Thyroid Study Questions Flashcards
How should the thyroid be assessed?
Inspect neck in normal position
Inspect neck slightly extended & while pt swallows a sip of water
How should the trachea & neck appear?
Trachea midline; neck symmetric
If there is noticeable enlargement, should you palpate?
No
It is normal if the thyroid can’t be palpated; however, in some persons it can. What should it feel like?
Smooth, firm consistency, non-tender to palpation
What would abnormal findings include?
Nodules, enlargement, asymmetric, hard
What are the major thyroid hormones?
T3 & T4
Which thyroid hormone is the most active form with a peak effect in 3 days?
T3
What is necessary for thyroid hormone synthesis?
IODINE
How long is thyroid hormone stored?
Up to 100 days
What do the thyroid hormones do?
Regulate metabolic rate of all cells (body heat production; carb, protein, fat catabolism)
Maintains GH secretion & skeletal growth
Stimulates CNS process & RBC production
Affects cardiac function & respiratory rate
What is the 3rd thyroid hormone partially responsible for decreasing calcium levels?
Calcitonin
How does calcitonin lower serum calcium levels?
Stops calcium loss from bone
Increases calcium storage in the bone
Increases renal excretion of calcium
What does Calcitonin antagonize?
PTH (Parathyroid hormone)
How is Calcitonin secretion regulated?
By serum calcium levels
What are the disorders of the thyroid when there is hyper function?
Hyperthryoidism (Graves disease) -> Thyroid storm
What are the disorders of the thyroid when there is hypo function?
Hypothyroidism -> Myexedema coma
Compare hypothyroidism with hyperthyroidism
Hyper - everything is increased! ^metabolism, ^CV function, ^GI function, heat intolerance & ^temperature, moist, pale skin; thin nails
Hypo - everything is decreased! \/metabolism, \/CV function, \/GI function, cold intolerance, dry skin, thick nails
What is hyperthyroidism?
Too much circulating T3 & T4
What is the most common form of hyperthyroidism?
Graves disease
What is the most severe form of hyperthyroidism called?
Thyrotoxicosis (Thyroid storm)
What type of disease is Graves?
Autoimmune disorder
What is expected in hyperthyroidism?
Enlarged thyroid & excessive thyroid hormone secretion
What are the three components of hyperthyroidism?
Hyperthyroid
Thyroid goiter
Exophthalmos
What is hyperthyroidism characterized by?
Remissions & exacerbations
What are the significant clinical manifestations of hyperthyroidism?
Heat intolerance Weight loss Diarrhea Bulging eyes Tachycardia Tremors Amenorrhea in women
What is a classic finding in Graves disease (hyperthyroidism)?
Exophthalmos (bulging eyes)
Usually bilateral but can be asymmetric
What does exophthalmos place pt at risk for?
Corneal ulcers -> eventual loss of vision
How can discomfort due to eye dryness be relieved?
Diuretics, eye wetting drops
What measure can be taken to help reduce periorbital edema thereby decreasing risk of ulceration?
Elevate the HOB
Once exophthalmos occurs, can it be reversed?
No
Cardiac complications of hyperthyroidism are r/t long standing stimulation b/c of untreated or under-managed hyperthyroidism. What are the most common cardiac complications?
Tachycardia, A-fib, CHF, Systolic HTN, angina
What is the nursing mgt for Graves disease?
Provide quiet-restful & cool environment Avoid physical / emotional stress Promote weight gain (high calorie/high protein diet – 6 small meals per day) – avoid Na+ to decrease periorbital edema Force fluids Protect eye(s) from injury
What is an acute episode of excessive thyroid hormone that is potentially fatal?
Thyroid Storm
What are the symptoms of thyroid storm?
High fever (> 105) Severe tachycardia Confusion; restless; agitated Profuse diaphoresis; dehydration N/V/D Seizures, delirium, coma Can lead to: CV collapse, heart failure, shock -> death
What is the nursing mgt for thyroid storm?
Decrease temperature
Hypothermia blankets
Acetaminophen (NO ASA – will ↑ bleeding)
IVF
Meds to block Thyroid hormone (PTU, iodine)
Control the adrenergic effects of thyroid hormone (beta blockers – i.e. Propranolol)
They help block the body’s response to the excess thyroid hormone
Protect from injury
Support CV status (ASSESS BP & HR!!!)
Goal is to decrease tachycardia
What are the 3 primary tx options to block the adverse effects of thyroid hormone & stop their oversecretion?
Anti-thyroid medications
Radioactive iodine therapy (thyroid ablation)
Surgical removal of thyroid gland
Pre-op tx: anti-thyroid meds & iodine to reduce hormone levels & beta blockers (lols) to relieve symptoms of excess hormone
What are the first line anti-thyroid drugs?
Propylthiouracil (PTU)
Tapazole (methimazole)
What does PTU do?
Blocks peripheral conversion of T4 to T3
How long does it take PTU to show good effects?
Improvement in 1-2 weeks; good results in 4-8 weeks
How long is PTU therapy continued?
6-15 months to allow for spontaneous remission (doesn’t happen for everyone though!)
What is the major disadvantage with these meds? (Anti-thyroid)
Non-compliance (must take 3x day); disease may recur when stopped
When are these (Anti-thyroid) drugs used?
Graves disease in young pt, hyperthyroidism esp pregnant women, to achieve euthyroid state pre-op or pre-radiation, thyroid storm mgt
What are the adverse effects of methimazole (Tapazole)?
Hives, itching, rash, fever, joint swelling, altered taste sensation
AGRANULOCYTOSIS (failure of the bone marrow to make enough white blood cells) – you need to monitor bone marrow function & review CBCs!
LIVER DAMAGE
APLASTIC ANEMIA
VASCULITIS
How can the nurse minimize GI irritation with these drugs?
Give with food
What iodine meds are used along with anti-thyroids to prepare a pt for thyroidectomy or during thyroid storm?
SSKI
Lugol’s solution
What do the iodine meds do?
Decrease the size & vascularity of the gland
How should these meds be given?
Check pts pulse rate first! Then give diluted in juice or milk WITH A STRAW after meals
What side effects should the nurse monitor for? (They indicate iodism)
Metallic taste, fever, rash, mucuous membrane lesions
What are some beta-adrenergic blockers that may be used to control the symptoms of hyperthyroidism?
Propranolol (Inderal)
Reserpine
Atenolol (Tenormin)
What is an additional plus of giving beta blockers in hyperthyroidism?
Helps prevent complications of cardiac disease secondary to excess thyroid hormone
What is the treatment of choice for non-pregnant adults with hypothyroidism?
Radioactive iodine (RAI)
What does Radioactive iodine do?
Destroys (ablates) thyroid tissue & lowers thyroid hormone
How is RAI given?
Single outpatient dose (may repeat x2)
How long does it take for RAI to become effective?
2-3 months
What must the pt be pre-treated with and given during the 1st 3 months before RAI administration?
Anti-thyroid meds & beta blockers
What is the high risk with thyroid ablation? (Pt should be taught these s/s)
Hypothyroidism
Are there any special precautions with RAI?
No
When is a full thyroidectomy completed?
When large goiter is present causing tracheal compression, thyroid CA, unresponsive anti-thyroids, not candidate for RAI
The preferred procedure is a partial thyroidectomy. What is it used to tx?
Overactive thyroid or simple goiters
How much of the thyroid gland is taken in a partial thyroidectomy?
About 5/6th
What will happen if too much thyroid gland is taken (hypothyroidism)?
Won’t regenerate after sx – pt will need HRT
What must occur pre-op to a thyroidectomy?
Achieve euthyroid state Anti-thyroid meds (suppress TH) Iodine (decrease gland size & vascularity) Be at adequate weight Get adequate rest Control CV symptoms
How long may pre-op prep for thyroidectomy take?
2-3 months
The thyroid is a highly vascular gland. What does this place the pt at risk for post-thyroidectomy?
Bleeding
Where should the nurse assess for bleeding?
The dressing, the back of the neck, & pillow
What are signs that a pt may have bleeding occuring?
Frequent swallowing or choking sensation
What is a priority assessment post-thyroidectomy?
Respiratory
What should the nurse keep at bedside in case of respiratory emergency post-thyroidectomy?
Tracheostomy tray & oxygen
Post-thyroidectomy, what position should the pt be in?
Semi-Fowlers
Should the pt be allowed to do deep breathing & coughing?
Deep breathing only! Avoid coughing!
What electrolyte imbalance is the post-thyroidectomy pt at risk for?
Hypocalcemia
What are some s/s of hypocalcemia?
Tetany, tingling of mouth/fingertips, (+) Chvosteks or Trousseau’s signs, dysrhythmias
What med should be kept at bedside post-thyroidectomy in case of emergency due to hypocalcemia?
Calcium gluconate (IV)
A thyroidectomy may cause large releases of thyroid hormone into the circulation. It also places the pt at risk of increased physical/emotional stress. What does this place the patient at risk for?
Thyroid storm
What should the nurse do if thyroid storm develops?
Notify the physician IMMEDIATELY
How is thyroid storm treated?
Beta blockers, anti-thyroid meds, glucocorticoids (reduce stress), support CV status
What should the pt be taught about neck tension post-thyroidectomy?
Turn head/neck in alignment; support neck with hands
The patient may be hoarse for 3-4 days following the thyroidectomy. What should the nurse tell the pt?
It is normal & will resolve; Pt should rest his/her voice
When should neck exercises be started following a thyroidectomy?
Post op days 2-4 (need to prevent contractures)
What should the pt be taught about home care post-thyroidectomy?
Reduce caloric intake,
Get adequate iodine (normal salt use or eat seafood 1-2x/week)
Regular exercise
Avoid temperature extremes
Keep follow-up appts
Will need HRT if total thyroidectomy (teach importance of compliance)
What is hypothyroidism?
Deficiency of circulating thyroid hormone
95% of the time hypothyroidism is due to failure of the thyroid gland. What is this called?
Primary hypothyroidism
What is it called when the actual problem is the anterior pituitary?
Secondary hypothyroidism
What happens in hypothyroidism?
DECREASES in volume, temp, metabolism, GI motility, RBC production
What is the most common cause of hypothyroidism worldwide?
Iodine deficiency
What is the most common cause of hypothyroidism in the U.S.?
Atrophy of the thyroid gland (Hashimoto’s disease)
What is hypothyroidism that occurs in infancy?
Cretinism
What causes cretinism?
Thyroid hormone deficiency during fetal or early neonatal life.
Infants born in the US are screened for cretinism and tx initiated for any babies diagnosed. What happens if left untreated?
Delayed brain development Thick protruding tongue Large anterior fontanel Hoarse cry Hypothermic Short adult stature < 4’9”
If hypothyroidism is due to a thyroidectomy or thyroid ablation or from tx with anti-thyroid drugs, onset can be acute. How can hypothyroidism be characterized otherwise?
Slow, insidious progression of slowing of body processes
May go undetected for months to years
What body systems are affected the most by hypothyroidism?
Neurologic, cardiovascular, GI, reproductive, hematologic
What Neuro s/s might you see with hypothyroidism?
Fatigue, lethargy, somnolen
Impaired memory, slowed speech
May appear depressed without actually being depressed
Sleep for long periods (although poor quality)
What cardiac s/s may be expected with hypothyroidism?
Low exercise tolerance
Short of breath on exertion
Decreased cardiac output; Decreased cardiac contractility
What are the effects on the GI system with hypothyroidism?
Decreased GI motility (constipation) Decreased HCl (alkalosis)
What hematologic problems may be expected with hypothyroidism?
Anemia
Easy bruising
Increased cholesterol -> artherosclerosis
If left untreated, what will eventually develop?
Goiter, myexedema
What other s/s may be expected with hypothyroidism?
Cold intolerance Dry coarse skin Weight gain Hair loss Receding hairline Thick tongue; slow speech
When does myexedma occur?
After long standing undiagnosed or under treated hypothyroidism
What are the characteristic signs of hypothyroidism?
Dry waxy skin
Periorbital/pretibial non-pitting edema
“Masklike” affect (no expressions)
What medical emergency can untreated myxedema lead to?
Myexedema coma (100% mortality when untreated)
What may precipitate myxedema coma?
Infection, certain drugs, cold exposure, trauma
What types of drugs can precipitate myexedema coma? (If you are already slowed down, what could slow you down even worse??)
Sedatives (opioids, tranquilizers, barbiturates)
If must be given – give < ½ usual dose
What are the manifestations of myxedema coma? (NOTE: EVERYTHING slowssss down)
Hypothermia Hypotension Hypoventilation Bradycardia Cerebral hypoxia Hyponatremia & water intoxication Hypoglycemia
What supportive measures are aimed at saving the life of the myxedema pt?
Patent airway; O2; ventilator if needed Maintain BP Replace fluids but watch Na+ levels Keep WARM Give IV Levothyroxine sodium, glucose, & corticosteroids
Once treated, how long should it take to see improvement in alertness & energy levels?
2-14 days
What other nursing mgt should the hypothyroid patient be given?
Keep environment warm
Prevent skin breakdown
Low cal diet; promote exercise
Prevent constipation
Increase fiber, fluids; give stool softeners
Plan activity schedule that offers frequent rest periods
Allow increased teaching-learning time
Stress importance of life-long compliance w/ HRT
Teach s/s hypo & hyperthyroidism
What is the goal of treatment for hypothyroidism?
Restore thyroid hormone to normal levels
What thyroid hormone replacement therapy drug is given to meet that goal?
Levothyroxine (Synthroid, Levothroid, L-Thyroxine)
Who should not be given Levothyroxine?
Hypersensitive, thyroid storm, acute MI
What are the adverse effects of Levothyroxine?
Hypertension, tachycardia, arrythmias
Anxiety, GI irritability, sweating, heat intolerance
So obviously, when giving thyroid HRT, what would be a priority to assess?
Cardiovascular function
What drugs can Levothyroxine interact with?
Anticoagulants (can potentiate causing increased risk for bleeding) – SHOULD decrease dose with anticoagulants!
Antilipemics
Ferrous sulfate
Digitalis (can decrease its effects)
What education should be given to the pt regarding Levothyroxine?
Compliance – take drug every day! Take at same time every day (AM is best) Avoid OTC drugs Should stick with same brand Take on empty stomach for best absorption Monitor insulin or oral diabetic therapy
How is a therapeutic dose of Levothyroxine achieved?
Increase initial dose every 1-2 weeks while monitoring thyroid levels
What are the s/s of Levothyroxine overdose?
Orthopnea; dyspnea
Tachycardia; palpitations
Nervousness; insomnia
For what pulse rate should you hold a levothyroxine dose?
> 100
When giving thyroid HRT, what should be reported to the physician?
HR > 100
Angina; other CV symptoms
Neuro changes: nervousness, insomnia, tremor
GI upset: N/V; increased appetite
What is a goiter that produces excessive levels of thyroid hormone?
Toxic goiter
What is a goiter that produces normal levels of thyroid hormone?
Non-toxic goiter
What is the most common cause of goiter worldwide?
Iodine deficiency
What are the causes of sporadic goiter?
Faulty iodine mechanism
Ingestion of goitrogens (inhibit T4 production)
What can goiter place pt at risk for?
Respiratory/swallowing problems
What is the tx for goiter?
Replace iodine (diet or supplements)
Measure TSH & T4
Sx: partial or total thyroidectomy
What is an inflammation of the thyroid gland?
Thyroiditis
What causes acute thyroiditis?
Bacterial infection
What causes sub-acute thyroiditis?
Possibly a virus
What causes chronic thyroiditis?
Hashimoto’s Disease
What is an autoimmune type of thyroiditis that is thought to be early Hashimoto’s disease?
Silent painless thyroiditis
What is the tx of sub-acute thyroiditis?
Manage symptoms
NSAIDs (if no response in 50 hrs) -> corticosteroids
Beta blocker (Propranolol or atenolol) to treat CV symptoms
Thyroid HRT if hypothyroid
What are pts with autoimmune thyroiditis at risk for?
Addison’s disease
Pernicious anemia
Premature gonadal failure
Graves disease
What are the s/s of thyroid CA?
Hard irregular painless nodules in enlarged thyroid gland
S/S hormone disruption
What is the tx for thyroid CA?
Chemo
Radiation
TSH suppressive therapy
Thyroidectomy
