Resp., BP, HR, and body temp. Need tracheostomy kit at bedside
–Admission to ICU w/ mech. resp. support when it progresses to COMA
RISKS: Post thyroidectomy/ abrupt stop of levothyroxine/ untreated hypothyroidism
Myxedema Coma
(AKA Hypothyroidism Crisis)
DECREASED Cardiopulmonary, Neurological fxn, and Cardiac Output
-Lithium (Antimanic)
-Thiocyanates (AntiHTN)
-Aminoglutethimide (AntiSteroid)
-Sodium or Potassium Perchlorate (Antithyroid)
-Cobalt (^RBC production; vit B12 component for anemia)
Drugs that IMPAIR thyroid hormone production.
The nurse is caring for a patient who tells the nurse she is always cold, always tired, and more forgetful. What information does the nurse expect to find in the patient’s medical record?
Hypothyroidism
r/t Decreased T3/T4
^ TSH
LOW T3/T4
–Radioactive iodine uptake (RAIU) SCAN = to measure the rate of iodine uptake by the thyroid gland
–Iodine is administered PO or parenterally.
No precautions need
AVOID if pregnancy
DIAGNOSTICS:
Hypothyroidism
Levothyroxine (Synthroid)
–>HypoTH DOC
–AM qday b4 breakfast, on EMPTY STOMACH
–3-4 weeks to work.
–AVOID Ca suppl. > 4 hr after to ^ absorption
–Dose is adjusted as needed to return TH lvl to normal ranges.
–1st dose low to prevent tachycardia and hypertension.
REPORT/ TEACH s/sx of hyperthyroidism/thyroid storm immediately
–lab work needed for TSH lvl
–TEACH pt. consult HCP before taking new meds=can ^ or decrease the absorption
–Medication must be taken for life (abruptly stopping med can cause MYXEDEMA COMA).
MED: Hypothyroidism DOC
Levothyroxine (Synthroid)
Helps to decrease size of goiter, Hypothyroid life treatment, avoid Ca, Report HYPER sx asap
A nodule on the thyroid gland may be benign (>95%) or malignant
– ^ @ RISK: >women than men, ^ dx in Caucasians and Asian American; Radiation to neck during childhood, + family hx, & personal hx of a goiter.
—>PAPILLARY thyroid cancer is the most common type. It is slow-growing and spreads to the lymph nodes in the neck.
—>FOLLICULAR thyroid cancer occurs > older pt. and metastasizes to the cervical lymph nodes before the neck lymph nodes.
—>MEDULLARY thyroid cancer has a genetic link; it metastasizes early and is poorly differentiated in cell type.
—>ANAPLASTIC thyroid cancer is the most aggressive type and responds poorly to treatment.
PATHO AND TYPES:
Thyroid Cancer
*4 Types
Who is most at risk for Thyroid Cancer?
- Girls and Women
- Caucasians and Asian Americans
–Painless, palpable nodules noted on an enlarged thyroid gland
–Goiter
–Dysphagia (dif. swallowing)
–Dyspnea (SOB)
–Hemoptysis (coughing up blood)
–Airway obstruction
CLINICAL MANIFESTATION:
Thyroid Cancer
- Surgery: Removal; Determines Metastatic sites but does not treat
- Radioactive Iodine Treatment: radioactive iodine is given to remove remaining cancer cells aftr 1st tx
- Radiation Treatment: external beam radiation when metastasis
- Chemotherapy: meds for advance dz; target therapy to tx metastatic cancerous cells
- Drug Therapy: High dose of TH therapy to STOP rls of TSH
TX OPTIONS: Thyroid Cancer
Precautions for pt. tx with radioactive iodine?
–Avoid children completely.
–Restrict time w/ and maintain >3 feet from adults for several days.
–DISCHARGE teaching =instructing patients to empty their bladders often and flush the toilet several times afterward.
A patient with a diagnosis of metastatic thyroid cancer is preparing for treatment. Which would be the best collaborative care treatment modality for the health care provider to prescribe for this patient?
Targeted Therapy
-*Maintain the pt. airway r/t proximity of surgical site to the trachea
ASSESS for laryngeal stridor; dyspnea, ^ swallowing, or bloody dressings, Chvostek’s and Trousseau’s signs
**Keep tracheostomy kit at the bedside RISK airway obstruction.
NOTIFY: HCP of purulent drainage from the neck incision.
MONITOR: VS and CA, Pain
–Thyroid hormone levels should be checked q4-6wk
–pt. needs thyroid replacement therapy for life.
–Place pt. semi-Fowler’s pos. w/ pillows behind the head/neck.
POST-OP CONSIDERATIONS
Thyroidectomy
^ PTH levels
^ CA level
LOW serum phosphorus level
^ CL
Bone density testing
DIAGNOSTICS: Hyperparathyroidism
LEADS TO LOW bone density (risk for fractures); Osteoporosis (CA is pulled from the bones)
CAUSES: ^ CA excretion in the urine; Renal Calculi
S/SX: LOW appetite (Anorexia),
Constipation, Fatigue,
Emotional disorders,
Shortened attention span,
Muscle weakness
PATHO: Hyperparathyroidism
LOW PTH
LOW CA (causes diarrhea)
^ Phosphorus
DIAGNOSTICS: Hypoparathyroidism
Parathyroid can’t maintain CA lvls=hypocalcemia
–Positive Chvostek’s and Trousseau’s signs
–Dysrhythmias
–Hypotension
–Weakness; Fatigue
–Tetany (involuntary muscle contractions)
–Seizures; Paresthesias (Tingling)
–Abdominal cramps; diarrhea
–Dry, scaly skin
S/SX: hypoparathyroidism
TEACH: ^ CA rich foods (dark green leafy vegetables, soy products e.g., tofu, and dairy)
Oral calcium supplements
**ADMIN: IV calcium and infuse it at a SLOW RATE
MONITOR: Telemetry (Dysrhythmias)
LABS: CA levels should be monitored q3 to 4X year
IMPLEMENTATIONS:
Hypoparathyroidism
-Chvostek’s and Trousseau’s signs
-Serum calcium levels
-Hyperactive reflexes
-Dysrhythmias
ASSESSMENT:
Hypoparathyroidism
A charge nurse working in the medical surgical unit receives a report on a patient hypoparathyroidism who will be admitted during the upcoming shift. What equipment should the charge nurse ensure is placed in the patient’s room?
Telemetry Monitor
Which assessment finding made by the nurse may indicate the onset of hypoparathyroidism?
Positive Chvostek’s Sign
