ENDOCRINE DISORDERS THYROID CONDITIONS

Cheryl Nagy, RN, MSN 2013

Thyroid Gland Function

Plays a role in metabolism by increasing the metabolic rate of most Text body tissues; accelerates food utilization for energy; speeds protein catabolism; excites mental processes; increases other endocrine gland functions Growth-accelerates growth in a child

Thyroid Gland Functions

Carbohydrate metabolism-stimulates CHO metabolism by increasing glucose uptake, glycolysis, gluconeogenesis, GI absorption of CHO, increased insulin release Fat metabolism-increases fat metabolism resulting weight loss Cardiovascular-vasodilatation of body tissues results in increased blood flow to tissues, increased cardiac output, increased heart rate, increased B.P.
Affects the glucose level, affects the fat metabolism
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Thyroid Gland Functions

Respiratory effects-with increased BMR, increased need for oxygen and formation of carbon dioxide resulting in increased respiratory rate and depth G.I.-increased appetite, food absorption, digestive juice production, G.I. motility C.N.S.- speeds mental processes, increases activity level, increases muscle tone Calcitonin-modifies Ca++ metabolism resulting in decreased Ca++ level
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HYPERTHYROIDISM

Most common form is Graves disease, others are toxic nodular goiter (nodules secrete T3, T4), thyroiditis (Hashimotos disease), thyroid cancer, pituitary disorders Incidence- 2% of women aged 30-50 ,and only 0.2% of men; 75% of all cases of hyperthyroidism are Graves disease

HYPERTHYROIDISM

Etiology of Graves= primarily an autoimmune disorder, some feeling there are genetic and environmental factors. Auto-antibodies attach to TSH receptors within thyroid and stimulate release of T3, T4, laboratory value will show an increase in TSAb

Hyperthyroidism

Assessments= 1.inspection/palpation of the thyroid gland=goiter: auscultation of gland=bruits 2. opthalmopathy=changes in eye appearance=exopthalamus, eyelid retraction, infrequent blinking 3. vital signs=> heart rate, palpitaitons, >BP, > temperature, dyspnea
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Hyperthyroidism
4. weight loss 5. muscle wasting and weakness 6. fine tremors 7. fatigue 8. facial flushing 9. increased irritability, nervousness 10. insomnia 11. increased appetite

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12. skin is warm, moist; vitiligo (white patches on skin) ;dermopathy=skin raised, thickened with hyper-pigmented, orange peellike patches which are itchy and painful, nails are thin and loose, clubbing, edema of the legs and feet 13. heat intolerance

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14. fine, straight hair, loose pigment, and hairline recedes 15. breast enlargement 16. GI=> motility causing an > in bowel sounds, nausea/vomiting, cramping, abdominal pain, diarrhea 17.gynecological oligomenorrhea/ amenorrhea, < fertility, < libido, abortion tendency, gynecomastia in men
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Diagnostic Studies
Decreased TSH Elevated FT4=Free thyroxine T3,T4 levels=T3=tri-iodothyronine, T4=thyroxine Radioactive iodine uptake test = (RAIU)=used to identify Graves from other thyroid disorders;Graves=35%-95% uptake Thyroiditis=< 20%

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Elevated T3 resin uptake Chest Xray shows enlarged heart Thyroid scan=check for tumors=if its a hot nodule nearly always benign and if a cold nodule then higher risk for cancer

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Medications

Antithyroid Medications=inhibit production of thyroid hormones, blocks peripheral conversion of T4 to T3 ie. Propythiouracil=PTU; Methimazole+Tapazole Iodine=preparation ofr thyroidectomy or treatment for thyrotoxic crisis as large dose inhibits T3,T4 and blocks release into circulation; < vascularity of gland and makes surgery safer
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Medications
Saturated solution of Potassium iodidide=(SSKI), Lugols solution Beta-adrenergic blockers=to relieve cardiac symptoms, ie. Propranolol (Inderal); Atenolol(Tenormin)

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Surgical Management

Subtotal thyroidectomy is preferred with 90% of the tissue removed. If too much removed results in hypothyroidism in the post-operative period Advantage=removes hormones quickly Endoscopic thyroidectomy=minimal invasion with a nodule <3mm and no cancer; less scar, less pain, and return to ADLs quicker
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Surgical Preparation

Need to achieve a euthyroid state preoperatively; Monitor for thyrotoxicosis=Thyroid storm=due to infection, trauma, surgery; s/s=severe tachycardia, heart failure, shock, temperature of 105.3. restlessness, can end in delirium and coma Teach to take antithyroid drugs preoperatively and beta adrenergic blocking agents
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Thyroidectomy

Preoperative teaching/care=1. calm, quiet environment, cool room 2. Restrict visitors, use communication to allay anxiety 3. Teach coughing and deep breathing 4. Teach exercise of the legs 5. Teach support of the head when lifting or turning in bed 6. Teach IV will be present/talking difficult
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Thyroidectomy: Nutrition
High caloric diet 4000-5000kcal/day to satisfy hunger and prevent breakdown 6 full meals a day to compensate for >metabolism High protein, CHO, minerals, vitamins No caffeine

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Thyroidectomy: Postoperative Care

Oxygen administration and suction PRN Tracheostomy tray at the bedside Check for laryngeal nerve damage=check voice quality Monitor respiratory=obstruction can be due to swelling of the neck tissues d/t hemorrhage or edema formation: will see frequent swallowing, irregular breathing patterns, choking Check for laryngeal stridor d/t tetany
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Check for hemorrhage=check dressing on the neck, bes sure to check the back of the neck and shoulders ; often Hemovac/Jackson Pratt present Position in Semi-Fowlers with two pillows; avoid hyperextension flexion, which > tension on suture line

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Check for tetany=tingling of the toes, fingers, or around the mouth (occurs here first); +Trousseaus, + Chvosteks signs; > difficulty speaking, hoarseness, laryngeal stridor Control postoperative pain Ambulated on the first day Takes fluids followed by a soft diet

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Home Care

Monitor thyroid hormone balanceas some become hypothyroid after surgery. Dr. will not give thyroid hormone immediately post op to allow the thyroid tissue to hypertrophy and release T3/T4: follow up with the doctor is required to check hormone levels
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Nursing Diagnosis
Activity intolerance r/t fatigue, exhaustion, and heat intolerance secondary hyper-metabolism AEB c/0 weakness, hyperactivity, short attention span, memory lapses, dyspnea, tachycardia, irritability Risk for injury(corneal ulceration r/t < blinking, or inability to close eyes secondary to exophthalamos

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Imbalanced nutrition: <body requirements r/t hyper-metabolism and inadequate diet AEB c/o weight loss; optimal body weight Anxiety r/t lack of knowledge about mangement and course of disease and hyper-metabolism AEB verbalization of inability to cope with stress

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Hypothyroidism/Myxedema

Etiology-one of most common disorders in the U.S.; 8% of women and 2% of men over age 50; results from < thyroid hormone Primary=destruction of thyroid tissue or defective hormone synthesis Secondary=pituitary disease r/t < TSH; hypothalamic dysfunction r/t < TRH Iodine deficiency, radiation therapy, surgery, thyroiditis
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Hypothyroidism Assessment of Signs/Symptoms

1. Monitor for fatigue 2. Assess if lethargic 3. Identify if personality and mental changes have occurred, psychoses 4. Impaired memory 5. Assess for slowed speech 6. Assess for somolence 7. Monitor for < cardiac output and slowed pulse rate
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8. Assess for S.O.B. with exertion 9. Monitor for anemia 10. Assess for bruising 11. GI motility is slowed=check for constipation 12. Identify cold intolerance 13. Assess for hair loss, hair being dry and coarse 14. Assess for dry, coarse skin 15. Assess for brittle nails
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16. Assess for hoarseness, thick tongue, slow speech 17. check for muscle weakness 18. Assess for swelling 19. Monitor for history of weight gain 20 Myxedema (if longstanding ) characterized by pufiness, periorbital edema, mask like or blank expression 21. Check for menorrhagia, infertility
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Ask about the taking of iodine or goitrogens Ask about muscle aches and pains

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HYPOTHYROIDISM DIAGNOSTIC STUDIES

TSH level=if elevated TSH defect in thyroid; if lowered, TSH defect in pituitary or hypothalamus ; if TSH elevated after TRH injection suggests hypothalamic dysfunction Elevated cholesterol, triglycerides Anemia Anti-thyroid antibodies with Hashimotos

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HYPOTHYROIDISM MANAGEMENT

Treat with Levothyroxine (Synthroid, Levothroid)=start with 0.05 mg. P.O. daily; and maintenance dose adjusted to the patients response and lab results; caution with elderly, will start with lower dose ie. 0.0125-0.025 mg/day d/t risk of increased myocardial demands resulting in risk of angina / arrhythmias; s/s begin to reverse in 2-3 days post Rx

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HYPOTHYROIDISM MANAGEMENT
Teach to report chest pain, palpitations, increased heart rate Monitor cardiac enzymes If no side effects, dose then elevated at 1 to 4 week intervals Inform replacement needed for life Low calorie diet to reduce weight Upon admission, warm environment

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HYPOTHYROIDISM MANAGEMENT
Skin care=lotions, check breakdown Constipation=increase exercise, fiber, stool softener, avoid enemas d/t cardiac effect of vagal stimulation

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HYPOTHYROIDISM MYXEDEMA COMA

Can occur with infection, cold, trauma, drugs ie. Narcotics, Tranquilizers, Barbiturates S/S=decreased temperature, decreased BP, decreased respirations Requires acute care (ICU)=mechanical ventilation may be needed, IV thyroid replacement hormone with EKG monitoring, hypertonic saline till Na+ at 130 mEq./L, check of core temperature needed

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HYPOTHYROIDISM PATIENT TEACHING

Medications Drug interactions examples 1. thyroid hormones may > blood glucose and insulin may be required 2. Dilantin will > effects of thyroid hormones (see p. 1454)

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Ineffective breathing pattern r/t depressed ventilation Disturbed thought processes r/t depressed metabolism and altered cardiovascular and respiratory status Imbalanced nutrition: more than body requirements r/t hypometabolism AEB weight gain Hypothermia r/t cold intolerance AEB c/o of feeling cold and shivering
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HYPOTHYROIDISM NURSING DIAGNOSIS

HYPOTHYROIDISM NURSING DIAGNOSIS

Constipation r/t GI motility AEB irregular, hard stools Activity intolerance r/t fatigue and depressed cognitive process Disturbed thought processes r/t depressed metabolism and altered cardiovascular and respiratory status Deficient knowledge about the therapeutic regimen for lifelong thyroid replacement therapy See, chart 42-3, pp. 1455-1458.

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Disorders of the Parathyroid Glands

A&P Review 1. Parathyroids secrete parathyroid hormone (parathormone) 2. Thyroid secretes Calcitonin 3. When calcium is high, phosphorus is low and when phosphorus is high calcium is low (Inverse relationship)

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Hyperparathyroidism

Incidence=older adults and 2-4 times more common in women Types 1. Primary=hyperplasia or adenoma (80% of cases) in one or more glands 2. Secondary=compensatory response by the parathyroid glands to chronic <Ca ( ie. vitamin D deficiency, malabsorption, chronic renal failure, > Ph) 3. Tertiary=hyperplasia of glands and loss of response to serum Ca levels ie. renal failure, kidney transplant following long dialysis treatment
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Hyperparathyroidism

Symptoms are related to the effects on the musculoskeletal, renal, and GI systems Musculoskeletal=Bone pain (back, joints, shins), pathologic fractures, muscle weakness of lower extremities, muscle atrophy Renal effects=renal calculi, polyuria, polydipsia GI=loss of appetite, abdominal pain, peptic ulcers, pancreatitis, nausea, constipation
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Hyperparathyroidism

Cardiovascular=arrhythmias, hypertension CNS=paresthesias, depression, psychosis Metabolic effects=acidosis, weight loss

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Hyperparathyroidism

Diagnosis=6 month history of S/S Lab work=check of serum levels of PTH, Ca, Phosphorus, bicarbonate, Cl ; urine for >Ca, >Ph, double antibody parathyroid hormone test X-rays and scans, MRI
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Hyperparathyroidism

Surgical Treatment=parathyroidectomy, partial or complete (endoscopically now) Criteria=serum Ca>12mg/dl(3.0mmol/L), Hypercalciuria=(400mg/day) Decreased bone density Overt symptoms (neuromuscular effects, renal stones) Very high Calcium=Emergency and treat with IV Na Phosphate, IV K Phosphate Re-implantation of parathyroid tissue to forearm or sternocleidomastoid muscle

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Hyperparthyroidism

Nonsurgical treatment=annual exam, check of PTH, Ca, Ph, alkaline phosphatase levels, x-rays, urine for Ca Avoidance of immobility Dietary measures= fluid intake of 2000ml./ day ;cranberry juice to lower urinary pH; low calcium intake; avoid large doses of vitamins A and D, antacids containing calcium, and calcium supplements; take 8-10 gm of Na d/t urinary loss with fluid losses from > urine output ;prune juice, stool softeners for constipation
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Hyperparthyroidism

Other medications=Phosphorus supplements= Pamidronate (Aredia) Alendronate (Fosamax); estrogen or progesterone; diuretics ie. Lasix ( no thiazide diuretics as < excretion of urinary Ca+ +); calcitonin; mithramycin; glucocorticoids

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Hyperparathyroidism

Nursing care=Postop same for thyroidectomy, special consideration to tetany d/t sudden drop in Ca level, if severe give IV Calcium gluconate Strict I&O Monitor Ca, Ph, K, Mg levels
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Hyperparathyroidism

Mobility=exercise needed for bones Dietary referral Monitor for S/S of >Ca and <Ca (Hypercalcemic Crisis, serum Ca level > 15mg/dl can occur, see p.1472)
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Hypoparathyroidism

Results from abnormally low PTH levels, resistance to PTH d/t genetic defects, from consistently low MG++ levels, chronic renal failure, massive blood transfusions, but most commonly d/t damage or removal of the parathyroid glands during thyroidectomy (1st 24-48 hrs. post surgery) Risk for tetany(serum Ca++5mg-6mg/ dl)
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Hypoparathyroidism
Laboratory findings= decreased serum Ca ++ and increased serum Ph++, < serum Mg++ level, <serum albumin level, <PTH level

Diagnostic studies=EKG= prolonged ST segment

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Hypoparathyroidism

Musculoskeletal=muscle spasms, facial grimacing, carpopedal spasms, tetany, extreme cases convulsions Integumentary=brittle nails, hair loss, dry scaly skin GI=abdominal cramps (pain), malabsorption

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Hypoparathyroidism

Cardiovascular=arrhythmias CNS=paresthesias (lips (circumoral), hands, feet), mood disorders (irritability, depression, anxiety), hyperactive reflexes, psychosis, >ICP

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Hypoparathyroidism/Treatment
1. Increasing calcium levels=(norm is 910.0 mg/dl) Use IV calcium gluconate or IV calcium chloride to reduce tetany 2. Will add sedative (Pentobarbitol) if neuromuscular irritabiitu/seizure activity continue 3. PTH administration can be used but allergic reaction is high
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Hypoparathyroidism
Chronic therapy=Oral calcium preparations=Calcium salts= carbonate (BioCal, Calsam, Caltrate, OsCal, Tums, etc.) ; calcium chloride; calcium citrate (Citrical); calcium glubionate, calcium gluceptate, calcium gluconate (Calcinate), calcium lactate

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Hypoparathyroidism
Administration of oral Calcium salts 1gm/day for patient <40 and 2gms/day >40 1. Administer 1-1.5 hours after meals and at bedtime

2. Give tablets with full glass of water

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Hypoparathyroidism
3. Do not take with food or milk and if possible do not take within 1-2 hrs. of other medications

4. Ca Gluconate causes constipation; >fiber/fluid

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Hypoparathyroidism
Adequate vitamin D intake= dihydrotachysterol (Hytakerol);1,25-dihydroxycholecalciferol (calcitrol); Ergocalciferol(Calciferol)=>diet/>sun Consideration of hormone replacement for women Aluminum hydroxide gel or aluminum carbonate (Gelucil, Amphojel) given after meals to bind phospate and promote elimination through the intestine

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Hypoparathyroidism
Rebreathing through a paper bag to lower blood pH which raises Ca level Nutrition=Foods high in Calcium= molasses, canned sardines, salmon, rhubarb, broccoli, collard greens, soy flour, (spinach avoided d/t formation of insoluble Ca++ substances ; Milk products also contain Ph++ and require restriction)
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Hypoparathyroidism
Monitor Ca++ level three to four times per year Teach S/S of >Ca++ and <Ca++(See Chart 42-9, p. 1474)

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Hypoparathyroidism

Nursing Diagnosis 1. Risk for Injury 2. Decreased cardiac output 3. Disturbed thought processes 4. Risk for ineffective breathing pattern

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