Disorders of Thyroid Gland • Hyperthyroidism • Hypothyroidism Consider where the gland is located and a priority system? Fluid & Electrolytes Mobility Perfusion Stress & Coping How will you know if your paCent has a thyroid disorder? What nursing assessments are involved? Fall 2019 Spring 2020 1
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Disorders of Thyroid Gland
• Hyperthyroidism • Hypothyroidism
² Consider where the gland is located and a priority system?
Fluid & Electrolytes Mobility
Perfusion Stress & Coping
How will you know if your paCent has a thyroid disorder?
What nursing assessments are involved?
Fall 2019 -‐ Spring 2020 1
Gland: Thyroid; Hormone: T3, T4
ETIOLOGY & PATHOPHYSIOLOGY: • Autoimmune disease – Diffuse thyroid enlargement – Excess thyroid hormone secretion
• Toxic nodular goiter • Thyroiditis • Excess iodine intake • Pituitary tumors • Thyroid cancer
• Thyroid hormone regulate energy metabolism and growth & development
• Hyperthyroidism –hyperacCvity of thyroid gland with sustained increase in synthesis and release of thyroid hormones
Fall 2019 -‐ Spring 2020 2
Changes in Metabolism AlteraAon DescripAon/DefiniAon ManifestaAons IntervenAon and
Therapies
Changes in metabolism
Metabolic processes of the body increase or decrease as a result of too much or too liLle thyroid hormone. • Hyperthyroidism • Hypothyroidism • Graves disease • ThyroidiCs • Thyroid cancer • Thyroid nodules
Increased metabolism results in excess energy and difficulty gaining weight. Decreased metabolism results in decreased energy, obesity, and difficulty losing weight. Hypothyroidism may be accompanied by goiter formaCon, myxedema, or myxedema coma
Hyperthyroidism and Graves disease treatments include radioacCve iodine (RAI), anCthyroid medicaCons, or a thyroidectomy. Hypothyroidism treatment includes daily use of syntheCc thyroid hormone levothyroxine administered orally. ThyroidiCs treatment depends on the clinical presentaCon. Thyroid cancer treatment includes surgery to remove the tumor or a thyroidectomy. Thyroid nodules oVen require no treatment unless symptomaCc. Treatment opCons range from medicaCon to surgical removal.
Fall 2019 -‐ Spring 2020 3
Hyperthyroidism • Most common form – Graves’ disease
• Thyrotoxicosis – Physiologic effects/clinical syndrome of hypermetabolism – Results from increased circulating levels of T3, T4, or both
• Hyperthyroidism and thyrotoxicosis usually occur together
DIAGNOSTIC STUDIES: • TSH, free T4 • Total T3 and T4 • Radioactive iodine
uptake (RAIU) Subclinical hyperthyroidism: Serum TSH level below 0.4 mIU/L Normal T4 and T3 levels Overt hyperthyroidism: Low or undetectable TSH Elevated T4 and T3 levels
Fall 2019 -‐ Spring 2020 4
Hyperthyroidism CLINICAL MANIFESTATIONS: Cardiovascular: Systolic hypertension; Bounding, rapid pulse; palpitations;↑ Cardiac output; Cardiac hypertrophy; Systolic murmurs; Dysrhythmias; Angina Respiratory: Dyspnea on mild exertion; Increased respiratory rate GI:↑ Appetite, thirst; Weight loss; Diarrhea; Splenomegaly; Hepatomegaly Integumentary: Warm, smooth, moist skin; Thin, brittle nails; Hair loss; Clubbing of fingers; palmar erythema; Fine, silky hair; premature graying; Diaphoresis; Vitiligo Musculoskeletal: Fatigue; Weakness; Proximal muscle wasting; Dependent edema; Osteoporosis
• ↑ Metabolism, ↑ Tissue sensitivity to stimulation by sympathetic nervous system • Goiter • Ophthalmopathy, Exophthalmos
5 Fall 2019 -‐ Spring 2020
Hyperthyroidism CLINICAL MANIFESTATIONS: Nervous: Nervousness, fine tremors; Insomnia , exhaustion; Lability of mood, delirium; Hyperreflexia of tendon reflexes; Inability to concentrate; Stupor, coma Reproductive: Menstrual irregularities; Amenorrhea; Decreased libido; Impotence; Gynecomastia in men; Decreased fertility Other clinical manifestations: Intolerance to heat; Elevated basal temperature; Lid lag, stare; Eyelid retraction; Rapid speech
Fall 2019 -‐ Spring 2020 6
Acute Thyrotoxicosis
• Thyrotoxic Crisis or Thyroid Storm – Excessive amounts hormones released
– Results from stressors – Thyroidectomy patients at risk
² What system is the priority? – Life-‐threatening emergency –why?
• Clinical Manifestations: – Severe tachycardia, heart failure
– Shock – Hyperthermia – Agitation – Seizures – Abdominal pain, vomiting, diarrhea
– Delirium, coma
Fall 2019 -‐ Spring 2020 7
Nursing ImplementaCon Acute Thyrotoxicosis
• Medications to block thyroid hormone production and SNS
• Monitoring for dysrhythmias & decompensation • Ensuring adequate oxygenation • Fluid and electrolyte replacement • Establish trusting relationships • Ensure adequate rest
– Calm, quiet room – Cool room – Light bed coverings
Fall 2019 -‐ Spring 2020 8
Interprofessional Care –Hyperthyroidism
Three primary treatment options: 1. Antithyroid medications:
Ø methimazole (Tapazole) Ø Iodine –potassium iodine and Lugol’s solution
Ø β-‐Adrenergic Blockers –propranolol, atenolol
2. Radioactive Iodine Therapy (RAI)
3. Surgery
GOALS: • Block adverse
effects of thyroid hormones
• Suppress hormone oversecretion
• Prevent complications
DRUG THERAPY: • Useful in
treatment of thyrotoxic states
Fall 2019 -‐ Spring 2020 9
Nutritional Therapy
• High-‐calorie diet (4000 to 5000 cal/day) – Six full meals/day with snacks in between – Protein intake: 1 to 2 g/kg ideal body weight – Increased carbohydrate intake
• Avoid highly seasoned and high-‐fiber foods, caffeine
• Dietitian referral
Fall 2019 -‐ Spring 2020 10
Interprofessional Care –Hyperthyroidism
• Administer medications to achieve euthyroidism
• Administer iodine to ↓ vascularity
• Assess for signs of iodine toxicity
• Patient teaching – Comfort and safety measures
– Leg exercises, head support, neck ROM
– Routine postoperative care
SURGICAL THERAPY: Preoperative Care Ø Surgical/
Anesthesia consent Ø Pre-‐op labs Ø Medical clearance Ø Pre/Post-‐op
teaching Ø NPO
Fall 2019 -‐ Spring 2020 11
Interprofessional Care –Hyperthyroidism
Subtotal thyroidectomy or Total thyroidectomy -‐What is the difference? SURGICAL THERAPY
INDICATIONS:
• Large goiter causing tracheal compression
• Unresponsive to antithyroid therapy
• Thyroid cancer • Not a candidate for
RAI • Rapid reduction in
T3 and T4 levels
Fall 2019 -‐ Spring 2020 12
Interprofessional Care –Hyperthyroidism
• Monitor vital signs, bleeding, tracheal compression
• Serial calcium levels –why? • Signs of hypocalcemia –What are assessment finding?
• Pain management • Ambulation • Psychosocial support
SURGICAL THERAPY: Postoperative Care Ø Surgical site Ø IVF , F&E balance Ø Diet Ø Activity Ø IV Ca+ (8.6 -‐10.2 mg/dL)
replacements Ø VTE prophylaxis Ø O2, suction set-‐up Ø Tracheostomy tray
Fall 2019 -‐ Spring 2020 13
Interprofessional Care –Hyperthyroidism
• Regular follow-‐up care • Decrease caloric intake • Adequate but not excessive
iodine intake • Regular exercise • Avoid ↑ environmental
temperature • Complete thyroidectomy: – Symptoms of hypothyroidism – Need for lifelong thyroid hormone replacement
SURGICAL THERAPY: Discharge Teaching
Fall 2019 -‐ Spring 2020 14
be able to tell
Interprofessional Care –Hyperthyroidism
• Overall Goals: – Experience relief of symptoms
– Have no serious complications related to disease or treatment
– Maintain nutritional balance – Cooperate with therapeutic plan
Nursing Diagnoses: • Activity
intolerance • Imbalanced
nutrition: less than body requirements
Fall 2019 -‐ Spring 2020 15
The nurse is caring for a patient who just returned to the surgical unit following a thyroidectomy. The nurse is most concerned if which is observed? a. The patient complains of increased thirst b. The patient makes harsh sounds when breathing c. The patient dressing is moist with serous drainage d. The patient reports a sore throat when swallowing
Audience Response Question
Fall 2019 -‐ Spring 2020 16
Gland: Thyroid; Hormone: T3, T4
ETIOLOGY & PATHOPHYSIOLOGY:
• Primary hypothyroidism –caused by destruction of thyroid tissue or defective hormone synthesis
• Secondary hypothyroidism –caused by pituitary or hypothalamic dysfunction (↓ TSH or TRH –thyrotropin-‐releasing hormone)
Hypothyroidism –deficiency of thyroid hormone , causes general slowing metabolic rate
Fall 2019 -‐ Spring 2020 17
HYPOTHYROIDISM • Systemic effects characterized by slowing of body processes
• Manifestations variable • Slow onset • Symptoms may be attributed to normal aging in older adult
CAUSES: • Iodine deficiency • Atrophy of the gland
–end result of Hashimoto’s thyroiditis or Graves’ disease
• Treatment for hyperthyroidism
• Drugs (amiodarone, lithium)
Fall 2019 -‐ Spring 2020 18
Hypothyroidism CLINICAL MANIFESTATIONS: Cardiovascular: (CV problems may be significant in patients with pre-‐existing cardiovascular disease): ↓ Cardiac contractility and output; ↑ Serum cholesterol and triglycerides; Anemia Respiratory: Low exercise tolerance; Shortness of breath on exertion Neurologic: Fatigue and lethargy; Personality and mood changes; Impaired memory, slowed speech, decreased initiative, and somnolence
DIAGNOSTIC STUDIES: • TSH and free T4 • TSH ↑ with primary
hypothyroidism • TSH ↓ with secondary
hypothyroidism • Thyroid antibodies Subclinical hypothyroidism: TSH is >4.5 mIU/L T4 levels normal
• ↑ Cholesterol • ↑ Triglycerides • ↑ Creatine kinase • ↓ RBCs (anemia)
Fall 2019 -‐ Spring 2020 19
Hypothyroidism
CLINICAL MANIFESTATIONS (con’t): Gastrointestinal: Decreased appetite; Nausea and vomiting; Weight gain; Constipation; Distended abdomen; Enlarged, scaly tongue; Celiac disease Integumentary: Dry, thick, inelastic, cold skin; Thick, brittle nails; Dry, sparse, coarse hair; Poor turgor of mucosa; Generalized interstitial edema; Puffy face; Decreased sweating; Pallor
Musculoskeletal: Fatigue, weakness; Muscular aches and pains; Slow movements; Arthralgia Reproductive: Prolonged menstrual periods or amenorrhea; Decreased libido, infertility Other Clinical Manifestations: Increased susceptibility to infection; Increased sensitivity to opioids, barbiturates, anesthesia; Intolerance to cold; Decreased hearing; Sleepiness; Goiter
Fall 2019 -‐ Spring 2020 20
Hypothyroidism • Myxedema coma – Precipitated by infection, drugs, cold, trauma
• Clinical Manifestations: • Impaired consciousness • Subnormal temperature, hypotension, hypoventilation • Cardiovascular collapse
² What system is the priority?
Fall 2019 -‐ Spring 2020 21
Nursing ImplementaCon Myxedema Coma
• Mechanical respiratory support • Cardiac monitoring • IV thyroid hormone replacement • Monitoring of core temperature • Vital signs, weight, I&O, edema • Cardiovascular response to hormone • Skin care • Energy level • Mental alertness Fall 2019 -‐ Spring 2020 22
Interprofessional Care –Hypothyroidism
• Drug of choice to treat hypothyroidism – Start with low dose – Monitor for cardiovascular side effects (chest pain, dysrhythmias), weight loss, nervousness, tremors, insomnia
– Increase dose in 4-‐ to 6-‐week intervals as needed
– Lifelong therapy
DRUG THERAPY:
Levothyroxine (Synthroid) • Take in morning on empty stomach • History of Cardiovascular disease • HR/PR >100 or irregular • Side effects Fall 2019 -‐ Spring 2020 23
Interprofessional Care – Hypothyroidism
Overall Goals: • Restoration of euthyroid state as safely and rapidly as possible
• Low-‐calorie diet • Comply and adhere to lifelong thyroid replacement therapy –most care outpatient
• Maintain a positive self-‐image
Nursing Diagnoses: • Activity
intolerance • Constipation • Impaired
memory
Fall 2019 -‐ Spring 2020 24
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