Care of Clients with Problems In Oxygenation, Fluids and Electrolytes, Metabolism and Endocrine (NCM103) Patients With Endocrine

Alterations III

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Disorders of the Thyroid Gland

Thyroid Function Tests A. Serum T3 and T4 B. Free Thyroxine C. Thyroid-Binding Globulin D. T3 Resin Uptake E. Thyroid Stimulating Hormone F. Thyroid Antibody G. Radio Iodine Uptake H. Thyroid Scan, Radioscan I. Fine-Needled Aspiration Biopsy

Topics Discussed Here Are: 1. Goiter 2. Hypothyroidism Myxedema Coma 3. Hyperthyroidism Thyroid Storm 4. Thyroidectomy

Thyroid Scan, Radio Scan

Uses a radioactive tracer and a special camera to measure how much traces the thyroid gland absorbs from the blood

Fine-Needled Aspiration Biopsy (FNAB)

A procedure by which tissue from within a thyroid nodule is removed to detect malignancy o It is often the initial test for evaluation of thyroid masses o Results are reported as: 1. (-) Benign 2. (+) Malignant 3. Intermediate (Suspicious) and; 4. Inadequate (Non diagnostic) Nursing Interventions: o Preventing Infection Make sure that biopsy area is prepped appropriately before procedure Make sure that instruments are maintained in sterile condition before use o Reducing client anxiety o Patient education and health maintenance Teach client that some soreness at the biopsy site should be expected for a frequent time Make sure that client follow-up results and definite

Goiter
A. Definition: Enlargement of the Thyroid gland seen both in HYPO and HYPER thyroidism Two major forms of simple goiter 1. Endemic Goiter 2. Sporadic Goiter Endemic Goiter - Caused principally by nutritional codeine deficiency - Twice as prevalent in women as it is in men - Commonly occurs in Adolescents, pregnant women and nursing mothers - People at risk are those who live in the Midwest, Northwest and Great Lake Region

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Sporadic Goiter - Is not restricted to any geographical area - Major causes involve: o Genetic defects resulting in faulty iodine metabolism o Ingestion of GOITROGENS (Goiter-producing agents that inhibit Thyroxine or T4), such as Cabbage, Soybeans, Spinach o Ingestion of medicinal goitrogens such as glucocorticoids, dopamine, and lithium B. Etiologic Factors C. Pathophysiology (LOOK AT HANDOUTS)
Lack of Sufficient Dietary Iodine / Suppressed Thyroid Hormone Production

Thyroid Gland compensates for hormonal insufficiency

Thyroid Gland ENLARGEMENT

Clinical Manifestations

D. Clinical Manifestations: Enlarged Thyroid gland upon palpation E. Diagnostic Test: Head and neck Physical Assessment Iodine Levels - Thyroid Stimulating Hormones - F. Medical/Surgical Management Depends whether HYPO or HYPER classification

Hypothyroidism
A. Definition: A condition that arises from inadequate amounts of thyroid hormones in the blood stream B. Etiologic Factors and Risk Factors Primary Hypothyroidism Is the most common form of this condition and is generally caused by: Auto-immune (Hashimotos Thyroid) Use of radioactive iodine Destruction, suppression or removal of all or some of the thyroid by thyroidectomy Dietary iodide deficiency Subacute thyroiditis Lithium Therapy Over treatment with Anti-thyroid drugs Secondary Hypothyroidism Disease of the Pituitary Gland (i.e. Tumor, necrosis) Caused by inadequate secretion of TSH Tertiary Hypothyroidism Disease of the hypothalamus (Inability to produce TSH) Metabolic activity of all CELLS

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C. Pathophysiology

Myxedema Coma
The most EXTREME, severe stage of Hypothyroidism with mortality rate Triggering Factors: o Undiagnosed Hypothyroidism o Exposure to stress Surgery and infection o Non compliance with thyroid treatment Clinical Manifestations: o Hypotension o Bradycardia o Hypoventilation o Hyponatremia o Convulsions (Possible) o Hypothermia o Unresponsive o Cerebral Hypoxia Medical Management o The PRIMARY GOAL of management is restoration of normal metabolic status (Euthyroid) by replacing the missing hormones Pharmacologic Treatment o T4 Levothyroxine (Synthronal, ) o T3 Liothyronine (Cytomel) o T3 and T4 Thyroglobulin (Proloid) Monitor Treatment Effects o Diuresis, decreased puffiness o Improved reflexes and muscle tone o Accelerated pulse rate o A slightly higher level of total serum T4 o All signs of hypothyroidism should disappear in 3 12 weeks o Decreasing TSH levels Nursing Management: 1. Perform multi-system assessment, monitor VS, especially heart rate 2. Administer hormone replacement on empty stomach 3. Instruct client to eat LOW CALORIE, LOW CHOLESTEROL and LOW FAT DIET to control weight 4. Manage constipation, Oral fluid intake and fiber intake 5. Provide a warm environment 6. Energy compensation technique and the need to activity gradually 7. Avoid sedatives and narcotics because of increased sensitivity to these medications 8. Instruct client to report chest pain promptly 9. The necessity of having blood evaluated periodically to determine thyroid levels

Hyperthyroidism
A. Definition: o Hypermetabolism condition characterized by excessive amounts of thyroid hormone on the blood stream o Graves Disease The most common type of Hyperthyroidism B. Etiologic Factors o More common in women than in men. Occurs in about 2% of the female population o Due to auto-immune etiology (Graves Disease) o Due to toxic nodular goiter, pre-existing goiter C. Pathophysiology ******************* Medical Management

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Pharmacotherapy 1. Drugs that INHIBIT hormone formation: a. Thionamide Propylthiouracil (PTU) b. Methimazole (Tapazole) MOA: Acts by depressing the synthesis of thyroid hormone by inhibiting perooxidase AE: Agranulocytosis Given on divided daily doses (q 8hrs) 2. Iodine Therapy Reduce vascularity of thyroid gland prior surgery Treat thyroid storm A. Iodine Preparation, Potassium Iodide, Lugols Solution > MOA: Prevent temporarily thyroid hormone release and thyroid hormone storage in the gland > Given 10 14 days only BEFORE the surgery B. Radioactive Iodine (131I) MOA: Limits secretion of thyroid hormone by destroying thyroid tissue Dosage is controlled so that hypothyroidism does not occur Chief Advantage: Lasting remission is achieved than Thionamides Chief Disadvantage: Permanent hypothyroidism can occur 3. Drugs to control peripheral manifestations of Hyperthyroidism Propanolol (Inderal) MOA: Abolishes tachycardia, tremor, excess neuromuscular Glucocorticoids MOA: Decreases the peripheral conversion of T3 and T4, a more potent thyroid hormone SURGERY (THYROIDECTOMY) *WALA XD G. Nursing Management Nursing Intervention: Provide Adequate Nutrition 1. Determine the clients food and fluid preferences 2. Provide HIGH CALORIE FOODS and FLUIDS consistent with clients requirements 3. Provide calm, quiet environment 4. Restrict stimulants (Coffee, tea, chocolates) 5. Weigh client daily, keep accurate I&O Maintain Skin Integrity 1. Assess skin frequently for diaphoresis 2. Bathe frequently with cool water; change linens when damp 3. Avoid soap to prevent drying and use lubricant and skin lotions 4. Protect and relieve pressure from bony prominences while

Patient Education and Health Maintenance

Instruct the patient as follows: 1. When to take medications 2. Signs and Symptoms of insufficient and excessive medications 3. Necessity of having blood evaluation periodically to determine thyroid levels 4. Signs and Symptoms of thyroid storm and predisposing factors to thyroid storm

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Thyroid Storm
A. Definition: Thyrotoxic Crisis, Thyrotoxicosis o Severe life-threatening form of hyperthyroidism o A medical emergency o Precipitated by stress Manifestations: o Altered Neurologic state o Hyperthermia 38.5C o Extreme tachycardia: Systolic Hypertension o Exaggerated symptoms of hyperthyroidism (Dyspnea, Chest pain) Encourage Management Goal: Reduction of body temperature and heart rate and prevention of vascular collapse o A hypothermia mattress or blanket, ice pack, a cool environment, hydrocortisone and acetaminophen (Tylenol) o Humidified O2 is administered to improve tissue oxygenation and meet the increased metabolic demands o IV o Inhibition of new hormone synthesis with Thionamide (PTU) o Inhibition of thyroid.

Thyroidectomy
A. Definition: Removal of thyroid gland Types of Operation: o Total Thyroidectomy (Removal of the ENTIRE thyroid gland) o Subtotal Thyroidectomy (95% of gland removed) to prevent damage to the parathyroid gland o Partial Thyroidectomy (One lobe or isthmus removed to treat nodular disease) The parathyroid glands are usually spared to prevent hypocalcemia PREOPERATIVE CARE The client must be Euthyroid at time of surgery Maintain restful and therapeutic environment and by providing a nutrition diet The client is prepared for surgery physically and emotionally in the following way: o Ensure that client has a good nights sleep preceding surgery o Explain that speaking is to be minimized immediately
POSTOPERATIVE CARE Observe for hemorrhage and arising edema 1. Position Client: Semi-fowlers, neck on neutral position 2. Monitor for respiratory distress Approach at bedside Tracheostomy set O2 tank and Suction machine 3. Check for edema and bleeding by noting the dressing anteriorly and at the back of the neck 4. Limit client talking 5. Assess for HOARSNESS Expected to be present initially, limit excess vocalization If persistent, may indicate damage to laryngeal nerve Monitor for laryngeal nerve damage. Respiratory (distress, dysphonia, voice changes, dysphagia and restlessness) OBSERVE FOR HYPOCALCEMIA 1. Monitor for signs of hypocalcemia and tetany due to trauma of the parathyroid 2. Prepare 3. Monitor for thyroid Storm

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