Nursing Study Group

THYROID
GLAND
DISORDERS
Peter D. Rabe
QUICK ANAPHY
OF THYROID
GLAND
Thyroid Overview
1. Hypothalamus -> TRH (Thyroid-releasing
hormone)
2. TRH stimulates Anterior Pituitary to secrete TSH
(Thyroid-stimulating hormone)
3. TSH travels through blood and stimulate Thyroid
Gland
4. Thyroid gland produce and secrete Thyroid
Hormone namely T3 and T4
5. Negative feedback mechanism
Thyroid Hormone Functions:
BONES
• Bone growth & bone development

MUSCLES
• Normal muscle function & development

METABOLISM
• Increase BMR and O2 usage.
• Lypolysis, glycolysis, gluconeogenesis
• Increase LDL uptake
Thyroid Hormone Functions (Cont.):
HEART SKIN
• Promotes normal cardiac output • Promotes normal hydration

NERVOUS SYSTEM
• Increase synapses
• Increase myelination
• Increase dendrites

GASTROINTESTINAL TRACT
• Promotes motility & secretions
Thyroid Hormone Synthesis
1. TRH Release from hypothalamus
2. Anterior Pituitary to release TSH
3. TSH Stimulates follicular cells to synthesize Thyroglobulins (TGB)
4. Iodide trapping
5. Oxidation of Idioded (TPO)
6. Iodination of Tyrosine Amino Acid
7. Couple DIT’s & MIT’s
8. Endocytosis of TGB with T3 + T4
9. Lysosomal enzymes cleave T3 + T4 out of TGB
10. Exotycosis of T3 + T4 into blood plasma
Target Organs of Thyroid
CELL
• Decrease Cellular ATP
• Increase O2 usage
• Increase metabolic rate
• Increase heat production
• Increase number of
mitochondria & size
(hypertrophy)
Target Organs of Thyroid
LIVER
• Increase blood glucose
• Glyconegolysis
• Gluconeogenesis
• Increase LDL uptake
Target Organs of Thyroid
HEART

• Stimulate B1-AR
• Increase cardiac
output/blood pressure
• Increase heart rate
Target Organs of Thyroid
CENTRAL NERVOUS SYSTEM
• Increase dendrites
• Increase myelination
• Increase synapses
Target Organs of Thyroid
BONE
• Maintain balance between
osteoblasts and osteoclasts
• Stimulate interstitial growth
• Stimulating and regulating
endochondral ossification
• Bone remodeling
Target Organs of Thyroid
ADIPOSE
• Lipolysis
Target Organs of Thyroid
MUSCLES
• Stimulate anabolism and
catabolism
Target Organs of Thyroid

INTEGUMENTARY
• Promote blood flow in the
skin
Target Organs of Thyroid

G.I TRACT
• Stimulate glandular
secretions
• Increase motility
• Increase secretions
ASSESSMENT &
DIAGNOSTIC FINDINGS
Thyroid Exam
1. INSPECTION
1. Anterior Approach
2. Lateral Approach

2. PALPATION
1. Anterior Approach
2. Posterior Approach

3. AUSCULTATION
Thyroid Exam
1. INSPECTION - Anterior Approach
1. The patient should be seated or standing in a comfortable position with the neck in a
neutral or slightly extended position.
2. Cross-lighting increases shadows, improving the detection of masses.
3. To enhance visualization of the thyroid, you can:
1. Extending the neck, which stretches overlying tissues
2. Have the patient swallow a sip of water, watching for the upward movement of
the thyroid gland.
Thyroid Exam
2. INSPECTION - Lateral Approach
1. After completing anterior inspection of the thyroid, observe the neck from the side.
2. Estimate the smooth, straight contour from the cricoid cartilage to the suprasternal
notch.
3. Measure any prominence beyond this imagined contour, using a ruler placed in the
area of prominence.
Thyroid Exam
3. PALPATION - Anterior Approach
1. The patient is examined in the seated or standing position.
2. Attempt to locate the thyroid isthmus by palpating between the cricoid cartilage and
the suprasternal notch.
3. Use one hand to slightly retract the sternocleidomastoid muscle while using the other
to palpate the thyroid.
4. Have the patient swallow a sip of water as you palpate, feeling for the upward
movement of the thyroid gland.
Thyroid Exam
4. PALPATION – Posterior Approach
1. The patient is examined in the seated or standing position.
2. Standing behind the patient, attempt to locate the thyroid isthmus by palpating
between the cricoid cartilage and the suprasternal notch.
3. Move your hands laterally to try to feel under the sternocleidomstoids for the
fullness of the thyroid.
4. Have the patient swallow a sip of water as you palpate, feeling for the upward
movement of the thyroid gland.
Thyroid Exam
AUSCULTATION
• Auscultation identifies the localized audible vibration of a bruit.
• This abnormal finding indicates increased blood flow through the thyroid gland and
necessitates referral to a physician.
Thyroid Function Test
• Laboratory measurement of thyroid hormones, thyroid scanning, biopsy, and
ultrasonography.
• The most widely used tests are serum immunoassay for TSH and free thyroxine
(FT4)
Thyroid-Stimulating Hormone
• The ability to detect minute changes in serum TSH makes it possible to distinguish
subclinical thyroid disease from euthyroid states in patients with low or high normal
values
• Values above the normal range of 0.4 to 6.15 μU/mL indicate primary
hypothyroidism, and low values indicate hyperthyroidism
• When the TSH is normal, there is a 98% chance that the FT4 is also normal.
• Current recommendations suggest TSH screening for all adults beginning at age 35,
and every 5 years thereafter
Serum Free Thyroxine
• The test most commonly used to confirm an abnormal TSH is FT4.
• The range of FT4 in serum is normally 0.9 to 1.7 ng/dL (11.5 to 21.8 pmol/L)
• An estimate (or index) of FT4 can also be calculated by multiplying total T4 by T3
resin uptake.
Serum T3 and T4
• The normal range for serum T3 is 70 to 220 ng/dL (1.15 to 3.10 nmol/L).
• Normal range for T4 is 4.5 to 11.5 μg/dL (58.5 to 150 nmol/L).
• T3 level appears to be a more accurate indicator of hyperthyroidism
T3 Resin Uptake Test
• The T3 resin uptake test is an indirect measure of unsaturated TBG.
• Its purpose is to determine the amount of thyroid hormone bound to TBG and the
number of available binding sites
• The normal T3 uptake value is 25% to 35% (relative uptake fraction, 0.25 to
0.35), which indicates that about one third of the available sites of TBG are occupied
by thyroid hormone.
Thyroid Antibodies
• Autoimmune thyroid diseases include both hypothyroid and hyperthyroid conditions
• Results of testing by immunoassay techniques for antithyroid antibodies, specifically
antimicrosomal antibodies, are positive in chronic autoimmune thyroid disease
(90%), Hashimoto’s thyroiditis (100%), Graves’ disease (80%)
Radioactive Iodine Uptake
• measures the rate of iodine uptake by the thyroid gland.
• The patient is administered a tracer dose of iodine-123 (123I) or another
radionuclide, and a count is made over the thyroid gland with use of a scintillation
counter, which detects and counts the gamma rays released from the breakdown of
123I in the thyroid.
• Patients with hyperthyroidism exhibit a high uptake of the 123I (in some patients, up
to 90%), whereas patients with hypothyroidism exhibit a very low uptake.
Fine-needle Aspiration Biopsy
• Using a small-gauge needle to sample the thyroid tissue for biopsy is a safe and
accurate method of detecting malignancy
• Results are reported as (1) negative (benign), (2) positive (malignant), (3)
indeterminate (suspicious), and (4) inadequate (nondiagnostic).
Thyroid scan, Radioscan, or
Scintiscan
• In a thyroid scan, a scintillation detector or gamma camera moves back and forth
across the area to be studied in a series of parallel tracks, and a visual image is made
of the distribution of radioactivity in the area being scanned.
Other Diagnostic Tests
• Ultrasound, CT scans, and MRI may be used to clarify or confirm the results of other
diagnostic studies.
NURSING IMPLICATIONS
1. When thyroid tests are scheduled, it is necessary to determine whether the patient
has taken medications or agents that contain iodine because these may alter the test
results.
THYROID GLAND
DISORDERS
 HYPOTHYROIDISM
• Hypothyroidism results from suboptimal levels of thyroid hormone.
• Thyroid deficiency can affect all body functions and can range from mild,
subclinical forms to myxedema, an advanced form.
• The most common cause of hypothyroidism in adults is autoimmune thyroiditis
(Hashimoto’s disease)
PATHOPHYSIOLOGY
Clinical Manifestations
• Reports of hair loss, brittle nails, and dry skin are common, and numbness and
tingling of the fingers may occur.
• voice may become husky, and the patient may complain of hoarseness.
• Menstrual disturbances such as menorrhagia or amenorrhea occur, in addition to loss
of libido.
• Severe hypothyroidism results in a subnormal temperature and pulse rate.
• gain weight even without an increase in food intake, although severely hypothyroid
patients may be cachectic
• skin becomes thickened because of an accumulation of mucopolysaccharides in the
subcutaneous tissues (the origin of the term myxedema).
Clinical Manifestations (Cont.)
• The hair thins and falls out; the face becomes expressionless and masklike.
• The patient often complains of being cold even in a warm environment.
• The mental processes become dulled, and the patient appears apathetic.
• Speech is slow, the tongue enlarges, and hands and feet increase in size.
• The patient frequently complains of constipation.
• Deafness may also occur.
• Advanced hypothyroidism may produce personality and cognitive changes
characteristic of dementia.
• Inadequate ventilation and sleep apnea can occur with severe hypothyroidism.
Clinical Manifestations (Cont.)
• Pleural effusion, pericardial effusion, and respiratory muscle weakness may also
occur.
• Severe hypothyroidism is associated with an elevated serum cholesterol level,
atherosclerosis, coronary artery disease, and poor left ventricular function.
• The patient with advanced hypothyroidism is hypothermic and abnormally sensitive
to sedatives, opioids, and anesthetic agents.
• Myxedema coma describes the most extreme, severe stage of hypothyroidism, in
which the patient is hypothermic and unconscious.
• The patient’s respiratory drive is depressed, resulting in alveolar hypoventilation,
progressive CO2 retention, narcosis, and coma.
MEDICAL MANAGEMENT
PHARMACOLOGIC THERAPY

1. Synthetic levothyroxine (Synthroid or Levothroid) is the preferred preparation for

treating hypothyroidism and suppressing nontoxic goiters.
PHARMACOLOGIC THERAPY
1. Prevention of Cardiac Function

• When thyroid hormone is administered, however, the oxygen demand increases, but
oxygen delivery cannot be increased unless, or until, the atherosclerosis improves.
• Angina or dysrhythmias may occur when thyroid replacement is initiated because
thyroid hormones enhance the cardiovascular effects of catecholamines.
• If angina or dysrhythmias occur, thyroid hormone administration must be
discontinued immediately.
PHARMACOLOGIC THERAPY (Cont.)
2. Prevention of Medication Interactions

• Thyroid hormones may increase blood glucose levels, which may necessitate
adjustment in the dosage of insulin or oral antidiabetic agents in patients with
diabetes.
• The effects of thyroid hormone may be increased by phenytoin (Dilantin) and
tricyclic antidepressant agents.
• Thyroid hormones may also increase the pharmacologic effects of digital glycosides,
anticoagulant agents, and indomethacin
• Bone loss and osteoporosis may also occur with thyroid therapy.
PHARMACOLOGIC THERAPY (Cont.)
2. Prevention of Medication Interactions

• Even in small doses, hypnotic and sedative agents may induce profound
somnolence, likely to cause respiratory depression.
• If their use is necessary, the dose is one-half or one-third that ordinarily prescribed in
patients of similar age and weight with normal thyroid function
SUPPORTIVE THERAPY
• Arterial blood gases may be measured to determine CO2 retention and to guide the
use of assisted ventilation to combat hypoventilation.
• Fluids are administered cautiously because of the danger of water intoxication.
• Application of external heat (eg, heating pads) is avoided.
• If hypoglycemia is evident, concentrated glucose may be prescribed
• Thyroid hormone (usually Synthroid) is administered intravenously until
consciousness is restored if myxedema has progressed to myxedema coma.
NURSING MANAGEMENT:
1. Modify activity - a major role of the nurse is assisting with care and hygiene while
encouraging the patient to participate in activities within established tolerance levels
to prevent the complications of immobility.

2. Monitor Physical Status – V/S & cognitive level

3. Provide Emotional Support - The patient and family may require assistance and
counseling to deal with the emotional concerns and reactions that result.
NURSING MANAGEMENT: (Cont.)
4. Promote home and Community-based care:

a.) Teaching patients self-care:

• Information and instruction that will enable them to monitor the pt’s
condition
• Instruct about medications (how and when to take prescribed medications)
• Importance of continuing medication as prescribed even after symptoms
improved
• Dietary instructions
NURSING MANAGEMENT: (Cont.)
4. Promote home and Community-based care:

b.) Continuing Care:

• needs considerable follow-up and health care.
• returns to an environment that will promote adherence to the prescribed
treatment plan
• Home care
 NURSING CARE PLAN
NURSING DX:
• Activity intolerance related to fatigue and depressed cognitive process
• Risk for imbalanced body temperature
• Constipation related to depressed gastrointestinal function
• Deficient knowledge about the therapeutic regimen for lifelong thyroid replacement therapy
• Ineffective breathing pattern related to depressed ventilation
• Disturbed thought processes related to depressed metabolism and altered cardiovascular and
respiratory status

COLLABORATIVE PROBLEM:
• Myxedema and myxedema coma
 In which patient population is hypothyroidism
most common?

African American
A adults B Middle-age adults

C Older adults D Pregnant women

>
tekhnologic
 Which of the following is characteristics of
patients with primary hypothyroidism

Increase serum thyroid- Decreased serum

A stimuling hormone (TSH) B cholesterol
Increase serum Increase serum
C free thyroxin (T4) D triiodothyronine (T3)

>
tekhnologic
 There are two types of hypothyroidism, primary and secondary. Symptoms of
primary hypothyroidism can be subtle and insidious. Secondary hypothyroidism is
less common. Which of the following characteristics noted on history and physical
examination best differentiates secondary hypothyroidism from primary
hypothyroidism?

A Dry hair B Amenorrhea

Pericardial
C Enlarged Heart D effusions
>
tekhnologic
 One of the symptoms of hypothyroidism is:

Intolerance to
A Fatigue B cold

C Weight gain D All of the above

>
tekhnologic
 In women, hypothyroidism can affect pregnancy
by:

Making labor and Boosting the chance

A delivery more difficult
Making miscarriage
C more likely
tekhnologic
B of getting pregnant
Reducing the chance
D of getting pregnant.
>
 A person with untreated hypothyroidism may
also have:

A Low blood sugar B High cholesterol

Low blood
C pressure D None of the above

>
tekhnologic
 How is hypothyroidism treated?

A With radiation B With surgery

With a synthetic The condition

C hormone D can’t be treated
>
tekhnologic
 The symptoms of hypothyroidism may be difficult
to detect, so the condition can best be diagnosed
with:

A An ultrasound B An MRI scan

A thyroid stimulating A haemoglobin test

C hormone test (TSH) D or haematocrit test
>
tekhnologic
 The most common thyroid disorder is:

A Hypothyroidism B Hyperthyroidism

C Riedel’s thyroiditis D Thyrocele

>
tekhnologic
 Hypothyroidism caused by hashimoto’s thyroiditis
is much more common in women than in men

A True B False

>
tekhnologic
 Mr. Jacole has been recently diagnosed with Hypothyroidism.
He gained weight and is suffering from cold intolerance. Nurse
Joy shall provide what nursing intervention for cold intolerance?

Instruct the patient to Encourage use of external

A exercise to reduce weight
and produce body heat
B heat source (eg, heating pads,
electric or warming blankets).

Monitor patient’s body

Provide extra layer of
C temperature and report if it
decreases from baseline value
D clothing or extra blanket

>
tekhnologic
 A patient reports they do not eat enough iodine in
their diet. What condition are they most
susceptible to?

A Hyperthyroidism B Hypothyrodism

Pheochromocyto
C ma D Thyroid Storm

>
tekhnologic
 A patient has an extremely high T3 and T4 level.
Which of the following signs and symptoms DO
NOT present with this condition?
Intolerance to
A heat B Smooth skin

C Hair loss D Weight loss

>
tekhnologic
 A patient is being discharged home for treatment
of hypothyroidism. Which medication is most
commonly prescribed for this condition?

A Syntheroid B Inderal

PTU
C Tapazole D (Propylthiouracil)
>
tekhnologic
 You are performing discharge teaching with a patient who is
going home on Synthroid. Which statement by the patient
causes you to re-educate the patient about this medication?

“I will not take this

“I will take this medication
A medication at the same
time I take my Carafate.”
B at bedtime with a snack.”

“If I have palpitations, chest

“I will never stop taking
C the medication abruptly.” D pain, intolerance to heat, or feel
restless, I will notify the doctor.”

>
tekhnologic
 A patient who is in her first trimester of pregnancy is
diagnosed with hyperthyroidism. Which medication
do you suspect the patient will be started on?

A Synthroid B Tapazole

Propylthiouracil
C Radioactive Iodine D (PTU)
>
tekhnologic
 A patient was recently discharged home for treatment of hypothyroidism and was ordered to take
Synthroid for treatment. The patient is re-admitted with signs and symptoms of the following: heart
rate 42, blood pressure 70/56, blood glucose 55, and body temperature of 96.8 'F. The patient is very
fatigued and drowsy. The family reports the patient has not been taking Synthroid since being
discharged home from the hospital. Which of the following conditions is this patient most likely
experiencing?

A Thyroid Storm B Myxedema coma

Toxic Nodular
C Iodism D Goiter
>
tekhnologic
 A patient is being educated on how to take their
anti-thyroid medication. Which of the following
statements are INCORRECT?
"I will take this medication C. "It may take a while before
A at the same time every
day."
B I notice that the medication
is helping my condition."

"I will continue "I will avoid foods

C taking aspirin daily." D containing high levels of
iodine."

>
tekhnologic
 Which of the following signs and symptoms causes
concern and requires nursing intervention for a
patient who recently had a thyroidectomy?
Heart rate of 35, blood Heart rate of 120, blood
A pressure 60/43,
temperature 95.3 'F
B pressure 220/102,
temperature 103.2 'F

Soft hair, irritable, Constipation,

C diarrhea D drowsiness, goiter
>
tekhnologic
 Which of the following side effects are possible
for a patient taking an anti-thyroid medication?

Agranulocytosis and
A Tachycardia B aplastic anemia
Joint pain and
C Skin discoloration D eczema
>
tekhnologic
 ___________ is an autoimmune disorder where the body attacks the
thyroid gland that causes it to stop releasing T3 and T4. The patient is
likely to have the typical signs/symptoms of hypothyroidism, however,
they may present with what other sign as well?

Myxedema coma; Toxic nodular goiter

A joint pain B (TNG); goiter
Thyroid storm; Hashimoto’s
C memory loss D Thyroiditis; goiter
>
tekhnologic
 A patient who has had hypothyroidism for a long period is
administered with thyroid hormone. As a nurse, what possible
nursing management/intervention are you going to provide?

Supply patient with oxygen due Educate the patient

A to increase oxygen demand
caused by the thyroid hormone.
Stop the thyroid hormone
C replacement immediately
B regarding thyroid
hormone replacement.
Check and be alert for signs and
D symptoms of angina or
dysrhythmias when thyroid
replacement is initiated

>
tekhnologic
 HYPERTHYROIDISM
• Hyperthyroidism is the second most prevalent endocrine disorder, after diabetes
mellitus
• Graves’ disease, the most common type of hyperthyroidism, results from an
excessive output of thyroid hormones caused by abnormal stimulation of the
thyroid gland by circulating immunoglobulins.
• It may appear after an emotional shock, stress, or an infection, but the exact
significance of these relationships is not understood.
PATHOPHYSIOLOGY
Clinical Manifestations
• Patients with well-developed hyperthyroidism exhibit a characteristic group of signs
and symptoms (sometimes referred to as thyrotoxicosis).
• The presenting symptom is often nervousness
• These patients are often emotionally hyperexcitable, irritable, and apprehensive;
• they cannot sit quietly;
• they suffer from palpitations;
• and their pulse is abnormally rapid at rest as well as on exertion.
Clinical Manifestations (Cont.)
• They tolerate heat poorly and perspire unusually freely. The skin is flushed
continuously, with a characteristic salmon color, and is likely to be warm, soft, and
moist.
• Elderly patients, however, may report dry skin and diffuse pruritus.
• A fine tremor of the hands may be observed.
• Patients may exhibit exophthalmos (bulging eyes), which produces a startled facial
expression.
• increased appetite and dietary intake, progressive weight loss, abnormal muscular
fatigability and weakness (difficulty in climbing stairs and rising from a chair)
Clinical Manifestations (Cont.)
• Amenorrhea
• Changes in bowel function
• The pulse rate ranges between 90 and 160 bpm;
• the systolic, but characteristically not the diastolic, blood pressure is elevated;
• atrial fibrillation may occur;
• and cardiac decompensation in the form of heart failure is common, especially in
elderly patients.
• Osteoporosis and fracture are also associated with hyperthyroidism.
Clinical Manifestations (Cont.)
• it may progress relentlessly, with the untreated person becoming emaciated,
intensely nervous, delirious, and even disoriented; eventually, the heart fails.
Assessment & Diagnostic Findings
• In advanced cases, the diagnosis is made on the basis of the symptoms and an
increase in serum T4 and an increased 123I or 125I uptake by the thyroid in excess
of 50%.
• Measurement of TSH is indicated in elderly patients with unexplained physical or
mental deterioration.
MEDICAL MANAGEMENT
A. PHARMACOLOGIC THERAPY

1. Radioactivie Idiodine therapy

2. Antithyroid medications
3. Adjunctive Therapy

B. SURGICAL MANAGEMENT
1. Surgery to remove thyroid tissue was once the primary method of treating
hyperthyroidism
NURSING MANAGEMENT:
1. Improving nutritional status
2. Enhancing coping measures
3. Improving self-esteem
4. Maintaining normal body temperature
5. Monitoring and managing potential complications
6. Promoting home and community-based care
1. Teaching patients self-care
2. Continuing care
 NURSING CARE PLAN
NURSING DX:
• Imbalanced nutrition, less than body requirements, related to exaggerated metabolic rate,
excessive appetite, and increased gastrointestinal activity
• Ineffective coping related to irritability, hyperexcitability, apprehension, and emotional instability
• Low self-esteem related to changes in appearance, excessiveappetite, and weight loss
• Altered body temperature

COLLABORATIVE PROBLEM:
• Thyrotoxicosis or thyroid storm
• Hypothyroidism
OTHER DISORDERS
• Thyroiditis
• Acute
• Subacute
• Chronic (Hashimoto’s Disease)
• Thyroid Tumors
• Endemic (Iodine-deficient) Goiter
• Nodular Goiter
• Thyroid Cancer