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happy is the man that findeth

wisdom, and getteth


understanding
Proverbs 3:13

DISORDERS
OF THE
THYROID
GLAND

OBJECTIVES

To understand the normal physiology of the

thyroid gland
Assess the clinical manifestation of client with
thyroid disorders
Discuss the etiology, risk factors and basic
pathophysiology of thyroid disorders
Develop plan of care for the management,
follow up care, self management education for
clients with thyroid disorders
Implement plan of care to restore, maintain
and promote health for clients with thyroid
disorder
Evaluate planned client outcomes utilized for
planning the care of clients with thyroid

Thyroid gland

Butterfly shaped organ located in the

lower neck anterior to the trachea


Consist of 2 lateral lobes connected
by an isthmus
5cm long, 3cm wide and weighs
about 30 grams
Its blood flow is very
high(5mL/min /gm of thyroid tissue),
about five times the blood flow to the
liver.

Thyroid gland

Thyroid gland

Triiodothyronine/T3 and Thyroxine/T4


Regulate metabolic rate of cells
Regulate carbohydrate, fat and protein

metabolism
Acts as insulin antagonist
Maintain growth hormone secretion and promote
skeletal mmaturation
Affect CNS development
Affect cardiac rate, force and output
Affect O2 utilization
Stimulate lipid turnover, free fatty acid release
and cholesterol synthesis
Stimulate SNS activity

Thyroid gland

Thyrocalcitonin/Calcitonin
Lowers serum Calcium level
Inhibits osteoclastic activity
Lowers phosphate levels
Decrease Ca and P absorption in the
GI tract
The relationship of calcitonin and Ca
is inverse

Neck assessment
Inspection

Inspect all areas of the neck anteriorly

and posteriorly: symmetry, lumps or


masses, unusual swelling or pulsations
and ROM
Thyroid-ask the pt to swallow and
observe for movement of an enlarge
thyroid gland at the suprasternal notch
Thyroid is not usually visible unless in
extremely thin persons.

Palpation
Thyroid: stand behind the pt and have him flex the

neck to relax the cervical muscles


Place the finger tips of your left hand behind the left
sternocleidomastoid muscle adjacent to the trachea
just below the larynx
Palpate the area over the trachea and to the left of
the trachea to discern the outline of the isthmus of
the left lobe of the thyroid gland
Note any enlargement , nodules, masses, consistency
Reverse the procedure and examine the right TG
Have the pt swallow to facilitate the examination of
the TG. The thyroid moves upward during swallowing
Thyroid gland is normally smooth, without nodules,
masses, or irregularities or bruits( gushing sound
produced by blood moving through a narrow vessels)

Goiter
Enlargement of the thyroid

gland
Due to increase amount of
TSH. It can be associated with
hyperthyroism, hyothyroidism
or euthyroidism.

Goiter

Hyperthyroidism
Hypersecretion of the thyroid hormone
Common cause is graves disease, also known

as toxic diffuse goiter


Incidence is higher in females, below 40 years
of age
It is primarily associated with severe emotional
stress, secondarily with autoimmune disorder
The clinical manifestation of hyperthyroidism
are based on the 3 basic concepts:
Increase metabolic rate(increase t3)
Increased body heat production(increased t4)
Hypocalcemia(increased thyrocalcitonin)

Thyroid hormones enhance the actions of

epinephrine and norepinephrine, increase


sympathetic activity and CNS function.
Hypocalcemia results to increased cell
membrane permeability. This leads to
neuromuscular irritability

Clinical manifestations:
Thyroid disturbances:
Activation of SNS and CNS functions:
restlessness, nervousness, irritability,

agitation
Fine tremors
Tachycardia
Hypertension
Diaphoresis
Increased metabolism
Increased appetite to eat
wt loss
Heat intolerance

Clinical manifestations:
Hypocalcemia
Diarrhea(increased peristalsis)
Fine, silky hair
Pliable nails
Altered reproductive function
Amenorrhea

Clinical manifestations:
Ophthalmopathy
Exopthalmus- protrusion of the eyeballs caused by

the accumulation of fluids at the fatpads behind the


eyeballs, pushing the eyeballs forward. This may
cause corneal ulceration, ophthalmitis and
blindness. It is irreversible.
Von Graefes sign(lid lag). Long and deep palpebral
fissure is still evident when one looks down
Jeffreys sign- the forehead remains smooth when
one looks up.
Dalyrimples sign(thyroid stare)- characterized by
bright-eyed stare and infrequent blinking
Dermopathy-manifested by warm, flushed sweaty
skin and thickened hyperpigmented at the pretibial
area

Basic concepts to remember in


hyperthyroidism
Signs and symptoms
Everything is high, fast and wet. Eg.

High and fast: hypertension, tachycardia,


elevated body temperature; wet:
diaphoresis(wet skin), diarrhea(wet stool)
Eye manifestations. Exopthalmos, lid
lag, bright-eyed stare

Diagnostic test

TSH test
T3/T4
Radioactive iodine uptake test
Thyroid scan

Collaborative Management
Provide adequate rest
Provide non-stimulating, quiet and cool environment:
prevent agitation and heat intolerance
Provide high calorie diet: maintain nutritional status
Low fiber diet if with diarrhea
Obtain daily wt: best indicator of nutritional status
Promote safety: high risk for injury due to
restlessness, nervousness, agitation and tremors
Protect the eyes, if with exopthalmus. Instill artificial
tears at regular intervals. Advise client to wear dark
sunglasses when going out under the sun
Avoid stimulants like caffeine
Replace fluid-electrolyte losses due to diarrhea and
diaphoresis

Pharmacotherapy

Anti-thyroid medications:
Iodides: Lugols solution and saturated
solution of potassium iodide(SSKI)
Inhibits the release of the thyroid hormones
Mix with water or fruit juice with ice to
improve palatability
Provide drinking straw to prevent
permanent staining of teeth
SE: (iodism) allergic reaction, metallic or
brassy taste in the mouth, increased
salivation, coryza, vomiting, abdominal pain

Pharmacotherapy

Thiomides: Tapazole(Methimazole),

PTU(Propylthiouracil)
Inhibit synthesis of thyroid
hormones
SE: agranulocytosis(neutropenia),
with leukopenia(fever, sore throat,
skin rash, diarrhea)

Pharmacotherapy

When thyroid medications are given:


Monitor VS (especially BP and PR) and wt.

these medications may cause HPN and


tachycadia. Wt gain indicates effectiveness of
medication
Administer with meals to avoid GI upset
Avoid ASA and medications containing iodine.
ASA elevates free thyroid hormone levels;
iodine-containing medications stimulate
thyroid function and antagonize anti-thyroid
medication
Advise pt to consult physician before eating
iodize salt and iodine rich foods
Observe for signs and symptoms of

Pharmacotherapy

Beta-blocker: Inderal(Propanolol)
To control tachycardia and hypertension
Glucocorticoids: dexamethasone
Inhibit the action of thyroid hormone
Radiation therapy: radioactive Iodine(I131)
Place client on isolation for few days. Body

secretions are radioactive-contaminated. Use


gloves when handling body secretions

Surgery
Subtotal thyroidectomy(5/6 of the gland is

removed)
Care of client undergoing thyroidectomy
Preoperative interventions
Promote euthyroid state
1. Obtain VS and wt. ensure vs are stable
2. Assess electrolyte levels
3. Assess for hyperglycemia and glucosuria.
Thyroid hormones act as insulin antagonist
Instruct client on how to perform DBCT
exercises and how to support the neck in the
postoperative period when coughing and
moving

Surgery
Administer the ff. medication as prescribed to

prevent thyroid storm:


1. Sodium Iodide Solution(Lugols solution)- to
reduce the size and vascularity of the
thyroid gland and prevent postop
hemorrhage and thyroid crisis
2. inderal9Propanolol) to control the HPN and
tachycardia
3. Glucocorticoids(dexamethasone) to inhibit
action of thyroid hormone
Check ECG. HF? Cardiac damage results from
HPN and tachycardia

Surgery
Postoperative intervention
1. Position: semi-Fowlers with head, neck,

shoulder erect. Hyperextension and flexion


of the neck may cause tension to the suture
line and cause bleeding
2. Monitor surgical site for bleeding and
edema. Check dressing anteriorly and at the
back of the neck. Respiratory distress may
indicate bleeding. Accumulation of the blood
in the neck may compress airways
3. Have tracheostomy set, O2, and suction
available at bedside. Inadvertent
parathyroid damage leads to hypocalcemia.
Hypocalcemia may cause laryngospasm

Surgery
Postoperative intervention

4. Assess for recurrent laryngeal nerve damage


Ask pt to speak every hr.
Limit pt talking and assess level of
hoarseness. Mild hoarseness is normal(due
to intubation during induction of anesthesia.
Severe hoarseness indicates laryngeal nerve
damage. Notify physician
Observe for signs of recurrent laryngeal nerve
damage like respiratory obstruction,
dysphonia, high pitched voice, stridor,
dysphagia and restlessness.

Surgery
Postoperative intervention

5. Monitor for signs of hypocalcemia and


tetany. These may due to trauma to
parathyroid gland
Ca Gluconate should be readily available for
tetany
Monitor BP. To assess for positive trousseaus
sign(carpal spasm) which indicates
hypocalcemia. Compression of the brachial
artery with bp cuff for 3 minutes is done to
assess trousseaus sign
Cardiac dysrhythmias, dysphagia, muscle and
abdominal cramps, numbness or tingling of
the face and extremities, positive Chvosteks

Surgery
Postoperative intervention

6. Monitor for thyroid storm


Thyroid storm is uncontrolled and potentially
life-threatening hyperthyroidism
Can occur from the release of the thyroid
hormone into the blood stream during
surgery; it can also follow severe infection
and stress
S/Sx: hyperthermia,
tachycardia/dysrhythmias, systolic HPN, GI
symptoms: N and V, diarrhea, restlessness,
agitation, irritability, anxiety, tremors,
confusion, seizures, delirium and coma

Surgery
Collaborative management of thyroid storm:
Patent airway and ventilation(O2 therapy)
Administer anti-thyroid medications: PTU,

Lugols solution, inderal, dexamethasone as


prescribed
Monitor VS, I and O, neurological status,
cardiovascular status every hour
Implement measures to lower fever: use
cooling blanket; administer acetaminophen
as prescribed
Avoid ASA: increase free thyroid hormone
levels
Maintain quiet, calm, cool, private

Surgery
Postoperative intervention

7. Patient teaching after thyroidectomy


Support neck with interlaced fingers when
getting up from bed to prevent
hyperextension of the neck
Start ROM exercises of the neck 3-4 days
after discharge
Massage incision site cocoa butter lotion,
once healing occur. To minimize scarring
Have regular follow-up case.

Hypothyroidism
Is the deficiency of thyroid hormone
Myxedema is hypothyroidism of adult;

critinism in children
Causes: autoimmune disorders(e.g.
Hashimotos disease, an autoimmune
disorder associated with recurrent respiratory
infections)
Thyroidectomy
Radioactive iodine therapy
Anti-thyroid drugs

Clinical manifestation are based on 3


basic concepts:
Decreased metabolic rate(due to

hyposecretion of T3)
Decreased body heat
production(hyposecretion of T4)
Hypercalcemia(hyposecretion of
thyrocalcitonin)
Hypocalcemia results to decreased cell
membrane permeability. This leads to
decreased neuromuscular irritability
Diagnostic tests
TSH
T3/T4

Clinical manifestation
Slowed physical, mental reaction
Apathy, lethargy, fatigue
Weakness, muscle aches, paresthesia
Dull, expressionless, mask-like face
Cold intolerance, subnormal body temperature
Generalized puffiness and edema around the

eyes and the face, obesity/wt gain


Anorexia, bradycardia, constipation, enlarge
tongue
Coarse, dry, sparse hair, loss of body hair
Dry skin, brittle nails, hyperlipidemia,
atherosclerosis
Cardiac enlargement, CHF, slow speech, husky

Clinical manifestation
Monitor VS. be alert for heart rate and
rhythm, which indicate cardiovascular
disorders
Monitor wt daily
Diet: low calorie, low cholesterol, low
saturated fat. To prevent obesity and
hyperlipidemia
Assess for constipation. Provide high
fiber/roughage and fluids to prevent
constipation

Collaborative management
Basic concept to remember in
hypothyroidism:
Everything is low, slow and dry
E.g. low and slow: slowed physical and
mental reactions, lethargy, low body
temperature, bradycardia and slow
metabolism
Dry: dry hair and skin, constipation(dry
stool)

Collaborative management
Administer thyroid replacement therapy
Synthroid, levothyroid,
levoxyl(levothyroxine)
Cytomel(liothyronine)
Thyrolar(leotrix)
Thycar(thyroid)

NI in thyroid replacement therapy


Monitor VS, especially BP and pulse
rate. Hold medication for HPN and
tachycardia.Notify AP
Monitor Wt. reduction of wt is desirable
Take medications in the morning
without meals. To ensure absorption
Avoid foods that can inhibit thyroid that
can inhibit thyroid secretion like
strawberries, peaches, pears, cabbage,
turnips, spinach, brussel sprouts,
cauliflower, radishes and peas
Start with low dose, then gradually

NI in thyroid replacement therapy


Thyroid hormone have the following
interactions:
Inhance the action of oral
anticoagulants, sympathomimetics, and
anti-deprssants
Decrease the action of insulin, oral
hypoglycemic agents and digitalis
Action of thyroid hormone is decreased
by dilantin(phenytoin),
tegretol(carbomazapine)
Thyroid hormone should be given at
least 4hrs apart from multivitamins,

Myxedema coma
Extreme, severe stage of
hypothyroidism. Precipitated by acute
illness, rapid withdrawal of thyroid
hormone, anesthesia, surgery,
hypothermia or use of sedatives and
narcotics
Clinical manifestation:
Hypotension
Bradycardia
Hypothermia
Hypoglycemia
Hyponatremia

Myxedema coma
All VS are profoundly depressed which
is potentially fatal
Collaborative management
Maintain patent airway
Administer fluids and synthroid/IV as
ordered
Administer glucose as ordered
Monitor temp, correct hypothermia.keep
warm
Monitor BP. manage hypotension
Monitor for changes in level of

Summary
Thyroid is an organ that regulates
metabolism
Thyroid disorders can be hyper/hypo
The real cause of the disease is
unknown but it could be due to
genetics, nutrition, autoimmunity and
bacterial of viral
It more common in women before their
40s
The treatment of this could be
medications,radiation and surgery
It is important for the nurse to monitor