Endocrine adult health 2

Hypothyroidism

• Hypothyroidism is a condition where there is a decrease in thyroid hormones, which leads to a slowdown of metabolic processes in the body.
• It is more commonly seen in women than in men.
• Hypothyroidism is the opposite of hyperthyroidism.

Causes of Hypothyroidism

• Direct issues with the thyroid gland itself can cause hypothyroidism
• Insufficient TSH (thyroid-stimulating hormone) production by the pituitary gland, which is needed to stimulate the thyroid to produce T3 and T4 hormones also causes hypothyroidism.
• Treatment for hyperthyroidism, such as thyroid removal or radioactive iodine therapy, can lead to an underactive thyroid and cause hypothyroidism.

Severe and Congenital Forms

• Myxedema is severe hypothyroidism in adults.
• Cretinism is congenital hypothyroidism present from birth.

Clinical Manifestations of Hypothyroidism

• The severity of symptoms varies depending on the degree of hormone deficiency, and not every individual will experience all manifestations.
• Symptoms are largely due to a decrease in metabolic processes.

Metabolic and Thermoregulatory Changes

• Decreased production of body heat results due to reduced cellular respiration leading to less heat generation.
• Cold intolerance is a heightened sensitivity to cold due to decreased body heat production.
• Weight gain results from metabolism slowing down.

Cardiovascular Effects

• Atherosclerotic changes can result in coronary artery disease.
• Decreased cardiac output and contractility results in reduced heart function.
• Bradycardia is a slow heart rate
• Decreased blood pressure is lower than normal blood pressure.

Neurological and Psychological Symptoms

• Mental status changes may include depression or paranoia, and impaired memory.
• Slowing of thought processes results in cognitive functions slowing.
• A decreased concentration results in difficulty focusing.
• There can be speech and hearing deficiencies such as, slow and deliberate speech.
• Lethargy occurs from fatigue and reduced energy levels.
• Forgetfulness may occur from memory issues.
• Irritability from increased agitation.

Reproductive and Physical Symptoms

• Decreased libido indicates reduced sexual desire.
• Infertility issues is difficulty conceiving.
• Anorexia results to a loss of appetite.
• Constipation occurs from slowed bowel movements.
• Menorrhagia is excessive menstrual flow.
• Thick, dry skin occurs from changes in skin texture.
• Thinning hair occurs from hair loss.
• Mask-like facial expression may occur with reduced facial expressiveness.
• Low, hoarse voice signifies changes in vocal tone.
• Mood swings are unstable emotional states.

Respiratory and Musculoskeletal Symptoms

• Decreased respirations is a slower breathing rate.
• Exercise intolerance results to difficulty with physical activity.
• Fatigue is extreme tiredness.
• Weakness results to loss of physical strength.
• Clumsiness is lack of coordination.
• Ataxia is a staggering gait or uncoordinated movements.

Myxedema lleus

• Myxedema ileus is a severe form of constipation leading to bowel obstruction, evaluate the abdomen for distension
• Exertional dyspnea is shortness of breath upon exertion.

Important Considerations

• Early diagnosis and treatment can prevent the full manifestation of these symptoms.
• Many individuals with hypothyroidism, especially those receiving treatment, may not exhibit all the listed symptoms.

Medical Management

• TSH (Thyroid Stimulating Hormone) Test measures the amount of TSH in the blood, and high TSH levels usually indicate hypothyroidism.
• T3 (Triiodothyronine) Test measures the level of T3 hormone.

Key Terms and Important Points

• TSH (Thyroid Stimulating Hormone) is secreted by the pituitary gland, and stimulates the thyroid gland to produce T3 and T4.
• T3 and T4 are thyroid hormones that regulate metabolism. Low levels of T3 and T4 indicate hypothyroidism.
• The hypothalamus detects low thyroid hormone levels and signals the pituitary to release more TSH
• TSH levels are high in hypothyroidism because the body is trying to stimulate the thyroid to produce more T3 and T4.
• T3 and T4 are low in hypothyroidism because the thyroid gland is not producing enough hormones.

Diagnosing Hypothyroidism

• Diagnoses involves measuring TSH levels and free T4 (FT4), where FT4 is the thyroxine that is not attached to a protein.

Key Terms and Important Points

• The TSH Test measures the amount of thyroid-stimulating hormone in the blood and high amount indicates hypothyroidism.
• The Free T4 (FT4) Test measures the amount of unbound thyroxine in the blood and low FT4 confirms hypothyroidism.
• FT4 is the active form of thyroxine and provides a more accurate assessment of thyroid function.

Treatment: Levothyroxine (Synthroid)

• The primary treatment for hypothyroidism is levothyroxine, a synthetic form of T4.

Key Terms and Important Points

• Levothyroxine (Synthroid) is a synthetic T4 hormone that replaces the thyroid hormone that the body is not producing.
• Oral administration of levothyroxine is typically in the morning and should be taken 30 minutes before food.
• Patient education includes advising patients to set reminders to take their medication.
• A dosage adjustment is started at a low dose and gradually increased until the patient reaches a therapeutic range.
• Hypothyroidism is not curable and treatment is lifelong.
• Hormone levels are monitored every 6-8 weeks initially and once hormone levels are stable, monitoring is typically done yearly.
• Dosage adjustments are made as needed based on hormone levels and symptoms.

Factors Affecting Levothyroxine Absorption

• Certain foods and substances can impair the absorption of levothyroxine, reducing its effectiveness.
• Food interaction can occur, and taking levothyroxine with food impairs absorption.
• Substances to avoid are soybean flour, cottonseed oil, and walnuts.

Nursing Considerations: Monitoring and Management

• Nurses play a crucial role in monitoring patients on levothyroxine and managing potential side effects.

Key Terms and Important Points

• Monitor for signs of hyperthyroidism if the dose is too high
• Patients may be intolerant to cold, keep the room warm (70-74 degrees Fahrenheit).
• Assess for constipation, which is a common symptom of hypothyroidism and the doctor may prescribe stool softeners or laxatives, encourage fruits, vegetables, and whole grains.
• Documentation includes recording bowel movements on flow sheets or in nurse's notes.
• Diet should be high in protein, high in fiber, and low in calories, encourage fluids, avoid sweets to manage weight gain.
• Monitor for cardiovascular issues by checking for chest pain and dyspnea, heart rate and rhythm, instruct the client to report any cardiac issues, and monitor vital signs carefully due to potential heart involvement.
• Time management includes allowing extra time for care to avoid rushing the client.

Iodine Intake

• Adequate iodine intake is essential for thyroid hormone production.

Key Terms and Important Points

• Sources of iodine are saltwater fish, milk, and eggs.
• Use iodized salt to ensure sufficient iodine intake.
• Patients with hypothyroidism are particularly sensitive to certain medications due to their slowed metabolism.

Key Points

• Hypothyroid patients are highly susceptible to sedatives, hypnotics, and anesthetics.
• Due to a slowed metabolic rate, these drugs are not eliminated from the body as quickly as in healthy individuals, which can lead to prolonged and intensified effects.
• Medications tend to have more lasting effects in hypothyroid patients, and careful monitoring and dosage adjustments are crucial to avoid complications.

Simple Goiter

• Simple goiter involves the enlargement of the thyroid gland due to insufficient iodine intake.

Key Points

• Simple goiter results from insufficient iodine intake, where low T3 levels fail to signal the pituitary gland to decrease TSH secretion.
• The thyroid gland responds by increasing the formation of thyroglobulin, which accumulates and causes thyroid enlargement.
• TSH levels are high because T3 and T4 levels remain low and this hormonal imbalance leads to the overgrowth of thyroid tissue.
• Assessment includes looking for dysphagia (difficulty swallowing) and hoarseness and symptoms can arise from the pressure of the enlarged thyroid gland on the esophagus and trachea.
• Monitor for worsening respiratory distress due to tracheal compression.
• Primary treatment is potassium iodide and dietary sources of iodine include seafood (including seaweed), dairy products, grains, iodized salt, and eggs.
• Lugol's solution is a form of potassium iodide commonly prescribed.
• Surgical removal of the thyroid gland may be necessary, with indications including impaired swallowing or respiration.
• Cosmetic reasons (patient self-esteem) may also be a factor, though insurance coverage is unlikely.
• Post-Thyroidectomy Care includes assessing for bleeding, tetany, and thyroid crisis.

Thyroid Cancer

• Thyroid cancer presents with specific signs and requires comprehensive management, including surgery and potential adjuvant therapies.

Key Points

• Assessment includes looking for a firm, fixed, small, rounded, and painless mass or nodule that may indicate thyroid cancer.
• Total thyroidectomy is typically performed and lifelong Synthroid (levothyroxine) replacement is necessary to manage resulting hypothyroidism.
• Additional treatments may include radiation therapy, chemotherapy, and radioactive iodine (I-131) therapy.
• Postoperative care includes assessing for respiratory distress and post-op care is similar to that of a subtotal thyroidectomy.
• Hypothyroid patients are particularly sensitive to sedatives, hypnotics, and anesthetics because due to a slowed metabolic rate, these drugs are not eliminated from the body as quickly as in healthy individuals, this can lead to prolonged and intensified effects.
• Medications tend to have more lasting effects in hypothyroid patients and careful monitoring and dosage adjustments are crucial to avoid complications.

Hypercalcemia

• Hypercalcemia refers to a condition characterized by elevated calcium levels in the bloodstream resulting from various underlying causes and impacting multiple body systems.

Key Terms/Points

• Hypercalcemia is when there are elevated calcium levels in the blood, often linked to increased bone resorption or excessive calcium intake, and affects neurological, gastrointestinal, renal, and cardiovascular functions.

Signs and Symptoms of Hypercalcemia

• Hypercalcemia manifests through a range of signs and symptoms, varying in severity based on the degree and duration of calcium elevation.

Key Terms/Points

• Neurological symptoms include weakness and fatigue, drowsiness, apathy, personality changes, disorientation, paranoia, and changes in the level of consciousness, potentially leading to coma.
• Gastrointestinal symptoms include nausea and vomiting, anorexia, constipation, and weight loss.
• Cardiovascular symptoms include bradycardia and dysrhythmias, and high blood pressure.
• Musculoskeletal symptoms include skeletal pain, especially during weight-bearing, pathologic fractures due to bone demineralization, and skeletal deformities.
• Renal symptoms include kidney stones, leading to flank pain (side pain) and hematuria.

Pathophysiology: Bone Demineralization and Pathologic Fractures

• A key feature of hypercalcemia is its impact on bone integrity where elevated calcium levels in the blood often result from calcium being drawn out of the bones, leading to demineralization and increased risk of fractures.

Key Terms/Points

• Demineralization is the process of calcium being removed from the bones, weakening them.
• Pathologic fractures are fractures that occur due to weakened bones, often without significant trauma.
• Bones become so weak that normal activities like walking can cause them to break.

Renal Complications: Kidney Stones

• Hypercalcemia significantly increases the risk of kidney stone formation due to the elevated concentration of calcium in the urine.

Key Terms/Points

• Kidney stone formation results from high blood calcium that leads to increased calcium in the urine, promoting stone formation.
• Symptoms include flank pain and hematuria.

Diagnostic Evaluation

• Diagnosis involves a combination of radiographic exams and laboratory tests to assess calcium and phosphate levels, as well as to identify potential underlying causes.

Medical and Surgical Management

• Treatment strategies range from medical management to surgical intervention, depending on the severity and underlying cause of the condition.

Key Terms/Points

• Surgical removal includes removing tumors or adenomas causing hyperparathyroidism and removing one or more parathyroid glands.
• Medical management includes monitoring for slightly elevated hormone levels and if very elevated, proceed with surgical removal of abnormal tissue.

Nursing Interventions

• Nursing care focuses on managing symptoms, preventing complications, and monitoring treatment effectiveness.

Key Terms/Points

• Fluid management includes IV fluids to promote calcium excretion and strict I&O (intake and output) monitoring.
• Medications include Lasix (furosemide) to decrease serum calcium levels and analgesics for bone pain.
• Monitor daily serum calcium levels while acute.
• Monitor effectiveness of pain management.
• Renal stone management includes straining urine to catch kidney stones for lab analysis and expect calcium-based stones.
• A calcium-based diet is low-calcium and avoids dairy products and antacids with calcium and cranberry juice to acidify urine.
• Post-operative care is similar to post-thyroidectomy care and monitor for hypocalcemia.
• Hypocalcemia management includes recognizing signs of tetany, dysrhythmias, and carpopedal spasms, and administering calcium gluconate IV as prescribed.

Potential Complications and Monitoring

• Vigilant monitoring is essential to detect and manage potential complications associated with hypercalcemia and its treatment.

Key Terms/Points

• Hypocalcemia is when you monitor for signs post-surgery looking for tetany, dysrhythmias, and carpopedal spasms.
• Monitor kidney stones, skeletal issues, and neurological changes

Importance of Calcium and Weight-Bearing Exercise

• Calcium is crucial for various bodily functions, and maintaining adequate levels is essential.
• Weight-bearing exercises play a significant role in calcium retention in bones.

Key Points

• Reduce calcium intake.
• Post-operative care includes managing pain and avoiding overhydration.
• Mild exercise is recommended to promote bone health and regain muscle strength.
• Weight-bearing exercises, like walking, draw calcium back into the bones, strengthening them.
• Avoid smoking as it negatively impacts bone health.

Hypoparathyroidism

• Hypoparathyroidism is characterized by decreased parathyroid hormone (PTH) levels, leading to low serum calcium and elevated phosphorus levels.

Key Points

• Definition - Hypoparathyroidism involves decreased parathyroid hormone (PTH)
• Common Cause - Often results from the removal of parathyroid glands during a thyroidectomy
• Hormone Levels - low PTH leads to increased phosphorus and decreased calcium levels
• Inverse Relationship - Unlike hyperparathyroidism, hypoparathyroidism presents with low calcium and high phosphorus.

Neuromuscular Effects of Hypocalcemia

• Low calcium levels in hypoparathyroidism can cause neuromuscular hyper-excitability, leading to various symptoms

Key Points

• Neuromuscular Hyper-excitability occurs from low calcium
• Muscle Spasms - Patients may experience muscle spasms and hypocalcemic tetany
• Laryngeal Spasm - Laryngeal spasms can occur, potentially closing off the airway and causing stridor.
• Stridor - Stridor is the sound of trying to get air through a small space
• Cyanosis is a Lack of oxygen ca lead to cyanosis
• Asphyxia results from severe cases of oxygen deprivation

Diagnostic Signs of Hypocalcemia

• Chvostek's and Trousseau's signs are indicative of hypocalcemia elicited through specific clinical tests.

Key Points

• Chvostek's Sign: Tapping the facial nerve causes facial muscle spasms.
• Trousseau's Sign: Inflating a blood pressure cuff above systolic pressure for three minutes induces carpal spasms.

Treatment and Management of Hypocalcemia

• Treatment involves calcium supplementation, monitoring, and dietary adjustments.

Key Points

• Calcium Gluconate is administered by a registered nurse (RN).
• Patient Education must include informing the patient they may experience a hot feeling on their tongue or skin during administration.
• Administration Rate must be given slowly to avoid complications.
• Infiltration - If calcium gluconate infiltrates into tissues, it can cause tissue sloughing and severe wounds
• Rapid Administration Risks include a drop in blood pressure, serious cardiac dysrhythmias, and cardiac arrest
• Cardiac Monitoring - Pts receiving IV calcium must be on a cardiac monitor
• Long-Term Management may involve calcium and vitamin D supplementation.
• Thiazide Diuretics increase calcium levels.
• When monitoring for Hypercalcemia, be wary of the symptoms such as vomiting, disorientation, anorexia, abdominal pain, and weakness.

Key Points

• Monitoring Side Effects; Pay attention to respiratory distress
• Adverse Reactions - Monitor for bradycardia, syncope, and decreased blood pressure. Dietary Adjustments that are key entail high-calcium and low-phosphorus foods.

Dietary Recommendations for Hypocalcemia

• Dietary adjustments are essential.

Key Points

• High-Calcium Foods include low-fat dairy foods, dark green leafy vegetables, soybeans, tofu, and canned fish with bones.
• Adults need 1000 mg of calcium per day, Individuals over 50 years old require an additional 200 mg per day, especially post-menopause
• Low-Phosphorus Foods: Soy milk, white rice, jam, honey, lemon-lime soda, cucumbers, lettuce, peppers, tomatoes, and non-organ meats
• Foods to Avoid (High in Phosphorus): Deli meats, hot dogs, processed cheese, cornbread