HYPERTHROIDISM/HYPOTHYROIDISM- franks exam 3
hyperthyroidism nursing management/nursing implementation: postoperative care thyroid surgery assess
- **OXYGEN, SUCTION & TRACH TRAY at BEDSIDE** - watch for hemorrhage or tracheal compression (edema or hemorrhage can compress the trachea -> most likely to occur in first 24 hours) - asses every 2 hours for 24 hours -> for signs of hemorrhage -> for tracheal compression •Irregular breathing, neck swelling, frequent swallowing, choking
hyperthyroidism diagnostic studies: laboratory tests
- Decreased TSH - Increased Free thyroxine (free T4) - Increased Triiodothyronine (T3 ) Thyroxine (T4)
hyperthyroidism collaborative care: antithyroid drugs
- Inhibit synthesis of thyroid hormone - Improvement in 1 to 2 weeks - Good results in 4 to 8 weeks - Therapy for 6 to 15 months (until spontaneous remission 20-40%)
nursing diagnoses
- LOTS of nursing diagnoses here, because remember this affects every body system •Activity intolerance •Imbalanced nutrition: Less than body requirements •Risk for injury •Anxiety •Insomnia
what does the thyroid do? - T3 and T4 affect all body systems
- Regulates metabolic rate, (meet body's demand of energy and caloric requirements), - regeneration of cells, digestion, carbohydrate and lipid metabolism, and thermoregulation - Tissue replacement and differentiation: during growth and development, - SNS nervous system and brain function
hyperthyroidism nursing management/nursing implementation: postoperative care thyroid surgery positioning/monitoring
- Semi-Fowler's position •Support head with pillows •Avoid hyperextension of neck - Tension on suture lines •Difficulty speaking/hoarseness •Some hoarseness for 3 to 4 days is expected •stridor = harsh vibratory sound, and choking - This stridor is due to injury to laryngeal nerve: (have them speak every 2 hours) •can lead to vocal cord paralysis if both cords are paralyzed then airway obstruction can occur -> TRACHE •Monitor vitals •Control pain •Check for tetany •Trousseau's and Chvostek •Monitor for 72 hours
remember that the thyroid gland produces 3 hormones:
- T4 thyroxine, T3 triiodothyronine and calcitonin •Calcitonin: reduces calcium levels in blood •bone calcium levels (keeps calcium in the bones), increases storage of calcium in bones, and increases renal excretion of calcium and phosphorous
feed-back loop thyroid
- Thermostat: receptor sites in anterior pituitary, and hypothalamus, (has to check and make sure circulating levels are normal) -> sense a decrease then will release more to further stimulate -
other causes of hyperthyroidism:
- Thyroiditis: (viral infection) inflammation of the thyroid gland usually T4 and T3 start elevated but become depressed with time (due to negative feedback) - Toxic nodular goiter(often associated with Graves) multiple nodules: less common OVERProduction of thyroid hormone due to presence of thyroid nodules. - Exogenous hyperthyroidism (excessive dosage of thyroid hormone) or iodine excess - Pituitary tumor - Thyroid cancer
hyperthyroidism collaborative care: drug therapy
- Useful in treatment of thyrotoxic states - Not considered curative •Anti-thyroid drugs •Iodine •β-Adrenergic blockers
hyper-function of the thyroid gland can lead to the following cardiovascular manifestations
- bruit over thyroid gland - systolic hypertension - bounding, rapid pulse - palpitations - increased cardiac output - cardiac hypertrophy - systolic murmurs - dysrhythmias - atrial fibrillation (more common in older adults) - angina - anytime our cardiology patients had new onset Atrial fibrillation-we check their TSH levels
hypothyroidism
- complete opposite of hyperthyroidism - slowing of metabolic rate (almost completely opposite findings) •Very common •Women>men •NOT ENOUGH circulating T3 and T4. •What would your labs look like: T3 and T4? LOW. TSH, depends on the cause of the hypothyroidism, primary problem (thyroid or hormone)
hyperthyroidism nursing management/nursing implementation: postoperative care thyroid surgery damage to parathyroid glands
- damage to (small peas-only 4) parathyroid glands -> which is why they watch calcium so closely - if hypocalcemia: will see tetany, tingling in toes fingers, around mouth muscular twitching and apprehension Trouseau and Chvostek •Can also hear stridor from tetany (from hypocalcemia) •Thyrotoxic crisis •Infection
hypothyroidism graves vs hashimotos
- graves (hyperthyroid autoimmune) the autoimmune disease destroys thyroid tissue) becomes hypo after a long period of time - hashimotos thyroiditis-autoimmune destroys thyroid -> hypothyroid*
hyperthyroidism
- hyper = high, too much thyroid hormones - a sustained increase in synthesis and release of thyroid hormones by thyroid gland - Occurs more often in women - Highest frequency in 20 to 40-year-olds
hypothyroidism etiology and pathophysiology: atrophy of the thyroid gland
- in places where iodine intake is adequate, the primary cause is atrophy of the gland - atrophy is the end result of Hashimoto's thyroiditis and Graves' disease - these autoimmune diseases destroy the thyroid gland - US most common cause of hypothyroidism is due to atrophy of the thyroid gland
Graves' disease
- is an autoimmune disease -> (unknown etiology but linked to insufficient iodine, stress, and genetics) - patient develops antibodies to the TSH receptor -> antibodies attach to the receptors - antibodies stimulate the thyroid gland to release T3, T4, or both. •(antibodies act as if they were TSH so now you are getting way too much) - Increased release of thyroid hormones = thyrotoxicosis •It may progress to destruction of the thyroid tissue, causing hypothyroidism (will usually see diffuse enlargement of thyroid) •More likely for women >men
hyperthyroidism collaborative care: radioactive iodine therapy (RAI) doses and precautions
- low dose of radiation is used but provide patient with precautions to prevent radiation exposure: - use private toilet facilities if possible (flush 2-3 times after each use) - no sharing of toothbrushes - not preparing food for others (if it requires handling for long periods) - separate laundering towels, bed linens, run washing machine 1 full cycle after contaminated clothes - avoid pregnant and children 7 days after treatment
hypothyroidism complications
- mental sluggishness (slow mentation) - drowsiness - lethargy progressing - gradually or suddenly to impairment of consciousness or coma - myxedema coma
severe longstanding hypothyroidism general clinical manifestations
- not abrupt onset, gradually occurs over time, may not be aware because some of the symptoms are vague - may display myxedema •accumulation of hydrophilic mucopolysaccharides in the dermis and other tissues •causes puffiness, periorbital edema, masklike effect
hyperthyroidism collaborative care surgical therapy: subtotal thyroidectomy
- preferred surgical procedure-if medication therapy fails or radiation is contraindicated - surgery also indicated if diffuse goiter or thyroid cancer - significant portion is removed (90%)
ultrasound is used for
- produces images of the thyroid and surrounding tissue (but wont tell you if benign so must get biopsies etc)
hypothyroidism etiology and pathophysiology: primary
- related to destruction of thyroid tissue or defective hormone synthesis - primary you will see increased TSH and decreased T3 and T4
hypothyroidism etiology and pathophysiology: secondary
- related to pituitary disease with ↓ TSH secretion or hypothalamic dysfunction - decreased TSH (related to pituitary disease or hypothalamic dysfunction) - decreased T3 and T4 (problem is with the glands sending out the message to produce thyroid hormone)
thyrotoxicosis (thyrotoxic crisis or thyroid storm)
- sudden surge of thyroid into bloodstream - is an acute, severe, and rare condition -> excessive amounts of thyroid hormones are released into the circulation. - although it is considered a life-threatening emergency. Thyrotoxicosis is thought to result from stressors •(e.g., infection, trauma, surgery) in a patient with preexisting hyperthyroidism
hyperthyroidism collaborative care: radioactive iodine therapy (RAI)
- treatment of choice in non-pregnant adults - damages or destroys thyroid tissue (therefore limiting thyroid hormone secretion) - is curative - might take 6-8 weeks to see effect (so they remain on anti-thyroid medications and beta blockers during the time period) - very effective but have HIGH incidence of -> post-treatment hypothyroidism! •Teach patient signs of hypothyroidism - also can see signs of radiation thyroiditis and parotiditis: use sips water, gargling three to four times per day
hyperthyroidism collaborative care: iodine therapy
- used in conjunction with other anti-thyroid meds - preparation for thyroidectomy - treatment of crisis - used short term only - inhibit synthesis of T3 and T4 and - block release of T3/T4 into circulation - decrease vascularity of thyroid gland to prepare for surgery - effect seen within 1 to 2 weeks - long-term iodine therapy is not effective •Saturated solution of potassium iodine (SSKI) •Lugol's solution - straw to avoid staining teeth, mix with juice, given after meals
hyper-function of the thyroid gland can lead to the following integumentary system manifestations
- warm, smooth, moist skin - thin, brittle nails detached from nail bed (onycholysis) - hair loss (may be patchy) - clubbing of fingers - palmar erythema - fine silky hair - premature graying (in men) - diaphoresis - vitiligo - elevated temp - heat intolerance
continuum of thyroid dysfunction
- whether too much T3 and T4 is circulating (hyper) - or not enough (hypo) you will see an INCREASE or DECREASE in metabolic rate and it affects all body systems! - here is the continuum showing you from HYPER (thyroid storm) to normal (euthyroid), to HYPO and then very low thyroid myxedema coma (severe) •Both sides of the spectrums can be clinical emergencies
hypothyroidism clinical manifestations
- will depend on the severity, how long they have had it, age of onset - systemic slowing of BODY processes throughout - variable amount of things that will occur of the body -thyroidectomy with hypothyroidism-rapid onset will be quick (the extreme fatigue, slow speech can all be signs of decreased SNS stimulation)
hypothyroidism etiology and pathophysiology: iodine deficiency
- world wide this is the biggest cause -> need iodine to produce T3 and T4 - added to table salt in U.S. - most common cause worldwide and is most prevalent in iodine-deficient areas
hyperthyroidism collaborative care: β-Adrenergic blockers
- would not take these alone because they do not decrease thyroid hormone levels (this is only for symptom relief and cardiac status) - treat the symptoms of the sympathetic nervous system: tachycardia, palpitations, nervousness, irritability and tremors - provide symptom relief (treat SNS effects) help with effects and comfort but do not decrease hormone levels! - often propranolol (atenolol for patients with asthma (beta one selective))
related to effect of thyroid hormone excess
- ↑ Metabolism - ↑ Tissue sensitivity to stimulation by sympathetic nervous system
hypothyroidism nursing diagnoses
1.Imbalanced nutrition: More than body requirements 2.Activity intolerance 3.Disturbed thought processes
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 reports a sore throat when swallowing. c. The patient supports her head when moving in bed. d. The patient makes harsh, vibratory sounds when breathing.
Answer: D Rationale: After thyroid surgery, the patient may experience an airway obstruction related to excess swelling, hemorrhage, hematoma formation, or laryngeal stridor (harsh, vibratory sound). Emergency equipment should be at the bedside, including oxygen, suction equipment, and a tracheostomy tray.
What do anti-thyroid meds do?
Blocks conversion of T4 to T3 (inhibits synthesis of thyroid hormone)
most common form of hyperthyroidism
Graves disease
clinical manifestations: exophthalmos
Protrusion of the eyeballs from the orbit; (graves disease (because this is long-term) - Increased fat deposits and fluid -> edema into orbital tissues and ocular muscles - Impaired drainage from the orbit is noted - Lid can't close easily causing dry eyes, ulcerations and infections. - Increased pressure may impair vision - Swelling and shortening of muscles may cause problems with focusing. - Photophobia •Seen in 20-40% of hyperthyroid patients
high levels of thyroid hormone ->
inhibit secretion of TRH from hypothalamus and inhibit TSH from ant. Pituitary gland
sources of iodine
primary = salt other = kalp, cows milk, strawberries, fish and shellfish, eggs, yogurt, mozerrella cheese,
low levels of thyroid hormone ->
stimulate hypothalamus to release more TRH and ant. Pit releases TSH secrete more hormones until normal levels are reached
hyperthyroidism collaborative care surgical therapy: subtotal thyroidectomy before surgery
• antithyroid drugs, iodine, β- adrenergic blockers may be administered •to achieve a euthyroid state and control symptoms - iodine decreases vascularity -> safer for surgery
clinical manifestations: opthalmopathy
•Abnormal eye appearance or function •Exophthalmos
hyperthyroidism nursing management/nursing implementation: preoperative care thyroid surgery
•Alleviate signs/symptoms of thyrotoxicosis •Control cardiac problems •Assess for signs of iodine toxicity (signs and symptoms: swelling of buccal mucosa excessive salivation, N/V/skin reactions) • explain to patient there will be an incision in the neck with a drain (and to be careful with it) •Might be some hoarseness following the procedure •Teach to support neck when performing deep breathing post-procedure (while coughing or moving) - have all oxygen, suction and trach tray available in case of emergency
hyperthyroidism collaborative care: three primary treatment options
•Antithyroid medications •Radioactive iodine therapy (RAI) (not to be confused with radioactive iodine uptake) • Surgery subtotal thyroidectomy
nursing interventions: nutritional therapy
•Assess food preferences •Provide high-calorie, high protein diet •Periodic weights to evaluate •Avoid caffeine, highly seasoned foods, and high-fiber - need increased calories because of increased metabolism rate - AVOID caffeine - These patients have hyperactive BS, increased GI motility and often diarrhea
nursing interventions: energy management
•Assess/monitor activity •Assist with care •Regular rest periods •Instruct energy conservation
hypothyroidism integumentary system clinical manifestations
•Cold intolerance •Hair loss •Dry/thick/cold coarse skin •Thick brittle nails •Coarse hair
hyperthyroidism nursing management/nursing implementation: preoperative teaching thyroid surgery
•Coughing, deep breathing and leg exercises •Supporting head while turning in bed •Range of motion exercises of neck •Speaking difficulty for a short time after surgery •Routine post-op care •Normal post op teaching, ROM, OOB, TCDB •Provide comfort of symptoms, cardiac issues look at
hypothyroidism gastrointestinal system clinical manifestations
•Decreased appetite •↓ Motility •Constipation •Distended abdomen
hyper-function of the thyroid gland can lead to the following musculoskeletal system manifestations
•Fatigue •Muscle weakness •Proximal muscle wasting •Dependent edema •Osteoporosis: because hyperthyroid increases blood levels of calcium (pulls out of bone
hypothyroidism neurologic system clinical manifestations
•Fatigued & lethargic •Personality & mood changes •Impaired memory, slowed speech •Decreased metabolism •Cognitive changes
hyper-function of the thyroid gland can lead to the following nervous system manifestations
•Fine tremors •Insomnia: body is on over-drive continuous stimulation to SNS •Ability of mood, delirium •Hyper-reflexia of tendon reflexes •Inability to concentrate
hyperthyroidism diagnostic studies
•H & P •Ophthalmologic exam •ECG •Radioactive iodine uptake (RAIU)
hypothyroidism: diagnostic studies
•H & P exam •ECG •Radioisotope scan and uptake -low uptake of iodine prep
hyperthyroidism collaborative care surgical therapy: subtotal thyroidectomy postoperative complications
•Hemorrhage -> thin ab location... biggest issue airway (swelling or hemorrhage around site) •Injury to laryngeal nerve -> vocal cord paralysis (monitor speech) •Hypothyroidism •Damage or inadvertent removal of parathyroid glands -> hypocalcemia/ removal (monitor calcium) •Thyrotoxic crisis -> from exogenous form from manipulation of the gland (released) •Infection
precipitating factors of graves disease
•Insufficient iodine •Infection •Stressful life events plus genetic factors - 80% of cases of hyperthyroidism
hypothyroidism collaborative care drug therapy
•Levothyroxine (Synthroid) •Same time each day •Best in early am (take on empty stomach) •Monitor for angina and cardiac dysrhythmias •Look for side effects, increase metabolism •Monitor HR or HTN •Look at side effects that are similar to hyperthyroidism •Tachycardia if heart cant tolerate -> may have chest pain •Monitor thyroid hormone levels and adjust dose as needed Patient/family teaching
hypothyroidism respiratory system clinical manifestations
•Low exercise tolerance (hormones cant meet body's energy demands) •SOB on exertion
nursing management/nursing implementation myxedema coma
•Mechanical respiratory support •Cardiac monitoring •IV thyroid hormone replacement (stat) •If hyponatremic •hypertonic saline may be administered •Monitor core temperature •Vitals •Weight • I&O •Visible edema •Cardiovascular response to hormone (BP low) •Energy level •Mental alertness
hypothyroidism reproductive system clinical manifestations
•Menorrhagia (heavy periods) •Decreased libido •Infertility
hyper-function of the thyroid gland can lead to the following reproductive system manifestations
•Menstrual irregularities •Amenorrhea •Decreased libido •Impotence •Gynecomastia in men •Decreased fertility
hyperthyroidism collaborative care: disadvantages include
•Noncompliance •Increased rate of recurrence - There is a risk of recurrence (20-40% of patients) compliance is important
nursing management/nursing implementation home care points to discuss
•Notify of any signs of overdose: •Tachycardia, palpitations, insomnia, nervousness •Report chest pain or weight loss • Diabetic should check frequently glucose - Requirements will change once they reach the euthyroid state •Small initial dose>>>>increases ♥ demand •Take in the morning •Take on an empty stomach •Potentiate (exaggerate) effects of digitalis compounds. And anti-coagulants
nursing management/nursing implementation home care
•Patient and family teaching is so important for these patients - replacement therapy is lifelong - Emphasize need for warm environment - Caution patient to avoid sedatives or use lowest dose possible - Measures to control constipation
hyperthyroidism collaborative care: first-line examples
•Propylthiouracil (PTU) •Methimazole (Tapazole) 1.PTU-if needed to treat rapidly, or pregnant (okay to use in 1st trimester) quick effectiveness -> moves toward euthyroid state - PTU you will see results more quickly but it must be taken 3 times a day 2. May cause liver failure 3. But medications are not curative 4. Methimazole: single daily dose - PTU and methimazole (patient education, do not abruptly stop -> would see hyperthyroid signs again (if stop abruptly) - And teach signs of toxicity which would be hypo. signs) - Will see improvement in 1-2 weeks - Continue therapy 6-15 months and remind patient the importance of compliance
hypothyroidism diagnostic studies: laboratory tests
•Serum TSH •Determines cause of hypothyroidism • Decreased Free T4 • Decreased Serum T3 & Serum T4 •If the problem is the primary thyroid the TSH will be elevated •If problem is higher up (pituitary) decreased TSH -> no signal received •If comes in with hypo. T3 and T4 will be decreased
hypothyroidism collaborative care drug therapy effects
•Thyroid 4-6 weeks until see the effect •Start at lowest dose, continue to check labs every 3 months •Some of the manifestations will go away •TSH will start to normalize and the T3 and T4 will start to come up to normal •Decreased activity, and CNS changes (mental status)
hypothyroidism general clinical manifestations
•Weight gain •Muscle weakness and swelling •Fatigue •Goiter
myxedema coma
•can be precipitated by recent infection, drugs, cold or trauma • metabolism slows so significantly they have: •subnormal temp, hypotension, hypoventilation, and lactic acidosis •IV thyroid hormone replacement therapy, may need ventilator support
radioactive iodine uptake
•oral radioactive iodine 24 hours before test •Nuclear medicine (used to differentiate Graves from other thyroiditis) will see uptake in Graves - Clarifies size and function of the gland, nodules, and activity, elevated intake=hyperthyroidism - Benign nodules -> warm spots -> uptake the radionuclide - Malignant tumors -> cold -> not take up radionuclide - Contraindicated in pregnant women - Ask about shellfish or iodine allergy before test - Avoid foods high in iodine 1 week prior to test
thyrotoxicosis clinical manifestations
•severe tachycardia, heart failure, shock, hyperthermia (up to 105.3º F [40.7º C]), •restlessness, irritability, seizures, abdominal pain, vomiting, diarrhea, delirium, and coma).
hyper-function of the thyroid gland can lead to the following GI system manifestations
•↑ Appetite, thirst •Weight loss •Diarrhea •Splenomegaly •Hepatomegaly - GI function is altered = increased activity stimulation, increased energy consumption and burning calories (appetite weight loss, diarrhea)... food is moving through the gut so fast, that decreased nutrition and absorption
hypothyroidism diagnostic studies: TRH stimulation test
•↑ in TSH after TRH injection •suggests hypothalamic dysfunction •No change after TRH injection •suggests anterior pituitary dysfunction •The TRH test just identifies whether problem is in AP or hypothal •Increase in TsH after injection: hypo. •No change: pituitary
hypothyroidism cardiovascular system clinical manifestations
•↓ Cardiac output •↓ Cardiac contractility •Anemia •Cobalamin, iron, folate deficiencies •↑ Serum cholesterol and triglycerides
