Thyroid Case Study

Thyroid Disorders
Chapter 50
Copyright 2014 by Mosby, an imprint of Elsevier Inc.
Structures and Functions of Endocrine System

Endocrine glands Released directly into circulation or have local effect Hormone secretion is regulated by a process call Feedback
Thyroid Disorder
Located in the lower neck anterior to the trachea Regulated by Thyroid-stimulating hormone (TSH)
Structures and Functions of Endocrine System

Thyroid Hormone
Thyroxine (T4) Triiodothyronine (T3)
Regulate cellular metabolism by increasing oxygen consumption
Calcitonin
Reduce plasma level of Calcium by increasing deposition in bone
Hyperthyroidism
A sustained increase in synthesis and release of thyroid hormones by thyroid gland Occurs more often in women, ages 20 to 40 years
Most common form

Graves disease
Other causes
Toxic nodular goiter Thyroiditis Excess iodine intake Pituitary tumors Thyroid cancer
Continuum of Thyroid Dysfunction
Etiology and Pathophysiology Graves Disease

Antibodies to TSH receptor stimulate release of T3, T4, or both
Leads to clinical manifestations of thyrotoxicosis
Remissions and exacerbations May progress to destruction of thyroid tissue
Hyperthyroidism
Thyrotoxicosis
Physiologic effects/clinical syndrome of hypermetabolism Results from increased circulating levels of T3, T4, or both
Hyperthyroidism and thyrotoxicosis usually occur together
Etiology and Pathophysiology Graves Disease

Autoimmune disease
Diffuse thyroid enlargement Excessive thyroid hormone secretion
Accounts for 80% of hyperthyroidism cases Precipitating factors interact with genetic factors Cigarette smoking increases risk
Clinical Manifestations
Related to effect of thyroid hormone excess
Metabolism Tissue sensitivity to stimulation by sympathetic nervous system
Goiter
Inspection Auscultation: bruits
Ophthalmopathy
Abnormal eye appearance or function
Exophthalmos
Increased fat deposits and fluid Eyeballs forced outward
Exophthalmos and Goiter of Graves Disease
Cardiovascular system
Systolic hypertension Bounding, rapid pulse; palpitations Cardiac output Cardiac hypertrophy Systolic murmurs Dysrhythmias (e.g., atrial fibrillation ) Angina
Respiratory system
Increased respiratory rate Dyspnea on mild exertion
GI system
Appetite, thirst Weight loss Diarrhea Splenomegaly Hepatomegaly
Integumentary system
Warm, smooth, moist skin Thin, brittle nails Hair loss Clubbing of fingers; palmar erythema Fine, silky hair; premature graying Diaphoresis Vitiligo
Acropachy
Musculoskeletal system
Fatigue Muscle weakness Proximal muscle wasting Dependent edema Osteoporosis
Nervous system
Nervousness, fine tremors Insomnia , exhaustion Lability of mood, delirium Hyperreflexia of tendon reflexes Inability to concentrate Stupor, coma
Reproductive system
Menstrual irregularities Amenorrhea Decreased libido Impotence Gynecomastia in men Decreased fertility
Intolerance to heat Elevated basal temperature Lid lag, stare Eyelid retraction Rapid speech
Thyrotoxicosis (Thyrotoxic Crisis)

Excessive amounts hormones released Life-threatening emergency Death rare when treatment initiated Results from stressors Thyroidectomy patients at risk
Thyrotoxicosis
Manifestations
Tachycardia, heart failure Shock Hyperthermia Restlessness, irritability Seizures Abdominal pain, vomiting, diarrhea Delirium, coma
Thyrotoxicosis
Treat by reducing circulating hormones Supportive therapy
Manage respiratory distress Reduce fever Replace fluids Eliminate or manage initiating stressor
Diagnostic Studies of Endocrine System

Thyroid laboratory studies
Thyroid-stimulating hormone (TSH) Thyroxine (T4) total Free thyroxine (FT4) Triiodothyronine (T3) total Free triiodothyronine (FT3) T3 uptake (T3 resin uptake) Thyroid antibodies (Ab) Thyroglobulin
Diagnostic Studies of Endocrine System

Thyroid radiologic studies
Ultrasonography Thyroid scan Radioactive iodine uptake (RAIU)
Diagnostic Studies
TSH and free thyroxine (free T4) Total T3 and T4 Radioactive iodine uptake (RAIU)
Differentiates Graves disease from other forms of thyroiditis
Collaborative Care
Three primary treatment options
Antithyroid medications Radioactive iodine therapy (RAI) Surgery
Drug Therapy
Useful in treatment of thyrotoxic states Not considered curative
Antithyroid drugs Iodine -Adrenergic blockers
Antithyroid Drugs
Propylthiouracil (PTU) and methimazole (Tapazole) Inhibit synthesis of thyroid hormone Improvement in 1 to 2 weeks Good results in 4 to 8 weeks Therapy for 6 to 15 months
Iodine
Potassium iodine (SSKI) and Lugols solution Inhibit synthesis of T3 and T4 and block their release into circulation Decreases vascularity of thyroid gland Maximal effect within 1 to 2 weeks Used before surgery and to treat crisis
-Adrenergic Blockers
Symptomatic relief of thyrotoxicosis Block effects of sympathetic nervous stimulation Propranolol (Inderal) Atenolol (Tenormin)
Radioactive Iodine Therapy (RAI)

Treatment of choice in nonpregnant adults Damages or destroys thyroid tissue Delayed response of 2 to 3 months Treated with antithyroid drugs and -blocker before and during first 3 months of RAI
Radioactive Iodine Therapy (RAI)

Given on outpatient basis Patient teaching
Oral care for thyroiditis/parotiditis Radiation precautions Symptoms of hypothyroidism
Surgical Therapy
Indications
Large goiter causing tracheal compression Unresponsive to antithyroid therapy Thyroid cancer Not a candidate for RAI
More rapid reduction in T3 and T4 levels
Surgical Therapy
Subtotal thyroidectomy
Preferred surgical procedure Involves removal of 90% of thyroid Can be done endoscopically
Nutritional Therapy
High-calorie diet (4000 to 5000 cal/day)
Six full meals/day with snacks in between Protein intake: 1 to 2 g/kg ideal body weight Increased carbohydrate intake
Avoid highly seasoned and high-fiber foods, caffeine Dietitian referral
Nursing Assessment
Subjective data
Past health history
Goiter, recent infection or trauma, immigration from iodinedeficient area, autoimmune disease
Medications
Thyroid hormones, herbal therapies
Weight loss Increased appetite, thirst Nausea/vomiting, diarrhea, polyuria Decreased libido - Impotence
-Amenorrhea
Nursing Assessment
Objective data
Agitation, Rapid speech, Anxiety, restlessness Enlarged or nodular thyroid gland Exophthalmos Eyelid retraction, infrequent blinking Thin, loose nails Fine, silky hair and hair loss Palmar erythema Clubbing Vitiligo Edema Warm, diaphoretic, velvety skin
Nursing Assessment
Objective data
Tachypnea, dyspnea on exertion Tachycardia, murmurs, dysrhythmias, HTN, bruit Bowel sounds, appetite, diarrhea, weight loss Hepatosplenomegaly
Objective data
Hyperreflexia, diplopia Fine tremors Muscle wasting
Nursing Assessment
Objective data
T3, T4 T3 resin uptake Or undetectable TSH Chest x-ray showing enlarged heart ECG findings of tachycardia, atrial fibrillation
Nursing Diagnoses & Plan

Activity intolerance Imbalanced nutrition: less than body requirements
Overall goals
Experience relief of symptoms Have no serious complications related to disease or treatment Maintain nutritional balance Cooperate with therapeutic plan
Nursing Implementation Acute Thyrotoxicosis

Necessitates aggressive treatment Medications to block thyroid hormone production Monitoring for dysrhythmias and oxygenation Fluid and electrolyte replacement Ensure adequate rest
Calm, quiet room Cool room Light bed coverings
Nursing Implementation Acute Thyrotoxicosis

If exophthalmos present
Apply artificial tears to relieve eye discomfort Salt restriction and elevate head of bed Dark glasses Tape eyelids closed if needed for sleep ROM of intraocular muscles
Nursing Implementation Preoperative Care

Administer medications to achieve euthyroidism Administer iodine to vascularity Assess for signs of iodine toxicity Patient teaching
Comfort and safety measures Leg exercises, head support, neck ROM Routine postoperative care
Nursing Implementation Postoperative Care

Monitor for complications
Hypocalcemia Hemorrhage and ifection Laryngeal nerve damage Thyrotoxic crisis
Maintain patent airway

O2, suction equipment, tracheostomy tray at bedside Monitor for laryngeal stridor IV calcium readily available

Assess every 2 hours during first 24 hours for signs of hemorrhage or tracheal compression Semi-Fowlers position Support head with pillows Avoid neck flexion and tension on suture line

Monitor vital signs and calcium levels Signs of hypocalcemia
Difficulty speaking and hoarseness Trousseaus and Chvosteks signs
Analgesics Ambulation Psychosocial support

Nursing Implementation Ambulatory and Home Care

Discharge teaching
Monitor hormone balance periodically Decrease caloric intake Adequate but not excessive iodine intake Regular exercise Avoid environmental temperature Complete thyroidectomy
Symptoms of hypothyroidism Need for lifelong thyroid hormone replacement
Hypothyroidism
Deficiency of thyroid hormone Slow metabolic rate More common in women than in men
Etiology and Pathophysiology

Primary hypothyroidism
Caused by destruction of thyroid tissue or defective hormone synthesis
Secondary hypothyroidism
Caused by pituitary or hypothalamic dysfunction ( TSH or TRH)
Etiology
Iodine deficiency Atrophy of the gland Treatment for hyperthyroidism Drugs Cretinism if occurs in infancy
Manifestations variable Slow onset Cardiovascular system
Cardiac contractility and output Angina, heart failure, myocardial infarction Anemia Cobalamin, iron, folate deficiencies Serum cholesterol and triglycerides
Respiratory system
Low exercise tolerance Shortness of breath on exertion
Neurologic system
Fatigue and lethargy Personality and mood changes Impaired memory, slowed speech, decreased initiative, and somnolence
Copyright 2014 by Mosby, an imprint of Elsevier Inc. Copyright 2014 by Mosby, an imprint of Elsevier Inc.
Gastrointestinal system
Decreased appetite Nausea and vomiting Weight gain Constipation Distended abdomen Enlarged, scaly tongue Celiac disease
Integumentary system
Dry, thick, inelastic, cold skin Thick, brittle nails Dry, sparse, coarse hair Poor turgor of mucosa Generalized interstitial edema Puffy face Decreased sweating Pallor
Musculoskeletal system
Fatigue, weakness Muscular aches and pains Slow movements Arthralgia
Reproductive system
Prolonged menstrual periods or amenorrhea Decreased libido, infertility
Other
Increased susceptibility to infection Increased sensitivity to opioids, barbiturates, anesthesia Intolerance to cold Decreased hearing Sleepiness Goiter
Common Features of Myxedema
Complications
Myxedema coma
Impaired consciousness Precipitated by infection, drugs, cold, trauma Subnormal temperature, hypotension, hypoventilation Cardiovascular collapse Treat with IV thyroid hormone
Diagnostic Studies
History and physical examination TSH and free T4
TSH with primary hypothyroidism TSH with secondary hypothyroidism
Thyroid antibodies Cholesterol Triglycerides Creatine kinase RBCs (anemia)

Collaborative Care
Levothyroxine (Synthroid)
Start with low dose Monitor for cardiovascular side effects (chest pain, dysrhythmias), weight loss, nervousness, tremors, insomnia Increase dose in 4- to 6-week intervals as needed Lifelong therapy
Nursing Assessment
Health History
Hyperthyroidism treatment Iodine-containing medications Changes in appetite, Weight gain Activity level Speech, memory, or skin changes
Physical examination
Cold intolerance Constipation Signs of depression Heart rate Gland tenderness Edema
Nursing Diagnoses
Imbalanced nutrition: more than body requirements Constipation Impaired memory
Nursing Implementation
Health promotion
Screen populations at high risk
Family history of thyroid disease History of neck irradiation Women older than 50 Postpartum women
Most outpatient therapy Myxedema coma necessitates acute care
Mechanical respiratory support Cardiac monitoring IV thyroid hormone replacement Monitoring of core temperature
Acute intervention
Skin care Vital signs, weight, I&O, edema Cardiovascular response to hormone Energy level Mental alertness
Patient teaching
Written instructions important Need for lifelong therapy Thyroid medicine in morning on empty stomach Side effects of medication Signs and symptoms of hypothyroidism and hyperthyroidism
Patient teaching
Regular follow-up care Do not switch brands Comfortable, warm environment Measures to prevent skin breakdown Emphasize need for warm environment Avoid sedatives or use lowest dose possible Measures to minimize constipation Avoid use of enemas

Thyroid Case Study

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Thyroid Disorders

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Structures and Functions of Endocrine System

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Structures and Functions of Endocrine System

Most common form

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Continuum of Thyroid Dysfunction

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Etiology and Pathophysiology Graves Disease

Remissions and exacerbations May progress to destruction of thyroid tissue

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Hyperthyroidism and thyrotoxicosis usually occur together

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Etiology and Pathophysiology Graves Disease

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Exophthalmos and Goiter of Graves Disease

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Thyrotoxicosis (Thyrotoxic Crisis)

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Diagnostic Studies of Endocrine System

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Diagnostic Studies of Endocrine System

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Radioactive Iodine Therapy (RAI)

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Radioactive Iodine Therapy (RAI)

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

More rapid reduction in T3 and T4 levels

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Avoid highly seasoned and high-fiber foods, caffeine Dietitian referral

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Diagnoses & Plan

Nursing Implementation Acute Thyrotoxicosis

Nursing Implementation Acute Thyrotoxicosis

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implementation Preoperative Care

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implementation Postoperative Care

Maintain patent airway

Nursing Implementation Postoperative Care

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Nursing Implementation Postoperative Care