Download Chapter 45 Thyroid and Parathyroid Disorders Learning Objectives

Chapter 45
Thyroid and Parathyroid Disorders
Learning Objectives
Identify nursing assessment data related to the functions of the thyroid and parathyroid glands.
Describe tests and procedures used to diagnose disorders of the thyroid and parathyroid glands
and nursing responsibilities relevant for each.
Describe the pathophysiology, signs and symptoms, complications, and treatment of
hyperthyroidism, hypothyroidism, hyperparathyroidism, and hypoparathyroidism.
Assist in the development of nursing care plans for patients with disorders of the thyroid or
parathyroid glands.
THE THYROID GLAND
What does this gland produce?
The Thyroid Gland
Plays a major role in metabolism and G & D
Thyroid hormone ( thyroxine or T4 )
Triiodothyronine ( T3 )
Both ^ the bodies rate of metabolism
Calcitonin regulate serum calcium levels
Age-Related Changes in
Thyroid Function
Increased incidence of thyroid nodules
Serum levels of T4 remain approximately the same in a healthy older person, but levels of T3
often decline
Incidence of hypothyroidism increases with age, especially among women
Assessment of the Thyroid Gland
Health history & PE for pts w/ Thyroid Disorders.. Ask about…
 Changes in energy level, sleep patterns, personality, mental function, emotional
state
 Unexplained weight changes
 Changes in menstrual cycles, sexual function, hydration, bowel elimination
pattern, and tolerance of heat and cold
Assessment of the Thyroid Gland cont’d
Diagnostic tests and procedures
 Serum T3, free T4, T4, and TSH
 Thyroid-releasing hormone (TRH) stimulation test
 Radioactive iodine (RAI) uptake test
 Thyroid ultrasonography
 MRI or CT
 Review Table 45-1 for patient preparation
What gland sends TSH to stimulate the Thyroid gland to produce T 3 and T4?
CRITICALLY THINK NOW !
If the lab values of your patient indicate an increased level of TSH and a lower than normal level
of T4 hormone,
What might this indicate to you? What gland is not responding? The thyroid or the pituitary
gland? And Why ?
Hyperthyroidism
Characteristics of Hyperthyroidism
Abnormally increased synthesis and secretion of thyroid hormones
Graves disease
 Most common type of hyperthyroidism
 Autoimmune disorder
 Antibodies activate thyroid-stimulating hormone (TSH) receptors, which in turn
stimulate thyroid enlargement and hormone secretion
 Most often develops in young women
Multinodular Goiter
Often in women in their 60s and 70s
Likely develop in people who have had goiter for a number of years
Caused by small thyroid nodules that secrete excess thyroid hormone
Increased hormone production is independent of TSH
Nodules can be benign or malignant
Symptoms are usually less severe
Signs and Symptoms
Weight loss and nervousness with a mild form
In more severe cases
 Restlessness, irritable behavior, sleep disturbances, emotional lability, personality
changes, hair loss, and fatigue
 Weight loss, even when the patient is eating well, is common
 Poor tolerance of heat and excessive perspiration
 Changes in menstrual and bowel patterns
 Warm, moist, velvety skin; fine hand tremors; swelling of the neck; and
ophthalmopathy including exophthalmos
 Tearing, light sensitivity, decreased visual acuity, and swelling around orbit of the
eye
 Tachycardia, increased systolic blood pressure, sometimes atrial fibrillation
Complications
Thyrotoxicosis (aka: Thyroid Storm or Crisis )
 Excessive stimulation caused by elevated thyroid hormone levels that produce
dangerous tachycardia and hyperthermia
Medical Diagnosis
Decreased TSH and elevated serum T4
Measurement of thyroid-stimulating antibodies and results of a radioactive iodine uptake test to
diagnose Graves disease
Medical Treatment
Goal dec. excessive thyroid hormone prod.
Drug therapy
 Antithyroid drugs Tapazole, Lugol’s solution
Radioactive iodine
 Accumulates in the thyroid gland, where it causes destruction of thyroid tissue
Surgical treatment
 Subtotal thyroidectomy
Surgical Treatment
Thyroidectomy or subtotal thyroidectomy
PreOp teaching is important !
Drsg is on front of neck
Avoid straining of neck, support head
Turn/deep breath… limit coughing
Care of the Patient Having a Thyroidectomy
Assess respiratory status
Elevate HOB
Assess LOC
Assess wound drng
Voice quality
Neuromuscular irritability ( tetany )
Chvostec’s Sign and Trousseau’s Sign
Hypothyroidism
Inadequate secretion of thyroid hormones
Cretinism
 If not treated early, hypothyroidism during infancy causes permanent physical and
mental retardation
In adults can be serious but usually reversible with treatment
Myxedema
 Facial edema from severe, long-term hypothyroidism
Cause and Risk Factors
Primary
 Atrophy of the thyroid gland after years of Graves disease or thyroiditis
 Treatment for hyperthyroidism
 Dietary iodine deficiency
 High intake of goitrogens
 Defects in thyroid hormone synthesis
Secondary
 Pituitary disorders or Thyroidectomy
Signs and Symptoms
Swelling of the lips and eyelids
Dry, thick skin
Bruising
Thin, coarse hair
Hoarseness
Generalized &/or Facial edema
May seem slow, depressed, or apathetic
Signs and symptoms may be more subtle in the elderly or may be masked by other diseases.
Note Thyroid function tests should be routine in the elderly population
Medical Diagnosis
Based on laboratory determination of free T4 and TSH
Complications
 Myxedema coma
Medical treatment
 Hormone replacement therapy
•
Levothyroxine (Synthroid) or liothyronine (Cytomel)
Nursing Dx What are your Interventions?
Activity Intolerance
Imbalanced Nutrition: More Than Body Requirements
Hypothermia
Constipation
Risk for Impaired Skin Integrity
Decreased Cardiac Output
Disturbed Thought Processes
Disturbed Body Image
Self-Care Deficit
Medical Treatment for Hypothyroidism
Synthroid
Cytomel
Patient’s will require lifelong hormone replacement therapy and should be monitored to evaluate
the response to therapy
Simple Goiter
Term used to describe the enlargement of the thyroid gland
 Causes
•
Iodine deficiency and long-term exposure to goitrogens
•
The gland may enlarge to compensate for hypothyroidism
•
Sometimes the enlarged gland produces excess hormones, making the
patient hyperthyroid
Simple Goiter cont’d
Treatment (dependent on cause)
 If mild enlargement and normal hormones, no intervention
 Some patients need hormone replacement therapy
 Surgery indicated if pressure on the trachea or esophagus or if the condition is
disfiguring
 If pt. is hyperthyroid  tx may be 2-3 wks of iodine, repeated 3-4/x each year to
reduce gland activity, but does not cure the goiter.
Thyroid Cancer
Uncommon
Fatal in less than 1% of all cases
Early stages: nodule that can be felt on thyroid
If cancer spreads, enlarged lymph nodes felt in the neck
Patient may not show dramatic changes in thyroid hormone levels
Total thyroidectomy is the usual treatment, f/b thyroid replacement therapy
 If malignancy spreads beyond thyroid gland, more radical surgery may be
indicated
The Parathyroid Glands
Nursing Assessment & PE
Physical examination
 Heart rate and rhythm, blood pressure, respiratory effort, muscle strength, muscle
twitching, and hair and skin texture
 Chvostek sign
•
Spasm of facial muscle when facial nerve tapped
 Trousseau sign
•
Carpopedal spasm when a blood pressure cuff is inflated above the
patient’s systolic blood pressure and left in place for 2 to 3 minutes
Diagnostic Tests and Procedures
Blood tests
Radiographs
Dental examination
Electrocardiogram
Hyperparathyroidism
High levels of PTH elevated bld calcium levels (hypercalcemia)
Pathologic (spontaneous) fractures (from Ca shifting into blood)
Renal calculi and obstruction
Dysrhythmias and hypertension
Nrsg. Dx Impaired urinary elimination r/t urinary calculi
Signs and Symptoms
Symptoms vague at first
 Weakness, lethargy, depression, anorexia, and constipation
 Elevated serum calcium levels
Other findings include mental and personality changes, cardiac dysrhythmias, weight loss,
urinary calculi, poor muscle tone, bone pain, HTN, fractures
Medical Diagnosis
Elevated serum calcium and decreased serum phosphate
Elevated PTH and 24-hour urine calcium
Skeletal radiographs and bone density studies
Surgical Treatment
Surgical intervention if tumor is cause
 Parathyroidectomy
 Surgeon attempts to leave some parathyroid tissue to prevent hypoparathyroidism
Medical & Nursing Treatment
Inc. Fluids  dilutes urine
Phosphates  reduces calcium level
Limit dietary calcium
Calcitonin
Postoperative Care
Airway obstruction from accumulated fluid and blood in surgical site compressing the trachea
 Monitor and document the respiratory rate and effort and the pulse rate
 Increasing pulse and respiratory rates, especially accompanied by restlessness,
suggest inadequate oxygenation
 Notify physician of indications of respiratory distress
 Keep an emergency tracheotomy tray at the bedside in the event of acute
obstruction
Postoperative Care cont’d
Airway obstruction related to severe hypocalcemia
Be alert for tetany
 Tingling around mouth and in the fingers
 It may progress to severe muscle spasms or cramps and even to laryngospasm
 Treated with oral or intravenous calcium supplements
Postoperative Care cont’d
Protect suture line from stress
Show patient how to support the head when changing positions
Inspect dressing and back of the neck for bleeding
Elevate patient’s head to reduce swelling
Hypoparathyroidism
Deficiency of (PTH)
Uncommon condition
Usually caused from accidental removal of/damage to parathyroid glands during surgery
Inadequate secretion of PTH leads to hypocalcemia
 Severe hypocalcemia can progress to convulsions and respiratory obstruction due
to spasms of the larynx
Hypoparathyroidism S/S
Classic signs  + Chvostek’s and Trousseaus sign
Fatigue and weakness
Tingling/twitching of face
Mental/emotional changes’
Dysrhythmias
Nrsg. Dx Decrease Cardiac Output r/t hypocalemia
Med/Nursing Treatment
Oral Calcium salts
Vitamin D
Teach patients s/s of calcium imbalances
Instruct to wear medical alert bracelet
CRITICAL THINKING QUESTION
A 46-year-old woman is experiencing fatigue and weight gain despite decreased food
intake. Her hair is thinning and her skin is very dry. She reports that she has had mild
swelling in her legs. She also reports feeling irritable and depressed. Laboratory tests
reveal a low serum T4 level and an elevated serum TSH level. What is the likely diagnosis
and what information can the nurse provide to the patient about her condition?
THAT IS IT !
YOU’VE MADE IT THROUGH ENDO… NOW REMEMBER WHAT YOU HAVE
LEARNED AND APPLY IT WHEN IN THE CLINICAL SETTING !