Askep Ggn Thyroid

Asuhan Keperawatan Pada Klien dengan Gangguan Thyroid

Nursiswati, M.Kep.,Sp.KMBTitis Kurniawan, MNS

Outline Anatomy & physiology Thyroid Gland

Thyroid Hormone Regulation

HyperthyroidPatophysiology (etiology, clinical manifestation,

complication, & Nursing problem)Diagnostic testNCP

HypothyroidPatophysiology (etiology, clinical manifestation,

complication, & Nursing problem)Diagnostic testNCP

Case Review

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

of butterfly Largest of all endocrine gland (weight = 25 – 30g) Regulation; low level of thyroid TRH (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

Thyroid Regulation

T3 & T4 Blood >>

TSH

TRH

Negative

feedback

T3 & T4 Blood <<

HyperthyroidismExcess thyroid hormone production 2nd most common endocrine disorder, after

diabetes mellitus. Women; 8 x more often (age = 30 – 50 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)

Clinical ManifestationsThyrotoxicosis; Loss weight, >> appetiteRapid pulse/Palpitation atrial

fibrilation/decompensatio cordisBlood pressure (systolic) M>> Warm & moist skinHeat intolerance, fatigueHand/tongue tremorNervousness, irritable HyperactiveExopthalmus/bulging eyeAmenorheaOsteoporosis/fracture

PatofisiologiGraves’ DiseaseThyroiditis Goiter Adenoma

Autoimmune

TSH >>

>> T3 & T4

Thyrotoxicosis

>> metabolism

Prot & Fat <<

Loss body weight

Symphatis

Tremors

Palpitaion

>> heat

>> sweat

DeComp/Atrial Fibrilation

Enlargment thyroid gland

Change body image

Substance like TSH

Cardiovascular System

Fibroblas & folikel

mata

Change Jar. Obital & otot mata

Exophthalmus

Iritation

Risk of Injury

Nutrition problem

Diagnostic TestTest Nature of

testNormal Range

Use in Diagnosis

Nx Implication

TSH test Laboratory Blood test

Adults: 2-12 microinternational unit/ml

Differentiate primary & secondary hypothyroid. Primary THS >>, secondary TSH << (absent) even with low level of T3 & T4

Prepare patient for blood test, fasting is not required, may be affected by recent radioisotop for other diagnostic

TSH stimulation test

Laboratory Blood test

Evidence increase thyroid function with administration of TSH

Help differentiate primary & secondary hypothyroid. Primary diseases unable to increase thyroid hormone

Prepare patient for blood test & fasting is not required

TRH test IV bolus of TRH Quick rise in TSH level within 30 minutes after bolus

Confirm the presence of primary hyperthyroidism. Little or no increase in TSH is seen doe to suppression effect of excess circulation of TH. Excessive increase of TSH early hypothyroid

Prepare patient for blood test & fasting is not required.Explain the procedures & monitoring the site of drug insertion

Diagnostic TestTest Nature of

testNormal Range

Use in Diagnosis Nx Implication

Thyroxine (T4) screen


Adults: 4 -11 mcg/dl

Identify T4 blood level . Increase T4 (Hyperthyroidism), low level of T4 (hypothyroid)

Preparation, result may be affected iodine contrast scans, medications (estrogen, oral contraception, seizure medication, opiates, & antithyroid drug

Tyroxine index (free T4 index)


Identify T4 or T3 blood level . Increase level (Hyperthyroidism), low level (hypothyroid)

Explain the procedure

Triiodothyronine radioimmunoassay


Accurately measure thyroid function. When level less than normal hypothyroid

Fasting is not required. May be affected by pregnancy, recent radioisotope administration.

Iodine uptake scan

Patient takes oral dose of radioactive iodine on an empty stomach (Iodine uptake by thyroid gland)

Measure how much iodine is taken by thyroid gland

Hypothyroid takes up little iodineHyperthyroid takes up a lot of iodine

NPO, usually done in conjunction with thyroid lab studies

Diagnostic Test

Test Nature of test

Normal Range

Use in Diagnosis Nx Implication

Thyroid scan

A radioactive substance is given to enhance visualization of the gland.

Reveal normal size, shape, position, & function

Differentiate thyroid nodule, Graves’ disease from Plummer’s disease

Contraindicated for pregnancy & allergies to iodine

Thyroid ultrasound

Ultrasound Reveal normal size, shape & position of gland

Differentiate cystic from solid thyroid nodules. Can be used to aid in placement of needle for biopsy.

Explain the procedures

Needle biopsy

Biopsy Differentiate malignant or benigna

Medical Management Treatment ; directed to reduce thyroid hyperactivity to

relieve symptoms & remove the cause of complications. Depends on the cause of the hyperthyroidism and may

require a combination of therapeutic approaches. Antithyroid drugs; inhibit production of active thyroid

hormone, 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 gland

reduce excessive thyroid hormone Subtotal thyroidectomy; most of thyroid gland

removed reduce thyroid hormone production

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), << WBC, sore throat, infection, impaired liver function, loss off appetite, abdominal pain

Instruct patient to have regular follow up, monitor WBC, liver function, report side effects symptoms

Methimazole (Tapazole, carbimazole)

Inhibits synthesis of TH Caution in patients with liver diseases, bone marrow disorder, allergy history, & congenital anomalies

Instruct patient to aware the side effect symptoms.Avoid giving when the (anti cancer drug, lithium, iodine-containing drug, sulfonamide, interferon) are given

Iodide or iodide products

Inhibits synthesis of TH & decrease size 7 vascularity of thyroid. Effective for short term treatment (7-14 days)

Diarrhea, vomiting, nausea, abdominal pain, skin rash, GI bleeding (adverse reaction)

Advise patient to drink all solution, use straw to prevent discoloration of teeth, not to withdraw and report iodism (abdominal symptoms)

Propanolol (Indrenal)

Beta-adrenergic blocking agents. Decrease the effect of hyperthyroidism

Decrease HR, myocardial oxygen consumption, & lowering blood pressure

CI for asthma, sinus bradycardia/hearth block,. Advise patient not to discontinue abruptly

Radioactive iodine (I-123)

Destroys thyroid tissue with maximum benefit apparent in 3-6 months.

No serious complications reported

Advise patient to have TH level monitored regularly, take thyroid replacement on empty stomach, don’t change the hormone’s brands without follow up monitoring

Recurrent HyperthyroidismNo 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 and permanent hypothyroidism.

The rate of relapse increases in patients who had very severe disease, a long history of dysfunction, ocular and cardiac symptoms, large goiter, and relapse after previous treatment.

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

metabolic rate, excessive appetite, and increased gastrointestinal activityAnxiety, restlessness, hand tremor, insomnia secondary to

hypermetabolism Ineffective coping related to irritability, hyperexcitability, apprehension, and

emotional instabilityBody image (change/disruption) related to changes in physical

appearances (weight loss, exophthalmus, thyroid enlargement)Risk for injury (eye) secondary to exophthalmus & inability to close eyelids

properlyRisk for decrease cardiac output related to hypermetabolic state

Nursing InterventionsImproving nutritional status;

Diet consultationNutritional supplementsInformation supports (effect of hypo/hyperthyroid on

body weight); Administer antithyroid as prescribedMonitor patients’ body weight

Enhancing coping;Restful environmentSocial supportInformation supports (effect of hypo/hyperthyroid); Administer antithyroid as prescribed

Nursing InterventionsRisk for injury

Encourage patients to flush eyes with warm water at interval while awake

Use artificial tearsCover eye while sleeping

Decrease Cardiac outputMonitor vital signs frequentlyAdminister antythyroid & cardiac medication as prescribedMaintain restful & calm environmentAssess toleration of physical activity

Monitoring and managing potential complicationsPromoting home and community-based care

Teaching patients self-care

Hypothyroidism

Results from suboptimal levels of thyroid hormone.

Thyroid deficiency can affect all body functions range from mild, subclinical forms to an advanced form (myxedema).

The most common cause of hypothyroidism in adults is autoimmune thyroiditis (Hashimoto’s disease)

PathophysiologyMore than 95% hypothyroidism primary or

thyroidal hypothyroidism dysfunction of the thyroid gland.

Central hypothyroidism thyroid dysfunction caused by failure of the pituitary gland, the hypothalamus, or both decreased stimulation of TRH << TH

Pituitary or secondary hypothyroidism pituitary disorder

Hypothalamic or tertiary hypothyroidism hypothalamus disorder

Cretinism thyroid deficiency present at birth (the mother may also suffer from thyroid deficiency).

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.

Clinical ManifestationsEarly symptoms nonspecific, but extreme fatigue

makes it difficult for the person to complete a full day’s work or participate in usual activities.

Integuments: Reports of hair loss, brittle nails, and dry skin are common, and numbness and tingling of the fingers may occur.

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

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

NURSING DIAGNOSESRisk 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, activity intolerance, & hypometabolic state

Risk for impaired skin integrity secondary to TH deficiency

Life Threatening ComplicationsMyxedema coma Thyroid Storm

Life threatening Occurs when precipitating event trauma, infection, sedation compromises the hypothyroid patients (older adults with long-standing primary thyroid diseases)

Occurs when there is failure of the compensatory metabolic, thermoregulatory, & cardiovascular system in 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

Nursing Interventions

Risk for imbalanced body temperatureGoal: Maintenance of normal body temperature1. 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 patient’s body temperature and report decreases from patient’s baseline value.

Nursing Interventions

Activity intolerance and fatigue secondary to hypometabolic state with decrease cardiac output

Goal: Increased participation in activities

1. Assess patient ability/activities tolerance level 2. Include patients in the low impact ativities3. Helps patients conducting ADL4. Include families during intervention5. Instruct patient on administration of hormone

replacement6. Avoid sadatives

Nursing Intervention

Nursing Dx: Constipation secondary to lethargy, activity intolerance, & hypometabolic stateGoal: Return of normal bowel function1. 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 patient’s exercise

tolerance.6. Encourage patient to use laxatives and enemas sparingly.

Nursing Intervention

Nursing Dx:Risk for impaired skin integrity secondary to TH deficiencyGoal: improve skin condition (intact, soft, moist, no itching/breaking)1. Avoid use of soap, astringents, or alcohol2. Liberally apply emollient skin lotion3. Cut patients’ nails properly4. Monitor skin integrity5. Consider air mattress if needed6. Administer replacing hormone therapy as prescribed

Askep Ggn Thyroid

Documents