DISORDERS OF THE THYROID AND PARATHYROID GLANDS

HYPERTHYROIDISM

 ETIOLOGY/PATHOPHYSIOLOGY • Also called Graves’ disease, or exophthalmic goiter, or thyrotoxicosis • DUE TO: Overproduction of the thyroid hormones T3 and T4  Exaggeration of metabolic processes

HYPERTHYROIDISM

• ETIOLOGY/PATHOPHYSIOLOGY cont.

• Exact cause unknown – Possible genetic factors with precipitive factors of: » Infection, ↓ iodine, or extreme physical or emotional stress • Affects females more than males • May occur during adolesence or pregnancy

HYPERTHYROIDISM

• CLINICAL MANIFESTATIONS: • Edema of the anterior portion of the neck • Exophthalmos (bulging eyeballs) – SUBJECTIVE ASSESSMENT : Pt. C/o: • Inability to concentrate; memory loss • Dysphagia • Hoarseness • Increased appetite • Weight loss, insomnia • Nervousness, jittery, excitable

EXOPTHALMUS

http://www.bing.com/images/search?q=exopthalmus+picture&id=910B1504DB452992E34365F19E0BE4C2EE3594 1E&FORM=IQFRBA#view=detail&id=36C1A29E6D537F51942094844C162CBA347F5CC6&selectedIndex=164 Internet picture

HYPERTHROIDISM

HYPERTHROIDISM

• CLINICAL MANIFESTATIONS – OBJECTIVE ASSESSMENT • Tachycardia; hypertension; bruit over thyroid • Warm, flushed skin • Fine hair • Amenorrhea • Elevated temperature/heat intolerance • Diaphoresis • Hand tremors, clumsiness • Hyperactivity for some

HYPERTHYROIDISM

• DIAGNOSTIC TESTS – Confirmed by: • ↓ TSH and ↑ Free T4 • RAIU – radioactive iodine uptake – uptake of 35-95% of the drug

HYPERTHYROIDISM

• MEDICAL MANAGEMENT –

Medications – Block production of thyroid hormone

– Propylthiouracil / PTU – Methimazole/ Tapazole •

Meds reduce symptoms in 6-8 wks.

HYPERTHYROIDISM

• MEDICAL MANAGEMENT – Medication may be followed by: •

Radioactive iodine/ ablation therapy

– Destroys some of the hypertrophied thyroid tissue – Low dose – no “radiation” precautions needed

HYPERTHYROIDISM

• MEDICAL MANAGEMENT cont.

– Radioactive iodine/ Ablation therapy cont.

• Outcome: in most pts.  treat with Levothyroxine hypothyroidism  • Adequate medical supervision follow up is important!

HYPERTHYROIDISM

•

MEDICAL MANAGEMENT cont.

– Surgery: for pts. who cannot tolerate antithyroid drugs; are not good candidates for radiation tx.; have a poss. malignancy; or have large goiters causing tracheal compression – Most common surgery: Subtotal Thyroidectomy • • Removal of 5/6ths of the thyroid gland If too much thyroid tissue is removed  regenerate  hypothyroidism gland will not

HYPERTHYROIDISM

• MEDICAL MANAGEMENT cont.

– Surgery: usually delayed until pt in a normal thyroid state d/t the risk of bleeding during surgery and thyroid crisis (thyroid storm) post op.

HYPERTHYROIDISM

• • • NURSING ASSESSMENT AND INTERVENTIONS: – Post-operative Subtotal Thyroidectomy • Assess for s/sx internal or external bleeding • Assess for tetany: – Chovstek’s Sign: is + when abnormal spasm of facial muscles occurs when elicited by light tapping on facial nerve in the pt. with low calcium – Trousseau’s Sign: is + if there is carpal spasm in the hypocalcemic and hypomagnesemia pt. When BP cuff inflated above pt. normal systolic pressure and held there for 3 min.

http://www.bing.com/videos/search?q=thyroid+storm+youtube&qpvt=thyroid+storm+youtube&FORM=V DRE#view=detail&mid=0B08D370F3270FFF14820B08D370F3270FFF1482 (3 min 5 sec) http://www.bing.com/videos/search?q=youtube+partial+thyroidectomy+personal+story&FORM=VIRE1#vi ew=detail&mid=613D00F1A54228D31139613D00F1A54228D31139 (9 min 49sec)

HYPERTHYROIDISM

• NURSING ASSESSMENT AND INTERVENTIONS: – Post-op Subtotal Thyroidectomy (cont.) • Assess for Thyroid Crisis/Storm – May occur as a result of manipulation of the thyroid gland during surgery releasing large amts of thyroid hormone  bloodstream – Occurs within the first 12 hrs.

– S/SX: exaggerated s/sx of hyperthyroidism + n/v, severe tachycardia, severe HTN, severe hyperthermia (106F+), extreme restlessness, dysrhythmias, delirium, heart failure  death – – http://www.bing.com/videos/search?q=thyroid+storm&FORM=HDRSC3#view=detail&mi d=8A8572C304A26127A35A8A8572C304A26127A35A (5 min 38 sec)Thyroid Storm part 1 http://www.bing.com/videos/search?q=thyroid+storm&FORM=HDRSC3#view=detail&mi d=CEB5AB156B2998E95407CEB5AB156B2998E95407 (5 min 47 sec) Thyroid Storm part 2

HYPERTHYROIDISM

– Thyroid Storm cont.: • DIAGNOSTIC TESTS – ↑FT4, ↓TSH • MEDICAL MANAGEMENT goals during thyroid storm: – 1. induce a normal thyroid state – 2. prevent cardio-vascular collapse – 3. prevent ↑ hyperthermia

HYPERTHYROIDISM

• NURSING ASSESSMENT AND INTERVENTIONS: – Post-op Subtotal Thyroidectomy (cont.) • Voice rest x48 hrs – provide communication tool • Voice checks – q 2-4 hrs. “ahh”; note hoarseness or other changes • Bed – semifowler’s position; pillow support for head and shoulders

HYPERTHYROIDISM

• NURSING ASSESSMENT AND INTERVENTIONS: – Post-op Subtotal Thyroidectomy (cont.) • Avoid hyperextension of neck; support head during position change • Reinforce DB exercises; check with MD re: coughing • Tracheotomy tray at bedside and suction • • Cool mist humidifier prn Nutrition care – watch for dysphagia

HYPERTHYROIDISM

• NURSING DIAGNOSES: – Pre-op • Risk for hyperthermia, related to increased metabolism • Imbalanced nutrition:less than body requirements r/t increased metabolism – Post-op • Impaired swallowing, r/t edema • Ineffective breathing,risk for, r/t post-op edema and pain

HYPERTHYROIDISM

• • PATIENT EDUCATION – Post op: • follow up with medical supervision • Thyroid function tests • Care incision site • Diet: high calorie, CHO’s , and protein PROGNOSIS: normal life with appropriate medical or surgical tx.

– Expophthalmos may remain to lesser degree

HYPOTHYROIDISM

–

Etiology/pathophysiology

• Due to insufficient secretion of thyroid hormones • Decreased hormones cause slowing metabolic processes of all • • • R/T Failure of thyroid or insufficient secretion of thyroid-stimulating hormone from pituitary gland Hashimoto talks: (Just to be funny-hehe) http://www.bing.com/videos/search?q=youtube+hashimoto&qpvt=youtube+hashimoto &FORM=VDRE#view=detail&mid=BC6F61D1587C03368265BC6F61D1587C03368265

Personal Story (5 minutes) http://www.bing.com/videos/search?q=youtube+hashimoto&qpvt=youtube+hashimot o&FORM=VDRE#view=detail&mid=0A19B271B30370332C210A19B271B30370332C21

HYPOTHYROIDISM

– Myxedema adults refers to severe hypothyroidism in • Will see edema in hand’s face, feet, and periorbital tissues – • Inflammation and thickening of the skin Cretinism – congenital hypothyroidism Floppy infant Thick,protruding tongue Poor feeding Choking episodes Constipation Prolonged jaundice Short stature Depression Loss of hair Rough voices Swollen eyelids Hearing problem Fatigue Weight gain

HYPOTHYROIDISM

• Clinical Manifestations: – Because all metabolism processes slow  • Hypothermia; intolerance to cold • Weight gain • ASHD/CAD  on exertion ↓exercise tolerance + dyspnea

HYPOTHYROIDISM

• SUBJECTIVE ASSESSMENT: • Mental and emotional assessment may include: – – Depression; paranoia Impaired memory; slow thought process – – Hearing/speech impairment Lethargic, forgetful, irritable – – Anorexia Constipation – – Cold intolerance Decreased libido; reproductive difficulties

HYPOTHYROIDISM

• OBJECTIVE ASSESSMENT • Menstrual irregularities • Thin hair, falls out • • Skin thick and dry Enlarged facial appearance • Low, hoarse voice • Bradycardia • Hypotension • Weakness, clumsiness, ataxia

HYPOTHYROIDISM

• Diagnostic tests : TSH, T3, T4, FT4 (low levels of these are the underlying stimuli for TSH) – For hypothyroidism: expect ↑TSH (compensatory); ↓T3, T4, and FT4

HYPOTHYROIDISM

• MEDICAL MANAGEMENT – Medications: replacement therapy ; titration needed – Synthroid – Levothyroid – Proloid – Cytomel • Symptomatic treatment

HYPOTHYROIDISM

• NURSING INTERVENTION/PT. TEACHING: – For the hospitalized pt. with severe hypothyroidism  focus on symptom relief • Watch for s/sx hyperthyroidism while adjusting doses of replacement medication • Watch for chest pain or dyspnea • • Keep room 70-74⁰F Avoid the pt. getting chilled • BM monitor/protocol

HYPOTHYROIDISM

– NURSING INTERVENTIONS/PT. TEACHING cont.

• Diet : ↑protein, fiber, fluid ↓ calories Adequate iodine intake – Instruct pt. to take med daily and not to stop without consulting his MD – Instruct pt./family – to anticipate clearing of mental slowness as pt. adjusts to dose of med

HYPOTHYROIDISM

• NURSING DIAGNOSES: – Decreased cardiac output r/t decreased metabolism – Constipation r/t decreased peristalsis – Risk for noncompliance r/t therapy – Risk for disturbed body image, r/t altered physical appearance (goiter)

HYPOTHYROIDISM

• • PROGNOSIS: Pt. will do well with medication and medical supervision. In children, if the T4 replacement begins before the epiphyseal fusion, chance for normal growth is greatly improved – https://www.youtube.com/watch?v=sVa0L1Rka4Y (Hypo/hyper/goiter symptoms & treatment 4 min 3 sec)

SIMPLE (COLLOID) GOITER

• ETIOLOGY/PATHOPHYSIOLOGY – Enlarged thyroid due to low iodine levels or the gland’s inability to use the iodine properly – Enlargement is caused by the accumulation of colloid in the thyroid follicles • When blood level of T3 is too low to signal the pituitary gland to reduce TSH secretion, the thyroid gland responds by increased formation of thyroid globulin (colloid)  accumulates in the thyroid follicles  gland enlargement – Usually caused by insufficient dietary intake of iodine  overgrowth of thyroid tissue

GOITER

SIMPLE (COLLOID) GOITER

• CLINICAL MANIFESTATIONS/ASSESSMENT – Assessment based on physical manifestations: – SUBJECTIVE ASSESSMENT: • Enlargement of the thyroid gland – Pt. emotional response to the enlargement • Interview to determine pt. need for medication, diet, and medical follow up • May c/o: Dysphagia, Hoarseness. Dyspnea

SIMPLE (COLLOID) GOITER

• • CLINICAL MANIFESTATIONS/assessment – OBJECTIVE DATA: • Assess increase of goiter • Voice changes • Adequate food/fluid intake MEDICAL MANAGEMENT • Potassium iodide • Diet high in iodine • Surgery—thyroidectomy

SIMPLE (COLLOID) GOITER

• • NURSING INTERVENTIONS/GOALS – Post Thyroidectomy: prevent complications such as bleeding, tetany, and thyroid crisis – Interventions: (discussed previously) NSG. DIAGNOSES – Risk for non-compliance with therapeutic regimen – Risk for disturbed body image r/t physical appearance

Figure 51-10

Simple goiter.

Thyroid Cancer

• • ETIOLOGY/PATHOPHYSIOLOGY • Malignancy of thyroid tissue; rare • About 75% are papillary well-differentiated adeno carcinoma- grows slowly, usually contained, doesn’t spread beyond adjacent lymph nodes; cure rates are excellent.

CLINICAL MANIFESTATIONS – Firm, fixed, small, rounded mass or nodule on thyroid

CANCER OF THYROID

Thyroid Cancer

• Assessment – SUBJECTIVE ASSESSMENT • Pt. coping method and support system • Pt. understanding of importance of medical follow up – OBJECTIVE ASSESSMENT • Progressive enlargement of tumor area • Response to 131I tx.

• Skin care post radiation

Thyroid Cancer

• • DIAGNOSTIC TESTS: • Thyroid scan • Thyroid function tests • Needle bx.

MEDICAL MANAGEMENT • Total thyroidectomy • Thyroid hormone replacement • If metastasis is present: radical neck dissection; radiation, chemotherapy, and radioactive iodine

CANCER OF THE THYROID

CANCER OF THE THYROID

Thyroid Cancer

• NURSING INTERVENTIONS/Pt. TEACHING – Per thyroidectomy (previously discusses) – Post op: • Risk for respiratory distress • • Risk for laryngeal damage Bleeding • S/sx hypothyroidism

Thyroid Cancer

• • NURSING DX.

– Anxiety r/t situational crisis – Ineffective coping r/t personal vulnerability in a crisis Pt. Teaching: – Proper medical follow up – Monitor thyroid replacement therapy – Proper care of surgical incision

PARATHYROID GLANDS

Website written information resource for students: http://www.parathyroid.com/hypoparathyroidism.htm

HYPERPARATHYROIDISM

http://www.youtube.com/watch?v=sD9st1ZPFrQ • ETIOLOGY/PATHOPHYSIOLOGY – Overactivity of the parathyroid glands, with increased production of parathyroid hormone (PTH) – Hypertrophy of one or more of the parathyroid glands (usually in the form of an adenoma) – Also from: CRF, Pyelonephritis, glomerulonephritis

HYPERPARATHYROIDISM

• CLINICAL MANIFESTATIONS – Hypercalcemia – primary clinical manifestation • Calcium leaves the bone  increases serum calcium • Bones become demineralized renal calculi, pathological fx.

 formation of • Skeletal pain; pain on weight-bearing

HYPERPARATHYROIDISM

• SUBJECTIVE ASSESSMENT – As a result of neuromuscular dysfunction, pts. c/o: • Fatigue, drowsiness • nausea, anorexia; • severe skeletal pain, muscle weakness • constipation • personality changes, disorientation

HYPERPARATHYROIDISM

• OBJECTIVE ASSESSMENT – Skilled observation for: • Skeletal deformity • Abnormal movement • Urine results • Vomiting, weight loss • HTN • Cardiac dysfunction • Bradycardia • ↓ LOC

HYPERPARATHYROIDISM

• DIAGNOSTIC TESTS – RADIOGRAPHS/XRAYS – PTH blood level (usually ↑) – Ca++ levels – Bone Density measurements – MRI, CT, and US to localize an adenoma

Hyperparathyroidism

HYPERPARATHYROIDISM

• MEDICAL MANAGEMENT • Removal of tumor • Removal of one or more parathyroid glands • Autotransplantation • NURSING INTERVENTIONS/Pt. TEACHING – Assess for hypercalcemia – Restore fluid and electrolyte imbalance – Diet: low in calcium

HYPERPARATHYROIDISM

• • NURSING INTERVENTIONS/Pt. TEACHING cont.

– Postoperatively, assess for hypocalcemia • Tetany, cardiac dysrhythmia, carpo-pedal spasms – Pain management – skeletal, renal stones NURSING DIAGNOSES – Activity intolerance r/t neuromuscular dysfunction – Acute pain r/t skeletal – joint pain, renal colic

HYPERPARATHYROIDISM

• PATIENT TEACHING – Body mechanics to prevent pathological fx – Mild exercise – Urine checks for blood and stones • PROGNOSIS: can lead a normal life with proper med-surg tx. With cancer dx. – prognosis is poor

•

HYPOPARATHYROIDISM

http://www.youtube.com/watch?v=E9QvAdxeap0 (2 min 42 sec) Etiology/pathophysiology – Decreased parathyroid hormone  serum calcium levels Decreased – Most common causes: • Inadvertent removal or destruction of one or more parathyroid glands during thyroidectomy • Also, can be autoimmune or familial in origin

HYPOPARATHYROIDISM

• CLINICAL MANIFESTATIONS – Lab results show: • ↓serum Ca++ and ↑ serum phosphorus  Neuromuscular hyperexcitability • Involuntary and uncontrollable muscle spasms • Hypocalcemic tetany

HYPOPARATHYROIDISM

• CLINICAL MANIFESTATIONS cont.

– Severe hypocalcemia: • Laryngeal spasms • Stridor • Cyanosis/asphyxia • Parkinson-like syndrome • Chvostek’s and Trousseau’s signs

TROUSSEAU’S SIGN

HYPOPARATHYROIDISM

• ASSESSMENT – SUBJECTIVE DATA – evidence of and/or c/o: • Dysphagia • Numbness/tingling lips, fingertips • Increased muscle tension • Parasthesis and stiffness • c/o anxiety, irritability, depression • • Headaches nausea

HYPOPARATHYROIDISM

• ASSESSMENT – OBJECTIVE DATA • + Chvostek’s and Trousseau signs • Laryngeal spasm, stridor, cyanosis • Decreased cardiac output, dysrhythmias • Tetany

HYPOPARATHYROIDISM

• DIAGNOSTIC TESTS – Serum PTH, Phosphorus, Calcium – Urinary calcium and phosphorus –  if + for hypo parathyroidism, results will be: • ↓ PTH, and serum Ca++ and ↑ urinary Ca++, with • ↑ serum phosphorus and ↓ urinary phosphorus

HYPOPARATHYROIDISM

• MEDICAL MANAGEMENT – Blood tests r/t ca levels • Calcium gluconate or calcium chloride will be given IV for hypoparathyroid tetany – NURSING: if IV rate is too rapid  ↓ BP, serious cardiac dysrhythmias/ cardiac arrest – IV may be irritating to vessel wall; watch for s/sx extravasation – EKG monitoring • Vitamin D orally – improves GI absorption of Ca++

HYPOPARATHYROIDISM

• NURSING INTERVENTIONS – Monitor for hypercalcemia: • Vomiting, disorientation, anorexia, abdominal pain, weakness – Assess for: • Respiratory function • VS – bradycardia, syncope, hypotension • Renal involvement

HYPOPARATHYROIDISM

• NURSING INTERVENTIONS cont.

– Preferred medications: • Hytakerol • Calcitriol (Rocaltrol) – Diet: ↑ dairy, dark green leafy veg., soybeans, tofu, canned fish with bones

HYPOPARATHYROIDISM

• NURSING DIAGNOSES: – Risk for injury r/t postop hypocalcemia – Imbalanced nutrition, less than body requirements, r/t calcium intake • Nearly all interventions r/t ca levels