Download Thyroid Dysfunction Prevention in Men and Women

THYROID DYSFUNCTION PREVENTION
Thyroid Dysfunction Prevention in Men and Women
Dacy Gaston
South University
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Abstract
A condition that affects men and women throughout all communities, thyroid dysfunction, is
found in three forms; hypothyroidism, subclinical hypothyroidism, and hyperthyroidism. If the
body is not euthyroid (normal thyroid state) then there is either too much or too little circulating
hormones that regulate energy for the body. In many of these instances signs and symptoms of a
thyroid dysfunction are vast and often times mistakenly overlooked for other diseases in the
body. It can be difficult to evaluate thyroid in a patient who presents with broad signs and
symptoms, especially if the healthcare provider is not aware of the importance in screening for
thyroid disorders. Hyperthyroidism will be discussed in brief, but for purposes of this education
paper the focus will be on hypo and subclinical hypothyroidism. This paper is intended to show
Nurse Practitioners (NPs), Physician Assistants (PAs), and Physicians a vast amount of
information obtained from evidence-based research and will explain the guidelines that will
assist them in further understanding the thyroid and how to properly diagnose and manage a
patient with a dysfunctional thyroid.
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Thyroid Dysfunction Prevention in Men and Women
An estimated 20 million Americans have some form of thyroid disease and up to 60
percent of those with thyroid disease are unaware of their condition (ATA, 2015). Thyroid
disorders often affect women twice as much as men, especially during the perimenopausal stage
of life (Whiteley, DiBonventura, Wagner, Alvir, & Shah, 2013). In the United States, 1 in 50
women have hypothyroidism. Hypothyroidism can manifest with general symptoms such as
fatigue, weight gain, depression, insomnia, cardiac, gastrointestinal and reproductive problems
(Carson, 2009). Because men and women are both at risk for having undiagnosed thyroid
disorders, it would make sense to screen all patients for thyroid function during an adult physical
exam. According to Shames (2012), many people go undiagnosed with a thyroid disorder
because the symptoms are so broad, and can be confused by the lay person with a multitude of
other syndromes. Undiagnosed thyroid disorder along with increasing age can also lead to
increased risk for atherosclerosis, cardiac abnormalities, kidney disease, hormone imbalance,
sleep apnea, and depression; therefore furthering the need for a proper thyroid assessment
(Kostoglou-Athanassiou, Ntalles, 2010).
To understand the importance of the thyroid one must understand the importance of the
endocrine system. The thyroid is involved in every aspect of the endocrine system, therefore; the
thyroid hormone is the regulator of the body’s “engine.” According to Johnstone, Hendry,
Farley & McLafferty (2014), “the thyroid hormones are necessary for regulation of metabolism
and heat production, regulation of the rate of oxygen consumption and energy expenditure,
enhancement of adrenaline and noradrenaline (increasing heart rate), and the normal
development of the nervous and musculoskeletal system; together with human growth hormone
and insulin” (p. 46). According to the CDC (2014), the top chronic diseases and leading causes
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of death in the Unites States are heart disease, stroke and obesity. One must ask themselves, is
this a lifestyle choice, an inherited problem, or even possibly an overlooked thyroid problem that
is contributing to the morbidity seen in today’s culture. The wave of the future for the
Affordable Care Act (ACA) is prevention. A simple thyroid screening assessment by the trained
healthcare provider could potentially alert an underlying problem and offset a potential health
problem in the future. ACA, which includes the Prevention and Public Health Fund (PPHF), will
support a new focus on prevention and wellness, offering opportunities to strengthen the public’s
health through workplace wellness initiatives. The PPHF of the ACA contains many new
provisions designed to improve public health and wellness. The ACA was designed to address 4
key prevention areas: 1) community prevention, 2) clinical prevention, 3) public health
infrastructure and training, and 4) research and surveillance focused on workforce wellness
(Anderko, Roffenbender, Goetzel, Millard, & Wildenhaus, 2012).
Nurse Practitioners, Physicians Assistants, and Physicians play a crucial role in
assessment and proper diagnosis and management of all health systems in a patient. Because the
thyroid gland regulates many functions of the body, it is important for the health and wellness of
each patient that each healthcare professional is; proficient in recognizing the signs and
symptoms of a dysfunctional thyroid, be able to properly assess and diagnosis the disorder, and
finally; must be knowledgeable in how to manage the disorder. The purpose of this paper is to
provide educational information to help in preventing overlooked, misdiagnosed, or mismanaged
thyroid disorder. This educational program will assist healthcare professionals in broadening
their knowledge and further understand the thyroid gland, and its importance in body regulation.
The education presentation will be targeted to Nurse Practitioners, Physician Assistants, and
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Physicians, and will focus on proper patient assessment, diagnosis, and management of the
thyroid gland.
Review of the Literature
In an effort to develop an educational tool, a review of the literature was conducted to
examine the importance in recognizing the signs and symptoms of thyroid dysfunction and to
obtain the necessary preventative screening tests to prevent an overlooked thyroid disorder that
my lead to comorbid health conditions. These preventative methods include; provider education
of the thyroid gland and endocrine system; knowledge of why the thyroid is an important
component to the body and its function in body regulation; finally, proper ordering of screening
tests by the healthcare provider in patients with possible thyroid dysfunction. These studies were
obtained using the CINAHL Plus nursing database where a large number of current scholarly
medical journals, and peer reviewed research articles are catalogued. Search words that were
included in this review of the literature include thyroid, hypothyroid, hyperthyroid,
hypothalamus, pituitary, thyroid disorder, and thyroid dysfunction.
Cardiac Function
Roef and colleagues explain that the heart is one of the most thyroid hormone-responsive
tissues in the body. A correlation exists between undiagnosed or misdiagnosed thyroid
dysfunction and increased alteration in cardiac function. This is an extremely important reason
to have a baseline thyroid function test is because the thyroid regulates many aspects of a
person’s body, especially cardiac function. Undiagnosed thyroid disorders have been shown to
alter cardiac function because of the importance of the thyroid hormone in the heart muscle. Too
much or too little of the circulating hormones can mean an increase or decrease in heart rate and
function (Roef, Taes, Kaufman, Van Daele, De Buyzere, Gillebert, & Rietzschel, 2013). Thyroid
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disorder symptoms are extremely broad and often times overlooked by the lay person as either a
symptoms of aging, fatigue, constipation, irregular periods, weight gain, slow reflexes and even
depression (Shames, 2012). The patient needs to have a more comprehensive history and
physical along with a baseline thyroid test to determine the true underlying degree of the
problem.
Subclinical hypothyroidism and clinical hypothyroidism have a direct correlation with
cardiovascular disease (Suh & Kim, 2015). The relationship between pathological thyroid
dysfunction and body weight is well established. An increasing amount of evidence indicated
that higher levels of TSH are associated with worsening blood pressure and altered lipid levels.
The meta-analysis found that the total cholesterol, low-density lipoprotein cholesterol, and
triglyceride levels of subclinical and clinical hypothyroid patients were increased relative to
euthyroid individuals (Suh & Kim, 2015).
Dyslipidemia
Dyslipidemia is one of the most common metabolic disorders associated with
hypothyroidism. According to Ohsfeldt, Gandhi, Fox, Bullano, & Davidson (2010), patients
with diagnosed atherosclerosis incur significant clinical and economic burden, indicating a need
for earlier diagnosis and treatment of atherosclerosis to help in reducing this burden. In a multicenter study on the prevalence of hypothyroidism in patients with hypercholesterolemia, 737
cases of men and women were subjected to assessment of thyroid function in addition to having
hypercholesterolemia. Hypothyroidism induces secondary hypercholesterolemia that increases
the incidence of atherosclerotic cardiovascular events, therefore, treatment for hypothyroidism
promptly improves cholesterol metabolism and consequently prevents those events (Tagami,
Kimura, Ohtani, Taneka, Hata, Salto, Miyazeki, Araki, Tanaka, Yonezawa, Sawamura, Ise, Ogo,
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Shimbo, Simatsu, & Naruse, 2011). According to the correlative significance between
hypothyroidism and dyslipidemia, it is necessary to evaluate thyroid function before starting any
anti-lipid agents on patients with dyslipidemia because many of these patients have no specific
clinical signs or complaints of hypothyroidism.
Kidney Disorders
There is a large correlation between hypothyroidism and kidney disorders (Mansourian,
2012). Shin, Lee, Kim, Oh, Kim, Han, Koo, Doh, Park, Han, Yoo, & Kang (2012), completed a
study to investigate the impact of thyroid hormone therapy on the changes in estimated
glomerular filtration rate (eGFR) in subclinical hypothyroidism patients with stage 2-4 chronic
kidney disease. A total of 309 patients were included in the final analysis to assess changes in
eGFR over time and were compared between patients with and without thyroid hormone
replacement therapy using a linear mixed model. Thyroid hormone therapy not only preserved
renal function better, but was also an independent predictor of renal outcome in chronic kidney
disease patients with subclinical hypothyroidism (Shin et al, 2012).
Liver Disorders and Non-Alcoholic Fatty Liver Disease
According to Ludwig, Holzner, Denzer, Gerinerrt, Haenle, Oeztuerk, Koening, Boehm,
Mason, Kratzer, & Graeter, (2015), non-alcoholic fatty liver disease (NAFLD) is one of the most
common disorders of the liver worldwide. There is a correlation between thyroid dysfunction
and NAFLD. The data was collected from 1,276 subjects; males and females aged 18-65 years;
by using a cross-sectional study which revealed and increased prevalence of hepatic steatosis in
subjects with reduced T4 concentrations. The findings absolutely confirm an association
between both subclinical and clinical hypothyroidism and hepatic steatosis (Ludwig et al., 2015).
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Coronary Heart Disease
A study conducted by McQuade, Skugor, Brennan, Hoar, Stevenson, & Hoogwerf (2011),
used a retrospective review of all patients seen in the Cleveland Clinic Preventative Cardiology
clinic. All of the patients had baseline laboratory tests including TSH, and other multiple
coronary heart disease (CHD) risk factors obtained at the patient’s baseline visit. The results
concluded that several CHD risk factors including age, systolic blood pressure, triglycerides, and
fibrinogen were more common in hypothyroid patients (McQuade, Skugor, Brennan, Hoar,
Stevenson & Hoogwerf, 2011).
Estrogen and Hormonal Dysfunction
A newer phenomenon that has surfaced is the effect of hypothyroidism on the female
reproductive hormones. In a study conducted by Saran, Gupta, Philip, Singh, Bende, Agroiya, &
Agrawal (2016), a total of 113 women with untreated primary hypothyroidism were included to
evaluate their reproductive hormone levels. The study used statistical comparison of two groups
of patients: the control was women with normal menstrual cycles, normal hormonal profile, and
without any endocrinologic disease, the variable being women with primary hypothyroidism.
The study showed a new understanding in the involvement of thyroid hormones and female
reproductive hormones by confirmed that the patients with hypothyroidism diminished the serum
Estrogen concentrations in reproductive age group. It further goes on to state that
hypothyroidism in women causes menstrual irregularities, and decreases serum levels of
estrogen, (Saran et al., 2016).
In conducting this review of the literature, several factors were found to impact thyroid
dysfunction prevention for both men and women. In many instances a simple knowledge deficit
among healthcare providers was to blame for poor adherence to maintaining a euthyroid state. A
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summary table of the literature review is provided in Appendix A where the research studies are
reviewed.
Theoretical Framework
In addition to a review of the literature, a nursing theory is utilized to guide the educator
and is grounded in research and theoretical principles. The purpose of this education proposal is
to educate other healthcare providers on the importance of thyroid testing. The educator is
assuming that there is a knowledge deficit in the healthcare community. In order for that deficit
to be filled, the education must be deemed worthy of importance to the medical community for a
change to occur. According to Mitchell (2013), this change can be explained by Everett Rogers
in his Diffusion of Innovation Theory. This theory explains that change comes about by
awareness in the problem, interest and evaluation of the problem, and ultimately; adoption of the
change. Cook (2014) explains that Diffusion of Innovations seeks to explain how innovations
are taken up in a population. An innovation is an idea, behavior, or object that is perceived as
new by its audience. In this case, the innovation is the need for thyroid testing to increase early
detection of preventable chronic conditions.
Using Rogers theory and introducing the medical community to the importance and
awareness of the benefits of having thyroid testing, can lead to a change in the thought process of
the healthcare provider in evaluating a patient’s current health status. This increase in
knowledge and education will benefit the patient, medical community, and the economy as a
whole.
Standards of Practice/Practice Guidelines
Standards of practice exist in order to provide guidelines for healthcare providers to
easily recognize a problem and properly manage the health of the patient. In order for the
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provider to understand why a thyroid test should be ordered in the management of a patient, they
must understand the basics of the endocrine system and the role of the hypothalamus, and the
significance of a thyrotropin-stimulating hormone (TSH) test.
Chaisera, (2013) explains that thyroid disease is usually seen in three forms;
underactivity (primary or secondary hypothyroidism); overactivity (hyperthyroidism); and
swelling of the thyroid. Diagnosis of hypo or hyperthyroidism should be done by thyroid
function tests in conjunction with the patient’s clinical symptoms (Hall, 2010), and a proposed
annual thyroid test is recommended by the American Association of Clinical Endocrinologists
Endocrinology at age 35. The hypothalamus stimulates the secretion of TSH from the anterior
pituitary which stimulates the synthesis and secretion of the thyroid hormones, tri-iodothyronine
(T3) and thyroxine (T4), which are then secreted into systemic circulation (American Thyroid
Association, 2014). T4 is produced only from the thyroid, whereas T3 is formed from the
deiodination of T4 in the extrathyroidal tissues. T3 deficiency is responsible for the clinical and
biochemical manifestations of hypothyroidism (Kostoglou-Athanassiou & Ntalles, 2010).
Primary hypothyroidism, according to Carson (2009), occurs when there is an autoimmune,
surgical or congenital destruction of the gland which leads to insufficient levels of T4 which
leads to high TSH levels in the body. Secondary hypothyroidism occurs when there is pituitary
or hypothalamic failure which leads to decreased TSH levels in the body. Both primary and
secondary hypothyroidism have similar symptoms. Gaitonde, Rowley & Sweeney (2012)
explains that hypothyroidism has common physical symptoms such as depression, weight gain,
dry hair, dry skin and fatigue; and clinical signs my include bradycardia, cognitive impairment,
hypothermia and goiter. In hyperthyroidism, clinical and physical signs may include heart
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palpitation, hyperactivity, insomnia, irritability, anxiety, diarrhea, heat intolerance and weight
loss (Chaisera, 2013).
To help distinguish between hyperthyroidism, primary hypothyroidism, and secondary
hypothyroidism, drawing TSH blood levels are first line recommendation (Mulryan, 2010).
Normal levels of TSH are between 0.4-4.0 mU/l. When those levels are on the upper limit,
hypothyroidism is suspected and free serum T4 can be drawn to conclude hypothyroidism
(Kostoglou-Athanassiou & Ntalles, 2010). Treatment of choice of hypothyroidism; after
objective and subjective evaluation by the primary care provider; begins with the administration
of Levothyroxine.
The American Association of Clinical Endocrinology (2012), states that “Serum TSH
measurement has the highest sensitivity and specificity of any single blood test used in the
evaluation of suspected thyroid dysfunction and should be used as an initial screening test.” The
AACE further goes on to give their recommendations for treatment of hypo and
hyperthyroidism. Recommendation one states “a radioactive iodine uptake should be performed
when the clinical presentation of thyrotoxicosis is not diagnostic of Graves Disease; a thyroid
scan should be added in the presence of thyroid nodularity.” Recommendation two states “Betaadrenergic blockade should be given to elderly patients with symptomatic thyrotoxicosis and to
other thyrotoxic patients with resting heart rates in excess of 90 bpm or coexistent cardiovascular
disease.” Recommendation three states “Beta-adrenergic blockade should be considered in all
patients with symptomatic thyrotoxicosis,” (AACE, 2012). In patients with clinical
hypothyroidism levothyroxine is the only replacement therapy recommended. Initial testing with
serum TSH and Free T4 is used to confirm new hypothyroid patients. Replacement therapy
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begins with 1.6mcg/kg of levothyroxine, with repeat testing done every three months until the
patient has reached a euthyroid state (ATA, 2012).
Teaching Plan
This teaching plan offers NPs, PAs, & MDs and educational program grounded in
evidence-based practice with extensive review of available literature on thyroid dysfunction.
This purpose of this teaching plan is to provide healthcare professionals with the most up to date
information on symptom recognition, risk factors, and appropriate diagnostic tools used to screen
patients with a possible thyroid disorder. The goal of these educational tools will aid the in faster
recognition of a thyroid disorder, and ultimately help to decrease the incidence of overlooked or
undiagnosed thyroid disorder that could lead to worsening comorbid health conditions. This
teaching plan will be based on the current standards of practice from the American Thyroid
Association and the American Association of Clinical Endocrinologists.
The targeted audience for this presentation is 15-20 Nurse Practitioners, Physician
Assistants, and Physicians working at multiple Curtis V. Cooper Healthcare centers in the
Savannah area. These healthcare professionals have identified with an interest in increasing their
individual knowledge and understanding of symptom recognition, diagnostic tools, and proper
management of a thyroid disorder. Located in Appendix B is the teaching plan for this
presentation with outcomes guided by Bloom’s Taxonomy. Outcomes of the learner from the
teaching presentation include increased understanding and knowledge of thyroid disorder
symptom recognition, diagnosis, and proper management (cognitive domain). The learner will
successfully demonstrate how to perform a clinical thyroid assessment and state the proper
diagnostic tests to order (psychomotor domain). Finally, the learner will verbalize how the
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education program will impact individual future practice with screening men and women for
thyroid disorders (affective domain).
Instructional Strategies
Several key methods will be used in providing this teaching presentation to the healthcare
professionals. To help understand the level of knowledge that the targeted audience already has,
a pre-test will be given to obtain the baseline knowledge of the learners before the presentation is
made. Direct instructional strategies include the provision of visual PowerPoint case scenario of
demonstrating correct techniques in patient assessment and proper blood work ordered when a
patient presents to clinic with signs and symptoms of a thyroid disorder. A literature review of
the current guidelines for diagnosing a thyroid disorder by the American Association of Clinical
Endocrinologist and the American Thyroid Association will be available as a PowerPoint; as well
as a quick reference guideline that will be given to the targeted audience. Interactive
instructional strategies will be integrated at this point while the educator will engage in
presentation of the case scenario and start a discussion session. Problem solving as a group,
talking circles for peer thought exchange, and open discussion with the educator will be utilized
to start off the first part of the presentation.
The direct instruction strategies will focus on providing a presentation of the information
to the nurse practitioners through lecture, handouts, PowerPoint case scenario, and AACE
guidelines to take into account when assessing a patient. A total of 30 minutes will be allotted
for this presentation and review with another 15 minutes of interactive instructional strategies
that will focus on assessing the level of understanding gained through the presentation and
handouts given to the targeted audience.
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Finally, at the end of the education session, the post-test will be given, and a group
discussion will end with using talking circles, think alouds and question and answers interaction
between the educator and the students about how this presentation has had an impact on them
and how it will impact their individual future practice. Lastly, any question and answers not
covered in the presentation will be available to the NPs, PAs and Physicians through handouts
that the educator will give the students before the teaching ends.
Evaluation Methods
Several methods will be used to evaluate the effectiveness of this teaching presentation.
A pre-test located in Appendix C is provided to the students prior to the teaching program. This
is used to evaluate the knowledge the learned has already accumulated throughout their
experiences as a healthcare professional. The pre-test is collected and answers are not discussed
with the class at this time. Upon completion of the teaching program, a post-test with the same
content as the pre-test is given to the class. Results of the pre and post-test are compared and the
students will be able to view their results and compare them to the pre-test to see if their
knowledge has improved with the post-test.
A successful teaching program will be achieved if the students score 80% or higher on
the post-test. In addition, the students will be provided with an evaluation form labeled
Outcomes Evaluation Form, and will be located in Appendix D. This form will allow the
students to anonymously answer questions regarding their satisfaction with the teaching
program, determine if it increased their knowledge of thyroid disorders and proper management;
and whether or not it will impact their individual future practice in screening for thyroid
dysfunction in men and women.
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This educational program was developed with the purpose of providing NPs, PAs, and
Physicians with knowledge of new clinical research information on comorbid conditions that are
exacerbated by overlooked or misdiagnosed thyroid disorders. The program also offers
diagnostic and treatment guideline recommendations from the ATA and AACE. It is hoped that
this teaching plan will prompt these healthcare professionals to listen and to properly assess each
and every patient, especially patients with vague symptoms that can be overlooked as a thyroid
disorder. With this new knowledge and information, these NPs, PAs and Physicians will
continue to do a complete assessment on each of their patients while keeping in mind comorbid
conditions that can arise from thyroid dysfunction. The goal of this project is to increase student
knowledge, pass information learned to friends, family, colleagues, and, ultimately; lead to an
increase in thyroid disorder awareness and decrease in the incidence of an overlooked or
mismanaged thyroid disorder resulting in comorbid complications.
Conclusion
The teaching project was completed with a total of seventeen healthcare professionals
that included five nurse practitioners, three physician assistants, two physicians, four nurse
practitioner students and three physician assistant students. The pre-test was collected and
graded before the presentation. Twelve out of the seventeen learners scored an 80% or higher on
the pre-test. The presentation was given in a conference room which facilitated think alouds, and
enabled the healthcare professionals an easy and open atmosphere to ask questions and get
feedback from the educator. After the completion of the discussion and the handout was given
the post-test was given. All of the learners scored 80% or higher on the post-test. This was an
improvement from just twelve learners scoring and 80% or higher on the pre-test; to all
seventeen learners scoring an 80% or higher on the post-test. The educational presentation was a
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success, and all of the learners stated that their knowledge in diagnosing and proper management
of thyroid disorders has increased.
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References
American Thyroid Association. (2014). What is Hypothyroidism? Retrieved from
http://www.thyroid.org/wp-content/uploads/patients/brochures/Hypo_brochure.pdf
American Association of Clinical Endocrinologists. (2012). Clinical Practice Guidelines for
Hypothyroidism in Adults. Retrieved from
https://www.aace.com/files/checklists_july_2014_ep.pdf
Anderko L, Roffenbender J, Goetzel R, Millard F, Wildenhaus K, DeSantis, C., Novelli, W.
(2012). Promoting prevention through the Affordable Care Act: workplace wellness.
Preventing Chronic Disease, 9, 120092. DOI: http://dx.doi.org/10.5888/pcd9.120092
Carson, M. (2009). Assessment and management of patients with hypothyroidism. Nursing
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Chakera, A., Pearce, S., Vaidya, B. (2011). Treatment for primary hypothyroidism: current
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Chiasera, J. (2013). Back to the basics: thyroid gland structure, function and pathology. Clinical
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Garber, J., Cobin, R., Gharib, H., Hennessey, J., Klein, I., Mechanick, J., Pessah-Pollack, R.,
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Mansourian, R. (2012). A literature review on the adverse effects of hypothyroidism on kidney
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Ohsfeldt, R., Gandhi, S., Fox, K., Bullano, M., Davidson, M. (2010). Medical and cost burden
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(2013). Thyroid hormone levels within reference range are associated with heart rate,
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Appendix A
Review of the Literature
Summary of Review of Literature
Student: Dacy Gaston
Project Title: Thyroid Dysfunction Prevention
Study
Design
Methods
Sample
Tools
Finding
Canaris,
QN
Observational, patient
794
Questionnaire
High le
Tape, Wigton, 2013
reported
Patients at health fair
previously undiag
thyroid disease wa
identified at the h
Roef, et. al
QL
2013
Roef, et. al
OL
2014
Population
2524 pts
Phenotyped,
Strong
representative random sample
ages 35-55 men and
comprehensive
association btwn t
(Asklepios study)
women
echocardiography,
hormone levels w
diastolic evaluation,
euthyroid range a
thyroid function
rate, and more su
parameters were
effects on cardiac
measured
and structure
Population
2524 ages
Thyroid
fT3 and
representative random sample
33-55 men and
function tests, c-reactive
ratio were positive
(Asklepios study)
women
protein measurements,
related to BMI
blood samples
Chin, et. al
2014
QL
Population based
cross-sectional
708
Blood
In euth
Chinese and Malay
collected, Total
Malaysian men, th
men 20 years and
cholesterol, HDL, TG, T3,
positive and signif
above
T4, fT3, TSH measured,
relationships btwn
plotted
TG level and betw
and cholesterol le
22
Summary of Review of Literature
Student: Dacy Gaston
Project Title: Thyroid Dysfunction Prevention
Study
Design
Methods
Sample
Tools
Finding
Wanjia, et.
QL
Retrospective study
406 male
TSH levels,
TSH lev
al 2012
Luc, et. al,
QN
Correlational
2013
and female euthyroid
Lipid profiles drawn,
correlated in a pos
non smokers with
plotted
linear manner wit
newly diagnosed
non-HDL-C and TG
asymptomatic CHD
euthyroid pts.
497 US
countries, Medicare-
Fatourechi,
QN
Correlational, theory
2009
Surveillance,
Marker
Epidemiology and SEER
higher levels of he
age, non medicare
access are associa
age cohorts over
higher papillary th
three decades
cancer incidence r
Patients
Meta analysis
Subclin
with Subclinical
hypothyroidism on
Hypothyroidism
TSH level, increase
possibility of
cardiovascular risk
Mishra,
Samanta, 2012
ArticlePeer Rev
Grounded theory
---
---
Increas
reduced action of
hormone on certa
molecular pathwa
heart and vasculat
causes relavent
cardiovascular
derangements.
23
Summary of Review of Literature
Student: Dacy Gaston
Project Title: Thyroid Dysfunction Prevention
Study
Design
Methods
Sample
Tools
Finding
Larson,
Article-
Review of Literature
---
---
Thyroid
Anderson, Koslawy,
Peer Rev
symptoms
2010
KostagolouAthanassiaou, Nettles,
Article-
Review of Literature
----
----
Peer Rev
Hypoth
updates
2010
Keller, et.
al, 2010
Article-
Review of Literature
----
----
Peer Rev
Perime
Women and
Hypothyroidism
Anderko, et.
al, 2010
Article-
Review of Literature
----
----
Peer Rev
Afforda
Act and its implica
providing prevent
services to patient
Oshfelt, et.
al, 2010
Article
Review of Literature
----
----
Peer Rev
Econom
Burden of atheros
to the economy
Summary
4 QL, 3 QN,
6 Peer Reviewed,
QN mostly
correlational, QL mostly
Ranged
from 20-75 years
Surveys,
Early de
observational studies,
of dysfunctional th
population based or cross
cohort, correlational,
state leads to less
sectional.
research, tables, graphs
factors of develop
multi organ dysfun
(esp. atherosclero
cardiac risk factor
by undiagnosed th
dysfunction.
24
Summary of Review of Literature
Student: Dacy Gaston
Project Title: Thyroid Dysfunction Prevention
Study
Design
Methods
Sample
Tools
Finding
25
Appendix B: Teaching Plan Outline
Title of
Offering:
Purpose:
Goal:
Target
Audience:
Learner
Objectives
1. The
Learner
will have
an
increased
understand
ing and
knowledge
of the
importance
in
screening
for thyroid
disorders;
and also
understand
the proper
screening
tools used
to diagnose
thyroid
dysfunctio
n.
(Cognitive
domain).
2. The
Learner
will
successfull
y state the
signs and
symptoms
Teaching Plan on Thyroid screening and prevention in men and women for Nurse
Practitioners
To educate Nurse Practitioners on the importance of screening and preventing thyroid
disorders and to educate the Nurse Practitioners on the proper screening guidelines for
male and female patients.
To increase Nurse Practitioners’ understanding and awareness of the importance of
thyroid screening; and to increase the Nurse Practitioners’ understanding in the proper
diagnostic criteria used to diagnose a thyroid disorder.
xx ARNP’s  Patients
Contact
Total Clock
 Staff
Hours:
Hours:
Content
Method of
Time
Resources Method of
Outcomes
Outline
Presentation Allotted
Evaluation
1.1 Provide
examples of
overlooked
and
misdiagnos
ed thyroid
disorder
and stress
the
importance
of
screening in
prevention
of
comorbid
complicatio
ns.
1.2 Provide
American
Association
of Clinical
Endocrinol
ogists
(AACE)
guidelines
for thyroid
screening.
1.1 Presentation of
Power Point
Review of the
Literature.
1.2 Presentation of
Power Point
Guidelines by
AACE.
15-20 Minutes
American
Association of
Clinical
Endocrinology
screening
guidelines for
providers.
Pre-test, Post-test
Learners will achieve a
score of 80% or higher
on post-test.
2.1 Showcase
possible
scenarios in
a clinical
setting of a
thyroid
disorder.
2.2 Showcase
the proper
thyroid
panel that
2.1 PPT
presentation of
possible case
scenario.
2.2 PPT
presentation of
guidelines and
interpretation
of thyroid
function tests
to result in
15-20 Minutes
Power Point on
possible clinical
scenarios with
diagnostic
interpretation.
2.1 Return
demonstration
on provided
information
about signs
and symptoms
to assess in
patient with
suspected
thyroid
disorder.
2.1 Learner will
successfully state
the signs and
symptoms to look
for in assessing a
patient with
possible thyroid
disorder.
2.2 Learner will
successfully
demonstrate an
26
that are
associated
with
thyroid
dysfunctio
n; how to
properly
assess a
patient
with
suspected
thyroid
dysfunctio
n; and
successfull
y state the
proper
tests to
order when
screening
for thyroid
dysfunctio
n.
(Psychomo
tor
domain).
3. The
Learner
will be
able to
verbalize
how the
education
program
will impact
their
further
practice
with
screening
for thyroid
dysfunctio
n in men
and
women.
would be
ordered.
3.1
Discussion,
question
and answers
among
learners
about
content
explained
3.2 Discussion,
question
and answers
about the
impact it
could
provide on
individual
future
practice.
hypo,
subclinical or
hyper thyroid
state.
3.1 Group format
with 15-20
nurse
practitioners.
3.2 Interaction of
Q&A with the
educator and
the learner
(nurse
practitioners)
to provide
impact of
teaching plan
on the group
members
2.2 Return
demonstration
of the proper
diagnostic
blood tests to
order in
patient with
suspected
thyroid
disorder.
15-20 Minutes
Notepads, pens,
discussion
questions.
Group discussion
and reporting of
what impact
teaching plain will
have on individual
future practice.
example thyroid
panel to be
ordered in
patients with
suspected thyroid
disorder.
3
Learner will
identify and
describe the
impact this
teaching program
will have on the
importance of
proper patient
assessment in
screening for
thyroid disorders
to ensure
prevention of
future healthcare
problems in men
and women that
could have been
prevented with
proper thyroid
evaluation.
27
(Affective
Domain).
References:
American Association of Clinical Endocrinologists. (2012). Clinical Practice Guidelines. Retrieved from
https://www.aace.com/files/checklists_july_2014_ep.pdf
28
Appendix C: Pre-Test/Post-Test Questionnaire
Thyroid Assessment, Diagnosis, Management and Prevention in Men and Women
Pre-Test and Post-Test for Advanced Practice Nurse Practitioners
1. What is the recommended age to obtain a baseline thyroid panel (TSH panel) by the
American Thyroid Association and the American Association Clinical Endocrinologist?
a. 25 years
b. 30 years
c. 35 years
d. 45 years
2. What are the signs and symptoms of Hypothyroidism?
a. Fatigue
b. Dry skin
c. Depression
d. Brittle hair and nails
e. All of the above
3. What are the signs and symptoms of Hyperthyroidism?
a. Heart palpitations (racing)
b. Weight loss
c. Anxiety
d. Insomnia
e. All of the above
4. Can thyroid disorders occur before the recommended testing age by the ATA and the
AACE?
a. Yes
b. No
5. What health conditions can be made worse by overlooking, misdiagnosing, or
mismanaging a thyroid disorder?
a. Hypertension
b. Hyperlipidemia
c. Depression
d. Difficulty in getting pregnant
e. All of the above
6. What is the ONLY recommended replacement hormone for patients with a confirmed
diagnosis of Hypothyroidism?
a. Armor Thyroid
b. Levothyroxine
29
c. Hormone replacement therapy
d. None of the above
7. What is the recommended blood panel that is taken from a patient with a suspected
thyroid disorder?
a. FSH, LH
b. TSH, FreeT4, TPO
c. Free T4, Free T3
d. TSH
8. When a patient is NEWLY diagnosed with hypothyroidism and started on a replacement
therapy, how often should they get their blood tested in order to maintain a steady
euthyroid state?
a. Every 6 months after diagnosis
b. Every 2 weeks after diagnosis
c. Every 3 months after diagnosis
d. Every year
9. What is a TSH test?
a. An antibody test to detect thyroid antibodies in your blood
b. A test that shows how much energy your body has
c. A test that shows how much your thyroid gland is stimulating release of hormones
d. A test that shows how big your thyroid gland is
10. T/F: When a patient has achieved a euthyroid state (whether they are hypo or
hyperthyroid), that patient still has to have annual thyroid testing.
a. True
b. False
Answers:
1. C
2. E
3. E
4. A
5. E
6. B
7. B
8. C
9. C
10. True
30
Appendix D: Outcomes Achievement Evaluation Form
Outcomes Evaluation form for Teaching Plan Participants
1. After this teaching presentation, has your knowledge of thyroid screening, diagnosis and
treatment increased?
a. Yes
b. No
c. There is no change
2. Has your comfort level in performing a proper thyroid assessment in a clinical setting
increased after this presentation?
a. Yes
b. No
c. There is no change
3. Will this teaching project impact your future practice and impact the way in which you
screen patients with signs and symptoms of a thyroid disorder?
a. Yes
b. No
c. There will be no future impact
4. Overall, did this teaching project increase or decrease your awareness to the vast majority
of comorbid complications that can be exacerbated by a misdiagnosed, overlooked, or
mismanaged thyroid disorder?
a. Increased
b. Decreased
c. Did not change my thinking
5. How likely would you recommend this course to a colleague, friend, or family member?
a. Very likely
b. Likely
c. Unlikely
d. Very unlikely
31
Appendix E: PowerPoint Presentation
PowerPoint Presentation
32
Appendix F: Thyroid Quick Reference Guide
QUICK REFERENCE GUIDE FOR HEALTHCARE
PROFESSIONALS:
**AACE/ATA RECOMMENDS THYROID TESTING AT AGE 35
**TSH/FT4/TPO USED TO DIAGNOSE NEW THYROID DISORDER
**TSH REFERENCE RANGE 0.4-4.0 MU/L
**FREE T4 0.7-1.9 NG/DL
**REPLACEMENT STARTS AT 1.6 MCG/KG/DAY
**USE THE SAME REFERENCE RANGE ON EACH INDIVIDUAL PATIENT
**LEVOTHYROXINE ONLY RECOMMENDED TREATMENT FOR HYPOTHYROID REPLACEMENT
**REPEAT TESTING ATA AND AACE EVERY 3 MONTHS UNTIL EUTHYROID THEN EVERY 6-12
MONTHS
**PAY ATTENTION TO SIGNS/SYMPTOMS OF YOUR PATIENT DON’T OVERLOOK!
33