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NUR 202 Week 4 > Thyroid Pt 2 - Hyperthyroid > Flashcards

Thyroid Pt 2 - Hyperthyroid Flashcards

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1
Q

Primary Dysfunction

HYPOthyroidism / HYPERthyroidism

A
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2
Q

?

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

A

Hyperthyroidism

Low

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3
Q

?

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

A

Hypothyroidism

High

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4
Q

?

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

Occurs more often in women

Highest frequency between ages 20-40

A

Hyperthyroidism

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5
Q

Hyperthyroidism

Most common form = ? → autoimmune

A

Graves’ disease (aka toxic diffuse goiter)

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6
Q

Hyperthyroidism

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

A
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7
Q

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
A
  • Remissions & exacerbations w/ or w/o treatment
  • May progress to destruction of thyroid tissue causing hypothyroidism or thyroiditis like Hashimoto’s
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8
Q

?

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

thyrotoxicosis

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

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9
Q

Manifestations

A
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10
Q
A
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11
Q

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
A
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12
Q

?

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
A

exophthalmos

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13
Q

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

A
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14
Q

?

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

A

Thyrotoxicosis aka thyroid storm

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15
Q

Thyrotoxicosis - Manifestations

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

✓ Treat by reducing circulating hormones

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

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16
Q

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
A

↓ TSH

↑ T4

17
Q

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%

A

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

18
Q

Collaborative Care: Goals

  • Block adverse effects of thyroid hormones
  • Suppress hormone over-secretion
  • Prevent complications
A
19
Q

3 primary treatment options

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

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
20
Q

Antithyroid Drug: Thionamides

1st line rx’s -

propylthiouracil (PTU) & methimazole (Tapazole)

A
  • 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

21
Q

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
A
  • Short-term therapy and/or before surgery
22
Q

β-Adrenergic Blockers

  • Symptomatic relief of thyrotoxicosis
  • Block effects of sympathetic nervous stimulation, decreasing tachycardia, nervousness, irritability, & tremors
A
  • 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
23
Q

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%)
A
  • Given on outpatient basis

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

24
Q

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
A
25
Q

?

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

A

subtotal thyroidectomy

26
Q

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
A
27
Q

Nursing Assessment: Subjective data

Past health history -
* Goiter, recent infection or trauma, immigration from iodine-deficient area, autoimmune dz

Medications -
* Thyroid hormones, herbal therapies

A
  • Family hx
  • Iodine intake
  • Wt loss
  • Inc appetite, thirst
  • n/v/d, polyuria
  • Sweating
28
Q
  • DOE
  • Palps
  • Muscle weakness, fatigue
  • Insomnia
  • CP
  • Nervousness
  • Heat intolerance, pruritus
A
  • Increased libido
  • Impotence
  • Gynecomastia
  • Amenorrhea
  • Emotional lability, irritability, restlessness
  • Personality changes, delirium
29
Q

Nursing Assessment: Objective data

  • Tachypnea, DOE
  • Tachycardia, bounding pulse
  • Murmurs, dysrhythmias, HTN, bruit
  • ↑ bowel sounds, ↑ appetite, diarrhea, wt loss
  • Hepatosplenomegaly
A
  • Hyperreflexia, diplopia
  • Fine tremors
  • Muscle wasting
  • Menstrual irregularities
  • Infertility
  • Impotence
  • Gynecomastia
30
Q
  • ↑ T3, T4, T3 resin uptake
  • ↓ or undetectable TSH
  • cxray showing enlarged heart
  • ECG findings of tachycardia, afib
A

Nursing Diagnoses

  • Activity intolerance r/t fatigue & heat intolerance
  • Imbalanced nutrition: less than body requirements r/t hyper-metabolism & inadequate food intake
31
Q

Planning: Overall goals

  • Experience relief of sx’s
  • Have no serious complications r/t dz or treatment
  • Maintain nutritional balance
  • Cooperate w/therapeutic plan
A
32
Q

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
A
  • Establish trusting relationships
  • Ensure adequate rest
  • Calm, quiet room
  • Cool room
  • Light bed coverings
  • Perform nsg interventions if exophthalmos present
33
Q

Nursing Implementation: Postoperative Care

  • For subtotal thyroidectomy as treatment of choice
A

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

34
Q

Monitor for complications

  • Hemorrhage
  • Laryngeal nerve damage
  • Thyrotoxic crisis
  • Infection
  • Hypocalcemia (tetany)
A

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)
35
Q

What clinical manifestations are indicated in the picture?

A

Trousseau sign (left)

Chvostek sign (right)

36
Q
  • 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
A
  • 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
37
Q

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

A
  • Regular follow-up care
  • Complete thyroidectomy
  • Sx’s of hypothyroidism
  • Need for lifelong thyroid hormone replacement
38
Q

Nursing Management: Evaluation

  • Relief of sx’s
  • No serious complications r/t dz or treatment
  • Cooperate w/therapeutic plan
A

NUR 202 Week 4 (5 decks)

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