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Submitted by: Rhea Sildo BSN-4E Submitted to: Mr. Mark Gil Dacutan

Sildo, Rhea C. BSN-4E

HypothyroidisM
Definition: Hypothyroidism results from suboptimal levels of thyroid hormone. Thyroid deficiency can affect all body functions and can range from mild, subclinical forms to myxedema, an advanced form. More than 95% of patients with hypothyroidism have primary or thyroidal hypothyroidism, which refers to dysfunction of the thyroid gland itself. When thyroid dysfunction is caused by failure of the pituitary gland, the hypothalamus, or both, it is known as central hypothyroidism. It may be referred to as pituitary or secondary hypothyroidism if it is caused entirely by a pituitary disorder, and hypothalamic or tertiary hypothyroidism if it is attributable to a disorder of the hypothalamus resulting in inadequate secretion of TSH because of decreased stimulation by TRH. When thyroid deficiency is present at birth, the condition is known as cretinism. In such instances, the mother may also suffer from thyroid deficiency. The term myxedema refers to the accumulation of mucopolysaccharides in subcutaneous and other interstitial tissues. Although myxedema occurs in long-standing hypothyroidism, the term is used appropriately only to describe the extreme symptoms of severe hypothyroidism. Epidemiology: Primary hypothyroidism is common. Population-based surveys reveal that it is present in almost 5% of individuals. It is more commonly diagnosed in women and with advancing age, although it occurs in men and younger individuals. It is more prevalent among whites and Latinos. Secondary hypothyroidism is rare, representing less than 1% of all cases.

Clinical Manifestations Fatigue and lethargy. Weight gain. Complaints of cold hands and feet. Temperature and pulse become subnormal; patient cannot tolerate cold and desires increased room temperature. Reduced attention span; impaired short-term memory. Severe constipation; decreased peristalsis. Generalized appearance of thick, puffy skin; subcutaneous swelling in hands, feet, and eyelids. Hair thins; loss of the lateral one-third of eyebrow. Menorrhagia or amenorrhea; may have difficulty conceiving or may experience spontaneous abortion; decreased libido. Neurologic signs include polyneuropathy, cerebellar ataxia, muscle aches or weakness, clumsiness, prolonged deep tendon reflexes (especially ankle jerk). Hyperlipoproteinemia and hypercholesterolemia. Enlarged heart on chest X-ray. Increased susceptibility to all hypnotic and sedative drugs and anesthetic agents. Other Routine Test Abnormalities Blood tests may reveal anemia, hyponatremia, hypoglycemia, and elevated creatine phosphokinase, prolactin, homocysteine, triglyceride, and total and LDL cholesterol levels. Electrocardiography may show sinus bradycardia with low voltage in the limb leads. Chest radiography and echocardiography may demonstrate a pericardial effusion.

Restoration of Normal Metabolic State (Euthyroid) Thyroid hormone: T4-levothyroxine (Synthroid, Levothroid, Levoxyl); T3-liothyronine (Cytomel); T3 and T4 mixed (Armour Thyroid, Thyrolar). Because T3 acts more quickly than T4 does, it is given via nasogastric tube if patient is unconscious. Sodium levothyroxine (Synthroid) is administered parenterally (until consciousness is restored) to restore T4 level. Later, the patient is continued on oral thyroid hormone therapy. With rapid administration of thyroid hormone, plasma T4 levels may initiate adrenal insufficiency; hence, steroid therapy may be started. Mild symptoms in the alert patient or asymptomatic cases (with abnormal laboratory results only) require only initiation of low-dose thyroid hormone given orally. Monitoring to anticipate treatment effects: Diuresis, decreased puffiness. Improved reflexes and muscle tone. Accelerated pulse rate. A slightly higher level of total serum T4. All signs of hypothyroidism should disappear in 3 to 12 weeks. Decreasing TSH level.

Complications: Mild Hypothyroidism Whether individuals diagnosed with mild hypothyroidism (i.e., an elevated or high-normal TSH level with a free T4 level within the reference range) benefit from thyroxine therapy is controversial. Proponents argue that treatment with thyroxine relieves symptoms, lowers cholesterol, avoids the emergence of overt hypothyroidism, and is relatively safe. Detractors counter that these purported benefits have not been confirmed in adequately powered, randomized controlled trials. In practice, many providers opt for a trial of therapy in mildly hypothyroid patients who are symptomatic, have underlying hypercholesterolemia, or demonstrate a high likelihood of progressing to overt hypothyroidism. Predictors of progressive thyroid failure include age older than 65 years, TSH level higher than 10 mIU/L, and the presence of circulating antithyroid antibodies indicating underlying autoimmune thyroiditis. Myxedema Coma Severe hypothyroidism can culminate in myxedema coma, a lifethreatening condition characterized by hypothermia, bradycardia,

hypotension, altered mental status, and multisystem organ failure. Risk factors include advanced age, poor access to health care, and other underlying major organ system diseases. Most patients have long-standing thyroid hormone deficiency. Treatment should include thyroxine (1.8 g/kg daily with or without a 500-g loading dose). Some experts advocate coadministration of triiodothyronine in divided doses to compensate for impaired conversion of T4 to T3. No controlled trials have been performed to evaluate the relative benefits and risks of these different approaches. Glucocorticoids should be administered in stress doses after a cosyntropin stimulation test has been performed to check for evidence of concomitant adrenal insufficiency. Care should be taken to avoid exposure to potent sedative or analgesic agents that may exacerbate altered mental status. Hypothermia should be treated with external warming to reduce the risk of circulatory collapse. Nonthyroidal Illness In patients with severe nonthyroidal illness, a characteristic constellation of thyroid function test changes occur that often appear to be consistent with hypothyroidism. The T3 level usually declines as a result of decreased extrathyroidal T4 to T3 conversion. With increasingly severe disease, total T4 and free T4 levels also decline. TSH levels are usually low to low-normal. During the course of recovery, the TSH level can rise above the upper limit of the normal range, producing a profile that can be mistaken for primary hypothyroidism. Clinical correlation is essential to assess thyroid function in severely ill patients (e.g., a history of preexisting thyroid or pituitary disease, the presence of a goiter, or features suggesting other elements of hypopituitarism). Because no benefit of thyroid hormone treatment has been shown for these patients, observation with retesting 6 to 8 weeks after recovery is the preferred approach. Nursing Diagnosis: Decreased Cardiac Output related to decreased metabolic rate and decreased cardiac conduction Nursing Interventions: Increasing Cardiac Output Monitor vital signs frequently to detect changes in cardiovascular status and ability to respond to stress. Monitor ECG tracings to detect arrhythmias and deterioration of cardiovascular status. Prevent chilling to avoid increasing metabolic rate, which, in turn, places strain on the heart. Provide bed socks, bed jacket, warm environment.

 Avoid rapid rewarming techniques (warmed I.V. fluids, hypothermia blanket) because the resulting increased oxygen requirements and peripheral vasodilation may worsen cardiac failure. Administer fluids cautiously, even though hyponatremia is present. Administer all prescribed drugs with caution before and after thyroid replacement begins. Monitor the effects of sedatives, opioids, and anesthetics closely because patient is more sensitive to these agents. After thyroid replacement is initiated, the thyroid hormones may increase the effects of digoxin (monitor pulse) and anticoagulants (watch for signs of bleeding). Report occurrence of angina, and be alert for signs and symptoms of myocardial infarction and cardiac failure. Monitor arterial blood gas levels to assess cardiopulmonary function.