1. Disorders of the Thyroid and Parathyroid
ACC, RNSG 1247
Created by Lydia Seese, RN

2. Just to give you an idea of how many organs are involved in the endocrine system…

3. Endocrine disorders may affect anyone!

4. Thyroid Enlargement/Goiter
Maybe caused by:
Increased TSH stimulation
Growth-stimulating immunoglobulins & other growth factors
Goitrogens
Iodine-deficiency areas (endemic goiter)
Increased TSH is caused by inadequate circulating thyroid hormones
Goitrogens are foods or drugs that contain thyroid inhibiting substances
In placess where there is iodine-deficency: e.g.,; no iodine in salt

5. Thyroid nodules Mostly benign
Malignant nodules: usually hard & painless
Diagnostics: US, US-guided FNA, thyroid scan
Treatment: unilateral to total thyroidectomy
Nodules maybe benign or malignant
Thyroid scan of cancerous nodules usually “cold” but not all cold nodules are malignant. Cold means does not take up the radioactive iodine or no activity.

6. Thyroiditis Subacute and acute thyroiditis:
Subacute - viral (as in subacute granulomtous thyroiditis)
Acute fungal or bacterial
Chronic autoimmune thyroiditis
Silent painless thyroiditis
Subacute and acute thyroiditis tend to be painful with abrupt onset.
Subacute granulomatous thyroiditis – viral; causes thyrotoxicosis. Acute thyroiditis – fungal or bacteria
Chronic autoimmune thyroiditis or Hashimoto's thyroiditis
Silent painless thyroiditis – maybe early Hashimoto’s, a form of lymphocytic thyroiditis, may occur in PP and usually resolves within a a year

7. Hashimoto’s thyroiditis
Chronic autoimmune disease
Most common cause of hypothyroidism in US
Diagnostics: T3 T4 usually low, TSH high, (+) for antithyroid antibodies
Chronic autoimmune disease
Thyroid tissue is replaced by lymphocytes and fibrous tissue

8. HYPERTHYROIDISM Graves’ Disease Toxic nodular goiters
Thyroiditis (hyper) – usually caused by virus as in viral subacute granulomatous thyroiditis
Thyrotoxic crisis (thyroid storm)
HYPERTHYROIDISM: Hyperactivity of the thyroid gland
THYROTOXICOSIS: Clinical syndrome resulting from hyperthyroidism
These are the specific disease characterized by hyperthyroidism

9. Graves Disease Autoimmune, unknown etiology
Antibodies attach to the TSH receptors and stimulate the thyroid to release T3 & T4
May lead to destruction of thyroid tissue , thus hypothyroidism
Graves’ disease accounts for most hyperthyroid cases.

10. Toxic Nodular Goiters
Release thyroid hormones independent of TSH stimulation
Maybe single or multinodular
These nodules are mostly benign adenomas

11. Diagnostics for Hyper/Hypothyroid Dysfunction
History and PE
Most reliable blood tests are:
TSH
Free T4
TSH and free T4 levels are the major tests used. The free hormone is the only form of the hormone that is biologically active ( free, meaning not bound to proteins)
TSH decreased in hyper; increased in hypo if cause is thyroid dysfunction, low if cause if pituitary or hypothalamus since TSH is produced in the pituitary.
Free T4 elevated in hyper

13. Diagnostics Continued
T3, T4
Radioactive iodine uptake (RAIU )
TRH stimulation test
ECG US
Thyroid scan
Antibody assay
T3 & T4 measure both free and bound hormones in the blood so not vey useful
TRH – thyrotropin-releasing hormone
Radioactive iodine uptake (RAIU ) – differentiates Graves disease from other forms of thyroiditis – increased uptake in Graves vs thyroiditis

14. Hyperthyroidism: Manifestations
S/sx of increased metabolism & stimulation of SNS
Goiter
Opthalmopathy; exophthalmus in Graves’
S/sx of increased metabolism & stimulation of SNS: EXS: Inc HR, palpitations, dyspnea on mild exertion, weight loss, warm smooth moist skin, fine hair, heat intolerance, nervousness PP 1300 LEWIS
Goiter on palpation, bruits on auscultation of thyroid gland
opthalmopathy- abnormal eye appearance or function
exophthalmus in Graves – protrusion of eyeballs DT increase pressure from fat and fluid deposits ST impaired venous drainage from the orbit

15. Goiter associated with Graves’ disease or hyperthyroidism
Goiter associated with Graves’ disease or hyperthyroidism. The thyroid cannot meet the metabolic needs of the body and enlarges to compensate. The administration of iodine effectively can reverse this. Thyroidectomy, or surgical removal of the entire gland, may be necessary in case in which the gland has become greatly enlarged

16. Exopthalmus
Hyperthyroidism-exopthalmus

17. Thyroid storm Rare but dangerous Systemic symptoms: examples
Hyperthermia
Tachycardia, esp. atrial arrhythmias
Agitation or delirium
The sx may be attributed to increased Beta receptors and catecholamines.
Treatment is designed to (1) reduce both circulating TH levels by inducing a block of TH synthesis (2) provide symptomatic and supportive care

18. Hyperthyroidism: Collaborative Care
Medications/Drugs
Radioactive Iodine
Nutritional
Surgical
Nutritional – high calorie diet, frequent feedings, no spicy or high fiber and caffeine containing foods
Surgical – subtotal thyroidectomy – preferred or endoscopic if nodule is small

19. Drug Therapy: Antithyroid drugs
Preferred Tx for pregnant women
Methimazole - tapazole
PTU - prophylthiouracil
Improvement begins 1-2 weeks
Good results in 4-8 weeks
Remission in 6-15 mos. in < 50% of cases
Patient concern: noncompliance
Antithyroid Drugs- first line drugs are PTU and Tapazole. Inhibit thyroid hormone synthesis, improvement begins approxx. In two weeks; nursing education: need for compliance
PTU – (prophylthiouracil) TID
Methimazole – (Tapazole) once daily
With continued use for 6-15 months, remission is possible for a little less than 50% of cases

20. Drug Therapy: B adrenergic blockers
Symptomatic relief of thyrotoxicosis
Propranolol - Inderal
Atenolol - Tenormin
Symptomatic relief of thyrotoxicosis from increased B adrenergic receptor stimulation
Propranolol (inderal) symptomatic relief
Atenolol l- preferred when patients have asthma or heart disease

21. Drug Therapy: Iodine Maximal effect in 1-2 weeks
Saturated solution of potassium iodine (SSKI)
Lugol’s solution
Iodine – used prior to thyroidectomy to decrease the vascularity of the thyroid gland, also in hyrotoxic crisis, inhibits release of T3T4 into circulation:
Lugol’s solution
SSKI saturated solution of potassium iodine
Iodine should be mixed with juice or water administered with straw after meals;not with milk; note for iodine toxicity

22. Radioactive Iodine Therapy
Preferred for most nonpregnant women
Damages thyroid hormone
Effect in 2-3 mos.
Delayed effect so patient is first given drugs
For outpatient:
No radiation safety precaution needed since therapeutic dose is low
Sips of water and or ice chips to avoid dryness and irritation of the mouth

23. Acute Intervention Support ABC’s Rest, minimal stimulation Eye care
Support ABC’s: oxygenation, cardiac dysrhythmias, IV fluids maybe needed if with diarrhea
Rest, minimal stimulation, quiet, cool room
Care for exophthalmus – artificial tears, elevate head, dark glasses, tape shut during sleep

24. Pre/Post operative Care
CDB, turning, ambulate w/in hrs post op
ROM of neck
Airway and incision site monitoring
Semi fowlers to prevent tension on suture lines
VS monitoring including tetany
Pain management
Fluids if tolerated, soft diet day after
Preoperative teachings should include:
Coughing, deep breathing, turning with head support
ROM of neck
Talking a little difficult
Post operatives:
Airway monitoring particularly laryngeal stridor, bleeding, swelling irregular breathing
Prevention of tension on the neck suture lines: semifowlers and support head with pillow when turning
VS monitoring including tetany; tingling, twitching
Check for Trousseu’s and Chvostek’s signs

25. Post operative & home care
Remaining thyroid tissue is allowed to regenerate post-op
Reduced caloric intake, adequate iodine
Regular exercise
Avoid temperature extremes
Regular follow up to monitor for hypothyroidism

26. HYPOTHYROIDISM
Primary – RT destruction of thyroid tissue or defective hormone synthesis
Secondary – RT pituitary disease
Primary – RT destruction of thyroid tissue or defective hormone synthesis
from atrophy of thyroid gland ST Hashimoto’s or Graves disease or treatment for hyperthyroidism
Secondary – RT pituitary disease

27. Hypothyroidism: Manifestations
Slowing of body process which develops over months to years
Exs: fatigue, cold intolerance, weight gain, systemic symptoms
Myxedema
Systemic effects could include decreased cardiac output and decreased cardiac contractility, anemia, decreased GI motility,
Myxedema results from accumulation of certain fat tissue in the dermis causing puffy face, masklike appearance

28. Myxedema Coma Rare but life threatening
Severe metabolic disorders, hypothermia, cardiovascular collapse, coma
Factors: infection, trauma, failure to take thyroid replacements

29. Hypothyroidism-myxedema

30. An adult cretin. Characteristic facial features, dwarfism, scant pubic hair, poorly developed genitalia
Hypothyroidism in infants occurs when thyroid tissue is absent leading to mental retardation. This can be somewhat reversed with thyroxine is given

31. Hypothyroidism: Collaborative care
Goal – euthyroid state
Low calorie diet
Thyroid hormone
Natural hormones
Low calorie diet to promote weight loss
Levothyroxine - commonly used hormone replacement …adjusted according to pt’s response and lab findings. Smaller initial dose for Pts with cardiac problems; dose is increased at 4-6 week intervals.
Other natural thyroid preparations are available but must be managed closely by the ordering physician

32. Hypothyroidism: Acute Intervention
IV thyroid hormone
Hypertonic saline solution
Close assessment
VS monitoring
Acute intervention is required for myxedema coma:
IV thyroid hormone – used since paralytic ileus maybe present leading to poor GI absorption
Hypertonic saline solution if pt is hyponatremic
Assessment and VS monitoring particularly temperature, I/O, edema

33. Thyroid malignancies
Occur more often in people who have undergone radiation of the head, neck or chest.
Symptoms of thyroid cancer include hoarseness, dysphagia
A nodule found in a man’s thyroid is more likely to be cancer than when found in woman. Most thyroid cancer can be cured with appropriate treatment. Thyroid cancer usually appears as small growth (nodules)

34. Most Common Types of Thyroid Cancer
Papillary thyroid cancer
Follicular thyroid cancer
Papillary: most common form in about 60-70%; affects more women than men. Usually involves surgery (thyroidectomy), followed with hormone therapy to suppress the pituitary gland from secreting more TSH and administration of radioactive iodine to destroy any remaining thyroid
Follicular thyroid cancer: occurs most often among elderly patients and accounts for about 15%. It is the most aggressive and tends to spread through the bloodstream to other parts of the body. Tx: surgery and administration of radioactive iodine.

35. The parathyroid glands
The parathyroid glands are imbedded in the thyroid; there are usually four glands, but it can vary from 2-10.
Normal ranges for serum calcium range from
These glands are responsible for secreting parathyroid hormones (PTH) that regulates calcium level of blood and tissue fluid

36. Disorders of the parathyroid glands
Hyperparathyroidism (hypercalcemia)
Hypoparathyroidism (hypocalcemia)
Tumors
Remember: most of the time that dysfunction occurs esp hypoparathyroidism, part of the glands have been removed following a thyroidectomy

37. Hyperparathyroidism Primary Secondary Tertiary
Primary – commonly ST a benign tumor; increased PTH secretions
Secondary – compensatory to a conditions that causes hypocalcemia ( the main stimulus to increased PTH secretion), eg; vitamin D deficiency, CRF
Tertiary – hyperplasia of parathyroid glands leading to automatic PTH secretion by the parathyroid gland

38. Hyperparathyroid
Major S/Sx: depression, fatigue, loss of appetite, constipation, osteoporosis, fractures, kidney stones
DX: bone x-rays, Ca & PTH levels
TX: decrease high serum levels, surgical removal of parathyroid
PTH as measured by radioimmunoassay is elevated ; serum Ca usually more than 10 mg/dl; phosphorus is usually below 3 mg/dl
Bone density test will be used to detect bone loss.
Certain criteria must be met for parathryoidectomy: overt symptoms of neuromusclar effects, ca > 12 mg/dl, etc.

39. Hyperparathyroidism: Nonsurgical Treatment
Close follow up
Active lifestyle.
Dietary measures
Drugs
Serum levels maybe decreased using meds if surgical approach is not feasible. Will include;
1. close follow up of labs and other tests – PTh, Ca, phosphorus, xrays
2. prevent sedentary lifestyle
3. dietary measures
4. drugs: a. phosphorus supplementation
b. Biphospahtes (Fosamax) – inhibit bone resorption of Ca to normalize Ca serum levels
c. oral phosphate –inhibit Vit D effects
d. diuretics
e. calcimimetic agenat 9cinacalcet) increase sensitivity of calcium receptor on parathyroid gland thus
decreased PTH secretion and serum Ca levels

40. Common Medications used in Hyperparathyroidism
Phosphorus
Biphosphates
Estrogen or progestin
Oral phosphate
Diuretics
Calcimimetic agents

41. Signs that indicate calcium levels are abnormal
Trousseau’s sign: temporarily occlude arterial blood flow (with BP cuff inflated) above the normal systolic pressure. A + Trousseau”s sign occurs when the hand and fingers contract from ischemia
Chvostek’s sign: tap on the facial nerve just below the temple. Sign is + when nose, eye, lip & facial muscles twitch
“Shev-stocks” sign Tapping on the side of the cheek out from ear elicits twitching of that eye
These signs are found in patients with hypocalcemia

42. Hypoparathyroidism
Results from abnormally low levels of PTH low Ca level
Symptoms: painful spasms of face, hands, arms, and feet; seizures
TX: IV Calcium; CalMag & vit D; Rebreathing
Severely low Calcium can then lead to tetany which is defined by an increased excitability of the nerves
Why seizures? ---- decreased calcium lowers the seizure threshold of the individual
Causes: accidental removal of a parathyroid gland when the thyroid is removed, or when part of the parathyroid tissue is removed. Other causes include absent parathyroid glands from birth or the sudden stop of function due to unknown reasons
Diagnosed by blood serum studies to measure for calcium and PTH levels.
Tx: IV Calcium Gluconate to provide immediate relief; po Calcium and vit D tabs for the rest of life. Remember: Vit D has to be taken for calcium to be absorbed, and the body will only absorb up to 500mg at a time;;;the rest will be excreted, so multiple doses may be prescribed.

43. Parathyroid Tumors Grow inside the gland itself
May cause  levels of PTH leading to hyper states.
Most are benign adenomas; malignancies are very rare
Sx of parathyroid tumors: resemble hyper conditions: n/v, fatigue, confusion, muscle weakness, aches and pains, depression, abd pain.
TX; the tumor is surgically removed

44. Nursing Diagnosis for thyroid/parathyroid patients
Imbalanced nutrition: _______ r/t hypermetabolic or hypometabolic state
Disturbed body image: r/t changes in appearance AEB exopthalmus (myxedema), skin changes, facial edema, presence of goiter
Risk for constipation r/t slowed metabolic states and decreased activity tolerance
Risk for fluid/electrolyte imbalance r/t changes in production of thyroid hormones 2° hypothyroidism

45. Nursing Diagnosis, cont.
Electrolyte imbalance r/t decreased/increased levels of calcium AEB….
Knowledge deficit: dietary, r/t decreased parathyroid function AEB calcium serum levels of_____, facial twitching, muscle cramps, …..
R/F impaired cardiac output
R/F Imbalanced body temperature
RF acute pain RT effects of renal stone
The decreased levels are from hypo: tetany, muscle twitching, etc manifested

46. The End