1. 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

2. 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.

3. 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

4. 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

5. 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

6. 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

7. 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.

8. 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

9. 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

10. 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

11. 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 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

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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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