Chapter 35 Care of the Clients with Thyroid and Parathyroid Disorders

Location of Endocrine glands

Actions of the “Master Gland”

Function of the Endocrine system Hormones are controlled by: Negative feedback control Circadian rhythms Stress

Example of Negative feedback control

Thyroid gland Where is it located? What does it do?

Assessment of the Thyroid gland

Diagnostic exams to assess function of the Thyroid gland TRH stimulation test TSH stimulation test TSH Serum T4 Serum T3 Free T4 Thyroid scan Ultrasound

Hyperthyroidism Caused by an excess production of thyroid hormone. More often in women and older adults. Disorders associated with hyperthyroidism are 1. Graves disease- most common cause of hyperthyroidism. Autoimmune disorder Thyrotoxic Crisis- Thyroid storm, rare today. 3. Caused by: auto immune response, excessive doses of thyroid medication or by excess secretion of thyroid-stimulating hormone from the pituitary gland. Result is increase in metabolic rate.

Hyperthyroidism Hyperthyroidism can place a strain on the cardiovascular system. If left untreated can result in cardiac dysrhythmias and heart failure. Increased metabolism of CHO proteins and lipids client has increased appetite yet loses weight. Nutritional deficiencies can occur. Multisystem manifestations. See text.

Graves’ Disease Most common cause of hyperthyroidism, autoimmune disorder. More often in women under age of 40 than general population. Increased production of TH results in enlargement of the thyroid gland or Goiter. Also causes forward protrusion of the eyeball called exophthalmos. This can lead to corneal dryness, infection and ulceration of the eyeball due to protruding eyeball.

Hyperthyroidism vs Graves (cont) Hyperthyroidism Most common cause= toxic multinodular goiter What is Exopthalmos? What causes Exopthalmos?

Exophthalmos

What is a goiter Is is a tumor? Why do people get goiters?

Goiter

Thyroid Crisis (Storm) Extreme state of hyperthyroidism rare today. Untreated hyperthyroidism or from hyperthyroidism along with a stressor such as infection untreated DKA, physical or emotional trauma or thyroid surgery. Life threatening condition and requires immediate medical attention. CM- fever over 102F, tachycardia, hypertension, restlessness and tremors, confusion, delirium, coma and seizures. Antithyroid medications (PTU) are given reduce thyroid production

Goiter

Hyperthyroidism Care Interdisciplinary: Reducing the production of TH and preventing or treating complications. DX: H&P. laboratory test elevated serum T3, and T4 decreased TSH levels 1. Medications to inhibit thyroid production- takes several weeks to see results. 2. Radioactive iodine therapy- destroy thyroid cells. 3. Surgery- partial removal of the thyroid gland. Discussion Textbook! Complications! Hypocalcemia, tetany.

Nursing Diagnosis for Hyperthyroidism Risk for Imbalanced Nutrition: Less than body requirements Fatigue Risk for Decreased Cardiac Output Risk for Injury: Corneal Abrasion Distrurbed Body Image

Tetany Trousseau’s sign

Tetany Chvostek’s sign

Getting ready for the post-op thyroidectomy client Calcium Gluconate Freq. Ca levels Tracheostomy set at bedside Oxygen therapy Suction

Case study, Thyroid Ms. Bernice Bell is a 40 year old single mother of two children. She works as a high school counselor and is a member of the city council. She was diagnosed with hyperthyroidism and is being admitted to the hospital for I 131 treatment. She is extremely anxious about the procedures as well as the results it will produce.

Questions 1-4, thyroid case 1. What signs and symptoms might you expect to find during your assessment? 2. Why should Ms. Bell undergo a cardiac assessment? 3. What labs should be drawn and what findings would you expect? 4. What is Graves disease?

Question 7, thyroid case 7. Ms. Bell did not respond to I131 and will have to undergo a thyroidectomy. A. ) What is the pre-op care for Ms. Bell? B.) What are the complications associated with a thyroidectomy? C) What is the nursing care for the post op thyroidectomy client?

Hypothyroidism Cause: Thyroid surgery Radioactive iodine therapy Lack of iodine—underdeveloped countries—lack in soil and water

Signs and symptoms of Hypothyroidism Freq. Sleeping Weight gain Low appetite Low temp—cold intolerance Low B/P Constipation Goiter Slow onset of all CM months or years. See textbook. Discussion

Untreated Hypothyroidism leads to Myxedema Coma Life threatening Cause: stress, untreated hypothyroidism Appearance Coarse features, edema around the eyes and face, a blank expression and a thick tongue

Goiter When TH production decreases the thyroid gland enlarges in an attempt to produce more hormone. This enlargement is called a goiter. Iodine deficiency can result in hypothyroidism. Iodine is necessary for TH synthesis and secretion. Iodized salt has reduced this risk in the US.

Myxedema/Hypothyroidism

Myxedema Coma Life threatening form of hypothyroidism requires immediate medical attention. Exposure to cold temperatures, infection or surgery along with trauma or use of central nervous system depressants- narcotics and tranquilizers. Winter older women with hypothyroidism TX: intravenous thyroid hormone. Text.

Hypothyroidism Hashimoto’s thyroiditis- most common cause of primary hypothyroidism. Autoimmune disorder antibodies destroy thyroid tissue. Primary CM is goiter Common women years old family history of thyroid disease.

Treatment of Hypothyroidism Thyroid replacement Synthyroid - Levothyroxine IV PO Final dose determined by TSH levels Subtotal Thyroidectomy

Nursing Diagnosis Hypothyroidism Decreased Cardiac Output Imbalanced Nutrition: More than body requirements Activity Intolerance Disturbed Thought Processes Bowel elimination

Critical thinking challenge The client is a 22 yr college senior nursing student who has been brought to the health center by her friends, who say she is not “acting right”. This former straight A student has been oversleeping and missing classes. Her grades have dropped to B’s and C’s. She has gained 40 lbs during the past semester and has not had a period for 5 months.She is wearing 2 sweaters and asking for a blanket even though the room is quite warm.

Do you think it is Hypothyroidism? What assessment data should you obtain first? What comfort measures will you provide to this client? What questions will you ask the client, and what questions will you ask her friends?

Parathyroid hormone Secreted by: Parathyroid Gland Controlled by: Calcium levels Remember—we are talking about calcium in the serum (blood) Where does the calcium come from? Bones Urine

Hyperparathryoidism Causes: Cancer Neck trauma Chronic renal failure What happens? PTH excretion

Hyperparathyroidism (Cont.) What happens? (cont) Increase calcium out of the bone and decrease calcium excretion in the urine Bone fractures Bone cysts Osteoporosis Renal calculi Results in serum calcium levels Results in serum phosphorus levels

Relationship of Calcium and Phosphorus

Calcitonin When does Calcitonin get released? Calcitonin decreases bone breakdown of calcium Remember: Calcitonin calcium Phosphorus

Parathyroid Hormone (PTH) PTH= Calcium levels PTH = Phosphorus levels

Hyperparathyroidism (Cont.) Treatment: Bisphosphonates Calcitonin Lasix Hydration Surgery

Hypoparathryoidism Causes: Thyroidectomy Hypomagnesemia—this causes impairment of PTH secretion and may decrease effectiveness of PTH on bones and kidneys

Hypoparathryoidism (cont.) Vitamin D is needed for calcium absorption PTH= decreased calcium levels Decreased calcium levels= Tetany S/S of Tetany?

Results of low serum calcium Numbness and tingling (circumoral) (+) Chvostek’s sign (+) Trousseau’s sign Cataracts Mental changes Loss of calcium from the teeth with enamel loss

Tetany Chvostek’s sign

Tetany Trousseau’s sign

Nursing Diagnosis Hyperparathyroidism Main treatment is surgical removal of the parathyroid glands. Nursing care is the same for that of a client having a thyroidectomy. Prioritizing Nursing Care: See text discussion.

Nursing Diagnosis Hypoparathyroidism 1. Risk for ineffective airway clearance R/T laryngeal muscle spasms 2. Risk for injury R/T tetany 3. Acute confusion r/t parathyroid disorder