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Adult nursing II > Thyroid Diseases > Flashcards

Thyroid Diseases Flashcards

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1
Q

Consider Possibility of Endocrine / Thyroid Changes When Assessing the Older Adult

A

Normal aging

  • Decreased hormone production/secretion
  • Altered hormone metabolism/activity
  • Decreased target tissue response
    Alteration in circadian rhythm

Changes of aging can mimic endocrine disorders

Hypothyroid symptoms of fatigue, constipation, mental impairment often missed because of sole attribution to aging

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2
Q

Thyroid Stimulating Hormone (TSH)

A

Anterior pituitary hormone
Stimulates thyroid gland to release hormones
2 – 10 U / mL

Serum levels
High = Defect within thyroid
Low = Defect in pituitary or hypothalamus

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3
Q

Thyroid Hormones

A

Regulate:
Energy metabolism
Growth & development

Dietary iodine necessary for synthesis

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4
Q

Triiodothyronine (T3)

A

More potent; greater metabolic effect

20 – 50 years: 70 – 205 ng/dL

> 50 years: 40 – 180 ng/dL

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5
Q

Thyroxine (T4)

A

Most abundant

Female 5 – 12 mcg/dL

Male 4 – 12 mcg/dL

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6
Q

Thyroid Antibodies

A

Anti-thyroglobulin antibody (Thyroid auto-antibody)
Marker for autoimmune thyroiditis
Normal: < 116 IU / mL

Anti-thyroid peroxidase antibody (Anti-TPO)
Normal: < 9 IU / mL

Increased levels:
Hashimoto’s thyroiditis
Thyrotoxicosis
Hypothyroidism
Thyroid cancer
Myxedema
Rheumatoid arthritis & collagen disease
Pernicious anemia

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7
Q

HYPERthyroidism

A

Sustained increase: Synthesis & release of thyroid hormones by thyroid gland
Occurs more often in women between 20 - 40 years

Grave’s Disease most common form
Other causes
Toxic nodular goiter
Thyroiditis
Excess iodine intake
Pituitary tumors
Thyroid cancer

Subclinical
TSH below 0.4 m IU/L
Normal T3 & T4 levels

Overt
Low or undetectable TSH
Increased T3 & T4 levels
Symptoms may or may not be present

Thyrotoxicosis
Physiologic effects / syndrome of hyper-metabolism
Results from increased circulating levels of T3, T4 or both
Hyperthyroidism & thyrotoxicosis usually occur together

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8
Q

HYPERthyroidism: Diagnostics

A

Decreased TSH (less than 0.4mU/L)

Increased free Thyroxine (free T4)

Total T3 & T4 (not definitive)

Radioactive iodine uptake (RAIU)
- —Distinguishes Graves’ disease from other forms of thyroiditis

Diagnostic Findings
Increased T3 & T4
Increased T3 resin uptake
Decreased or undetectable TSH
Chest x-ray showing enlarged heart
ECG: Tachycardia

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9
Q

Graves’ Disease

A

Autoimmune disease

—-Diffuse thyroid enlargement

—–Excess thyroid hormone secretion

Causative factors interact with genetic factors

Patients with female natal sex 5 times more likely to develop than those with male natal sex

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10
Q

Clinical Manifestations of Grave’s Disease

A

Effect of thyroid hormone excess
Increased metabolism
Increased tissue sensitivity to SNS stimulation

Goiter
Inspection, Palpation
Auscultation: Bruits

Ophthalmopathy; Abnormal eye appearance or function
Exophthalmos
Increased fat deposits & fluid
Eyeballs forced outward

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11
Q

Cardiovascular system
- Graves Disease

A

Systolic hypertension
Bounding, rapid pulse; palpitations
Increased cardiac output
Cardiac hypertrophy
Systolic murmurs
Dysrhythmias
Angina

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12
Q

Respiratory system
- Graves disease

A

Dyspnea on mild exertion
Increased respiratory rate

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13
Q

GI system
- Graves disease

A

Increased appetite, thirst
Weight loss
Diarrhea
Splenomegaly
Hepatomegaly

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14
Q

Skin
- Graves disease

A

Warm, smooth, moist skin
Thin, brittle nails
Hair loss
Fine, silky hair
Premature graying in patients with natal male sex
Diaphoresis
Vitiligo

Acropachy; Soft-tissue swelling & clubbing of fingers; palmar erythema

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15
Q

Musculoskeletal system
- Graves disease

A

Fatigue
Weakness
Proximal muscle wasting
Dependent edema
Osteoporosis
Intolerance to heat
Elevated basal temperature
Lid lag, stare
Eyelid retraction
Rapid speech

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16
Q

Nervous system
- Graves disease

A

Hyperactive deep tendon reflexes
Nervousness, fine tremors
Insomnia
Difficulty focusing eyes
Lability of mood, delirium
Lack of ability to concentrate
Stupor, coma

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17
Q

Reproductive system
- Graves disease

A

Menstrual irregularities
Amenorrhea
Decreased libido
Decreased fertility
Impotence & gynecomastia in patients with natal male sex

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18
Q

Acute Thyrotoxicosis Thyrotoxic Crisis OR “Thyroid Storm”)

A

Excessive amounts of hormones released
Life-threatening emergency
Death rare when treatment started early
Results from stressors
Thyroidectomy patients at risk

Manifestations
Severe tachycardia, heart failure
Shock (Cardiogenic)
Hyperthermia (up to 106° F [41.1° C])
Agitation
Seizures
Abdominal pain, vomiting, diarrhea
Delirium, coma

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19
Q

Acute Thyrotoxicosis Thyrotoxic Crisis OR “Thyroid Storm”)

A

Excessive amounts of hormones released
Life-threatening emergency
Death rare when treatment started early
Results from stressors
Thyroidectomy patients at risk

Manifestations
Severe tachycardia, heart failure
Shock (Cardiogenic)
Hyperthermia (up to 106° F [41.1° C])
Agitation
Seizures
Abdominal pain, vomiting, diarrhea
Delirium, coma

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20
Q

Acute Thyrotoxicosis Thyrotoxic Crisis OR “Thyroid Storm”)
- interprofessional care

A

Therapeutic goals
Block adverse effects of thyroid hormones
Suppress hormone oversecretion
Prevent complications
Three primary treatment options
Anti-thyroid medications
Radioactive iodine therapy (RAI)
Surgery

Evaluation
Relief / control of symptoms
No serious complications r/t disease or treatment
Adhere to therapeutic plan
Maintain nutritional balance

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21
Q

Acute Thyrotoxicosis Thyrotoxic Crisis OR “Thyroid Storm”)
- medication therapy

A

Useful in treatment of thyrotoxic states
Not considered curative
Anti-thyroid medications
Iodine
β-Adrenergic blockers

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22
Q

Anti-thyroid Medications

A

Propylthiouracil (PTU)
Methimazole (Tapazole)
Daily dose usually divided in three, every 8-hours
Initial daily doses:
15 mg (mild)
30 - 40 mg (moderate)
60 mg (severe)
Maintenance: 5 - 15 mg daily

Inhibit thyroid hormone synthesis
Improvement 1 - 2 weeks
Results 4 - 8 weeks
Therapy for 6 - 15 months

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23
Q

Iodine

A

Inhibits synthesis of T3 & T4
Blocks release into circulation
Decreases vascularity of thyroid making surgery safer & easier
Maximal effect within 1 - 2 weeks

Potassium iodine (SSKI)
250 mg or 0.25 mL three times per day (Dissolve in 4-ounces water, milk or juice)
Lugol’s solution (100 mg/mL potassium iodide & 50 mg/mL of iodine)
Hyperthyroidism: 1 mL three times per day
Prep for Thyroidectomy: 3 - 5 drops three times per day for 10-days

24
Q

β-Adrenergic Blockers

A

Symptomatic relief of Thyrotoxicosis
Block effects of SNS stimulation; Decreases tachycardia, nervousness, irritability, tremors
Propranolol (Inderal)
Atenolol (Tenormin)
Preferred in patients with Asthma or CAD

25
Q

Nutritional Therapy

A

High-calorie diet (4000 to 5000 cal/day)
6 full meals/day with snacks in between
Protein intake: 1 to 2 g/kg ideal body weight
Increased carbohydrate intake
Avoid highly seasoned foods, high-fiber foods, caffeine
Dietitian referral

26
Q

HYPOthyroidism

A

Deficiency of thyroid hormone causing general slowing in metabolic rate
More common in patients with female natal sex than those with male natal sex
Subclinical
TSH greater than 4.5 mIU/L
T4 levels normal
Affects up to 10% of those with natal female sex over 60
Non-thyroidal illness syndrome (NTIS)
Critically ill patients
Low T3, T4, & TSH levels

27
Q

HYPOthyroidism Diagnostics

A

History & physical examination
TSH & free T4
TSH increases with primary hypothyroidism
TSH decreases with secondary hypothyroidism
Thyroid antibodies (Autoimmune origin)
High cholesterol
High triglycerides
High creatine kinase (CK)
Low RBCs (anemia)

28
Q

HYPOthyroidism
Etiology and Pathophysiology

A

Primary; Caused by destruction of thyroid tissue or defective hormone synthesis
Secondary:
Pituitary disease (decreased TSH)
Hypothalamic dysfunction or (decreased TSH)
Iodine deficiency
Atrophy of thyroid gland
Hashimoto’s thyroiditis
Graves’ disease
Treatment for hyperthyroidism
Drugs
Cretinism; physical deformity & learning disabilities caused by congenital thyroid deficiency

29
Q

Thyroiditis

A

Acute infection and/or inflammation
Manifestations
Silent & painless
Sub-acute
Acute
Granulomatous (Bacterial or viral)
Chronic autoimmune (Hashimoto’s)
Most common cause of hypothyroid goiter

Management
NSAID’s
Corticosteroids (Prednisone)
Antibiotics
Surgical drainage
Patient teaching; Importance of adherence to plan

30
Q

Clinical Manifestations of Hypothyroidism

A

Systemic effects characterized by slowing of body processes
Manifestations variable
Slow onset
Tired, lethargic, impaired memory, low initiative, weight gain

31
Q

Clinical Manifestations of Hypothyroidism
Cardiovascular system

A

CV problems may be significant in patients with history of cardiovascular disease
Decreased cardiac contractility and output
Increased serum cholesterol & triglycerides
Anemia

32
Q

Clinical Manifestations of Hypothyroidism
Respiratory

A

Low exercise tolerance
SOB on exertion

33
Q

Clinical Manifestations of Hypothyroidism
GI system

A

Decreased appetite
Nausea, vomiting
Weight gain
Constipation
Distended abdomen
Enlarged, scaly tongue
Celiac disease

34
Q

Clinical Manifestations of Hypothyroidism
Skin

A

Dry, thick, inelastic, cold skin
Thick, brittle nails
Dry, sparse, coarse hair
Poor turgor of mucosa
Generalized interstitial edema
Puffy face
Decreased sweating
Pallor
Increased susceptibility to infection
Increased sensitivity to opioids, barbiturates, anesthesia
Intolerance to cold
Decreased hearing
Sleepiness
Goiter

35
Q

Clinical Manifestations of Hypothyroidism
Musculoskeletal system

A

Fatigue, weakness
Muscular aches & pains
Slow movements
Arthralgia

36
Q

Clinical Manifestations of Hypothyroidism
Neurologic

A

Fatigue, lethargy
Personality, mood changes
Impaired memory, slowed speech, decreased initiative, somnolence

37
Q

Clinical Manifestations of Hypothyroidism
Reproductive system

A

Prolonged menstrual periods or amenorrhea
Decreased libido, infertility

38
Q

Common Features of Myxedema

A

Dull, puffy skin
Coarse, sparse hair
Periorbital edema
Prominent tongue

Interprofessional Care
Treatment goal; Restore euthyroid state as safely & rapidly as possible
Hormone therapy
Low-calorie diet
Relief / control of symptoms
Maintain euthyroid state
Maintain positive self-image
Adhere with lifelong thyroid therapy

39
Q

Myxedema coma

A

Precipitated by infection, drugs, cold, trauma
Characterized by:
Impaired consciousness
Subnormal temperature
Hypotension
Hypoventilation
CV collapse
Treated with IV thyroid hormone

40
Q

Patient Teaching: Hypothyroidism

A

Written instructions important
Need for lifelong therapy & regular follow-up care
Avoid abruptly stopping drugs
Side effects of medication
Signs & symptoms of hypothyroidism and hyperthyroidism
Comfortable, warm environment
Measures to prevent skin breakdown

Do not switch brands
Medication interactions
Avoid sedatives or use lowest dose possible
Measures to minimize constipation
Relapses occur if treatment is interrupted

41
Q

Levothyroxine (Synthroid)

A

Low dose; Increased in 4 – 6 week intervals PRN based on TSH levels
Lifelong therapy
Monitor for tachycardia, especially:
During initiation of therapy
In the elderly

Teach - Notify Provider for:
Chest pain
Weight loss
Nervousness
Tremors
Insomnia

42
Q

Thyroid Nodules & Cancer

A

Thyroid CA
Papillary (70-80%)
Follicular (10-15%)
Common in elderly
Medullary (5-10%)
Hereditary
Anaplastic (<5%)
Most aggressive
Primary sign: Painless, palpable nodule(s)

43
Q

Treatment for Thyroid Cancer

A

Thyroidectomy: Primary treatment w/ Lymph node dissection PRN
Some patients may receive RAI
External beam radiation: Palliative treatment in metastatic cases
High-dose thyroid hormone therapy
Chemotherapy for advanced disease

44
Q

Radioactive Iodine Therapy (RAI)

A

Treatment of choice for most non-pregnant adults; Damages, destroys thyroid tissue
Delayed response up to 3 months; Anti-thyroid drugs & β-blocker before & during first 3-months
Outpatient
Radiation Precautions:
Private toilet, double-flushing
Separate laundry daily
No food prep with bare hands
Avoid pregnant women/children for 7-days after treatment
80% have post-treatment hypothyroidism

Patient Teaching
Oral care (Thyroiditis / Parotiditis)
Water / ice chips
Salt & soda gargle
“Magic Mouthwash” (Antacid, Benadryl, Viscous Lidocaine)
Radiation precautions
Symptoms of hypothyroidism

45
Q

Surgical Therapy
Thyroid cancer

A

Indications
Large goiter causing tracheal compression
Unresponsive to anti-thyroid therapy
Thyroid cancer
Not a candidate for RAI
Rapid reduction in T3 & T4 levels

Subtotal Thyroidectomy
Preferred procedure
Removal of up to 90% of thyroid
Minimally invasive procedures possible
Endoscopic
Robotic surgery

46
Q

Preoperative Care for Thyroidectomy

A

Administration of medications to achieve euthyroid state
Administration of iodine to decrease vascularity
Patient teaching
Comfort & safety measures
Leg exercises, head support, neck ROM
Routine postoperative care

47
Q

Thyroidectomy: Post-op Assessment

A

Frequent vital signs
Assess for signs of:
Hemorrhage
Tracheal compression
Avoid flexion / tension on suture lines
Semi-Fowler’s position
Support head with pillow(s)

Difficulty speaking?
Voice hoarse?
Smile symmetrical?
Tongue midline?
Monitor for 72-hours
Chvostek’s
Trousseau’s
Caloric adjustment?
Complete thyroidectomy?
Life long thyroid hormone replacement

48
Q

Postoperative Care for Thyroidectomy

A

Monitor for complications
Hypothyroidism
Hypocalcemia
Hemorrhage
Laryngeal nerve damage
Thyrotoxicosis
Infection
Maintain patent airway
Oxygen, suction equipment, tracheostomy tray in patient’s room
Monitor for laryngeal stridor

Assess frequently during first 24-hours for hemorrhage or tracheal compression
Semi-Fowler’s position
Support head with pillows to avoid tension on suture line
Monitor vital signs
Signs of hypocalcemia
IV calcium readily available
Ambulation
Psychosocial support

49
Q

Discharge Teaching
Thyroid cancer

A

Monitor hormone balance periodically
Decrease caloric intake
Adequate but not excessive iodine intake
Regular exercise
Avoid high environmental temperature
Regular follow-up care
Complete thyroidectomy
Symptoms of hypothyroidism
Need for lifelong thyroid hormone replacement

50
Q

HYPERparathyroidism

A

Parathyroid hormone (PTH) regulates Calcium & Phosphate levels
HYPERcalcemia
HYPOphosphatemia

Decreased bone density
Weakness
Increased urinary calcium
Calculi
Stimulates biologically active Vitamin D, which increases Ca+ uptake and hypercalcemia

51
Q

HYPERparathyroidism
Primary

A

Primary (30-70 years of age)
Increased secretion of PTH; Disorders of Ca+, phosphate, bone metabolism
Benign tumors

52
Q

HYPERparathyroidism
Secondary

A

Secondary; Compensatory to conditions that cause HYPOcalcemia
Vitamin D deficiency
Malabsorption
CKD
HYPERphosphatemia

53
Q

HYPERparathyroidism
Tertiary

A

Tertiary; Hyperplasia of parathyroid & loss of negative feedback from circulating Ca+
Kidney transplant s/p long term hemodialysis

54
Q

Surgery for HYPERparathyroidism

A

Most effective treatment for Primary & Secondary
Criteria
Serum Ca+ > 12
HYPERcalciuria > 400 mg / day
Decreased bone density
Partial or complete
Auto-transplantation of normal tissue
If not, Ca+ supplements for life

55
Q

HYPOparathyroidism (Uncommon) & Treatment of Tetany

A

Re-breathing in a paper bag or rebreather oxygen mask may partially relieve muscle cramps & mild tetany by decreasing serum pH
SLOW IV administration:
Calcium Chloride (CaCl)
Venous irritation, inflammation
Careful infusion, check IV patency
Calcium Gluconate
500 mg – 2 Grams
Rate not more than 200 mg/min

ECG monitoring advised
High serum Ca+
Hypotension
Arrhythmias
Cardiac arrest
Oral Ca+ supplements
Correct HYPOmagnesemia
Vitamin D to enhance GI absorption of Ca+
Dark, green vegetables
Soy products & tofu
Spinach & Rhubarb (inhibit absorption of Ca+)

Adult nursing II (7 decks)

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