Thyroid Pt 2 - Hyperthyroid

Question 1

Primary Dysfunction

HYPOthyroidism / HYPERthyroidism

Question 2

?

Too much T3-T4 = TSH is HIGH or LOW ?

Answer 2

Hyperthyroidism

Low

Question 3

?

Too little T3-T4 = TSH is HIGH or LOW ?

Answer 3

Hypothyroidism

High

Question 4

?

A sustained increase in synthesis & release of thyroid hormones by thyroid gland

Occurs more often in women

Highest frequency between ages 20-40

Answer 4

Hyperthyroidism

Question 5

Hyperthyroidism

Most common form = ? → autoimmune

Answer 5

Graves’ disease (aka toxic diffuse goiter)

Question 6

Hyperthyroidism

Other causes
* Toxic nodular and/or multinodular goiter
* Thyroiditis
* Excess iodine intake
* Pituitary tumors
* Thyroid cancer
* (Excessive synthetic thyroid med, e.g., levothyroxine)

Question 7

E&P: Graves’ Disease

• Autoimmune disease
• Diffuse thyroid enlargement
• Excessive thyroid hormone secretion
• Antibodies to TSH receptor stimulate release of T3 T4 or both
• Leads to clinical manifestations of thyrotoxicosis

Answer 7

• Remissions & exacerbations w/ or w/o treatment
• May progress to destruction of thyroid tissue causing hypothyroidism or thyroiditis like Hashimoto’s

Question 8

?

• Physiologic effects/clinical syndrome of hypermetabolism
• Results from increased circulating lvls of T3 T4 or both

Answer 8

thyrotoxicosis

! Hyperthyroidism & thyrotoxicosis usually occur together, as in Graves’ disease

Question 9

Manifestations

Answer 9

Question 10

Question 11

Exophthalmos & Goiter of Graves’ Disease - Exophthalmos Interventions

• HOB elevated
• Use artificial tears
• If photophobia: wear dark glasses, eye patches
• Gently tape eyelids @ night if eyelid lag
• Short-term steroid
• Diuretics
• Orbital decompression

Question 12

?

Results from increased fat deposits & fluid (edema) in the orbital tissues & ocular muscles

• Increased pressure forces the eyeballs outward; upper lids are usually retracted & elevated, w/the sclera visible above the iris
• When the eyelids do not close completely, the exposed corneal surfaces become dry & irritated
• Serious consequences, like corneal ulcers & eventual loss of vision, can occur
• Change in ocular muscles → diplopia

Answer 12

exophthalmos

Question 13

If the exophthalmos is severe, treatment options include corticosteroids, radiation of retro-orbital tissues, orbital decompression, & corrective lid or muscle surgery

Question 14

?

Excessive amounts of thyroid hormones are released
* Life-threatening emergency
* Death rare when treatment started
* Results from stressors (e.g., infection, trauma, surgery) in a pt w/pre-existing hyperthyroidism
* Thyroidectomy pts at risk

Answer 14

Thyrotoxicosis aka thyroid storm

Question 15

Thyrotoxicosis - Manifestations

• Tachycardia, HF
• Severe HTN
• Shock
• Hyperthermia
• Restlessness, irritability
• Seizures
• Abdominal pain, vomiting, diarrhea
• Delirium, coma

Answer 15

✓ Treat by reducing circulating hormones

Supportive therapy
- Manage respiratory distress
- Reduce fever
- Replace fluids
- Eliminate or manage initiating stressor(s)

Question 16

Diagnostic Studies: Hyperthyroidism

___ TSH & ___ free T4

Total T3 and T4 assessed but not as definitive

• Radioactive iodine uptake (RAIU)
• Differentiates Graves’ dz from other forms of thyroiditis

Answer 16

↓ TSH

↑ T4

Question 17

The patient with Graves’ dz will show a diffuse, homogenous uptake of 35-95%, whereas the pt w/thyroiditis will show an uptake of <2%

Answer 17

The person w/a nodular goiter will have an uptake in the high normal range

Question 18

Collaborative Care: Goals

• Block adverse effects of thyroid hormones
• Suppress hormone over-secretion
• Prevent complications

Question 19

3 primary treatment options

1. Antithyroid rx’s
2. Radioactive iodine therapy (RAI)
3. Surgery

Answer 19

Drug therapy for thyrotoxic states - not considered curative

• Antithyroid rx’s
• Iodine
• β-adrenergic blockers
• Lithium can sometimes be used to intentionally decrease thyroid function

Question 20

Antithyroid Drug: Thionamides

1st line rx’s -

propylthiouracil (PTU) & methimazole (Tapazole)

Answer 20

• Inhibit synthesis of thyroid hormones
• Improvement in 1-2 wks
• Good results in 4-8 wks
• Therapy for 6-15 mos

! Teach pts to report darkening of the urine, or a yellowing of the skin or eyes

! Teach pts to watch for wt gain, slow HR, cold intolerance

! Avoid people who are ill; assess sleep & constipation

Question 21

Iodine

• Potassium iodine (SSKI) & Lugol’s solution
• Inhibits synthesis of T3 and T4 & blocks their release into circulation
• Decreases vascularity of thyroid gland, making surgery safer & easier
• Maximal effect within 1-2 wks
• Used before surgery & to treat thyrotoxic crisis

Answer 21

• Short-term therapy and/or before surgery

Question 22

β-Adrenergic Blockers

• Symptomatic relief of thyrotoxicosis
• Block effects of sympathetic nervous stimulation, decreasing tachycardia, nervousness, irritability, & tremors

Answer 22

• Propranolol (Inderal) usually admin’d w/other antithyroid rx’s
• Atenolol (Tenormin) is preferred β-adrenergic blocker for use in hyperthyroid pts w/asthma or heart dz

Question 23

Radioactive Iodine Therapy (RAI)

• Treatment of choice in non-pregnant adults
• Damages or destroys thyroid tissue, limiting thyroid hormone secretion
• Delayed response of 2-3 mos
• Treated w/antithyroid rx’s & β-blocker before & during first 3 mos of RAI
• There’s a high incidence of post-treatment hypothyroidism (80%)

Answer 23

• Given on outpatient basis

Patient teaching
- Oral care for thyroiditis/parotiditis
- Radiation precautions
- Sx’s of hypothyroidism

Question 24

Surgical Therapy: Thyroidectomy

Indications
- Large goiter causing tracheal compression
- Unresponsive to antithyroid therapy
- Thyroid cancer
- Not a candidate for RAI

• More rapid reduction in T3 and T4 levels than RAI

Question 25

? Preferred surgical procedure - Involves removal of 90% of thyroid - Can be done endoscopically; is minimally invasive - Is an appropriate procedure for pts w/small nodules (<3cm) in whom there's no evidence of malignancy ✓ Less scarring, less pain, & faster recovery than open procedure

Answer 25

subtotal thyroidectomy

Question 26

Nutritional Therapy High-calorie diet (4000-5000 cal/day) * 6 small meals/day w/snacks in-between * Protein intake: 1-2 g/kg ideal body wt * Increased carb intake * Avoid highly seasoned & high-fiber foods, caffeine * Dietitian referral

Question 27

Nursing Assessment: Subjective data Past health history - * Goiter, recent infection or trauma, immigration from iodine-deficient area, autoimmune dz Medications - * Thyroid hormones, herbal therapies

Answer 27

* Family hx * Iodine intake * Wt loss * Inc appetite, thirst * n/v/d, polyuria * Sweating

Question 28

* DOE * Palps * Muscle weakness, fatigue * Insomnia * CP * Nervousness * Heat intolerance, pruritus

Answer 28

* Increased libido * Impotence * Gynecomastia * Amenorrhea * Emotional lability, irritability, restlessness * Personality changes, delirium

Question 29

Nursing Assessment: Objective data * Tachypnea, DOE * Tachycardia, bounding pulse * Murmurs, dysrhythmias, HTN, bruit * ↑ bowel sounds, ↑ appetite, diarrhea, wt loss * Hepatosplenomegaly

Answer 29

* Hyperreflexia, diplopia * Fine tremors * Muscle wasting * Menstrual irregularities * Infertility * Impotence * Gynecomastia

Question 30

* ↑ T3, T4, T3 resin uptake * ↓ or undetectable TSH * cxray showing enlarged heart * ECG findings of tachycardia, afib

Answer 30

Nursing Diagnoses * Activity intolerance r/t fatigue & heat intolerance * Imbalanced nutrition: less than body requirements r/t hyper-metabolism & inadequate food intake

Question 31

Planning: Overall goals * Experience relief of sx's * Have no serious complications r/t dz or treatment * Maintain nutritional balance * Cooperate w/therapeutic plan

Question 32

Nursing Implementation: Acute Thyrotoxicosis * Necessitates aggressive treatment (often in an ICU) * Rx's to block thyroid hormone production & SNS * Monitoring for dysrhythmias & decompensation * Ensuring adequate oxygenation * F&E replacement

Answer 32

* Establish trusting relationships * Ensure adequate rest - Calm, quiet room - Cool room - Light bed coverings * Perform nsg interventions if exophthalmos present

Question 33

Nursing Implementation: Postoperative Care * For subtotal thyroidectomy as treatment of choice

Answer 33

Administer rx's to achieve euthyroidism - Administer iodine to **↓ vascularity** & **subseq reduce risk of hemorrhage** - ***Mixed w/water or juice; sipped through a straw, & given >meals*** - Assess for signs of iodine toxicity **! Swelling of buccal mucosa & other mucous membranes, excessive salivation, n/v, & skin rxns** Patient teaching - Comfort & safety measures - Leg exercises, head support, neck ROM - Routine post-op care, e.g., IV infusions

Question 34

Monitor for complications - Hemorrhage - Laryngeal nerve damage - Thyrotoxic crisis - Infection - Hypocalcemia (tetany)

Answer 34

Maintain patent airway - Oxygen, suction equipment, tracheostomy tray in pt's room - Monitor for laryngeal stridor - IV calcium salts readily avail (e.g., ca gluconate, ca gluceptate)

Question 35

What clinical manifestations are indicated in the picture?

Answer 35

Trousseau sign (left) Chvostek sign (right)

Question 36

* Assess q2h during first 24 hrs for signs of hemorrhage or tracheal compression like irregular breathing, neck swelling, freq swallowing, sensations of fullness @ incision site, choking, & blood on the anterior or posterior dressings * Semi-Fowler's position; support head w/pillows * Avoid neck flexion & tension on suture line

Answer 36

* Monitor VS & calcium levels Signs of hypocalcemia - Difficulty speaking & hoarseness (anticipate 3-4 days post d/t edema) - Trousseau's & Chvostek's signs * Analgesics * Ambulation * Psychosocial support

Question 37

Ambulatory & Home Care Discharge teaching - Monitor hormone balance periodically - Decrease caloric intake - Adequate but not excessive iodine intake - Encourage regular exercise to stimulate thyroid gland - Avoid ↑ environmental temps b/c they inhibit thyroid regeneration

Answer 37

- Regular follow-up care - Complete thyroidectomy * Sx's of hypothyroidism * Need for lifelong thyroid hormone replacement

Question 38

Nursing Management: Evaluation * Relief of sx's * No serious complications r/t dz or treatment * Cooperate w/therapeutic plan