Thyroid and Parathyroid Endocrine Disorders Chapter 19

1. Thyroid and ParathyroidEndocrine DisordersChapter 19 Lecture 2 Fall 14 Mary L. Dunlap, MSN

2. Thyroid Disorders • Hyperthyroidism • Hypothyroidism • Thyroiditis • Thyroid Cancer

3. Hyperthyroidism Excessive hormone secretion • Creates Thyrotoxicosis • Mild- manifestations subtle • Sever- manifestations life threatening • Temporary or permanent depending on the cause

4. Hyperthyroidism • Hypermetabolism • Increased sympathetic nervous system activity- cardiac stimulation • Sex hormone changes

5. Hyperthyroidism • Graves’ Disease • Toxic Multinodular Goiter • Exogenous Hyperthyroidism • Thyroid Storm/Crisis

6. Graves’ Disease • Hallmark sign- diaphoresis • Dyspnea- with or with out exertion • Ophthalmapathy • Visual changes • Energy level changes • Libido

7. Exophthalmos in a patient with Graves’ disease. The disease causes edema of fat deposits behind the eyes and inflammation of the extraocular muscles. The accumulating pressure forces the eyes outward from their orbits. Source:Elsevier Ltd

8. Toxic multinodular goiter. The formation and growth of numerous nodules in the thyroid gland cause the characteristic massive enlargement of the neck. Source: Marka / Custom Medical Stock Photo, Inc.

10. MULTISYSTEM EFFECTS OF Hyperthyroidism

11. Graves’ Disease • Assessment History Physical Psychosocial • Laboratory • Diagnostic

12. TABLE 19–1 Laboratory Findings in Thyroid Disorders

13. Graves’ Disease Nursing Diagnosis

14. Graves’ Disease Interventions • Nonsurgical • Surgical

15. Nonsurgical Nursing Interventions • Monitor vital signs at least every 4 hours • Instruct patient to report any C/O palpitations, dyspnea, vertigo or chest pain • Encourage rest • Bathe and change linens frequently to promote comfort

16. Nonsurgical Drug Therapy • Antithyroid drugs block thyroid hormone production by preventing iodide binding in the thyroid gland • Iodine preparations • Lithium carbonate

18. Nonsurgical Radioactive Iodine Therapy • RAI is picked up by the thyroid gland • Outpt treatment may require more than one TX • Radiation is low enough that radiation precautions are not needed

19. Graves’ Disease Surgical Management • Procedure • Preoperative care • Postoperative care • Thyroid Storm

20. Procedure Surgery is done for the following reasons: • large goiter causing tracheal or esophageal compression • Did not respond to other treatment • Surgery partial-decrease hormone production • Total-no hormone production, requires replacement therapy for life

21. Preoperative care • Achieve a euthyroid state & control symptoms • Administer Iodine preparations • Diet • Preoperative teaching

22. Postoperative care • Monitor V.S. • Positioning • Pain management • Respiratory care • Monitor for complications

24. Thyroid Storm • Less common now due to preoperative preparation • Still can occur if excessive thyroid hormone is released. • Key symptoms- fever, tachycardia and systolic hypertension • Maintain airway, fever and stabilize hemodynamics

25. Hypothyroidism • Decrease metabolism due to low levels of hormones • Primary: abnormality in the thyroid gland • Secondary: pituitary gland does not secrete TSH or the hypothalamus does not secrete TRH • Inadequate intake of iodide and tyrosine

26. Hypothyroidism • Myxedema- non pitting edema that forms everywhere • Myxedema coma – progression of myxedema to the point of tissue & organ failure

29. MULTISYSTEM EFFECTS OF Hypothyroidism

30. Hypothyroidism • Assessment History Physical Psychosocial • Laboratory

31. Hypothyroidism Nursing Diagnoses • Ineffective breathing pattern related to decreased energy, obesity, and fatigue • Decreased cardiac output: related to altered heart rate and rhythm as a result of decreased myocardial metabolism

32. Nursing Outcomes Ineffective Breathing • Spo2 at least 90% • Absence of cyanosis • Maintenance of cognitive orientation

33. Nursing Outcomes Decreased Cardiac Output • Maintain HR above 60 • B/P within normal limits for patient • No dysrhythmias, peripheral edema or neck vein distention

34. Hypothyroidism Nursing Interventions • Monitor respiratory rate and depth • Assess for respiratory distress • Monitor circulatory status • Monitor for signs of inadequate tissue oxygenation • Monitor for changes in mental status

35. Hypothyroidism Medical Management • Chronic condition managed on an out patient basis • Most important educational need is to understand hormone replacement therapy and it’s side effects

36. Hypothyroidism Hormone Replacement Therapy • Used to treat all forms of the disease • Used for patients whose thyroid gland was surgically removed or destroyed by radioactive iodine

37. Hypothyroidism Hormone Replacement Therapy • Replaces what the thyroid gland cannot produce to achieve normal thyroid levels (euthyroid) • Works the same way as Thyroid hormones

38. Hypothyroidism Hormone Replacement Therapy • Levothyroxine (Synthroid, Levothyroid) synthetic thyroid hormone T4 • Preferred drug due to its hormonal content is standardized and effect is predictable

40. Hypothyroidism Hormone Replacement Therapy • Adverse effects- cardiac dysrhythmia most significant • Tachycardia, palpitations, angina hypertension

41. Congenital Hypothyroidism • Present from birth • Thyroid gland does not produce enough thyroid hormone to meet metabolic needs • Caused by an absent, underdeveloped or ectopic thyroid gland

42. Pathophysiology

43. Etiology of Congenital Hypothyroidism • Spontaneous gene mutation • Autosomal recessive genetic transmission of an enzyme deficiency • Iodine deficiency • Failure of the central nervous system/thyroid feedback system mechanism to develop

44. Clinical Manifestations • Large for age despite having poor feeding habits; increased birth weight • Puffy face, swollen tongue • Hoarse cry • Poor muscle tone • Cold extremities

45. Clinical Manifestations • Persistent constipation; bloated or full to the touch • Lack of energy, sleeps most of the time, appears tired even when awake • Little to no growth • Often appears perfectly normal at birth, which is why screening is vital

46. Diagnostic Evaluation • State-required screening: TSH / T4 • ↓T4, ↑TSH, or both indicate hypothyroidism • Positive test results may be followed by scan for bone age • Blood tests before 48 hours after birth may be falsely interpreted because of the rise in TSH immediately after birth

47. Nursing Considerations • Monitor growth and development of the infant (serial measurements of height, weight, and head circumference and screens for developmental milestones) • Assess for retarded physical growth and slow intellectual development; if cognitive impairment has occurred, provide support to family

48. Nursing Considerations • Teach family importance of daily administration of medication; drug therapy is need for life • Medication can be crushed and added to a small amount of formula, food, or water, or can be offered mixed with formula through a syringe or a nipple

49. Nursing Considerations • Never put medication in a whole bottle of formula in case infant does not finish the bottle • Include instructions on taking pulse in the teaching plan to monitor for signs of drug overdose

50. Thyroiditis Inflammation of the thyroid gland • Three types Acute Subacute Chronic (Hashimoto’s disease)