Download Disorders of the Thyroid and Parathyroid

Thyroid Gland- drop in T3 and
T4
Pituitary Gland releases TSH
The TSH stimulates the
thyroid gland to release of
T3 and T4
Thyroxine (T4)
and
Triiodothyronine (T3)
These are responsible for
 increase in metabolic rate
 increase protein and bone turnover
 increase responsiveness to catecholamines
 Fetal and infant growth and development
Calcitonin
 Lowering blood calcium and phosphate levels
Normal
An increase in release of thyroid hormone

What are the clinical manifestations in each body
system that reflect the increase in metabolism
caused by the excessive release of thyroid
hormones?
 Cardiovascular
 Respiratory
 Gastrointestinal
 Integumentary
Musculoskeletal
Nervous
Reproductive
Other

History

Physical examination

Ophthalmologic examination

ECG

Radioactive iodine uptake (RAIU)
◦ Indicated to differentiate Graves’ disease from
other forms of thyroiditis

Laboratory tests
TSH
RAIU – radioactive
iodine uptake

Goals
◦ Block adverse effects of thyroid hormones
◦ Stop hormone oversecretion

Three primary treatment options
◦ Antithyroid medications
◦ Radioactive iodine therapy (RAI)
◦ Subtotal thyroidectomy

Action:
◦ Inhibit synthesis of thyroid hormone
◦
First-line examples
 Propylthiouracil (PTU)
 Also blocks conversion of T4 to T3
 Methimazole (Tapazole)

◦
Nursing Implications:
 Instruct the patient that it will take several weeks
for the drug to be effective
◦ Improvement in 1 to 2 weeks
◦ Good results in 4 to 8 weeks
◦ Therapy for 6 to 15 months
Disadvantages include
 Patient noncompliance
 Increased rate of recurrence when medication is
discontinued

Uses:
◦ Used with other antithyroid drugs in preparation for
thyroidectomy or treatment of thyrotoxic crisis
◦ Given several weeks preoperatively
◦ Decrease the vascularity of thyroid gland
decreasing bleeding making surgery safer
◦
Action:
 Inhibit synthesis of T3 & T4 and block release into
circulation to slow metabolism
◦
Examples
 Saturated solution of potassium iodine (SSKI)
 Lugol’s solution
Action:
◦ Symptomatic relief of thyrotoxicosis resulting
from β-adrenergic receptor stimulation
 Uses:
◦ Helps to control nervousness, tachycardia,
tremor, anxiety, and heat tolerance.


Example
◦ Propranolol (Inderal) administered with other
antithyroid agents

Uses:
 Used to destroy thyroid tissue thereby limiting
thyroid hormone secretion.
 Effects not seen for 2-3 months
 Dose of RAI is low so no radiation safety precautions
are needed

Complication
 High incidence of post-treatment hypothyroidism –
need to be taught symptoms
RAI Not an option during pregnancy

Indications
◦ Unresponsive to drug therapy
◦ Large goiters with tracheal compression
◦ Possible malignancy
 Oxygen, suction equipment, tracheostomy tray
available in room
 Postoperative care
◦ Every 2 hours for 24 hours
 Assess for signs of hemorrhage
 Assess for tracheal compression
 Irregular breathing, neck swelling, frequent
swallowing, choking
◦ Semi-Fowler’s position
 Support head with pillows
 Avoid flexion of neck
 Tension on suture lines
◦ Postoperative care
 Monitor vitals
 Control pain
 Check for tetany
 Muscle cramps or laryngeal stridor – treat with calcium
gluconate
 Trousseau’s and Chvostek sign should be monitored
 Monitor for 72 hours
 Evaluate difficulty in speaking/hoarseness
 Some hoarseness for 3 to 4 days is expected

Ambulatory and home care
◦ Discharge teaching
 Monitor hormone balance periodically
 Decrease caloric intake to prevent weight gain
 Adequate iodine
 Regular exercise
 Avoid ↑environmental temperature

Why is the patient placed on a High-calorie diet
(4000-5000 kcal/day)?

What foods are encouraged?

What foods should be avoided?
◦ Change linens frequently if diaphoretic
◦ Eye Care for exophthalmos
◦ Apply artificial tears to prevent corneal
ulceration
◦ Elevate HOB and salt restriction for edema
◦ Tape eyelids shut for sleep if they cannot close
◦ Dark glasses to reduce glare and prevent
environmental irritants
Thyrotoxic crisis (Thyroid Storm)

Acute, rare condition where all manifestations
of hyperthyroidism are heightened

Life-threatening emergency/death rare when
treatment initiated early and is vigorous.
◦ Manifestations include:
 Respiratory distress – dyspnea
 Hyperthermia – up to 105.30
 Tachycardia – pulse > 130 BPM
 Heart failure, chest pain
 Shock
 Restlessness, Agitation
 Seizures
 Abdominal pain, Nausea
 Delirium
 Coma

Goal of Treatment
◦ ↓ Thyroid hormone levels and clinical
manifestations with drug therapy

Interventions
◦ Manage respiratory distress – oxygen
◦ Fever reduction – with antipyretics or cooling
blankets, cool room
◦ fluid replacement – IV fluids and electrolytes,
and management of stressors
◦ Administer medications – PTU, methimazole,
Iodine, β-blockers
◦ Treatment of Heart failure
Case Study:
Beth Minton, 43 y/o,
Admitted to hospital with high fever.
Following an endocrine workup she was
diagnosed with Graves Disease.
Objective Data:
•Has fever of 1040 F, B/P of 150/78, P - 11, R – 24
•Flushed, with hot, moist skin
•Has fine hand tremors and appears nervous
•Has 4+ deep tendon reflexes
1.
What is the etiology of Beth’s symptoms?
2.
What diagnostic studies were probably ordered?
What would the results have been to establish the
diagnosis of Grave’s Disease?
3.
She has a subtotal Thyroidectomy planned for 2
months later – why is surgery being delayed?
4.
Beth is started on propylthiouracil (PTU) and
propranolol (Inderal). What is the purpose of
drug therapy for Beth?
5.
What are Beth’s immediate learning needs; pre-op
needs, and post-op needs?
6.
What are the nursing interventions for successful
long-term management of Beth after the subtotal
thyroidectomy?
7.
Based on assessment data presented, write
appropriate nursing diagnosis pertinent to Beth
while hospitalized.
A condition in which the body lacks
thyroid hormones

What are the clinical manifestations in each body
system that reflect the decrease in metabolism
caused by the lack of thyroid hormones?
 Cardiovascular
 Respiratory
 Gastrointestinal
 Integumentary
Musculoskeletal
Nervous
Reproductive
Other


History and physical examination
Laboratory tests
◦ Serum TSH
 Determines cause of hypothyroidism
◦ Other abnormal findings are
↑ cholesterol and triglycerides, anemia, and
↑ creatine kinase



Levothyroxine (Synthroid)
◦ Must take regularly
◦ Monitor for angina and cardiac dysrhythmias
◦
Monitor thyroid hormone levels and adjust (as
needed)
Patient/family teaching
◦ Because of the impaired memory - Be sure to
provide patient with written instructions and teach
family as well as patient
◦ Lifelong therapy
◦ Teach measures to prevent skin breakdown
◦ Emphasize need for warm environment
◦ Caution patient to avoid sedatives or use lowest
dose possible
◦ Discuss measures to minimize constipation
 Avoid enemas because of vagal stimulation in
cardiac patient
◦ Teach patient to notify physician immediately if
signs of overdose appear
 Orthopnea, dyspnea, rapid pulse, palpitations,
nervousness, insomnia

Those with severe
longstanding hypothyroidism
may display myxedema
◦ Accumulation of hydrophilic
mucopolysaccharides in the
dermis and other tissues
◦ Causes puffiness, periorbital
edema, masklike effect
Medical emergency
 Hypoventilation- respiratory drive is decreased
resulting in alveolar hypoventilation
 Mental sluggishness
 Drowsiness
 Lethargy progressing gradually or suddenly to
impairment of consciousness or coma
 Subnormal temperature
 Hypotension
 Decrease pulse – does not perfuse tissues

Vital functions must be supported
 Mechanical respiratory support
 Cardiac monitoring

Administer IV thyroid hormone replacement

If hyponatremic – give Hypertonic saline
solution

Close assessment

VS monitoring
 Monitor core temperature
Hyperthyroidism
Hypothyroidism

There is overproduction of parathormone
which is characterized by bone
decalcification.

The patient will have an increase in blood
calcium.
What is a complication of increase
in calcium in the blood?
What are the clinical manifestations of
hyperparathyroidism?
Hint: They Mimic those of Hypercalcemia

Serology
◦ Parathyroid hormone levels - 
◦ Serum calcium - >10 mg/dl
◦ Serum phosphorus - < 3 mg/dl
◦ Urine calcium, serum chloride, creatinine,
amylase, alkaline phosphatase – all
elevated

Bone x-rays and bone scans

Ultrasound and MRI
Most common way to
diagnose
Hyperparathyroidism
is by
persistent elevated
_____ ______levels
and PTH

Hydration Therapy – force fluids. WHY?

Avoid Immobility / Active Lifestyle
◦ Bones subjected to normal stress give up less
calcium so encourage walking

Dietary measures- avoid diet with excess calcium

Post – op Nursing Care
◦ Assess for hemorrhage
◦ Assess Fluid and Electrolytes
◦ Assess for Tetany – occurs with sudden
decrease in calcium levels
 What medication should be available at the
bedside?

Explain the use of the following medications in
treatment:
◦ Bisphosphates
 Fosamax
◦ Calcimimetic Agent
 Cinacalcet
Results from abnormally low levels of
PTH low Ca level
What are the clinical manifestations
of hypoparathyroidism:
Hint: They mimic those of
hypocalcemia

Chvostek’s sign: tap on
the facial nerve just
below the temple.

Positive - when nose,
eye, lip & facial muscles
twitch


Trousseau’s sign:
temporarily occlude arterial
blood flow (with BP cuff
inflated) above the normal
systolic pressure.
Positive Trousseau’s sign
occurs when the hand and
fingers contract from
ischemia




IV calcium such as calcium gluconate – infuse slowly
 Prevent hypotension, cardiac dysrhythmia,
cardiac arrest
ECG monitoring
Rebreathing using paper bag – increases carbonic
acid in blood lowering blood pH.
Other Drugs
◦ Calcium
◦ Vitamin D – promotes intestinal calcium absorption
and bone resorption

Diet Therapy
◦ Encourage high-calcium
◦ What are examples of foods high
in calcium?

Use a gait belt when assisting a patient with muscle
weakness

Collaborate with dietitian to teach patients about
diets that are restricted in calcium

Use a lift sheet to move or reposition a patient with
hypocalcemia

Keep environment of a patient with risk for thyroid
storm cool, dark, quiet.

Keep emergency suctioning and trach tray in room of
patient who has had thyroid or parathyroid surgery.

Monitor the hydration status of patients who
have hypercalcemia

Teach patients that hormone replacement
therapy for hypothyroidism is lifelong

Teach patients to use clinical manifestations
such as number of bowel movements, ability
to sleep as indicators of therapy
effectiveness