Management of Patients With Thyroid Disorders

1. Management of Patients With Thyroid Disorders Dr. Belal M. Hijji, RN. PhD May 7th & 9th, 2012

2. Learning Outcomes At the end of this lecture, students will be able to: • Describe the thyroid gland, its functions, and hormones • Examine relevant assessment and diagnostic studies. • Recognise the outcomes related to abnormal thyroid function. • Define hypothyroidism, its causes; discuss its pathophysiology, clinical manifestations, medical and nursing management • Define hyperthyroidism and its causes; discuss its clinical manifestations, diagnostic evaluation, medical and nursing management

3. Management of Patients With Thyroid Disorders • The thyroid gland: • Is a butterfly-shaped organ located in the lower neck anterior to the trachea. • Is about 5 x 3 cm2 , weighs about 30 g. • Has a very high blood supply (about 5 mL/min per gram of thyroid tissue). • Produces thyroxine (T4), triiodothyronine (T3), and calcitonin. T4 & T3 are referred to collectively as thyroid hormone.

4. Thyroid Function and Dysfunction • Various hormones and chemicals are responsible for normal thyroid function. • Key among them are thyroid hormone, calcitonin, and iodine.

5. Thyroid Hormone • The two separate hormones, thyroxine (T4) and triiodothyronine (T3) are produced by the thyroid gland and that make up thyroid hormone, are amino acids that regulate the cellular metabolic activity. They influence cell replication, are important in brain development, and necessary for normal growth. The thyroid gland and surrounding structures

6. Calcitonin • Is another important hormone secreted by the thyroid gland. • It is secreted in response to high plasma levels of calcium. It reduces the plasma level of calcium by increasing its deposition in bone. Iodine • Is essential to the synthesis of the thyroid gland hormones. • Is mainly used by the thyroid. • Deficiency alters thyroid function. • Iodide is ingested in the diet, absorbed & its ions are converted to iodine molecules. • Molecules react with tyrosine (an amino acid) to form the thyroid hormones.

7. Assessment and Diagnostic Findings • Inspection: Identification of landmarks. • Look for swelling or asymmetry. • Palpation: Palpate the gland for size, shape, consistency, symmetry, and the presence of tenderness. • Auscultate the enlarged gland to identify localized audible vibration of a bruit. This indicates increased blood flow necessitates referral to a physician. Continued…..

8. Thyroid Function Tests • Thyroid function tests, TSH and free thyroxine (FT4), are elevated in hyperthyroidism and decreased in hypothyroidism. • Thyroid scanning. • Biopsy. • Ultrasonography.

9. Nursing Implications for Thyroid tests • Determine whether the patient has taken drugs or agents that contain iodine. These include: • Contrast agents (radiopaque, dye-like substances that may contain iodine) and medications used to treat thyroid disorders. • Topical antiseptics, multivitamin preparations, cough syrups; and amiodarone, an antiarrhythmic agent. • Estrogens, salicylates, amphetamines (drugs that produce increased wakefulness and focus such as dextrostat), chemotherapeutic agents, antibiotics, and corticosteroids. • Ask the patient about the use of these drugs and note their use on the laboratory requisition.

10. Abnormal Thyroid Function • In infancy: Hypothyroidism results in stunted physical and mental growth because of general depression of metabolic activity. • In adults: Hypothyroidism manifests as lethargy, slow mentation, and generalized slowing of body functions. • Hyperthyroidism is manifested by a greatly increased metabolic rate. • Oversecretion of thyroid hormones is usually associated with an enlarged thyroid gland (goiter).

11. Hypothyroidism • Suboptimal levels of thyroid hormone. • Thyroid deficiency can affect all body functions. Causes of Hypothyroidism • Chronic lymphocytic thyroiditis (Hashimoto’s thyroiditis). • Atrophy of thyroid gland. • Therapy for hyperthyroidism: • Radioactive iodine (131I) & thyroidectomy • Medications. • Lithium (controversal), iodine rich compounds (amiodarone), and antithyroid drugs (propylthiouracil). • Radiation to head and neck. • Infiltrative diseases of the thyroid (amyloidosis, scleroderma) • Iodine deficiency and iodine excess.

12. Why Does High Iodine Intake Induce Hypothyroidism? • Thyroid disorder? (Monaco, Satta, & Shapiro, 1993). • The thyroid gland has a capacity to reduce thyroid hormone production in the presence of excess iodine (Wolff-Chaikoff effect). This effect is usually temporary and within a few days thyroid hormone synthesis returns to normal through the so-called 'escape' phenomenon. However in a few normal individuals and in some susceptible patients, the escape does not occur. (Wémeau, 2002)

13. Pathophysiology of Hypothyroidism • Thyroidal hypothyroidism is responsible for more than 95% of patients with hypothyroidism. • Central hypothyroidism causes thyroid dysfunction due to failure of the pituitary gland, the hypothalamus, or both. • Secondary hypothyroidism is caused entirely by a pituitary disorder. • Neonatal thyroid deficiency is known as cretinism. • The term myxedema, advanced case of hypothyroidism, refers to the accumulation of mucopolysaccharides in subcutaneous and other interstitial tissues.

14. Clinical Manifestations of Hypothyroidism • Early symptoms are nonspecific. • Extreme fatigue. • Hair loss, brittle nails, dry skin, and numbness and tingling of the fingers may occur. • Voice may become husky [hoarse and dry]. • Menstrual disturbances & loss of libido. • In severe hypothyroidism: • Hypothermia & bradycardia. • Weight gain even without ↑ in food intake. • Thick skin, thin hair that falls out. • Expressionless and masklike face. Continued…

15. Subdued emotional responses, and dull mental processes. • Slow speech and enlarged tongue, hands, and feet. • Constipation. • Sleep apnea, pleural effusion, and pericardial effusion. • ↑cholesterol level, atherosclerosis, coronary artery disease, and poor left ventricular function. • Intraoperative hypotension and postoperative heart failure may occur to undiagnosed patients. • Myxedema coma describes the most extreme, severe stage of hypothyroidism, in which the patient is hypothermic and unconscious. • The patient would develop respiratory complications culminating in coma. • Cardiovascular collapse and shock. Mortality rate is high.

16. The aim of medical management is to: • restore a normal metabolic state by replacing the missing hormone. Pharmacologic Therapy • Synthetic levothyroxine (Synthroid or Levothroid) is the preferred preparation for treating hypothyroidism and suppressing nontoxic goiters.

17. Nursing Management Modifying Activity • The patient experiences decreased energy and lethargy. As a result, the risk for complications from immobility increases. • The patient has decreased ability to exercise and participate in activities due to changes in cardiovascular and pulmonary status. • The nurse’s role is to assist with care and hygiene while encouraging the patient to participate in activities as tolerated to prevent the complications of immobility. Continued….

18. Monitoring Physical Status • Close monitoring of the vital signs and cognitive level to detect the following: • Deterioration of physical and mental status • Signs and symptoms indicating that treatment has resulted in the metabolic rate exceeding the ability of the cardiovascular and pulmonary systems to respond • Continued limitations or complications of myxedema

19. Promoting Physical Comfort • Extra clothing and blankets are provided. • Use of heating pads and electric blankets is avoided. This is because the patient could be burned by these items without being aware of it because of delayed responses and decreased mental status.

20. Providing Emotional Support • The patient may experience severe emotional reactions. The nonspecific, early symptoms may produce negative reactions by family members and friends, who may have labeled the patient mentally unstable, uncooperative, or unwilling to participate in self-care activities. • The nurse informs the patient and family that the symptoms and inability to recognize them are common but treatment is successful and symptoms are reversible. The patient and family may require assistance and counseling to deal with the emotional concerns and reactions that result.

21. Promoting Home and Community-Based Care Teaching Patients Self-Care • The patient and family require information and instruction that will enable them to monitor the patient’s condition and response to therapy. • The nurse instructs the patient and a family member about medications. • The nurse provides written instructions and guidelines for the patient and family. • Dietary instruction is provided to promote weight loss once medication has been initiated.

22. Continuing Care • Before discharge, arrangements are made to ensure that the patient returns to an environment that will promote adherence to the prescribed treatment plan. The nurse: • Assists in devising a schedule or record to ensure accurate and complete administration of medications. • Reinforces the importance of continued thyroid hormone replacement and periodic follow-up testing and instructs the patient and family members about the signs of overmedication and undermedication. • May refer the patient for home care. • Documents and reports to the patient’s primary health care provider, subtle signs and symptoms that may indicate either inadequate or excessive thyroxine hormone.

23. Hyperthyroidism • Hyperthyroidism: The second most prevalent endocrine disorder. • Graves’ disease: Excessive output of thyroid hormones. • It affects women eight times more frequently than men. • It may appear after an emotional shock, stress, or an infection. • Other common causes of hyperthyroidism include thyroiditis and excessive ingestion of thyroid hormone.

24. Clinical Manifestations • Patients exhibit a characteristic group of signs and symptoms (thyrotoxicosis). The presenting symptom is often nervousness. • Emotionally hyperexcitable, irritable, and apprehensive; cannot sit quietly; palpitations; tachycardia at rest and on exertion. • Poor heat tolerance and unusual perspiration. • The skin is flushed continuously. • Skin is dry and diffuse pruritus. • Exophthalmos. Continued…..

25. Increased appetite and dietary intake, weight loss, abnormal muscular fatigability and weakness, amenorrhea, and changes in bowel function. • Elevation of systolic blood pressure • Atrial fibrillation. • Osteoporosis and fracture.

26. Assessment and Diagnostic Findings • Enlarged thyroid. • It is soft and may pulsate; with a bruit. • Diagnosis is made on the basis of the symptoms and ↑ in serum T4 and an increased 123I or 125I uptake by the thyroid in excess of 50%.

27. Medical Management • Aims at reducing thyroid hyperactivity to relieve symptoms and remove the cause of important complications. • Treatment depends on the cause of the hyperthyroidism and may require a combination of therapeutic approaches. These are discussed next. Continued….

28. Pharmacologic Therapy • Radioactive iodine therapy • Destroys the overactive thyroid cells. • Is the most common treatment in elderly patients. • Antithyroid medications • The overall aim of pharmacotherapy is to decrease thyroid hormone production. • The most commonly used medications are propylthiouracil (Propacil, PTU) or methimazole (Tapazole) until the patient is euthyroid. • Medications may take several weeks for relief of symptoms. Withdrawal of the medication is gradual. • Toxic complications of antithyroid medications are relatively uncommon.

29. Surgical Management • Surgery is reserved for special circumstances. • Subtotal thyroidectomy ensures a prolonged remission in most patients with exophthalmic goiter. • Before surgery, propylthiouracil is administered until signs of hyperthyroidism have disappeared. • Propranolol may be used to reduce the heart rate. • Iodine (Lugol’s solution or potassium iodide) may reduce blood loss.

30. Nursing Management of Patient with Hyperthyroidism • Assessment: Focus should be on the patient’s: • and family’s report of irritability and increased emotional reaction. • ability to cope with stress. • nutritional status. • changes in vision and appearance of the eyes. • cardiac status. • emotional & psychological status.

31. Nursing Diagnoses • Imbalanced nutrition, less than body requirements, related to exaggerated metabolic rate, excessive appetite, and increased gastrointestinal activity. • Ineffective coping related to irritability, hyperexcitability, apprehension, and emotional instability. • Low self-esteem related to changes in appearance, excessive appetite, and weight loss. • Altered body temperature.

32. Planning and Goals • Improved nutritional status. • Improved coping ability. • Improved self-esteem. • Maintenance of normal body temperature. • Absence of complications.

33. Nursing Interventions Improving Nutritional Status • Up to six well-balanced meals of small size are offered daily. • Foods and fluids are selected to replace fluid lost through diarrhea and diaphoresis. • To reduce diarrhea, highly seasoned foods and stimulants such as coffee, tea, cola, and alcohol are discouraged. • High-calorie, high-protein foods are encouraged. • Monitor weight, dietary intake, and nutritional status. Continued….

34. Enhancing Coping Measures • Reassure the patient that the emotional reactions will be controlled with effective treatment. • Similar reassurance needs to be made to family and friends. • Minimise stressful experiences for the patient. • Keep the patient’s environment quiet and noiseless. • The nurse encourages relaxing activities if they do not overstimulate the patient. • Educate patient about medications to be taken in anticipation for surgical intervention.

35. Improving Self-esteem • The patient with hyperthyroidism may lose self-esteem due to changes in appearance, appetite, and weight, and due to his inability to cope well with family and the illness. • Cover or remove mirrors. • Remind family members and personnel to avoid bringing these changes to the patient’s attention. • Explain the temporary nature of these changes. • Provide eye care as appropriate. Instruct the patient on how to use eye preparations.

36. Maintaining Normal Body Temperature • The patient with hyperthyroidism frequently finds a normal room temperature too warm because of an exaggerated metabolic rate and increased heat production. • The nurse maintains the environment at a cool, comfortable temperature and changes bedding and clothing as needed. Cool baths and cool or cold fluids may provide relief.

37. Teaching Patients Self-Care • Provide instruction and written plan about the medications. • Provide verbal and written instruction about the actions and possible side effects of the medications. • Identify adverse effects that should be reported. • Provide information to the patient about what to expect if total or subtotal thyroidectomy is anticipated.

38. Evaluation Expected Patient Outcomes • Improves nutritional status • Reports adequate dietary intake and ↓ hunger • Identifies foods with high-calorie, high-protein and those to be avoided • Avoids use of alcohol and other stimulants • Reports decreased episodes of diarrhea • Achieves increased self-esteem • Verbalizes feelings about self and illness • Describes feelings of frustration and loss of control • Describes reasons for increased appetite