PN 142 Day 3

Report
DISORDERS OF THE THYROID
AND PARATHYROID GLANDS
HYPERTHYROIDISM
ETIOLOGY/PATHOPHYSIOLOGY
• Also called Graves’ disease, or exophthalmic
goiter, or thyrotoxicosis
• DUE TO: Overproduction of the thyroid
hormones T3 and T4  Exaggeration of
metabolic processes
HYPERTHYROIDISM
• ETIOLOGY/PATHOPHYSIOLOGY cont.
• Exact cause unknown
– Possible genetic factors with precipitive factors of:
» Infection, ↓ iodine, or extreme physical or
emotional stress
• Affects females more than males
• May occur during adolesence or pregnancy
HYPERTHYROIDISM
• CLINICAL MANIFESTATIONS:
• Edema of the anterior portion of the neck
• Exophthalmos (bulging eyeballs)
– SUBJECTIVE ASSESSMENT : Pt. C/o:
•
•
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Inability to concentrate; memory loss
Dysphagia
Hoarseness
Increased appetite
Weight loss, insomnia
Nervousness, jittery, excitable
EXOPTHALMUS
http://www.bing.com/images/search?q=exopthalmus+picture&id=910B1504DB452992E34365F19E0BE4C2EE3594
1E&FORM=IQFRBA#view=detail&id=36C1A29E6D537F51942094844C162CBA347F5CC6&selectedIndex=164
Internet picture
HYPERTHROIDISM
HYPERTHROIDISM
• CLINICAL MANIFESTATIONS
– OBJECTIVE ASSESSMENT
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Tachycardia; hypertension; bruit over thyroid
Warm, flushed skin
Fine hair
Amenorrhea
Elevated temperature/heat intolerance
Diaphoresis
Hand tremors, clumsiness
Hyperactivity for some
HYPERTHYROIDISM
• DIAGNOSTIC TESTS
– Confirmed by:
• ↓ TSH and ↑ Free T4
• RAIU – radioactive iodine uptake – uptake of 35-95% of
the drug
HYPERTHYROIDISM
• MEDICAL MANAGEMENT
– Medications – Block production of thyroid
hormone
–Propylthiouracil / PTU
–Methimazole/ Tapazole
• Meds reduce symptoms in 6-8 wks.
HYPERTHYROIDISM
• MEDICAL MANAGEMENT
– Medication may be followed by:
• Radioactive iodine/ ablation therapy
–Destroys some of the hypertrophied
thyroid tissue
–Low dose – no “radiation” precautions
needed
HYPERTHYROIDISM
• MEDICAL MANAGEMENT cont.
– Radioactive iodine/ Ablation therapy cont.
• Outcome: in most pts.  hypothyroidism
treat with Levothyroxine
• Adequate medical supervision follow up is
important!
HYPERTHYROIDISM
• MEDICAL MANAGEMENT cont.
– Surgery: for pts. who cannot tolerate antithyroid
drugs; are not good candidates for radiation tx.;
have a poss. malignancy; or have large goiters
causing tracheal compression
– Most common surgery: Subtotal Thyroidectomy
• Removal of 5/6ths of the thyroid gland
• If too much thyroid tissue is removed  gland will not
regenerate hypothyroidism
HYPERTHYROIDISM
• MEDICAL MANAGEMENT cont.
– Surgery: usually delayed until pt in a normal
thyroid state d/t the risk of bleeding during
surgery and thyroid crisis (thyroid storm) post op.
HYPERTHYROIDISM
• NURSING ASSESSMENT AND INTERVENTIONS:
– Post-operative Subtotal Thyroidectomy
• Assess for s/sx internal or external bleeding
• Assess for tetany:
– Chovstek’s Sign: is + when abnormal spasm of facial muscles
occurs when elicited by light tapping on facial nerve in the pt.
with low calcium
– Trousseau’s Sign: is + if there is carpal spasm in the
hypocalcemic and hypomagnesemia pt. When BP cuff inflated
above pt. normal systolic pressure and held there for 3 min.
•
•
http://www.bing.com/videos/search?q=thyroid+storm+youtube&qpvt=thyroid+storm+youtube&FORM=V
DRE#view=detail&mid=0B08D370F3270FFF14820B08D370F3270FFF1482 (3 min 5 sec)
http://www.bing.com/videos/search?q=youtube+partial+thyroidectomy+personal+story&FORM=VIRE1#vi
ew=detail&mid=613D00F1A54228D31139613D00F1A54228D31139 (9 min 49sec)
HYPERTHYROIDISM
• NURSING ASSESSMENT AND INTERVENTIONS:
– Post-op Subtotal Thyroidectomy (cont.)
• Assess for Thyroid Crisis/Storm
– May occur as a result of manipulation of the thyroid gland during
surgery releasing large amts of thyroid hormone  bloodstream
– Occurs within the first 12 hrs.
– S/SX: exaggerated s/sx of hyperthyroidism + n/v, severe
tachycardia, severe HTN, severe hyperthermia (106F+), extreme
restlessness, dysrhythmias, delirium, heart failure  death
– http://www.bing.com/videos/search?q=thyroid+storm&FORM=HDRSC3#view=detail&mi
d=8A8572C304A26127A35A8A8572C304A26127A35A(5 min 38 sec)Thyroid Storm part 1
– http://www.bing.com/videos/search?q=thyroid+storm&FORM=HDRSC3#view=detail&mi
d=CEB5AB156B2998E95407CEB5AB156B2998E95407 (5 min 47 sec) Thyroid Storm part 2
HYPERTHYROIDISM
– Thyroid Storm cont.:
• DIAGNOSTIC TESTS
– ↑FT4, ↓TSH
• MEDICAL MANAGEMENT goals during thyroid storm:
– 1. induce a normal thyroid state
– 2. prevent cardio-vascular collapse
– 3. prevent ↑ hyperthermia
HYPERTHYROIDISM
• NURSING ASSESSMENT AND INTERVENTIONS:
– Post-op Subtotal Thyroidectomy (cont.)
• Voice rest x48 hrs – provide communication
tool
• Voice checks – q 2-4 hrs. “ahh”; note
hoarseness or other changes
• Bed – semifowler’s position; pillow support for
head and shoulders
HYPERTHYROIDISM
• NURSING ASSESSMENT AND INTERVENTIONS:
– Post-op Subtotal Thyroidectomy (cont.)
• Avoid hyperextension of neck; support head
during position change
• Reinforce DB exercises; check with MD re:
coughing
• Tracheotomy tray at bedside and suction
• Cool mist humidifier prn
• Nutrition care – watch for dysphagia
HYPERTHYROIDISM
• NURSING DIAGNOSES:
– Pre-op
• Risk for hyperthermia, related to increased
metabolism
• Imbalanced nutrition:less than body
requirements r/t increased metabolism
– Post-op
• Impaired swallowing, r/t edema
• Ineffective breathing,risk for, r/t post-op edema
and pain
HYPERTHYROIDISM
• PATIENT EDUCATION
– Post op:
•
•
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follow up with medical supervision
Thyroid function tests
Care incision site
Diet: high calorie, CHO’s , and protein
• PROGNOSIS: normal life with appropriate
medical or surgical tx.
– Expophthalmos may remain to lesser degree
HYPOTHYROIDISM
– Etiology/pathophysiology
• Due to insufficient secretion of thyroid hormones
• Decreased hormones cause slowing of all
metabolic processes
• R/T Failure of thyroid or insufficient secretion of
thyroid-stimulating hormone from pituitary gland
• Hashimoto talks: (Just to be funny-hehe)
http://www.bing.com/videos/search?q=youtube+hashimoto&qpvt=youtube+hashimoto
&FORM=VDRE#view=detail&mid=BC6F61D1587C03368265BC6F61D1587C03368265
• Personal Story (5 minutes)
http://www.bing.com/videos/search?q=youtube+hashimoto&qpvt=youtube+hashimot
o&FORM=VDRE#view=detail&mid=0A19B271B30370332C210A19B271B30370332C21
HYPOTHYROIDISM
– Myxedema refers to severe hypothyroidism in
adults
• Will see edema in hand’s face, feet, and
periorbital tissues
Floppy infant
• Inflammation and thickening of the skin
Thick,protruding tongue
Poor feeding
– Cretinism – congenital hypothyroidism Choking episodes
Constipation
Prolonged jaundice
Short stature
Depression
Loss of hair
Rough voices
Swollen eyelids
Hearing problem
Fatigue
Weight gain
HYPOTHYROIDISM
• Clinical Manifestations:
– Because all metabolism processes slow 
• Hypothermia; intolerance to cold
• Weight gain
• ASHD/CAD  ↓exercise tolerance + dyspnea
on exertion
HYPOTHYROIDISM
• SUBJECTIVE ASSESSMENT:
• Mental and emotional assessment may include:
– Depression; paranoia
– Impaired memory; slow thought process
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Hearing/speech impairment
Lethargic, forgetful, irritable
Anorexia
Constipation
Cold intolerance
Decreased libido; reproductive difficulties
HYPOTHYROIDISM
• OBJECTIVE ASSESSMENT
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Menstrual irregularities
Thin hair, falls out
Skin thick and dry
Enlarged facial appearance
Low, hoarse voice
Bradycardia
Hypotension
Weakness, clumsiness, ataxia
HYPOTHYROIDISM
• Diagnostic tests : TSH, T3, T4, FT4 (low levels of
these are the underlying stimuli for TSH)
– For hypothyroidism: expect ↑TSH
(compensatory); ↓T3, T4, and FT4
HYPOTHYROIDISM
• MEDICAL MANAGEMENT
– Medications: replacement therapy; titration
needed
– Synthroid
– Levothyroid
– Proloid
– Cytomel
• Symptomatic treatment
HYPOTHYROIDISM
• NURSING INTERVENTION/PT. TEACHING:
– For the hospitalized pt. with severe
hypothyroidism  focus on symptom relief
• Watch for s/sx hyperthyroidism while adjusting doses of
replacement medication
• Watch for chest pain or dyspnea
• Keep room 70-74⁰F
• Avoid the pt. getting chilled
• BM monitor/protocol
HYPOTHYROIDISM
– NURSING INTERVENTIONS/PT. TEACHING cont.
• Diet : ↑protein, fiber, fluid
↓ calories
Adequate iodine intake
– Instruct pt. to take med daily and not to stop
without consulting his MD
– Instruct pt./family – to anticipate clearing of
mental slowness as pt. adjusts to dose of med
HYPOTHYROIDISM
• NURSING DIAGNOSES:
– Decreased cardiac output r/t decreased
metabolism
– Constipation r/t decreased peristalsis
– Risk for noncompliance r/t therapy
– Risk for disturbed body image, r/t altered physical
appearance (goiter)
HYPOTHYROIDISM
• PROGNOSIS: Pt. will do well with medication
and medical supervision.
• In children, if the T4 replacement begins
before the epiphyseal fusion, chance for
normal growth is greatly improved
– https://www.youtube.com/watch?v=sVa0L1Rka4Y
(Hypo/hyper/goiter symptoms & treatment 4 min 3 sec)
SIMPLE (COLLOID) GOITER
• ETIOLOGY/PATHOPHYSIOLOGY
– Enlarged thyroid due to low iodine levels or the
gland’s inability to use the iodine properly
– Enlargement is caused by the accumulation of colloid
in the thyroid follicles
• When blood level of T3 is too low to signal the pituitary
gland to reduce TSH secretion, the thyroid gland responds by
increased formation of thyroid globulin (colloid) 
accumulates in the thyroid follicles  gland enlargement
– Usually caused by insufficient dietary intake of iodine
 overgrowth of thyroid tissue
GOITER
SIMPLE (COLLOID) GOITER
• CLINICAL MANIFESTATIONS/ASSESSMENT
– Assessment based on physical manifestations:
– SUBJECTIVE ASSESSMENT:
• Enlargement of the thyroid gland
– Pt. emotional response to the enlargement
• Interview to determine pt. need for medication, diet,
and medical follow up
• May c/o: Dysphagia, Hoarseness. Dyspnea
SIMPLE (COLLOID) GOITER
• CLINICAL MANIFESTATIONS/assessment
– OBJECTIVE DATA:
• Assess increase of goiter
• Voice changes
• Adequate food/fluid intake
• MEDICAL MANAGEMENT
• Potassium iodide
• Diet high in iodine
• Surgery—thyroidectomy
SIMPLE (COLLOID) GOITER
• NURSING INTERVENTIONS/GOALS
– Post Thyroidectomy: prevent complications such
as bleeding, tetany, and thyroid crisis
– Interventions: (discussed previously)
• NSG. DIAGNOSES
– Risk for non-compliance with therapeutic regimen
– Risk for disturbed body image r/t physical
appearance
Figure 51-10
Simple goiter.
Thyroid Cancer
• ETIOLOGY/PATHOPHYSIOLOGY
• Malignancy of thyroid tissue; rare
• About 75% are papillary well-differentiated adeno
carcinoma- grows slowly, usually contained, doesn’t
spread beyond adjacent lymph nodes; cure rates are
excellent.
• CLINICAL MANIFESTATIONS
–Firm, fixed, small, rounded mass or nodule
on thyroid
CANCER OF THYROID
Thyroid Cancer
• Assessment
– SUBJECTIVE ASSESSMENT
• Pt. coping method and support system
• Pt. understanding of importance of medical follow up
– OBJECTIVE ASSESSMENT
• Progressive enlargement of tumor area
• Response to 131I tx.
• Skin care post radiation
Thyroid Cancer
• DIAGNOSTIC TESTS:
• Thyroid scan
• Thyroid function tests
• Needle bx.
• MEDICAL MANAGEMENT
• Total thyroidectomy
• Thyroid hormone replacement
• If metastasis is present: radical neck dissection;
radiation, chemotherapy, and radioactive iodine
CANCER OF THE THYROID
CANCER OF THE THYROID
Thyroid Cancer
• NURSING INTERVENTIONS/Pt. TEACHING
– Per thyroidectomy (previously discusses)
– Post op:
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Risk for respiratory distress
Risk for laryngeal damage
Bleeding
S/sx hypothyroidism
Thyroid Cancer
• NURSING DX.
– Anxiety r/t situational crisis
– Ineffective coping r/t personal vulnerability in a
crisis
• Pt. Teaching:
– Proper medical follow up
– Monitor thyroid replacement therapy
– Proper care of surgical incision
PARATHYROID GLANDS
Website written information resource for students:
http://www.parathyroid.com/hypoparathyroidism.htm
HYPERPARATHYROIDISM
http://www.youtube.com/watch?v=sD9st1ZPFrQ
• ETIOLOGY/PATHOPHYSIOLOGY
– Overactivity of the parathyroid glands, with
increased production of parathyroid hormone
(PTH)
– Hypertrophy of one or more of the parathyroid
glands (usually in the form of an adenoma)
– Also from: CRF, Pyelonephritis, glomerulonephritis
HYPERPARATHYROIDISM
• CLINICAL MANIFESTATIONS
– Hypercalcemia – primary clinical manifestation
• Calcium leaves the bone  serum calcium
increases
• Bones become demineralized  formation of
renal calculi, pathological fx.
• Skeletal pain; pain on weight-bearing
HYPERPARATHYROIDISM
• SUBJECTIVE ASSESSMENT
– As a result of neuromuscular dysfunction, pts. c/o:
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•
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Fatigue, drowsiness
nausea, anorexia;
severe skeletal pain, muscle weakness
constipation
personality changes, disorientation
HYPERPARATHYROIDISM
• OBJECTIVE ASSESSMENT
– Skilled observation for:
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Skeletal deformity
Abnormal movement
Urine results
Vomiting, weight loss
HTN
Cardiac dysfunction
Bradycardia
↓ LOC
HYPERPARATHYROIDISM
• DIAGNOSTIC TESTS
– RADIOGRAPHS/XRAYS
– PTH blood level (usually ↑)
– Ca++ levels
– Bone Density measurements
– MRI, CT, and US to localize an adenoma
Hyperparathyroidism
HYPERPARATHYROIDISM
• MEDICAL MANAGEMENT
• Removal of tumor
• Removal of one or more parathyroid glands
• Autotransplantation
• NURSING INTERVENTIONS/Pt. TEACHING
– Assess for hypercalcemia
– Restore fluid and electrolyte imbalance
– Diet: low in calcium
HYPERPARATHYROIDISM
• NURSING INTERVENTIONS/Pt. TEACHING cont.
– Postoperatively, assess for hypocalcemia
• Tetany, cardiac dysrhythmia, carpo-pedal spasms
– Pain management – skeletal, renal stones
• NURSING DIAGNOSES
– Activity intolerance r/t neuromuscular dysfunction
– Acute pain r/t skeletal – joint pain, renal colic
HYPERPARATHYROIDISM
• PATIENT TEACHING
– Body mechanics to prevent pathological fx
– Mild exercise
– Urine checks for blood and stones
• PROGNOSIS: can lead a normal life with
proper med-surg tx. With cancer dx. –
prognosis is poor
HYPOPARATHYROIDISM
http://www.youtube.com/watch?v=E9QvAdxeap0
(2 min 42 sec)
• Etiology/pathophysiology
– Decreased parathyroid hormone  Decreased
serum calcium levels
– Most common causes:
• Inadvertent removal or destruction of one or more
parathyroid glands during thyroidectomy
• Also, can be autoimmune or familial in origin
HYPOPARATHYROIDISM
• CLINICAL MANIFESTATIONS
– Lab results show:
• ↓serum Ca++ and ↑ serum phosphorus 
Neuromuscular hyperexcitability
• Involuntary and uncontrollable muscle spasms
• Hypocalcemic tetany
HYPOPARATHYROIDISM
• CLINICAL MANIFESTATIONS cont.
– Severe hypocalcemia:
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Laryngeal spasms
Stridor
Cyanosis/asphyxia
Parkinson-like syndrome
Chvostek’s and Trousseau’s signs
TROUSSEAU’S SIGN
HYPOPARATHYROIDISM
• ASSESSMENT
– SUBJECTIVE DATA – evidence of and/or c/o:
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Dysphagia
Numbness/tingling lips, fingertips
Increased muscle tension
Parasthesis and stiffness
c/o anxiety, irritability, depression
Headaches
nausea
HYPOPARATHYROIDISM
• ASSESSMENT
– OBJECTIVE DATA
•
•
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+ Chvostek’s and Trousseau signs
Laryngeal spasm, stridor, cyanosis
Decreased cardiac output, dysrhythmias
Tetany
HYPOPARATHYROIDISM
• DIAGNOSTIC TESTS
– Serum PTH, Phosphorus, Calcium
– Urinary calcium and phosphorus
–  if + for hypoparathyroidism, results will be:
• ↓ PTH, and serum Ca++ and ↑ urinary Ca++, with
• ↑ serum phosphorus and ↓ urinary phosphorus
HYPOPARATHYROIDISM
• MEDICAL MANAGEMENT
– Blood tests r/t ca levels
• Calcium gluconate or calcium chloride will be given IV
for hypoparathyroid tetany
– NURSING: if IV rate is too rapid  ↓ BP, serious
cardiac dysrhythmias/ cardiac arrest
– IV may be irritating to vessel wall; watch for s/sx
extravasation
– EKG monitoring
• Vitamin D orally – improves GI absorption of Ca++
HYPOPARATHYROIDISM
• NURSING INTERVENTIONS
– Monitor for hypercalcemia:
• Vomiting, disorientation, anorexia, abdominal pain,
weakness
– Assess for:
• Respiratory function
• VS – bradycardia, syncope, hypotension
• Renal involvement
HYPOPARATHYROIDISM
• NURSING INTERVENTIONS cont.
– Preferred medications:
• Hytakerol
• Calcitriol (Rocaltrol)
– Diet: ↑ dairy, dark green leafy veg., soybeans,
tofu, canned fish with bones
HYPOPARATHYROIDISM
• NURSING DIAGNOSES:
– Risk for injury r/t postop hypocalcemia
– Imbalanced nutrition, less than body
requirements, r/t calcium intake
• Nearly all interventions r/t ca levels

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