Thyroid & Parathyroid Dysfunction Kelly DeCoste, Ellie O’Brien & Clare Dearing

Objectives  Thyroid Statistics  Anatomy & Physiology of the Thyroid Gland  Thyroid Hormones, Calcitonin & Iodine  Thyroid Function Tests  Thyroid Dysfunctions (Definition, Cause, Diagnosis, Treatment, Medical Management)  Hypothyroidism & Hyperthyroidism  Hypoparathyroidism & Hyperparathyroidism  Thyroiditis  Thyroid Cancer  Case Study  Conclusion

Thyroid Statistics  Worldwide: estimated that 200 million people are affected by thyroid disease  1 in 10 Canadians suffer from some type of thyroid disease (Thyroid Foundation of Canada)  6,000 Canadians will be diagnosed with thyroid cancer. (Canadian Cancer Society)

Anatomy & Physiology of the Thyroid  The thyroid gland is a small butterfly-shaped gland located in the anterior portion of the neck.  It is the regulator of all body functions, with the major function being the production, storage, and release of the thyroid hormones, which are essential to all growth and metabolism.

Thyroid Hormones T3-Thyroxine T4-Tri-iodthyronine Actions: Influence every major organ system Control cellular metabolic activity Increase metabolic processes Help convert food into energy & heat Influence cellular replication Important in brain development Necessary for normal growth Increase body temperature

Calcitonin & Iodine

Thyroid Function Tests  Thyroid Stimulating Hormone (TSH)  Free Thyroxine (FT4)  Thyroxine (T4)  Tri-Iodothyronine (T3) The two tests most commonly used

Thyroxine (T4) & Tri-Iodothyronine (T3)  T4 is one of the first tests performed to diagnose thyroid function and makes up nearly all of thyroid hormone.  T3 is a measurement used to primarily diagnose hyperthyroidism. Only 7-10% of thyroid hormone is composed of T3.

Hypothyroidism  Thyroid gland becomes underactive and does not produce enough thyroid hormones.  Deficient levels of thyroid hormone can range from mild (subclinical forms) to myxedema (advanced, severe symptoms).  Primary: due to the malfunctioning of the thyroid gland itself.  Secondary: due to malfunctioning of pituitary gland, thyroid is not being stimulated by pituitary to produce hormones.  Most commonly affects women aged 30-60

Hypothyroidism: Causes  Hashimoto’s disease  Autoimmune disorder attacking the thyroid gland, damaging it resulting in underproduction of thyroid hormones. Results in inflammation of the thyroid and possibly goiter  Other causes:  Radiation of the head and neck  Patients with previous hyperthyroidism who have been treated with anti-thyroid medications/surgery

Hypothyroidism: S&S  Early Signs and Symptoms  Usually non-specific  Extreme fatigue  Hair loss, brittle nails, dry skin, numbness/tingling of fingers.

Myxedema  Severe/prolonged hypothyroidism leads to myxedema  Myxedema: physiological reaction to lack of sufficient thyroid hormone  Accumulation of mucopolyshaccharides in subQ tissues  Subnormal temp & pulse  Thickened skin  Mental processes dulled, enlarged tongue, slow speech  Cognitive changes similar to dementia  Cardiovascular changes: inc. cholesterol, atherosclerosis, coronary artery disease, poor left ventricular function

Myxedema Coma  If prolonged/untreated  Most extreme and severe stage of hypothyroidism  Pt is hypothermic and unconscious  High mortality rate

Medical Management  Restore metabolic state with hormone replacement therapy  Synthetic Levothyroxine (Synthroid)  Prevention of Cardiac Dysfunction

Nursing Management  Modifying activity  Monitor Physical Status  Promote Physical comfort  Provide emotional Support Remember: administer medications with caution as metabolic rates slowed. ** Opioids, anesthetic agents**

Hyperthyroidism  Thyroid gland produces an excess of thyroid hormones  More common in women  Most frequent between the ages of  Thyrotoxicosis-hypermetabolic state caused by excess T3 or T4

Clinical Manifestations

Hyperthyroidism  Causes  Graves’ Disease  Toxic Nodular Goitres  Thyroditis  Excessive ingestion of thyroid hormone  Diagnosis  Medical history  Physical exam  Blood tests (TSH & thyroxine)  Radioactive iodine uptake test  Thyroid scan

Graves’ Disease

Treatment of Hyperthyroidism  Drug Therapy  Anthithyroid drugs  Iodine  Beta Blockers  Radioactive Iodine Therapy  Surgical Therapy  Thyroidectomy  Nursing Management

Thyrotoxic Crisis “Thyroid Storm”  Manifestations of HYPERthyroidism are heightened  Life-threatening emergency!!!  Cause- infection, trauma, surgery  Signs & Symptoms  Treatment

Parathyroid Glands

Hypoparathyroidism  A rare condition associated with inadequate circulating PTH.  Signs & Symptoms: - Tetany, increased muscle tension, stiffness, painful tonic spasms, dysphagia, laryngospasms, Chvostek’s & Trousseau’s signs.  Diagnosis: - Abnormal laboratory findings which include decreased serum calcium and PTH levels and increased serum phosphate levels.  Management: - Treat acute complications, maintain normal serum calcium levels, and prevent long-term complications.

Inadvertent surgical removal = hypoparathyroidism

Phosphate levels RISE Calcium levels FALL

Trousseau’s Sign  A carpal spasm induced by inflating a blood pressure cuff above the systolic pressure for a few minutes.

Chvostek’s Sign  A contraction of facial muscles in response to a light tap over the facial nerve in front of the ear.

Hyperparathyroidism  An excess secretion of parathyroid hormone (PTH) from the parathyroid gland  Primary-benign neoplasm or a single adenoma, malignant tumor (rare), hyperplasia  Secondary-compensatory response to other causes of hypocalcemia

Hyperparathyroidsim  Manifestations  Loss of appetite, need more sleep, forgetfulness  Complications  Renal failure, pancreatitis, cardiac changes, fractures  Diagnosis  Blood tests, urine tests, bone mineral density test, diagnostic imaging

Hyperparathyroidism Treatment  Surgical-Parathyroidectomy  Most effective treatment  Non-Surgical  Annual tests (blood, urine & diagnostic imaging)  Drugs  Biophosphates, estrogen & progestin, oral phosphate, calcimimetics  Exercise  Nutrition  Nursing Management

Thyroiditis  There are three types of thyroiditis, each type characterized by inflammation, fibrosis or lymphocytic infiltration.  Can cause thyrotoxicosis, hypothyroidism or both  Acute Thyroiditis  Subacute Thyroiditis (2 types)  Chronic Thyroiditis (Hashimoto’s disease)

Thyroid Cancer  Accounts for 90% of endocrine malignancies. 47,000 new cases are diagnosed each year.  Papillary Adenocarcinoma (most common)  Follicular Adenocarcinoma  Medullary  Anaplastic  Thyroid lymphoma  Treatment: surgical removal, radioactive iodine used to eradicate residual affected thyroid tissue, thyroid replacement therapy (lifelong)

Case Study  Mrs. Graves is a 26 year-old female who presented to your clinic describing feelings of nervousness and irritability and difficulty sleeping at night. She has lost 15lbs in the last two months even though her eating & exercise patterns have not changed. Vitals signs are: BP 142/60, P 106, R 22, T Your physical exam reveals that she appears thin, restless & tearful. Her hair is thinning at the temples, her thyroid is enlarged & her eyes are protruding.

Nursing Diagnoses

QUESTIONS??

References  Canadian Cancer Society. (2014). Anatomy and physiology of the thyroid gland. Retrieved from  Endocrine Web. (2012). How Your Thyroid Works: “A Delicate Feedback Mechanism”. Retrieved from  Lewis, S. L., Heitkemper, M. M., Dirksen, S. R., O’Brien, P.G.,& Bucher, L. (2010). Medical-surgical nursing in Canada: Assessment and management of clinical problems Toronto: Elsevier Mosby  Mayo Clinic. (2012). Hyperthyroidism (overactive thyroid). Retrieved from conditions/hyperthyroidism/basics/definition/con  Mayo Clinic. (2014). Hyperparathyroidism. Retrieved from conditions/hyperparathyroidism/basics/definition/con  National Instituites of Health. (2014). Iodine: Fact Sheet for Health Professionals. Retrieved from  Pike-MacDonald, S. (2013). Mosby’s Canadian manual of diagnostic and laboratory tests. Toronto, ON: Elsevier  Thyroid Foundation of Canada. (2014). Hyperthyroidism (Thyrotoxicosis). Retrieved from