Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 1 Chapter 45 Thyroid and Parathyroid Disorders

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 2 Learning Objectives  Identify nursing assessment data related to the functions of the thyroid and parathyroid glands.  Describe tests and procedures used to diagnose disorders of the thyroid and parathyroid glands and nursing responsibilities relevant for each.  Describe the pathophysiology, signs and symptoms, complications, and treatment of hyperthyroidism, hypothyroidism, hyperparathyroidism, and hypoparathyroidism.  Assist in the development of nursing care plans for patients with disorders of the thyroid or parathyroid glands.

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 3 THE THYROID GLAND What does this gland produce?

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 4 The Thyroid Gland  Plays a major role in metabolism and G & D  Thyroid hormone ( thyroxine or T4 )  Triiodothyronine ( T3 )  Both ^ the bodies rate of metabolism  Calcitonin regulate serum calcium levels

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 5 Age-Related Changes in Thyroid Function  Increased incidence of thyroid nodules  Serum levels of T 4 remain approximately the same in a healthy older person, but levels of T 3 often decline  Incidence of hypothyroidism increases with age, especially among women

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 6 Assessment of the Thyroid Gland  Health history & PE for pts w/ Thyroid Disorders.. Ask about…  Changes in energy level, sleep patterns, personality, mental function, emotional state  Unexplained weight changes  Changes in menstrual cycles, sexual function, hydration, bowel elimination pattern, and tolerance of heat and cold

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 7 Assessment of the Thyroid Gland cont’d  Diagnostic tests and procedures  Serum T 3, free T 4, T 4, and TSH  Thyroid-releasing hormone (TRH) stimulation test  Radioactive iodine (RAI) uptake test  Thyroid ultrasonography  MRI or CT  Review Table 45-1 for patient preparation

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 8 What gland sends TSH to stimulate the Thyroid gland to produce T 3 and T4?

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 9 CRITICALLY THINK NOW !  If the lab values of your patient indicate an increased level of TSH and a lower than normal level of T4 hormone,  What might this indicate to you? What gland is not responding? The thyroid or the pituitary gland? And Why ?

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 10 Hyperthyroidism

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 11 Characteristics of Hyperthyroidism  Abnormally increased synthesis and secretion of thyroid hormones  Graves disease  Most common type of hyperthyroidism  Autoimmune disorder  Antibodies activate thyroid-stimulating hormone (TSH) receptors, which in turn stimulate thyroid enlargement and hormone secretion  Most often develops in young women

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 12 Multinodular Goiter  Often in women in their 60s and 70s  Likely develop in people who have had goiter for a number of years  Caused by small thyroid nodules that secrete excess thyroid hormone  Increased hormone production is independent of TSH  Nodules can be benign or malignant  Symptoms are usually less severe

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 13 Signs and Symptoms  Weight loss and nervousness with a mild form  In more severe cases  Restlessness, irritable behavior, sleep disturbances, emotional lability, personality changes, hair loss, and fatigue  Weight loss, even when the patient is eating well, is common  Poor tolerance of heat and excessive perspiration  Changes in menstrual and bowel patterns  Warm, moist, velvety skin; fine hand tremors; swelling of the neck; and ophthalmopathy including exophthalmos  Tearing, light sensitivity, decreased visual acuity, and swelling around orbit of the eye  Tachycardia, increased systolic blood pressure, sometimes atrial fibrillation

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Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 15 Complications  Thyrotoxicosis (aka: Thyroid Storm or Crisis )  Excessive stimulation caused by elevated thyroid hormone levels that produce dangerous tachycardia and hyperthermia

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 16 Medical Diagnosis  Decreased TSH and elevated serum T 4  Measurement of thyroid-stimulating antibodies and results of a radioactive iodine uptake test to diagnose Graves disease

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 17 Medical Treatment  Goal  dec. excessive thyroid hormone prod.  Drug therapy  Antithyroid drugs  Tapazole, Lugol’s solution  Radioactive iodine  Accumulates in the thyroid gland, where it causes destruction of thyroid tissue  Surgical treatment  Subtotal thyroidectomy

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 18 Surgical Treatment  Thyroidectomy or subtotal thyroidectomy  PreOp teaching is important !  Drsg is on front of neck  Avoid straining of neck, support head  Turn/deep breath… limit coughing

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 19 Care of the Patient Having a Thyroidectomy  Assess respiratory status  Elevate HOB  Assess LOC  Assess wound drng  Voice quality  Neuromuscular irritability ( tetany )  Chvostec’s Sign and Trousseau’s Sign

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 20 Hypothyroidism  Inadequate secretion of thyroid hormones  Cretinism  If not treated early, hypothyroidism during infancy causes permanent physical and mental retardation  In adults can be serious but usually reversible with treatment  Myxedema  Facial edema from severe, long-term hypothyroidism

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Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 23 Cause and Risk Factors  Primary  Atrophy of the thyroid gland after years of Graves disease or thyroiditis  Treatment for hyperthyroidism  Dietary iodine deficiency  High intake of goitrogens  Defects in thyroid hormone synthesis  Secondary  Pituitary disorders or Thyroidectomy

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 24 Signs and Symptoms  Swelling of the lips and eyelids  Dry, thick skin  Bruising  Thin, coarse hair  Hoarseness  Generalized &/or Facial edema  May seem slow, depressed, or apathetic

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 25 Signs and symptoms may be more subtle in the elderly or may be masked by other diseases. Note  Thyroid function tests should be routine in the elderly population

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 26 Medical Diagnosis  Based on laboratory determination of free T 4 and TSH  Complications  Myxedema coma  Medical treatment  Hormone replacement therapy Levothyroxine (Synthroid) or liothyronine (Cytomel) Levothyroxine (Synthroid) or liothyronine (Cytomel)

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 27 Nursing Dx  What are your Interventions?  Activity Intolerance  Imbalanced Nutrition: More Than Body Requirements  Hypothermia  Constipation  Risk for Impaired Skin Integrity  Decreased Cardiac Output  Disturbed Thought Processes  Disturbed Body Image  Self-Care Deficit

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 28 Medical Treatment for Hypothyroidism  Synthroid  Cytomel  Patient’s will require lifelong hormone replacement therapy and should be monitored to evaluate the response to therapy

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Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 30 Simple Goiter  Term used to describe the enlargement of the thyroid gland  Causes Iodine deficiency and long-term exposure to goitrogens Iodine deficiency and long-term exposure to goitrogens The gland may enlarge to compensate for hypothyroidism The gland may enlarge to compensate for hypothyroidism Sometimes the enlarged gland produces excess hormones, making the patient hyperthyroid Sometimes the enlarged gland produces excess hormones, making the patient hyperthyroid

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 31 Simple Goiter cont’d  Treatment (dependent on cause)  If mild enlargement and normal hormones, no intervention  Some patients need hormone replacement therapy  Surgery indicated if pressure on the trachea or esophagus or if the condition is disfiguring  If pt. is hyperthyroid  tx may be 2-3 wks of iodine, repeated 3-4/x each year to reduce gland activity, but does not cure the goiter.

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Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 33 Thyroid Cancer  Uncommon  Fatal in less than 1% of all cases  Early stages: nodule that can be felt on thyroid  If cancer spreads, enlarged lymph nodes felt in the neck  Patient may not show dramatic changes in thyroid hormone levels  Total thyroidectomy is the usual treatment, f/b thyroid replacement therapy  If malignancy spreads beyond thyroid gland, more radical surgery may be indicated

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 34 The Parathyroid Glands

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Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 36 Nursing Assessment & PE  Physical examination  Heart rate and rhythm, blood pressure, respiratory effort, muscle strength, muscle twitching, and hair and skin texture  Chvostek sign Spasm of facial muscle when facial nerve tapped Spasm of facial muscle when facial nerve tapped  Trousseau sign Carpopedal spasm when a blood pressure cuff is inflated above the patient’s systolic blood pressure and left in place for 2 to 3 minutes Carpopedal spasm when a blood pressure cuff is inflated above the patient’s systolic blood pressure and left in place for 2 to 3 minutes

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Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 38 Diagnostic Tests and Procedures  Blood tests  Radiographs  Dental examination  Electrocardiogram

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 39 Hyperparathyroidism  High levels of PTH  elevated bld calcium levels (hypercalcemia)  Pathologic (spontaneous) fractures (from Ca shifting into blood)  Renal calculi and obstruction  Dysrhythmias and hypertension  Nrsg. Dx  Impaired urinary elimination r/t urinary calculi

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 40 Signs and Symptoms  Symptoms vague at first  Weakness, lethargy, depression, anorexia, and constipation  Elevated serum calcium levels  Other findings include mental and personality changes, cardiac dysrhythmias, weight loss, urinary calculi, poor muscle tone, bone pain, HTN, fractures

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 41 Medical Diagnosis  Elevated serum calcium and decreased serum phosphate  Elevated PTH and 24-hour urine calcium  Skeletal radiographs and bone density studies

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 42 Surgical Treatment  Surgical intervention if tumor is cause  Parathyroidectomy  Surgeon attempts to leave some parathyroid tissue to prevent hypoparathyroidism

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 43 Medical & Nursing Treatment  Inc. Fluids  dilutes urine  Phosphates  reduces calcium level  Limit dietary calcium  Calcitonin

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 44 Postoperative Care  Airway obstruction from accumulated fluid and blood in surgical site compressing the trachea  Monitor and document the respiratory rate and effort and the pulse rate  Increasing pulse and respiratory rates, especially accompanied by restlessness, suggest inadequate oxygenation  Notify physician of indications of respiratory distress  Keep an emergency tracheotomy tray at the bedside in the event of acute obstruction

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 45 Postoperative Care cont’d  Airway obstruction related to severe hypocalcemia  Be alert for tetany  Tingling around mouth and in the fingers  It may progress to severe muscle spasms or cramps and even to laryngospasm  Treated with oral or intravenous calcium supplements

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 46 Postoperative Care cont’d  Protect suture line from stress  Show patient how to support the head when changing positions  Inspect dressing and back of the neck for bleeding  Elevate patient’s head to reduce swelling

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 47 Hypoparathyroidism  Deficiency of (PTH)  Uncommon condition  Usually caused from accidental removal of/damage to parathyroid glands during surgery  Inadequate secretion of PTH leads to hypocalcemia  Severe hypocalcemia can progress to convulsions and respiratory obstruction due to spasms of the larynx

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 48 Hypoparathyroidism S/S  Classic signs  + Chvostek’s and Trousseaus sign  Fatigue and weakness  Tingling/twitching of face  Mental/emotional changes’  Dysrhythmias  Nrsg. Dx  Decrease Cardiac Output r/t hypocalemia

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 49 Med/Nursing Treatment  Oral Calcium salts  Vitamin D  Teach patients s/s of calcium imbalances  Instruct to wear medical alert bracelet

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 50 CRITICAL THINKING QUESTION  A 46-year-old woman is experiencing fatigue and weight gain despite decreased food intake. Her hair is thinning and her skin is very dry. She reports that she has had mild swelling in her legs. She also reports feeling irritable and depressed. Laboratory tests reveal a low serum T4 level and an elevated serum TSH level. What is the likely diagnosis and what information can the nurse provide to the patient about her condition?

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 51 QuizletQuizlet for learning, reviewing and revising Endo Quizlet

Elsevier items and derived items © 2012 by Saunders, an imprint of Elsevier Inc. 52 THAT IS IT ! YOU’VE MADE IT THROUGH ENDO… NOW REMEMBER WHAT YOU HAVE LEARNED AND APPLY IT WHEN IN THE CLINICAL SETTING !