Nursing Care & Interventions for the Client with Disorders of the Thyroid Gland Keith Rischer RN, MA, CEN Hyperthyroid common endocrine disorder…graves disease most common 20-40 Women 4x more than men 1

Today’s Objectives… Compare and contrast pathophysiology & manifestations of thyroid/parathyroid gland dysfunction. Identify, nursing priorities, and client education associated with thyroid/parathyroid gland dysfunction. Interpret abnormal laboratory test indicators of thyroid/parathyroid gland dysfunction. Analyze assessment to determine nursing diagnoses and formulate a plan of care for clients with thyroid/parathyroid gland dysfunction. Describe the mechanism of action, side effects and nursing interventions of pharmological management with thyroid/parathyroid gland dysfunction.

Thyroid Glands:Patho Thyroid gland Functions Thyroxin (T3) Triiodothyronine (T4) Functions Controls metabolism of all cells Regulate protein, CHO, fat metabolism Exert chronotropic/inotropic cardiac effects

Hyperthyroidism:Causes Graves disease Goiter T3 Thyrotoxicosis Thyroid cancer Tumors in body Hyperthyroidism-normal feedback control over thyroid hormone secretion Excess secretion incr metabolism and SNS activity Graves disease Autoimmune…antibodies increase size of gland and incr production of hormones Goiter Multiple thyroid nodules…hyperfunction T3 Thyrotoxicosis Increase in t3 secretion-unknown cause Thyroid cancer uncommon Tumors in body Secrete TSH or thyroid hormones mimicking hyperthyroid activity 4

Hyperthroidism: Assessment chart 67-1 p.1482 Early Visual changes Blurred Double vision Photophobia Heat intolerance/diaphoresis Weakness, fatigue Other exopthalmos Tachycardia or systolic hypertension Agitation, tremors, anxiety Palpitations Increased libido, amenorhea Restlessness, confusion, psychosis seizures Because thyroid hormones impact overall metabolism, lyte balance and excitable membrane activity…influence is significant and systemic Mild…symptoms are subtle…severe can be life threatening Treatment of hyperthyroidism does not correct eye and vision problems of Graves’ disease. Exopthalmos….edema in extraocular muscles and increased fatty tissue behind eyes which pushes eyes out forward 5

Hyperthyroidism:Diagnostic Tests Serum thyronine (T4) Serum Triodothyronine (T3) Thyroid stimulating hormone (TSH) low in Graves high in secondary (due to pituitary disorder) Thyroid scan increase radioactive iodine uptake Ultrasound ECG 6

Nursing Diagnostic Priorities Imbalanced nutrition…less than body requires High in calories, proteins, and carbohydrates with supplemental feedings Hyperthermia r/t increased metabolic rate Bedding change frequently (diaphoresis) Sponge baths Cool environment Fatigue r/t sleep deprivation Encourage rest – fatigue Keep environment quiet Deficient knowledge Exopthalmos NUTRITION Dietary intake of iodine is needed to produce thyroid hormones Exopthalmos Elevate the head of bed at night. Tape eyelids if will not close Instill artificial tears. Treat photophobia with dark glasses. Give steroid therapy.

Thyroid Crisis/Storm Patho Uncontrolled hyperthyroidism Excess thyroid hormone release Physical assessment Extreme temperature Hypertension Tachycardia Treatment Inderal Closely monitor VS-rhythm-temp Fever reduction Mortality rate 25% Triggered by trauma, infection, pregnancy, diabetic ketoacidosis Other sx Restless, confused, psychotic, seizures leading to coma TREATMENT Maintain airway (ABCs) Provide adequate ventilation Stabilize hemodynamic status Medications to decrease overactive thyroid symptoms: 8

Hyperthyroidism:Medical Management Antithyroid medications Propylthiouracal (PTU) block synthesis of thyroid hormone Iodine (SSKI) reduce vascularity of thyroid gland Beta blockers Radioactive iodine therapy To ablate thyroid to make the pt become hypothyroid; Taken orally Relief of symptoms may take 6-8 weeks Radioactive iodine therapy Easier to treat hypothyroidism than hyperthyroidism Not used in pregnant women 9 9

Hyperthyroidism:Surgical Management Preop care Post op care ABC’s Humidified O2 Support of neck with movement & coughing Semi-Fowlers position Incisional care Postoperative complications Hemorrhage Respiratory distress Stridor Tracheotomy equipment readily available Laryngeal nerve damage Hoarseness/weak voice Surgery possible in absence of good response to drug therapy. Removal of all or part of thyroid gland Pt is euthyroid—normal thyroid through anti-thyroid drugs state before surgery Preop care…HTN-dysrhythmias and tachy must be controlled…improve nutritional status Post op care 10

Hypothyroidism Patho Causes Decreased metabolism Myxedema coma Cellular edema Generalized NP edema…eyes, hands, feet, tongue Causes Thyroid surgery/radioactive iodine treatment Iodide deficiency Can occur anytime in lifespan Most often seen in women 30-60 yrs Women have 7-10x more often Correlation between hypothyroid and DM PATHO Cells damaged Thyroid functional but iodide deficient Lowered metabolism causes ant pituitary to make TSH in higher amount-which then causes thyroid to enlarge Myxedema…abnormal metabolites build up in cells which increases water and mucous inside cells 11 11

Hypothyroidism: Assessment chart 67-5 p.1488 Change in sleep habits more lethargic Decreased libido Generalized weakness Muscles aches Cold intolerance Constipation 12

Myxedema Coma Those at highest risk Surgery Chemo Withdrawal thyroid meds Assessment Respiratory failure Hypotension Labs Emergency care ABC’s Replace fluids Administering meds. Steroids, IV glucose, Levothyroxine sodium (thyroid) Monitor Temp. & BP frequently Those at highest risk New dx hypothyroidism Hypothyroid with other medical problems Untraeted leads to Coma, respiratory failure, hypotension, Labs… hyponatremia, hypothermia, hypoglycemia 13

Hypothyroidism: Diagnostic Tests Laboratory studies Serum T3 Serum T4 TSH high in primary Low in secondary Treat with Lifelong thyroid replacement Levothyroxine (Synthroid) Assess thyroid levels. May start low to avoid cardiac problems 14 14

Nursing Diagnostic Priorities Decrease cardiac output Assess for bradycardia, dysrhythmias O2 if needed Ineffective Breathing pattern care when giving sedation Disturbed thought processes assess lethargy, memory deficit, poor attention span, difficulty communicating Constipation Deficient knowledge Deficient knowledgeTeach S/S of hyperthyroidism and hypothyroidism 15 15

Hyperparathyroidism Parathyroid glands Labs Causes Regulate calcium and phosphate balance Labs Hypercalcemia and hypophosphatemia Causes Tumor Chronic renal failure Vit. D deficiency Neck trauma or radiation Patho Increased levels parathyroid hormone act directly on kidney causing increased kidney reabsorption of calcium and increased phosphate excretion Primary due to one or more parathyroid glands do not respond to normal feedback of serum calcium PHOSPHORUS Maintains cell metabolism Storage and utilization of cell energy Bone and tooth formation Calcium regulation Majority stored in bone CALCIUM MOST ABUNDANT CATION IN BODY 99% in bone Critical for nerve conduction, muscle contraction, hormone secretion, blood coagulation 16 16

Hyperparathyroidism: Assessment Bone fractures from demineralization from bones Recent weight loss Arthritis Psychological distress History of Radiation to neck GI N/V, diarrhea, constipation Renal stones 17

Hyperparathyroidism: Medical Management Diet restrict Calcium…esp milk products Medications Lasix Increased excretion of calcium Phosphates Inhibits bone resorption and interferes with calcium absorption Calcitonin Use to decrease skeletal calcium release Hyperparathyroidectomy Same Hyperparathyroidectomy as thyroidectomy 18

Hyperparathyroidism: Nursing Interventions Hydration (strict I & O) IV saline in large amounts and lasix to excrete calcium Assess for Congestive heart failure R/T fluid overload Cardiac monitoring Serum Calcium levels need to be done frequently Educate client to report N/V, palpations, numbness Care to reduce fractures – lift gently Ambulation helps prevent demineralization Observe for renal calculi 19