Med surg chapter 66
Which type of thyroid cancer is the most aggressive?
Anaplastic thyroid cancer, common manifestation is stridor and hoarseness
What is the most common type of thyroiditis?
Hashimotos (chronic thyroiditis)
What is the hallmark of hyperthyroidism?
Heat intolerance
What is the most important educational need for the patient with hypothyroidism?
Hormone replacement therapy and its side effects
What are some safety precautions for patients receiving an unsealed radioactive isotope?
use toilet not used by others 2 weeks after receiving sit to urinate, flush 3 X after each use is urine is spilled, use paper bag them in sealed bags and take to hospital radiation department men with incontinence should use condom catheter women w/ incontinence should use facial tissue use lax on 2-3rd day after wear machine wash clothes/wash separate from others after washing clothes run a full cycle avoid close contact w/ pregnant, infants, young child do not share toothbrush/toothpaste tubes, disposable tissues, disposable utensils, avoid meat w/ bone, fruit w/ core
Who is most likely to get graves disease?
women and between the ages of 20-40
Who is most commonly affected by hypothyroidism?
women between 30-60 yrs old
Can you have a goiter with hypothyroidism?
yes a goiter does not indicate hyperthyroidism only, it can also represent hypothyroidism
What are some key features of hypothyroidism?
bradycardia, enlarged heart, hypotension, decreased body temp, cold intolerance, confusion, depression, paranoia, withdrawal, anorexia, wt gain, prolonged menses, decreased libido, facial puffiness, nonpitting edema thick tongue, anemia,
What do the parathyroid gland maintain?
calcium and phosphate balance
What risk increases once a pt is dx with hypothyroidism?
diabetes mellitus
While monitoring for respiratory distress after a thyroidectomy what would you need to keep in the room?
emergency tracheostomy equipment (check to make sure o2 and suctioning equipment are nearby and working)
What is the definition of hyperthyroidism?
excessive thyroid hormone secretion from the thyroid gland
What does sub acute thyroiditis look like?
fever, chills, muscle/joint pain, thyroid gland feels hard on palpation, enlarged
Which type of thyroid cancer occurs most often in the older patient?
follicular thyroid cancer, it invades the blood vessels and spreads to the bone and lung tissue
goiter classification- no palpable or visible goiter?
goiter grade 0
goiter classification- mass is not visible with neck in the normal position, goiter can be palpated and moves up when the patient swallows
goiter grade 1
goiter classification- mass is visible as swelling when neck is in the normal position, goiter is easily palpated and is usually asymmetric
goiter grade 2
What are some common complications after thyroidectomy?
hemorrhage (1st 24 hr) respiratory distress, parathyroid gland injury and thyroid storm
What electrolyte imbalances would you expect with hyperparathyroidism?
hypercalcemia and hypophosphatemia
What is exogenous hyperthyroidism?
hyperthyroidism caused by excessive use of thyroid replacement hormones
What is a toxic multinodular goiter?
hyperthyroidism caused by multiple thyroid nodules that may be enlarged thyroid tissues or benign tumors. No exophthalmos or pretibial edema.
What do you do first if you suspect a thyroid storm?
immediately assess the pts cardiac status, if monitor check for dysrhythmias
What are the lab levels for hyperthyroidism by secondary or tertiary cause?
increased in all T3, T4 and TSH
What is a thyroid storm?
it is a life threatening event that occurs with uncontrolled hyperthyroidism and is characterized by high fever and severe hypertension. Immediately report a temp increase of even one degree
What are the interventions needed for a pt in a thyroid storm?
maintain airway, give antithyroid drug as prescribed, administer sodium iodide solution, give propranolol slowly, give glucocorticoids, monitor for cardiac dysrhythmias, monitor vs q 30min, provide comfort (cooling blanket) non salicylate antipyretics, ns IV
What is the emergency care for a pt with myxedema coma?
maintain airway, replace fluids with normal or hypertonic saline, give levothyroxine iv, give glucose iv, give corticosteroids, check temp hrly, monitor bp q1 hr, cover pt with warm blanket, monitor for change in mental status, turn q 2 hrs, institute aspiration precautions
What do you do after a thyroidectomy?
monitor pt vs q 15 min until stable and then q 30 min for 24 hr. semi fowler position, humidify the air, ask pt q1 hr about tingling around the mouth or toes/fingers or muscle twitching (ca deficiency) Make sure to have calcium for IV use should it be needed
What are some nonsurgical steps for a pt with hyperthyroidism?
monitor vs, reduce stimulation, promote comfort (reduce room temp, ice water, cool showers) drug therapy
what does acute thyroiditis look like?
neck tenderness, fever, difficulty swallowing,
What is graves disease closely associated with and give examples?
other autoimmune disorders examples of diabetes and RA
What does chronic thyroiditis look like?
painless thyroid enlargement and difficulty swallowing
What are some things a pt with hyperthyroidism should report immediately?
palpitations, dyspnea, vertigo, or chest pain, or increased temp
What is the most common thyroid cancer?
papillary and occurs most often in younger women
What are the 4 types of thyroid cancer?
papillary, follicular, medullary, and anaplastic
Secondary causes of hypothyroidism
pituitary tumors, trauma, infections or infarctions, congenital pituitary defects, hypothalamic tumors, trauma, infections or infarctions
What is a good way to teach a pt to cough/deep breath after thyroidectomy?
put the hands behind the neck when coughing to support the neck
primary causes of hypothyroidism
removal of thyroid, radiation tx of thyroid, endemic iodine deficiency, lithium, PTU
What do you expect to find in a patient with high PTH levels
renal calculi (kidney stones)
What treatment is done for acute thyroiditis?
resolves with antibiotic treatment
The thyroid related to age?
the gland deceases in size, hormone secretion decreases but level remains stable, older pts require lower doses of replacement thyroid hormone
What are the key features of hyperthyroidism?
thinning of scalp hair, SOB, rapid shallow respirations, palpitations, increased bp, tachycardia, wt loss, increased appetite, heat intolerance, fatigue, restless, amenorrhea, increased libido, decreased total WBC, hyperglycemia,
What are some causes of hypoparathyroidism
thyroid ablation, parathyroidectomy, hypomagnesemia
What are the manifestations of hyperthyroidism called?
thyrotoxicosisa
What causes chronic thyroiditis?
bacterial or viral. the thyroid is invaded by antithyroid antibodies and lymphocytes causing thyroid tissue destruction
What are the 2 easiest areas to monitor for effectiveness of thyroid replacement at home?
Need for sleep and bowel movements, more sleep needed and constipation = may need dose increased
Do all patients with a goiter have hyperthyroidism?
No not all patients with a goiter have hyperthyroidism
What are some concerns when a pt is taking PTU or methimazole for hyperthyroidism?
black box warning,PTU incidence of liver injury (yellow of sclera, dark urine, clay colored stool, elevated lft) Methimazole- birth defects- use before PTU
What do you do when stridor, dyspnea, or other symptoms occur post thyroidectomy?
Contact rapid response, in some agencies the nurse can remove clips or sutures when medical assistance is not immediately available and swelling at the surgical site is obstructing the airway
What are key features of graves disease?
Goiter, exophthalmos (protrusion of the eyes), pretibial myxedema (dry waxy swelling of the fronts of lower legs),
What is the most common cause of hyperthyroidism?
Graves disease (toxic diffuse goiter)
What is an indicator that a thyroid storm may be about to take place?
Increased temperature
What is Hashimotos disease?
It is another name for chronic thyroiditis
What is granulomatous thyroiditis?
It is another name for sub acute thyroiditis
Which type of thyroid cancer occurs most often in a patient over 50?
Medullary thyroid cancer
What are some examples of drug therapy for hyperthyroidism?
PTU, methimazole, lithium, propranolol (supportive therapy) radioactive iodine therapy (not used in pregnancy)
How often should a person with hyperthyroidism have their v/s monitored?
at least q 4 hr, apical pulse, bp and temp
What causes acute thyroiditis?
bacterial invasion of the thyroid gland
Lab levels for hypothyroidism
T3 T4 are low and TSH are high in primary
What are the lab levels for graves disease?
T3, T4 are increased and TSH is decreased
Can you have thyrotoxicosis from taking large amounts of synthetic thyroid hormones?
Yes, a person who takes a large amount of synthetic hormone can have thyrotoxicosis but does not have hyperthyroidism
What is negative nitrogen balance?
a net loss of body protein
What is the initial manifestation of thyroid cancer?
a single painless lump/nodule on the thyroid gland
What causes sub acute thyroiditis?
a viral infection of the thyroid gland after a cold or other URI
What does increases levels of parathyroid hormone PTH do?
act on the kidney causing increased kidney absorption of calcium and increased phosphate excretion
What are some causes of hyperparathyroidism
adenoma, carcinoma, vit d def, neck trauma or radiation,
What is the definition of graves disease?
an autoimmune disorder in which antibodies (TSI) are made and attach to the TSH receptors on the thyroid tissue. The thyroid gland responds by increasing the number and size of glandular cells which enlarges the gland forming a goiter
Is surgical or nonsurgical more common now for hyperthyroidism?
antithyroid drugs and RAI therapy are now most common, not surgical