Care of client with endocrine and metabolic disorder

The thyroid hormone/organ

Butterfly shaped organ located in the lower neck anterior to the trachea - Consists of two lateral lobes
connected by an isthmus - 5 cm long, 3 cm wide and weigh 30 g - Blood flow is 5 mL/min per gram of
thyroid tissue approximately 5 times the blood flow to the liver

Three hormones produced

1. T4 or Thyroxine
Produced by thyroid
2. T3 or Triiodothyronine follicular cells

3. Calcitonin Produced by thyroid C cells

Thyroid hormones

T3 & T4 - two separate hormones and are amino acids that contain iodine molecules bound in each
molecule - synthesized and stored bound to protein in the cell of the thyroid gland until needed for
release in the bloodstream. - 75% of bound thyroid hormone is bound to thyroxine binding (protein)
globulin (TBG) and the remaining is bound to thyroidbinding prealbumin and albumin

Synthesis of thyroid hormone

IODINE

– Essential to the thyroid gland for synthesis of Iodide absorbed in the blood
its hormones
Iodide concentrates in the cells
- The major use is for thyroid
Conversion of iodide ions to iodine molecules
- Deficiency may lead to alteration in thyroid
function React to tyrosine (amino acid)

Form thyroid hormone

Regulation of thyroid hormones

A. TSH (THYROID STIMULATING HORMONE)

- or known as thyrotropin

- controls the rate of thyroid hormone through negative feedback mechanisms

Euthyroid- thyroid hormone production in normal limits

B. THYROTROPIN-RELEASING HORMONE

- secreted by hypothalamus

- exerts a modulating influence on the release of TSH from pituitary

- affected by environmental factors such as decrease in temperature which leads to increase in TRH and
therefore increase of thyroid hormones

Functions of the thyroid hormone

1. Control of cellular and metabolic activity

2. Increase level of enzymes that contribute to oxygen consumption

3. Influence cell replication

4. Brain development

5. Essential for normal growth

Hypothyroidism

-results from suboptimal level of thyroid hormone

- More often in women ages 30-60

- Most common cause is autoimmune thyroiditis known as HASHIMOTO’S DISEASE in which immune
system attacks thyroid gland.

Terms associated with hypothyroidism

PRIMARY OR THYROIDAL HYPOTHYROIDISM - Dysfunction of thyroid gland itself

CENTRAL HYPOTHYROIDISM - If the cause of thyroid dysfunction is the failure of the pituitary gland or
hypothalamus or both

SECONDADY OR PITUITARY HYPOTHYROIDISM - If the cause is pituitary disorder

TERTIARY OR HYPOTHALAMIC HYPOTHYROIDISM - If the cause is due to disorder of hypothalamaus

which causes decrease in TRH and TSH thereby decreasing secretion of T3 and T4.

IATROGENIC - Surgical removal of gland or overtreatment of the disease

MYXEDEMA - Accumulation of mucopolysaccharides in subcutaneous and interstitial

Pathophysiology

Deficient thyroid hormone

Decreased metabolic activity

Affects fetal growth Affects physical and mental growth

Stunted physical and mental growth Lethargy, slow mentaion and slowing body
function
Cretinism
Hypothyroidism

Clinical manifestations

1. Hair loss Late signs severe

2. Brittle nails
3. Dry skin 1. subnormal temperature
2. Decreased pulse rate
4. Numbness and tingling skin and fingers
5. Husky voice 3. Anorexia
4. Weight gain
6. Hoarseness
7. Menorrhagia 5. Constipation
6. Fatigue
8. Amenorrhea
9. Loss of libido 7. Slowed mental process
8. Dullness
9. Increased sensitivity to sedatives,
narcotics and anesthetic.

Myxedema

- Syncope - Lethargy
 - Bradycardia - Hypoventilation
- Hypotension - Subnormal temperature

Medical management

I. PHARMACOLOGIC THERAPY
1. Synthetic levothyroxine ( synthroid or levothroid )
 Nursing considerations
A. Prevention of cardiac dysfunction due to:
a) Increased serum cholesterol
b) Atherosclerosis
c) Coronary artery disease
B. Prevention of Medications Interactions
a) thyroid hormones increase blood glucose which may need to adjust with insulin dosage
b) effect of Phenytoin ( Dilantin and TCA )
II. SUPPORTIVE THERPY
1. Maintain vital functions
2. ABG
3. Pulse oximeter
4. Fluid cautiously administered
5. No pad or heating pad allowed because it increases oxygen requirement and may lead to
vascular collapse.

Nursing management

1. Monitor vital signs

2. Monitor input and output
3. Weigh patient daily
4. Observe for edema
5. Watch out for sign of cardiovascular complication
6. Observe sign of thyrotoxicosis ( tachycardia, palpitation, nausea, vomiting, diarrhea, sweating,
tremors, agitation and dyspnea)
7. Provide comfortable position and warm environment (provide blanket: rationale- patient has
cold intolerance)
8. Low calorie diet
9. Avoid sedatives
10. Institute measure to prevent skin breakdown
11. Increase fiber intake
12. Stool softener
13. Teaching patient about medication
-take meds in the morning to avoid insomnia
-self monitor for signs of thyrotoxins

Hyperthyroidism

- Second most prevalent disorder in endocrine after diabetes

- Known as grave disease
- Results from excessive output of thyroid hormones
- More often in women ages 30-50 yrs old
- Exact cause is unknown but maybe an autoimmune process

Pathophysiology
 Iodine deficiency

Low levels of circulating thyroid hormones (feedback)

Stimulates release of TSH

Overproduction of thyroglobulin (precursor of T3 and T4)

Hyperthrophy of thyroid gland

Hyperthyroidism

Clinical manifestation

THYROTOXICOSIS

 Nervousness
 Irritability
 Apprehension
 Cant sit quietly
 Palpitations
 Rapid pulse at rest and exertion
 Heat intolerance
 Flushed skin
 Fine tremor
 Increased appetite
 Sweating
 Insomnia
 Diarrhea
 Weight loss
 Expothalamos
 Warm, smooth skin
 Fine, soft hair
 Pliable nails
 Tachycardia
 Increased BP

Diagnostic tests

- Elevated T3 and T4
- RAIU elevated

Medical management

a. Radioisotopes 131
- Used to destroy overactive thyroid cells
b. Ant thyroid mediations

Drugs Action Nursing function

1. PROPHYTHIOURACIL (PTU)
2. Methimazole
Blocks synthesis of hormones
Blocks synthesis of thyroid
hormones
1. Watch out for rash, nausea
and vomiting
2. Monitor cardiac parameters
3. Give by mouth
1. Watch out for rash, nausea
and vomiting
2. Monitor cardiac parameters
3. Give by mouth
 3. Sodium Iodide
4. Potassium Iodide
5. Saturated Solution of
Potassium Iodide (SSKI)
6. Dexamethasone
7. Beta-blockers (Propranolol)
Suppress release of thyroid
hormones
Suppress release of thyroid
hormones
Suppress release of thyroid
hormones
Suppress release of thyroid
hormones
Beta-adrenergic blocking agent
1.Give 1 hour after PTU or
methimazole
2. Watch out for edema,
hemorrhage and GI upset
Discontinue with rashes
1.Mix with juice or milk
2. Give with straw to prevent
staining of teeth
1.Monitor input and output
2. Monitor glucose
3. May cause HPN, anorexia,
nausea, vomiting, infection
1. Monitor cardiac status
2. Hold for bradycardia or
decreased cardiac output
3. Use with caution in heart
failure

Surgical management

Thyroidectomy

- Partial or total removal of the thyroid gland

Subtotal – hyperthyroidism
Total – thyroid cancer

Pre OP

1. Ensure that client is adequately prepared

2. Give PTU
3. Give propranolol to reduce heart rate
4. Give Lugol’s Solution to reduce vascularity
5. No ASPIRINS weeks before the surgery

Post OP

1. Monitor vital signs

2. Monitor input and output
3. Check dressing for hemorrhage
4. Semi-fowler’s position with head pillows
5. Observe respiratory distress from hemorrhage, edema of glottis, laryngeal nerve damage or
tetany.
6. Keep tracheostomy, oxygen and suction set available
7. Assess tetanty- due to hypocalcemia from accidental removal of the parathyroid gland
8. Encourage to rest voice
9. Observe for thyroid storm
10. Administer IV fluids
11. Analgesics
12. Relieve discomfort from sore throat