Download Hypothyroidism

Endocrine:
Thyroid and Parathyroid
Created by: D.Losicki, MSN, RN
Adapted by: C.Perez, MSN,RN.
Thyroid Gland
Functions of thyroid hormone in Adults
• Control metabolic rate of cells
• Promote sufficient pituitary secretion of growth hormone
and gonadotropins
• Regulate protein, carbohydrate and fat metabolism
• Exert effects on heart rate and contractility
• Increase red blood cell production
• Affect respiratory rate and drive
• Increase bone formation and decrease bone resorption
of calcium
• Act as insulin antagonist
Collaborative Assessment
Thyroid Studies
• Thyroid-stimulating hormone (TSH) (thyrotrophic)
Reference interval: 4.6-11.0 mcg/dL (59-142 nmol/L)
• Free thyroxine (FT4)
Reference interval: 0.8-2.7 ng/dL (10-35 pmol/L
• Triiodothyronine (T3), total
Ages 20-50: 70-204 ng/dL (1.08-3.14 nmol/L)
Ages >50: 40-181 ng/dL (0.62-2.79 nmol/L)
Diagnostics
• Thyroid scan:
• RAIU uptake test:
Thyroid Function Test
Hyperthyroidism
• T3, T4, Free T4, T3 are all increased
• TSH is high
• TRSH stimulation test: little or no TSH response
Thyroid Function Test
Hypothyroidism
• T3, T4, Free T4, T3 are all decreased
• TSH is high in primary, low in secondary hypothyroidism
• TRSH stimulation test: Elevated 2 or more times the
normal in primary hypothyroidism
Affects of Aging
Thyroid Spectrum
Common Assessment Abnormalities
• Hypothyroidism: Cool, Pale dry scaly skin, Decreased
hair growth, poor wound
healing, Depression, Paranoia,
Withdrawal, Weight gain (IE,
Eeyore)
Hyperthyroidism: Warm, smooth, moist skin
T
Thinning of scalp hair,
HTN, Tachycardia, weight
loss, Restlessness ( IE, Tigger)
Thyroid Conditions
• Hashimotos thyroiditis: Autoimmune
hypothyroidism
• Graves Disease: Autoimmune, most common form of
hyperthyroidism
• Exophthalmos
Goiter
Collaborative Care
Hyperthyroidism:
1. Antithyroid medications (Chart 66-3)
a. propylthiouracil (PTU)
b. methimazole (Tapazole)
c. Lithium( Eskalith)
2. Radioactive iodine therapy [RAI]:
3. Sub total thyroidectomy
4. Nutritional Therapy
a. High-calorie diet [4,000-5,000cal/day]
b. High-protein diet [1-2g/kg ideal body weight]
c. Frequent meals
Safety Precautions of Patients receiving
radioactive isotope
•
•
•
•
•
Use toilet that no one else uses for 2 weeks, men need
to sit to urinate, If urine is somewhere other than toilet,
clean up, and bag cleaning supplies and take to hospital
radiation department for disposal.
Wash laundry separate from family , then after run
washer for one cycle to clean it.
Stay away from pregnant women and young children.
Do not share toothbrushes, paper/plastic eating utensils
Chart 66-4
HYPERthyroid Care Plan:
• Activity intolerance: r/t fatigue, exhaustion, and heat
intolerance 2nd to hypermetabolism AEB: complaints of
weakness, inability to perform usual activities, short
attention span, memory lapses, dyspnea, tachycardia
• Imbalanced nutrition: less than body requirements r/t
hypermetabolism and inadequate food intake AEB:
complaints of weight loss; less than optimal body weight
Post Thyroidectomy
1.Assess: every 2 hours for 24 hours
• irregular breathing, neck swelling, frequent
swallowing, sensations of fullness at the incision
site, choking, and blood on the anterior or posterior
dressings. VS, tetany
2. Treat: Place in a semi-Fowler's position
• support the head with pillows,
• avoid flexion of the neck and any tension on the suture
lines.
• Pain management
• Ambulate [if no complications
• Fluids as soon as tolerated and soft diet the next day
Thyrotoxicosis/Thyroid Storm
• Nursing management:
• Assess: cardiac dysrhythmias, decompensation
• Treat: administer antithyroid medications
IV fluids and electrolyte replacement
Calm, quiet room
Ensure rest
• Teach: Encourage exercise involving large muscle
groups
self medication management
food selections
Thyroid Storm/Thyroid Crisis
• Uncontrolled hyperthyroidism and occurs often with
Graves’ disease
• Triggered by : trauma, infection, DKA, and pregnancy
• Caused by excessive thyroid hormone released
• S&S: Fever, Tachycardia, and systolic hypertension
• As Thyroid storm continues: Anxious, tremors,
restless, confused psychotic and seizures, leading to
a coma. And even death.
*** When caring for a pt with hyperthyroidism, even after
a partial thyroidectomy, immediately report a temp
increased even 1 degree, it may indicate impending
thyroid crisis
Care during Thyroid Storm
• Maintain Airway
• Give antithyroid med
• Give sodium iodide
• Give propranolol
• Give glucocorticoids
• Monitor for dysrhythmias( Vitals every 30 mins)
• Correct dehydration with NS infusion
• Apply cooling blankets/ice packs to reduce fever
** Table 66-5
Myxedema
Hypothyroid: Collaborative Care
• Thyroid hormone replacement (e.g., levothyroxine)
(lifelong)
• Teach pt and families to take drug exactly and not
change the dose without talking to provider. Also, do
not change brands because the response to a
different drug brands can vary.
• Monitor thyroid hormone levels and adjust dosage (if
needed)
• Nutritional therapy to promote weight loss
• Patient and caregiver teaching
Hypothyroid Care Plan
• Imbalanced nutrition: more than body requirements
r/t calorie intake in excess of metabolic rate AEB: weight
gain 2nd hypometabolism
• Constipation r/t gastrointestinal hypomotility as
evidenced by irregular, hard stools
• Impaired memory r/t hypometabolism AEB:
forgetfulness, memory loss, somnolence, and personality
changes
Parathyroid
Function of Parathyroid Glands
• Regulates Calcium
• Regulates Phosphorus
• Excretes Parathyroid Hormone (PTH)
• Increases bone resorption
Parathyroid Disorders
• Hyperparathyroidism:
• Increased secretion of PTH
• over secretion of PTH is associated with increased
serum calcium levels, and low Phosphate
• Diagnostic Studies:
• Elevated serum PTH
• Elevated serum calcium
• Decreased phosphorus
• Bone Dexa Scan
• TABLE 66-3 CAUSES PARATHYROID DYSFUNCTION
Collaborative Assessment:
Parathyroid Studies
Vitamin D
• 15-60 ng/mL
Phosphate
• 3.0-4.5 mg/dL
Calcium Ionized
• 4.64-5.28 mg/dL
Calcium (total)
• 9-10.5 mg/dL
Magnesium
• 1.3-2.1 mEq/L
Parathyroid hormone (PTH)
• 50-330 pg/mL
*** Look over chart 66-10 VERY GOOD TO KNOW!
Parathyroid Disorders
• Hyperparathyroidism: Uncommon
Manifestations
• Hypocalcemia
• Decreased PTH
• Increased phosphorus
• Tetany: tingling lips, extremities, tonic spasms
dysphagia, laryngospasm
Hyperparathyroidism: Collaborative Care
• Surgical Therapy
• Most effective
• Causes rapid serum calcium reductions every 4 hour calcium lab
until stabilized
• Check for Chvostek’s sign and Trousseau’s sign.
• Criteria serum calcium > 12mg/dl
• Decreased bone density
• Non Surgical Therapy
• Does not met criteria for surgery [labs, elderly]
• Annual exam, labs, bone density, urinary calcium
• Mobility must be maintained
• Medications: bisphosphonates, calcimimetic agents
Nursing Management
• Post parathyroidectomy:
• Assess: bleeding, fluid, electrolyte imbalance
Tetany: early post op to several days,
Trousseau’s and Chvostek’s sign
Labs: calcium, potassium, phosphate,
magnesium
Treat: Ambulation
Collaborative Care
• Treat acute complications:
• Tetany: IV calcium chloride, calcium gluconate
• Cardiac monitoring
• Rebreathing
Long Term management
- Replacement therapy
- PTH, Oral calcium, Vit D, Ergocalciferol
Hyperparathyroidism
• Very rare
• Hypocalcemia
• Treatment: correcting hypocalcemia, vit D deficiency and
hypomagnesaemia.
• Teach: eat foods high in calcium and low in phosphorus,
milk, yogurt and processed cheeses are avoided.