Thyroid Gland Disorders

• The thyroid gland is located in the neck, near the thyroid cartilage and trachea.
• The thyroid gland has right and left lobes, connected by the isthmus.
• Parathyroid glands are located on the back side of the thyroid gland.

Thyroid Gland Hormones

• Thyroxine (T4) aids in body heat production; regulates CHON, CHO, and catabolism in all cells; and is an insulin antagonist.
• Triiodothyronine (T3) assists with metabolic rate.
• T3 functions include skeletal maturation, CNS development, muscle tone, cardiac rate, GI secretion, respiratory rate, oxygen utilization, and RBC production.
• Thyrocalcitonin/Calcitonin which stores calcium in the bones, reduces calcium and phosphorus levels in the serum, along with calcium and phosphorus absorption in the GIT, and deters bone deterioration and resorption.
• Iodine is essential for the thyroid gland to produce thyroid hormones.
• The thyroid gland requires three iodine molecules to create T3 and four for T4.

Diagnostic Tests

• Diagnostic tests: inspection, palpation, and auscultation if an enlarged thyroid gland is observed.
• Palpation should be done at the thyroid cartilage (Adam's apple).
• Palpate the isthmus and then assess each thyroid lobe individually.
• Auscultate each lobe of the thyroid while listening for a thyroid Bruit.
• Bruit indicates increased blood flow through the thyroid gland.
• Euthyroid is the state of having normal thyroid function.
• TSH (Thyroid Stimulating Hormone) testing, thyroid scanning, thyroid biopsy, and ultrasonography are performed.
• Serum TSH: The normal range is approximately 0.5 to 4.5 or 5.0 mIU/L; this is the best screening test for thyroid function, with 98% sensitivity and 92% specificity; to be started at age 35 and every 5 years.
• Serum Free Thyroxine confirms an abnormal TSH correlated with metabolic activity; the normal range is 0.9 - 1.7 ng/dl.
• Serum T3 has a normal range between 80 to 200 ng/dL; T4 has a normal range between 5.4 to 11.5 mcg/dL.
• Fine Needle Aspiration Biopsy uses a small gauge needle on thyroid tissue for cytological exam, results can be benign/negative, malignant/positive, suspicious/indeterminate, non-diagnostic/inadequate.
• Radioactive Iodine Uptake measures the absorption of the iodine isotope to determine thyroid gland functioning.
• For Radioactive Iodine Uptake a tracer dose of iodine 123 or iodine 131 is given orally or IV.
• For Radioactive Iodine Uptake a scintillation detector/gamma camera is placed over the neck after 2, 6, and 24 hours after administration.
• Increased Radioactive Iodine Uptake indicates HYPERthyroidism and decreased uptake indicates HYPOthyroidism.
• Basal Metabolic Rate (BMR) expresses the rate at which oxygen is used by the body cells and measures oxygen consumption at the lowest cellular activity.
• During BMR, a patient should rest for 8-10 hrs and fast for 10-12 hrs and not get up from bed until the test is done.
• For BMR, a device is used with a nose clip and mouthpiece to monitor breathing.
• BMR results: +/- 20% is normal, increased indicates HYPERthyroidism, and decreased indicates HYPOthyroidism.

Hypothyroidism

• Hypothyroidism is classified by a decreased metabolic rate, decreased body heat production, and hypercalcemia, the adult version is called myxedema and children is called cretinism.
• Myxedema is defined by a slow weakening thyroid gland function, primarily in older adults, and more frequently in women with a rate of 5x more often.

Early Clinical Manifestations of Hypothyroidism

• Extreme fatigue
• Menstrual disturbances (Menorrhagia)
• Hair loss, brittle nails, dry skin
• Intolerance to cold
• Anorexia
• Constipation
• Weight gain
• Lethargy, sluggishness, sleepiness
• Apathy
• Slowed mental process, slurred speech
• Dry, sparse hair
• Infertility, decreased libido
• Decreased body temperature

Late Clinical Manifestations of Hypothyroidism

• Subnormal body temperature
• Bradycardia
• Lethargy
• Periorbital puffiness
• Non-pitting edema of feet & hands
• Large tongue
• Pale, cool, rough skin
• Coma
• Myxedema Coma is a rare but serious disorder resulting from consistently low TH production.
• Myxedema Coma is the most extreme, severe stage of hypothyroidism.
• Myxedema Coma symptoms include decreased RR, cardiovascular collapse, hypotension, hypothermia, hypoglycemia, respiratory failure, shock, and coma.

Medical Treatment for Hypothyroidism

• Replacement of deficient thyroid hormones, such as:
  • Thyroid USP (desiccated thyroid combination of T3 & T4)
  • Thyroglobulin (Proloid)
  • Levothyroxine Na (Synthroid & Levothroid) – T4
  • Liothyronine Na (Cytomel) – T3
• This medical treatment does not stimulate the thyroid to secrete TH; it will increase metabolic rate, heat production, & oxygen consumption.
• Side Effects: nervousness, insomnia, HTN, and tremors.
• Monitor BP & pulse rate (PR) prior to the administration of medication.
• Start with a low dosage, then gradually increase; take daily.
• Toxicity symptoms: Hyperthyroidism/ Thyrotoxicosis/ Thyroid Storm.
• Encourage diet high in CHON and Calcium supplement
• Low in calories, cholesterol, and high in fiber.

Cretinism

• Cretinism is congenital hypothyroidism, caused by failure in embryonic development of the thyroid gland.

Early and Late clinical manifestation of Cretinism

• Early symptoms of Cretinism are prolonged physiologic jaundice, feeding problems/impaired GI secretions, excessive sleeping, minimum crying, and hypotonic abdominal musculature.
• Late symptoms of Cretinism are impaired Nervous System development, mental retardation, slow awkward movement, severe stunted skeletal development, short forehead, protruding tongue, defective dentition, and CV changes.
• Administer oral Thyroxine & Vitamin D before 3 months old to maintain normal development.

Hyperthyroidism

• Hyperthyroidism is classified by increased metabolism, increased body heat production, and hypocalcemia.
• Graves' Disease is excessive T3 & T4 and also known as Parry's Disorder, Basedow's Disorder, Exophthalmic Goiter, and Toxic Diffuse Goiter.

Clinical Manifestations of Hyperthyroidism

• Thyroidal Disturbances that are characterized by:
  • Restlessness, nervousness, irritability, tremors
  • Tachycardia, HTN
  • Increased appetite BUT weight loss
  • Heat intolerance
  • Diaphoresis
  • Amenorrhea
  • fine, silky hair, smooth skin
  • Pliable nails
• Ophthalmopathy, such as Exophthalmos, Von Graefe's Sign, Dalrymple's Sign, and Joffroy's Sign
  • Exophthalmos- accumulation of fluid at the fat pads behind the eyeballs, pushing the eyeballs forward.
  • Von Graefe's Sign (Lid Lag)- the patient looks down, there is a long and a deep palpebral fissure
  • Dalrymple's Sign (Thyroid Stare)-bright-eyed stare; infrequent blinking
  • Joffroy's Sign- the forehead remains smooth when one looks up
• Dermopathy, such as clubbing of fingers and toes, skin that is raised, thickened, very itchy and hyperpigmented.

Nursing Management for Hyperthyroidism

• Encouraging rest, diet, safety, eye protection, and replacing fluids and Electrolyte losses.

Pharmacotherapy for Hyperthyroidism

• Beta-blockers like Propranolol or Inderal
• Iodides like Lugol's Solution/ KISS/ SSKI, which decreases the activity of the thyroid gland, decreases vascularity, and decreases the size of the gland.
  • Iodides must be mixed with fruit juice with ice or a glass of water for palatability and ingested through a drinking straw, to prevent teeth staining; side effects include allergic reaction, increased salivation, and coryza.
• Thioamides like PTU or Tapazole, which inhibits the synthesis of TH, and has side effects of Agranulocytosis/ Neutropenia, Fever, Sore Throat, and Skin Rashes.
• Other medications include Calcium Channel Blockers and Dexamethasone.

Hyperthyroidism Radiation and Surgical treatment

• Radiation Therapy (I131/1132) using radioactive isotope administered orally, with effectiveness showing signs of hyperthyroidism subsiding in 3 weeks and thyroid function normalizing in 2 months, pregnancy to be avoided for 6 months after
• Isolate patient for a few days.
• Surgery includes:
  • Partial Thyroid Lobectomy: rare procedure only part of the thyroid is removed.
  • Thyroid Lobectomy: entire thyroid lobe removed -Thyroid Lobectomy with Isthmusectomy: the whole thyroid lobe and the thyroid isthmus are removed.
  • Subtotal Thyroidectomy: One thyroid lobe, the isthmus, and part of the other thyroid lobe is removed.
• The patient must be in a Euthyroid state, to be achieved by administering iodides & thioamides, do ECG and to prevent occurrence of thyrotoxicosis during the surgery.

Post-Op Care for Thyroid Removal

• Proper Positioning and attention to prevent hemorrhage
• Set up a Tracheostomy in the first 48 hrs, in case of emergency.
• Asking the patient to speak every hour to check for nerve functionality.
• Provide Calcium gluconate availability.
• Monitor body temperature
• Steam inhalation to soothe irritated airway.
• Encourage supporting the neck with interlaced fingers when getting up out of bed.
• ROM exercises of neck 3-4 times a day after discharge, massage incision site with cocoa butter lotion minimize scarring, and administer regular follow-up care with an overseeing physician

Possible Negative Complications Post Thyroid Removal

• Hemorrhage
• Airway obstruction
• Tetany: a condition marked by intermittent muscular spasms, caused by malfunction of the parathyroid glands and a consequent deficiency of calcium.
• Recurrent Laryngeal Nerve
• Damage: Thyroid crisis/storm or Thyrotoxicosis
• Monitor temperature, intake & output, neurologic, and CV status every hour.

Thyroid Storms

• Thyroid Storms can be addressed by:
  • Administering increasing dosages of oral PTU every 6 hours
  • Following a loading dose as prescribed
  • Iodide preparation
  • Dexamethasone
  • Propranolol
  • Implementing measures to lower fever and admin. Acetaminophen
  • Oxygen as needed.
  • Maintain a quiet, calm, cool, and private environment until the crisis is over.

Goiter

• Goiter is the enlargement of the thyroid gland that may occur in euthyroid, hypothyroid, or hyperthyroid states.
• Goiter pathology can be caused by iodine deficiency, congenital defects preventing hormone synthesis, chemical agents, and certain drugs.
• Goiter can manifest as an enlarged gland and potential tracheal/esophagal compression that causes stridor, dysphagia, and potentially hoarseness from laryngeal nerve compression.
• Diagnostic tests include TH levels and RAIU; management includes drug therapy, avoidance of goitrogens, surgery, and iodized salts.

Thyroiditis

• Thyroiditis is the painful inflammation and swelling of the thyroid gland.
• Acute Thyroiditis (De Quervain's Thyroiditis) is associated with URTI.
  • Common in left lobe for children and the right lobe in adults presenting hyperthyroid state associated unilateral pain, aggravated by hyperextension of neck, swelling, fever, chills, sore throat, hoarseness, and dysphagia,
  • Acute Thyroiditis Treatment: Control of infection, bed rest, steroids. In weeks or months it typically balances out.
• Chronic Thyroiditis (Hashimoto's Thyroiditis) is an autoimmune disorder with signs & symptoms of Hypothyroid State.
  • Chronic Thyroiditis signs can be controlled by steroid or PTU therapy that will reduce inflamation and supress TSH hormones

Parathyroid Glands

• The parathyroid glands affect calcium and phosphorous.
• Calcium (Ca) normal lab levels = 4.5 – 5.5 meq/L or 8.2 – 10.2 mEq/L
• Phosphorus (P) normal lab value of 2.5 - 4.5 mg/dl or 1.8-2.6 mEq/L
• Parathyroid glands decrease serum calcium triggers the releases of parathormone.
• Parathormone releases triggers Withdrawing Calcium from the bones which Increases Serum Calcium levels which causes the over and under expression of HYPERPARATHYROIDISM and HYPOPARATHYROIDISM

Hyperparathyroidism and Hypoparathyroidism

• Hyperparathyroidism causes HYPERcalcemia
• Hypoparathyroidism causes HYPOCALCEMIA
• Hyperparathyroidism may lead to BONE DECALCIFICATION & RENAL CALCULI and muscular activity depression.

Early Signs & Symptoms of Hyperparathyroidism

• Apathy
• Fatigue
• Muscle Weakness
• N/V
• Constipation
• HTN & Cardiac Dysrhythmias
• Kidney stones
• Bone deformities
• Bone demineralization and pathological fractures
• Skeletal pain on weigh bearing joints
• Psychological manifestation HYPERCALCEMIC CRISIS is a potential complication occurring where serum Calcium reach 15 mg or greater resulting:
• Life Threatening Neuro, Cardio, and Renal symptoms.

Diagnositic Ttesting and Management of Hyperparathyroidism

• Elevated serum calcium and parathormone, as P goes down.
• Bone x-ray and scan used to reveal bone demineralization
• Ultra sound UTZ, MRI, thallium scan & fine needle biopsy.
• Management requires increased Hydration therapy and Mobility.
• Diet should include all common foods except foods high in Calcium and with an added Acid-Ash rich foods like Meat, eggs, fish, poultry, grapes, citrus fruits, bread, cereals along with medications like Mithramycin. Surgical procedure is a PARATHYROIDECTOMY.

HYPOPARATHYROIDISM

• HYPOPARATHYROIDISM is mainly caused a surgical removal complications arising from Interuption of blood supply; surgical removal; radical neck dissection, atrophy all classified as idiopathic and un common.

Manifestations of HYPOPARATHYROIDISM

• Latent tetany-is triggered by the application of electrical & mechanical stimulation from feelings such as numbness, tingling, paresthesia, and cramps.
• Overt tetany-causes clinical responses like bronchospasm, laryngeal spasm, cardiac dysrhythmias, seizures.
• Other symptoms are anxiety, irritability, depression, delirium, ECG changes, and HYPOtension.
• Trousseau's sign is observed by eliciting an occlusion of the brachial or radial artery, then noting any hand and finger spasms.
• Chvostek's Sign is observed by tapping the facial nere after a neck dissection around the zygomatic arch and the corner of the mouth , a positve response from twitching of the lip at the corner of the mouth or all facial muscles is expected in a Hypocaleic patient

Nursing Responsibilities for Hypoparathyroidism

• Monitor Serum Calcium , Phosphate lvls-Ca will be down, Phosphate levels will be up
• Keep a at bed side a Traeacheostomy set, O2 delivery, Bronchodialator, suction and Calcium Gluconate

Hypoparathyroidism Mangement

• Goal is to increase Calcium lvls to 9-10mg/dl via:
• Adminstering Calcium Gluconate
• Pentobarbital agents to decrease neuromuscular Irritability
• Parenteral parathormone
• Vtamin D-increased Gl absorption of Calcium
• Amphojel-bindng of phosphate