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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