132161647 Askep Ggn Thyroid

7/28/2019 132161647 Askep Ggn Thyroid

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Nursiswati, M.Kep.,Sp.KMB

Titis Kurniawan, MNS


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OutlineAnatomy & physiology Thyroid Gland

Thyroid Hormone Regulation

Hyperthyroid Patophysiology (etiology, clinical

manifestation, complication, & Nursingproblem)

Diagnostic test

NCP

Hypothyroid Patophysiology (etiology, clinical

manifestation, complication, & Nursingproblem)

Diagnostic test

NCP

Case Review


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Anatomy of Thyroid GlandSingle, bi-lobed gland in the anterior neck, shape of

butterfly

Largest of all endocrine gland (weight = 25 30g)

Regulation; low level of thyroidTRH (thyrotropin

releasing hormone) pituitary gland release TSH(thyroid-stimulating hormone) anterior pituitary

gland release thyroid (T3 and T4)

Hormone produced:

Thyroxine (T4) & tri-iodothyronin (T3)

dependent on iodine & BMR responsible for

cell metabolism (oxidasi & termogenesis), growth

& development

Calcitonin regulating blood calcium level

Isthmus


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Thyroid Regulation

T3 & T4Blood >>

TSH

TRH

Negativefeedback

T3 & T4Blood


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Hyperthyroidism

Excess thyroid hormone production

2nd most common endocrine disorder, after

diabetes mellitus.

Women; 8 x more often (age = 3050 years)

Etiology: Graves disease, toxic multinodular

goiter, thyroiditis, adenoma thyroid gland, &

excess iodine/thyroid intake

Graves disease; autoimmune disorder (Ig

stimuli TSH), most cause of hyperthyroid

Risk factors:pregnancy, trauma, stress,

amiodarone therapy, and age

(Tierney et al., 2001)


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Clinical Manifestations

Thyrotoxicosis; Loss weight, >> appetite

Rapid pulse/Palpitationatrialfibrilation/decompensatio cordis

Blood pressure (systolic) M>> Warm & moist skin

Heat intolerance, fatigue

Hand/tongue tremor

Nervousness, irritable

Hyperactive

Exopthalmus/bulging eye

Amenorhea

Osteoporosis/fracture


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PatofisiologiGraves DiseaseThyroiditis Goiter Adenoma

Autoimmune

TSH >>

>> T3 & T4

Thyrotoxicosis

>> metabolism

Prot & Fat > heat

>> sweat

DeComp/Atrial Fibrilation

Enlargmentthyroid gland

Change body image

Substance like TSH

CardiovascularSystem

Fibroblas & folikel

mata

Change

Jar. Obital & otot mata

Exophthalmus

Iritation

Risk of Injury

Nutrition problem


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Diagnostic TestTest Nature of test Normal Range Use in Diagnosis Nx Implication

TSH test Laboratory Bloodtest

Adults: 2-12microinternationalunit/ml

Differentiate primary &secondary hypothyroid.Primary THS >>,secondary TSH


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Thyroxine(T4) screen Laboratory Bloodtest Adults: 4 -11 mcg/dl Identify T4 blood level .Increase T4(Hyperthyroidism), lowlevel of T4 (hypothyroid)

Preparation, resultmay be affected iodinecontrast scans,medications(estrogen, oralcontraception, seizuremedication, opiates, &antithyroid drug

Tyroxineindex (freeT4 index)

Laboratory Bloodtest

Identify T4 or T3 bloodlevel . Increase level(Hyperthyroidism), lowlevel (hypothyroid)

Explain the procedure

Triiodothyronineradioimmunoassay

Laboratory Bloodtest

Accurately measurethyroid function. Whenlevel less than normal hypothyroid

Fasting is notrequired. May beaffected by pregnancy,recent radioisotopeadministration.

Iodineuptake scan

Patient takes oraldose of radioactiveiodine on anempty stomach(Iodine uptake by

thyroid gland)

Measure how muchiodine is taken bythyroid gland

Hypothyroid takes uplittle iodineHyperthyroidtakes upa lot of iodine

NPO, usually done inconjunction withthyroid lab studies


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Thyroid scan A radioactivesubstance is givento enhancevisualization of

the gland.

Reveal normal size,shape, position, &function

Differentiate thyroidnodule, Graves disease

from Plummers disease

Contraindicated forpregnancy & allergiesto iodine

Thyroidultrasound

Ultrasound Reveal normal size,shape & position ofgland

Differentiate cystic fromsolid thyroid nodules.Can be used to aid inplacement of needle forbiopsy.

Explain theprocedures

Needlebiopsy

Biopsy Differentiate malignantor benigna


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Medical ManagementTreatment ; directed to reduce thyroid hyperactivity to

relieve symptoms & remove the cause ofcomplications.

Depends on the cause of the hyperthyroidism andmay require a combination of therapeutic approaches.

Antithyroid drugs; inhibit production of active thyroidhormone, initial & long term treatment

PTU (Propilthiouracil); 3 divided doses

Methimazole; one daily dose, rapid improvement in T3& T4 serum & better patients compliance

Radioactive iodine; destrys all/part thyroid glandreduce excessive thyroid hormone

Subtotal thyroidectomy; most of thyroid glandremoved reduce thyroid hormone production


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Medical ManagementMedication Action Side Effects Nx Care

PTU Slowing TH production.

Given several months &

may cause temporary/long-term remission of

hyperthyroidism

Allergic (rash, hives, fever,

joint pain),


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Recurrent Hyperthyroidism

No treatment for thyrotoxicosis without side

effects, and all three treatments (radioactive

iodine therapy, antithyroid medications, and

surgery) share the same complications:

relapse or recurrent hyperthyroidism andpermanent hypothyroidism.

The rate of relapse increases in patients who

had very severe disease, a long history ofdysfunction, ocular and cardiac symptoms,

large goiter, and relapse after previous

treatment.


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Nursing ManagementNursing diagnoses: Imbalanced nutrition, less than body requirements, related to

exaggerated metabolic rate, excessive appetite, and increasedgastrointestinal activity

Anxiety, restlessness, hand tremor, insomnia secondary tohypermetabolism

Ineffective coping related to irritability, hyperexcitability, apprehension,and emotional instability

Body image (change/disruption) related to changes in physicalappearances (weight loss, exophthalmus, thyroid enlargement)

Risk for injury (eye) secondary to exophthalmus & inability to closeeyelids properly

Risk for decrease cardiac output related to hypermetabolic state


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Nursing Interventions Improving nutritional status;

Diet consultation

Nutritional supplements

Information supports (effect of hypo/hyperthyroid on

body weight); Administer antithyroid as prescribed

Monitor patients body weight

Enhancing coping;

Restful environment

Social support

Information supports (effect of hypo/hyperthyroid);

Administer antithyroid as prescribed


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Nursing Interventions Risk for injury

Encourage patients to flush eyes with warm water atinterval while awake

Use artificial tears

Cover eye while sleeping

Decrease Cardiac output

Monitor vital signs frequently

Administer antythyroid & cardiac medication as prescribed

Maintain restful & calm environment

Assess toleration of physical activity Monitoring and managing potential complications

Promoting home and community-based care

Teaching patients self-care


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Hypothyroidism

Results from suboptimal levels of thyroid

hormone.

Thyroid deficiency can affect all bodyfunctions range from mild, subclinical

forms to an advanced form (myxedema).

The most common cause of hypothyroidism

in adults is autoimmune thyroiditis(Hashimotos disease)


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Pathophysiology More than 95% hypothyroidism primary orthyroidal hypothyroidism dysfunction of the

thyroid gland.

Central hypothyroidismthyroid dysfunctioncaused by failure of the pituitary gland, the

hypothalamus, or both decreased stimulation ofTRH


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Pathophysiology Myxedema the accumulation of

mucopolysaccharides in subcutaneous and other

interstitial tissues.

Myxedema occurs in long-standing hypothyroidism,

the term is used appropriately only to describe the

extreme symptoms of severe hypothyroidism.


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Clinical Manifestations Early symptoms nonspecific, but extreme fatigue

makes it difficult for the person to complete a full dayswork or participate in usual activities.

Integuments: Reports of hair loss, brittle nails, and dryskin are common, and numbness and tingling of thefingers may occur.

The voice may become husky, and the patient maycomplain of hoarseness.

Menstrual disturbances; menorrhagia or amenorrheaoccur, in addition to loss of libido.


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NURSING DIAGNOSES

Risk for imbalanced body temperature;

hypothermia secondary to metabolic

dysfunction

Activity intolerance and fatigue secondary to

hypometabolic state with decrease cardiac

output

Constipation secondary to lethargy, activityintolerance, & hypometabolic state

Risk for impaired skin integrity secondary to

TH deficiency


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Life Threatening Complications

Myxedema coma Thyroid Storm

Life threatening Occurs when precipitating event trauma,

infection, sedation compromises the hypothyroidpatients (older adults with long-standing primary

thyroid diseases)

Occurs when there is failure of the compensatory

metabolic, thermoregulatory, & cardiovascular systemin hyperthyroid patients

Early symptoms Weight gain, extreme fatigue, bradycardia,

lethargy, mental dullness, memory impairment,

cold intolerance

Significant unexplained weight loss, warm, moist skin,

heat intolerance, cardiac palpitation, tachycardia,

tachypneu, & dyspneu on exertion

Signs & synptoms Very low body temperature (32,8 35C), skin cold

& dry, seizure, severe bradycardia, delayed deep

tendon reflexes, non pitting edema (face and

around eyes), enlarged tongue, loss of

consiousness, mood disturbance, & psychosis

Tachycardia (> 14x/mnt), atrial fibrilation, arrhytmias,

increase stroke volume, synptoms of high output

hearth failure with pulmonary edema.

Very high body temperature > 40 C, restlessness,

agitation, abdominal pain, nausea, vomiting, coma,

emotional lability, exophthalmus, goiter, coma

Laboratory values Low TSH (if pituitary is involved) & very high TSH

(thyroid gland is affected tissue), low serum FT4,

hyponatremia, hypoglycemia, hyperlipidemia,respiratory acidosis, ECG; prolong QT intervals,

pleural/pericardial effusions, presence antithyroid

antibodies

Low level TSH, high serum FT4, elevated liver

function test, elevated alkaline phosphatase

Assessment Vital signs, level of consciousness Body temperature, blood glucose level

Treatment Hormone replacement therapy Antithyroid drugs, surgery


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Nursing InterventionsRisk for imbalanced body temperature

Goal: Maintenance of normal body temperature

1. Provide extra layer of clothing or extra blanket.2. Avoid and discourage use of external heat

source (eg, heating pads, electric or warming

blankets).

3. Monitor patients body temperature and reportdecreases from patients baseline value.


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Nursing InterventionsActivity intolerance and fatigue secondary tohypometabolic state with decrease cardiac output

Goal: Increased participation in activities

1. Assess patient ability/activities tolerance level

2. Include patients in the low impact ativities

3. Helps patients conducting ADL

4. Include families during intervention

5. Instruct patient on administration of hormonereplacement

6. Avoid sadatives


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Nursing Intervention

Nursing Dx: Constipation secondary to lethargy, activity

intolerance, & hypometabolic state

Goal: Return of normal bowel function

1. Encourage increased fluid intake within limits of fluid restriction.2. Provide foods high in fiber.

3. Instruct patient about foods with high water content.

4. Monitor bowel function.

5. Encourage increased mobility within patients exercise tolerance.

6. Encourage patient to use laxatives and enemas sparingly.


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Nursing Intervention

Nursing Dx:Risk for impaired skin integrity secondary to TH

deficiency

Goal: improve skin condition (intact, soft, moist, no

itching/breaking)1. Avoid use of soap, astringents, or alcohol

2. Liberally apply emollient skin lotion

3. Cut patients nails properly

4. Monitor skin integrity

5. Consider air mattress if needed

6. Administer replacing hormone therapy as prescribed

132161647 Askep Ggn Thyroid

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