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Disturbances of Pituitary Continued and Thyroid part 1 Ann MacLeod, RN, BScN, MPH Agenda Review Anterior & Posterior Pituitary Hypo/ Hypersecretion Thyroid Gland Hyporsecretion & Hypersecretion • assessment • nursing diagnoses • managment Anterior pituitary Hypo - GH,TSH,FSH,LH dwarfism • Tx supplementation Hyper - GH giantism & ACTH Cushings • Tx: Parlolel (bromocriptine) • dopamine recptor agonist, blocks release of prolactin and GH • use of condoms, irritant to stomach with food, lightheaded, drowsiness • Tx: transphenoidal hypophysectomy,radiation • reminder: keep HOB elevated other intracranial postop measures Posterior Pituitary Hyposecretion ADH or vasopressin diabetes insipidus • Tx: DDAVP (desmopressin) ( synthetic vasopressin) • also clotting factor VIII and enuresis) • vial & spray in fridge, oral pills not • side effects: drowsiness, nasal irritation, GI cramping, monitor I & O Hypersecretion ADH Inappropriate ADH Secretion Syndrome • Tx: fluid restriction and Lasix (furosemide) & eat salt, treat cause (tumours) Thyroid T3 & T4 3 (tri-idodothyroxine) (morre potent) & T4 (thyroxine) represent the number of idone atoms attached to tyrosine required for storage in the thyroid low T3 & T4 hypothalmus, Thyrotropin Releasing Hormone TSH T3 & T4 & Calitonin Thyroid Physiology Thyroid Gland Butterfly shaped gland located in the lower neck anterior to the trachea (extremely vascular) produces: Thyroxine (T4) , Triiodone thyronine (T3) and calcitonin Iodine in needed for the thyroid gland to produce hormones Function of Thyroid Hormones T3 and T4 control cellular metabolism Calcitonin: is not controlled by TSH, it is secreted by the thyroid gland in response to increased calcium blood levels Diagnostic Tests Serum blood tests: T3 & T4 is increased in hyperthyroidism FreeT4 .7-2 ng/dl, TSH .2-5.4 mU/L especially > 60 years T4 5.5-13.5 g/dl, T3 80-250 g/dl TSH is increased with hypothyroidism Needle Biopsy Diagnostic Tests Thyroid Scan: helpful in determining location, size, shape and function of the thyroid gland Radioactive Iodine Uptake/Scan: measures the rate of iodine uptake by the thyroid Nsg: if pt. Has ingested iodine it will alter result, need to check for allergy to iodine and scan dyes, on BCP, lasix, antibiotics, etc. Hypothyroidism Usually Primary: Insufficient secretion of thyroid hormone thyroid dysfunction may result from: congenital defects (cretinism) • slow mentation, lethargy Hashimoto’s disease • auto-immune thyroiditis, low TRH or TSH Secondary: suppression of Tsh r/t pit. Tumours inadequate medication therapy post thyroid surg Myxedema - extreme hypothyroidism Assessment: affects women more Fatigue, hairloss, brittle nails, dry skin numbness, tingling of fingers menstrual changes constipation, wt gain,enlarged tongue hands and feet inability to tolerate cold Low TPR irritable, fatigue, apathy, slow, Dementia? Myxedema comapotentiated by opiates/sedatives Collaborative Management: Goal is to establish normal metabolic state by replacing missing hormone synthetic replacement: synthroid, levothyroxine myxedema: severe hypothyroidism in adults Management cont’d Adults who have severe myxedema for a prolonged period of time may have increased se. Cholesterol, CAD and atherosclerosis must assess for angina thyroid drugs may affect blood sugar and dilantin levels Nursing Diagnoses Activity intolerance r/t fatigue Altered body temp constipation r/t decreased GI function Knowledge deficit r/t therapeutic regime ineffective breathing altered thought process present with severe myxedema Nursing interventions Limit activity Promote comfort and warmth Ensure safe environment re mental status Emotional support for depression symptoms Thyroxine supplements: Eltroxin, Synthroid (levothyroxine) • taper doses, to .05-.1 mg PO /day • few side effects, cardiovascular, wt. Gain/los Hyperthyroidism Over secretion of thyroid hormone can be r/t a number of disease processes a) Grave’s disease:excessive stimlation of thyroid glands by immunoglobulins mid aged women b) struma ovarii-tumor of the ovary that secretes thyroid hormone c)thyroiditis- inflam. Leading to increased hormone levels d) Cancer of the thyroid gland Assessment: Increased thyroid hormone stimulates the heart resulting in: tachycardia, palpitations, increased cardiac output, and increased peripheral blood flow, hypertension also: Increased metabolism, diarrhea, increased appetite, muscle weakness, osteoporosis, wt. loss, sweating, flushing, heat intolerance agitation, irritability, anxiety Assessment cont’d Menstrual irreg., elevated eyelids: EXOPTHALMUS which leads to corneal ulceration the gland may increase in size (goiter) Nursing Diagnoses: Alt. Nutrition r/t increased metabolic rate Ineffective Coping r/t irritability and excitability Disturbance in Self esteem r/t changes in appearance Alt. Body temp. Patient/Family Teaching: meds, importance of long term follow-up s/s of hypothyroidism pre-op : re surgery how to avoid thyroid storm Pharmacological Approaches Pharm: employing anti-thyroid drugs that interfere with thyroid hormone synthesis , and other drugs that control symptoms Irradiation: Radioisotope Iodine for destructive effects of the thyroid gland 1-2 oral tasteless, colorless doses kills thyroid cells within 2-3 weeks Radioactive Iodine: used in conjunction with anti-thyroid drugs radiation safety protocol must be followed by personnel Pharm cont’d. propylthioracil (Propacil, PTU): commonly given until the client is euthyroid - normal thyroid levels blocks extra cellular conversion of T4 to T3 few s/s: agranulocytosis, watch for s/s of infection, urticaria *not given in preg: may cause CRETINISM in fetus Supportive Patient Adaptation Suggest Hi Cal Hi Protein, reduce GI stimulants Calming environment Emotional Support, reassurance, eye care cooler environment Encourage rest Partial - Total Thyroidectomy: Considered for the following reasons: • severe Thyroiditis (staph aureus abscess) • chronic thyroiditis ( Hashimoto’s disease) • thyroid tumour also called goiter • iodine defiicient goiter may require surgery- low thyroxine stimulates production of TSH Surgery Removal of approx. 5/6 of the gland (sub-total thyroidectomy) prior to the surg., the client takes PTU to bring them to a euthyroid state Lugol’s solution of Potassium Iodine is given to reduce the size and vascularity of the goiter or gland (excess saliva, gingivitis) Beta Adrenergic blocker (Propanolol) to bring heart rate down Post-op Thyroidectomy: Vitals q 15 min, semi fowler’s position support head and neck with pillows or sandbags I+O, fluids as tol. Analgesics, DB+C, T q4hx24hrs Trach set at bedside, avoid speaking if parathyroids removed, low Ca+, monitor spasms & electrolytes Thyroid Storm(Thryrotoxic crisis): A form of severe hyperthyroidism with an abrupt onset usually precipitated by stress, injury, infection, surgery, abrupt d/c of Synthroid usually in poorly controlled cts. Increased temp, extreme tachycardia, altered mental state, chest pain Life threatening , if untreated>>FATAL Management: Immediate objective is to reduce body temp and HR. then prevent vascular collapse hypothermia mattress, ice packs O2, IV containing Dextrose, Hydrocortisone, Propanolol, Digitalis Proplthioracil: given to block conversion of T4 to T3 Iodine to decrease output of T4