1. Endocrine Disorders Thyroid Gland
Jane E. Binetti DNP MSN RN

2. Thyroid Gland In the neck, anterior to the trachea Extremely vascular
Regulated by:
TSH
Produces and secretes
T4 (thyroxine)
T3 (triiodothyronine)
Calcitonin

3. What about Thyroid Gland
Thyroid disorders are the most common of all endocrine issues
Thyroid hormones regulate
Metabolism
Growth and development
Disorders of the thyroid
Goiter
Nodules
Thyroiditis
Hyper/hypo

4. Goiter Large thyroid gland Gland is stimulated to grow
Can lead to hyperthyroidism or hypothyroidism
Worldwide, most often due to lack of iodine
In US caused by:
Nodules, or over/under production of hormone
Goitrogens are thyroid inhibiting substances
Broccoli, cabbage, kale, cauliflower, mustard, peanuts
Lithium, amiodorone, salicylates, sulfonamides

5. More on Goiters Non toxic Goiters Nodular Goiter Toxic Nodular Goiter
Enlargement not from inflammation or cancer
Pt has normal thyroid levels
Nodular Goiter
Secrete thyroid hormone without TSH stimulation
Usually benign adenoma
Toxic Nodular Goiter
Toxic because they cause hyperthyroidism
Most frequent after 40
Common in Grave’s Disease

6. Thyroiditis Inflammation of thyroid that can cause a goiter Types
Subacute - viral infections
Acute - bacteria and fungus
Hashimoto’s is autoimmune; tissue is destroyed by antibodies
Silent painless goiter occurs within 6 mo post partum
Autoimmune reaction to fetal cells in the mom’s thyroid ? Early Hashimoto’s?

7. Thyroiditis Treatment
Acute or subacute may resolve in weeks or months with no treatment
Antibiotics as necessary for bacterial, even drainage
NSAIDS or steroids for inflammation
Propranolol (Inderal) or atenolol (Tenormin) for cardiac sx
Thyroid hormone for resulting hypothyroidism
Teach compliance with treatment

8. Hyperthyroidism Over secretion of thyroid hormones
Seen more in women than men
20-40 years old
Most common form is Grave’s disease
Other causes: thyroiditis, toxic nodular goiter, excess iodine intake, pituitary tumors, thyroid CA
Thyrotoxicosis is acute, severe hyperthyroidism

9. Grave’s Disease 75 - 80% of hyperthyroidism cases Autoimmune
Diffuse large thyroid gland
Antibodies attach to TSH receptors, cause over secretion of T3 and T4
Can remit and exacerbate without tx
Precipitating risk:
iodine, infection, stress, genetic factors, smoking
Can cause thyrotoxicosis
Can degrade the thyroid, lead to hypothyroidism

10. What do you see? Excess thyroid hormone causes: Large gland – goiter
Bruit in the gland
Exophthalmos
Tachycardia, bounding pulse
Nervousness, irritability, tremors
Flushed skin, heat intolerance
Diarrhea, weight loss
Fatigue, muscle weakness, edema, osteoporosis

11. Exophthalmos

13. Diagnostics Thyroid studies
TSH – most accurate test of thyroid function
Total T4, Free T4
Total T3, Free T3
Thyroid antibodies
Thyroid scans, ultrasound
Biopsies

14. Diagnostics TSH levels will be decreased Free T4 levels increased
Total T3 and T4 not definitive
RAIU – Radioactive Iodine Uptake
Used to differentiate Grave’s from thyroiditis
Grave’s uptake = 35% - 95%
Thyroiditis = < 2%

16. Complications Thyrotoxicosis (Thyroid Storm) Symptoms
Life threatening, rare
Abrupt onset -sudden release of thyroid hormones
Precipitated by stress, thyroidectomy, trauma or an acute infection
Symptoms
Extreme fever, tachycardia
Tremors, Seizures
Loss of mental acuity -> Delirium Stupor -> Coma

17. Collaborative Care Goal is to stop the effects of overproduction
Anti-thyroid medications
Radioactive Iodine therapy
Subtotal or total thyroidectomy
Choice of therapy depends on
Patient age
Severity of disease
Complicating situations

18. More on therapies Anti-thyroid drugs:
PTU – (propylthiouracil)
Inhibits synthesis of thyroid hormones
Blocks peripheral conversion of T4 to T3
Tapazole (methimazole)
Improvement in 1-2 weeks, better in 4-8
20-40% have spontaneous remission (6-15mo)
Noncompliance is a big issue
Used for Grave’s, in pregnancy, and need for euthyroid before surgery or radiation

19. Anti-Thyroid meds continued
Iodine
Used with other drugs for thyroidectomy prep or thyrotoxic crisis
Inhibits synthesis of T3 and T4 and blocks release
Decreases vascularity in gland
Max effect in 1-2 weeks
Reduced effect long term
SSKI and Lugol’s solution

20. Beta Adrenergic Blockers
Symptomatic relief of thyrotoxicosis
Block sympathetic nervous stimulation
Excess thyroid hormone stimulates B adrenergic receptors
Beta Adrenergics used in conjunction with anti thyroids
Propranolol (Inderal)
Atenolol (Tenormin) for asthmatics and cardiacs

21. Radioactive Iodine Therapy
Treatment of choice in non-pregnant adults
Damages or destroys all thyroid tissue to control secretion of hormones
High incidence of post treatment hypothyroidism
Delayed response requires anti-thyroid drugs and beta adrenergics initially
Radioactivity is low, so done outpatient
Pt Education important!!!

22. Surgical Therapy Thyroidectomy Subtotal Endoscopic
Large goiters with compression
Non responsive to medical tx
Cancer
Subtotal
Removes most of gland but not all
Endoscopic
Small incisions to take some gland, or nodes
Prior to surgery meds can make pt euthyroid

23. Post op complications Hypothyroidism
Damage or removal of parathyroid glands
Causes hypoparathyroidism and hypocalcemia
Hemorrhage
Injury to recurrent laryngeal nerve
Thyrotoxic crisis
Infection

24. Nutritional Therapy Hyperthyroid state
Hypermetabolic state needs increased caloric intake
Satisfy hunger, prevent catabolic state
High protein, high carbs
Avoid highly seasoned, high fiber foods
No caffeine

25. What do you do? Hyperthyroidism is treated as outpatient
Acute thyrotoxicosis are admitted to ICU
Assess your patient!
Meds ordered to block thyroid hormone production
O2, IVs, watch electrolytes, EKGs
Calm, quiet, cool environment
Emotional support
Eye protection, elevate HOB, skin care
Dietary support
Pt education

26. Post -op Assess your patient!! Semi-Fowlers, post op VS
Laryngeal nerve irritation or damage can lead to spasm and stridor
Can be related to tetany – damage to parathyroids and hypocalcemia
Watch for signs of hypoparthyroidism
Assess tingling of extremities and mouth
Chvostek’s and Trousseau’s
Watch bleeding – neck swelling and behind the neck
Hoarse for 3-4 days
Post op pain meds

27. Hypothyroidism Undersecretion of thyroid hormones Transient causes:
One of most common medical disorders in US
1 in 50 women; 1 in 300 men
Primary from destruction of thyroid or defective synthesis
Secondary from pituitary or hypothalamic disease or dysfunction
Radiation exposure to the neck, family history, women >50 and post-partal
Transient causes:
Thyroiditis
Non-compliance

28. Primary Hypothyroidism
Worldwide caused by lack of iodine in diet
In US most common cause is atrophy of gland
Hashimoto’s thyroiditis
Grave’s disease for long time
Treatment of hyperthyroidism causes hypothyroidism
Surgical removal
RAI
Drugs
Amiodorone (Cordarone) – has iodine
Lithium blocks hormone release
Develops in infancy - cretinism

29. What do you see? Deficiency causes:
Capillary fragility, varied BP, cardiac hypertrophy, anemia, angina, MI
Dyspnea
Decreased appetite, N/V, constipation, wt gain, scaly tongue
Brittle nails, poor turgor, puffy face, pallor, decreased sweating

31. Diagnostics
TSH and free T4 are most often used in conjunction with physical exam
TSH helps determine cause
High TSH = defect in the gland
Low TSH = defect in the hypothalamus or pituitary
After TRH stimulation
Hi TSH = hypothalamus issues
No change = anterior pituitary
TPO AB means cause is autoimmune

32. Complications Myxedema Coma Symptoms
Progressive or sudden onset
Usually severe long term hypothyroidism
Medical Emergency
Precipitated by:
Infection, medications, exposure to cold, or trauma
Symptoms
Subnormal temp
Hypotension
Hypoventilation
Tx: IV thyroid hormone replacement, VS support

33. Collaborative/Nursing Care
Euthyroid is the goal
Synthroid – levothyroxine
Adjusted to pt response and labs
Cardiac pts have reduced dose
Daily dose taken regularly
Liotrix – 4:1 T4:T3; for pts acutely ill, faster onset
Low calorie diet to aid weight loss
Mechanical cardiac /respiratory support prn
Assess VS, I/O, wt, mental status
Pt education – compliance!