Disorders of the Thyroid and Parathyroid

1. Disorders of the Thyroid and Parathyroid ACC, RNSG 1247 Created by Lydia Seese, RN

4. Thyroid Enlargement/Goiter Maybe caused by: • Increased TSH stimulation • Growth-stimulating immunoglobulins & other growth factors • Goitrogens • Iodine-deficiency areas (endemic goiter)

5. Thyroid nodules • Mostly benign • Malignant nodules: usually hard & painless • Diagnostics: US, US-guided FNA, thyroid scan • Treatment: unilateral to total thyroidectomy

6. Thyroiditis • Subacute and acute thyroiditis: Subacute - viral (as in subacute granulomtous thyroiditis) Acute fungal or bacterial • Chronic autoimmune thyroiditis • Silent painless thyroiditis

7. Hashimoto’s thyroiditis • Chronic autoimmune disease • Most common cause of hypothyroidism in US • Diagnostics: T3 T4 usually low, TSH high, (+) for antithyroid antibodies

8. HYPERTHYROIDISM • Graves’ Disease • Toxic nodular goiters • Thyroiditis (hyper) – usually caused by virus as in viral subacute granulomatous thyroiditis • Thyrotoxic crisis (thyroid storm)

9. Graves Disease • Autoimmune, unknown etiology • Antibodies attach to the TSH receptors and stimulate the thyroid to release T3 & T4 • May lead to destruction of thyroid tissue , thus hypothyroidism

10. Toxic Nodular Goiters • Release thyroid hormones independent of TSH stimulation • Maybe single or multinodular

11. Diagnostics for Hyper/Hypothyroid Dysfunction • History and PE • Most reliable blood tests are: • TSH • Free T4

13. Diagnostics Continued • T3, T4 • Radioactive iodine uptake (RAIU ) • TRH stimulation test • ECG • US • Thyroid scan • Antibody assay

14. Hyperthyroidism: Manifestations • S/sx of increased metabolism & stimulation of SNS • Goiter • Opthalmopathy; exophthalmus in Graves’

16. Exopthalmus

17. Thyroid storm • Rare but dangerous • Systemic symptoms: examples • Hyperthermia • Tachycardia, esp. atrial arrhythmias • Agitation or delirium

18. Hyperthyroidism: Collaborative Care • Medications/Drugs • Radioactive Iodine • Nutritional • Surgical

19. Drug Therapy: Antithyroid drugs • Preferred Tx for pregnant women • Methimazole - tapazole • PTU - prophylthiouracil • Improvement begins 1-2 weeks • Good results in 4-8 weeks • Remission in 6-15 mos. in < 50% of cases • Patient concern: noncompliance

20. Drug Therapy: B adrenergic blockers • Symptomatic relief of thyrotoxicosis • Propranolol - Inderal • Atenolol - Tenormin

21. Drug Therapy: Iodine • Maximal effect in 1-2 weeks • Saturated solution of potassium iodine (SSKI) • Lugol’s solution

22. Radioactive Iodine Therapy • Preferred for most nonpregnant women • Damages thyroid hormone • Effect in 2-3 mos.

23. Acute Intervention • Support ABC’s • Rest, minimal stimulation • Eye care

24. Pre/Post operative Care • CDB, turning, ambulate w/in hrs post op • ROM of neck • Airway and incision site monitoring • Semi fowlers to prevent tension on suture lines • VS monitoring including tetany • Pain management • Fluids if tolerated, soft diet day after

25. Post operative & home care • Remaining thyroid tissue is allowed to regenerate post-op • Reduced caloric intake, adequate iodine • Regular exercise • Avoid temperature extremes • Regular follow up to monitor for hypothyroidism

26. HYPOTHYROIDISM • Primary – RT destruction of thyroid tissue or defective hormone synthesis • Secondary – RT pituitary disease

27. Hypothyroidism: Manifestations • Slowing of body process which develops over months to years • Exs: fatigue, cold intolerance, weight gain, systemic symptoms • Myxedema

28. Myxedema Coma • Rare but life threatening • Severe metabolic disorders, hypothermia, cardiovascular collapse, coma • Factors: infection, trauma, failure to take thyroid replacements

31. Hypothyroidism: Collaborative care • Goal – euthyroid state • Low calorie diet • Thyroid hormone • Natural hormones

32. Hypothyroidism: Acute Intervention • IV thyroid hormone • Hypertonic saline solution • Close assessment • VS monitoring

33. Thyroid malignancies • Occur more often in people who have undergone radiation of the head, neck or chest. • Symptoms of thyroid cancer include hoarseness, dysphagia

34. Most Common Types of Thyroid Cancer • Papillary thyroid cancer • Follicular thyroid cancer

35. The parathyroid glands

36. Disorders of the parathyroid glands • Hyperparathyroidism (hypercalcemia) • Hypoparathyroidism (hypocalcemia) • Tumors

37. Hyperparathyroidism • Primary • Secondary • Tertiary

38. Hyperparathyroid • Major S/Sx: depression, fatigue, loss of appetite, constipation, osteoporosis, fractures, kidney stones • DX: bone x-rays, Ca & PTH levels • TX: decrease high serum levels, surgical removal of parathyroid

39. Hyperparathyroidism: Nonsurgical Treatment • Close follow up • Active lifestyle. • Dietary measures • Drugs

40. Common Medications used in Hyperparathyroidism • Phosphorus • Biphosphates • Estrogen or progestin • Oral phosphate • Diuretics • Calcimimetic agents

41. Signs that indicate calcium levels are abnormal • Trousseau’s sign: temporarily occlude arterial blood flow (with BP cuff inflated) above the normal systolic pressure. A + Trousseau”s sign occurs when the hand and fingers contract from ischemia • Chvostek’s sign: tap on the facial nerve just below the temple. Sign is + when nose, eye, lip & facial muscles twitch

42. Hypoparathyroidism • Results from abnormally low levels of PTH low Ca level • Symptoms: painful spasms of face, hands, arms, and feet; seizures • TX: IV Calcium; CalMag & vit D; Rebreathing

43. Parathyroid Tumors • Grow inside the gland itself • May cause  levels of PTH leading to hyper states. • Most are benign adenomas; malignancies are very rare

44. Nursing Diagnosis for thyroid/parathyroid patients • Imbalanced nutrition: _______ r/t hypermetabolic or hypometabolic state • Disturbed body image: r/t changes in appearance AEB exopthalmus (myxedema), skin changes, facial edema, presence of goiter • Risk for constipation r/t slowed metabolic states and decreased activity tolerance • Risk for fluid/electrolyte imbalance r/t changes in production of thyroid hormones 2° hypothyroidism

45. Nursing Diagnosis, cont. • Electrolyte imbalance r/t decreased/increased levels of calcium AEB…. • Knowledge deficit: dietary, r/t decreased parathyroid function AEB calcium serum levels of_____, facial twitching, muscle cramps, ….. • R/F impaired cardiac output • R/F Imbalanced body temperature • RF acute pain RT effects of renal stone

46. The End