Download Disturbances of Pituitary Continued and Thyroid part 1

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