Thyroid Gland Disorders Explained - PDF

 THYROID GLAND 1. THYROXINE (T4) – body heat production Functions: ✔ Regulates CHON, CHO, fat catabolism in all cells ✔ Insulin Antagonist 2. TRIIODOTHYRONINE (T3) – for metabolic rate Functions: ✔ Maintain skeletal maturation ✔ Affects CNS development & function ✔ Nece...

 THYROID GLAND 1. THYROXINE (T4) – body heat production Functions: ✔ Regulates CHON, CHO, fat catabolism in all cells ✔ Insulin Antagonist 2. TRIIODOTHYRONINE (T3) – for metabolic rate Functions: ✔ Maintain skeletal maturation ✔ Affects CNS development & function ✔ Necessary for muscle tone & vigor ✔ Maintain cardiac rate, force & output ✔ Maintain secretion of the GI ✔ Affects RR & oxygen utilization ✔ Affects RBC production 3. THYROCALCITONIN / CALCITONIN Functions: ✔Stores calcium in the bones ✔ Lowers serum calcium & phosphorus levels ✔ Decreases calcium & phosphorus absorption in the GIT ✔ Inhibits bone deterioration/resorption IODINE – is an essential element that enables the thyroid gland to produce thyroid hormones. Three iodine molecules are added to make T3 and four for T4 -- the two key hormones produced by the thyroid gland -- so iodine is essential to the production of these two hormones of the master gland of metabolism. DIAGNOSTIC TESTS: Euthyroid 1. Inspection & Palpation 2. Auscultation – if TG is enlarged **BRUIT – it indicates increased blood flow through the TG then referral to AP 3. THYROID FUNCTION TESTS Measurement of Thyroid Hormones Thyroid Scanning Thyroid Biopsy and Ultrasonography 4. TSH MEASUREMENT Serum TSH – single best screening test for thyroid function – 98% sensitivity – 92% specificity – Start @ 35 y/o every 5yrs – N = approx 0.5 to 4.5 or 5.0 mIU/L. 5. SERUM FREE THYROXINE - Confirms an abnormal TSH🡪 correlated with metabolic activity - N = 0.9 – 1.7 ng/dl 6. SERUM T3 & T4 - Measurement of total T3 & T4 includes protein-bound and free hormone levels that occur in response to TSH secretion. T3 = 80 to 200 ng/dL T4 = 5.4 to 11.5 mcg/dL 7. FINE NEEDLE ASPIRATION BIOPSY Use of small gauge needle – thyroid tissue for cytological exam Results: ❑ Benign / Negative ❑ Malignant / Positive ❑ Suspicious / Indeterminate ❑ Non-diagnostic / Inadequate 8. RADIOACTIVE IODINE UPTAKE Measures the absorption of the iodine isotope to determine how the thyroid gland is functioning Tracer dose of iodine 123 or iodine 131 given per orem or IV 2, 6, 24 hrs after administration, a scintillation detector/ gamma camera is placed over the neck Results: ❑ Increase Uptake = HYPERthyroidism ❑ Decrease Uptake = HYPOthyroidism 9. BASAL METABOLIC RATE (BMR) An expression of the rate at which OXYGEN is used by the body cells Measure the oxygen consumption at the lowest cellular activity Patient at rest (8 – 10 hrs) & fast (10 – 12 hrs) Do not get up from bed the following morning until the test is done. 9. BASAL METABOLIC RATE (BMR) A device with a nose clip and a mouthpiece is used, the client performs DBE. Results: ❑ +/- 20% - Normal ❑ Increased - HYPERthyroidism ❑ Decreased – HYPOthyroidism HYPOTHYROIDISM BASIC CONCEPTS: 1. Decreased metabolic rate 2. Decreased body heat production 3. Hypercalcemia ❑ Children: CRETINISM ❑ Adults: MYXEDEMA  MYXEDEMA ▪ Characterized by a slow deterioration of the TG function ▪ Primarily in older adults; frequently 5x in women EARLY CLINICAL MANIFESTATIONS: 1. Extreme fatigue 2. Menstrual disturbances (Menorrhagia) 3. Hair loss, brittle nails, dry skin 4. Intolerance to cold 5. Anorexia 6. Constipation  EARLY CLINICAL MANIFESTATIONS: 7. Weight gain 8. Lethargy, sluggishness, sleepiness 9. Apathy 10. Slowed mental process, slurred speech 11. Dry, sparse hair 12. Infertility, decreased libido 13. Decreased body temperature LATE CLINICAL MANIFESTATIONS: 1. Subnormal body temperature 2. Bradycardia 3. Lethargy 4. Periorbital puffiness 5. Non-pitting edema of feet & hands 6. Large tongue 7. Pale, cool, rough skin 8. Coma  MYXEDEMA COMA rare but serious disorder that results from persistently low TH production Most extreme, severe stage of hypothyroidism Decreased RR, cardiovascular collapse, hypotension, hypothermia, hypoglycemia, respiratory failure, shock, coma  MEDICAL TREATMENT: 1. Replacement of deficient thyroid hormones. ❑ Thyroid USP (desiccated thyroid combination of T3 & T4) ❑ Thyroglobulin (Proloid) ❑ Levothyroxine Na (Synthroid & Levothroid) – T4 ❑ Liothyronine Na (Cytomel) – T3  MEDICAL TREATMENT: 1. Replacement of deficient thyroid hormones. ✔ Does not stimulate the thyroid to secrete TH – will increase metabolic rate, increase heat production, & 02 consumption ✔ Side Effects: nervousness, insomnia, HTN, tremors ✔ Check for BP & PR prior to admin ✔ Start with low dosage, then gradually increase; take daily ✔ TOXICITY: HYPERTHYROIDISM/ THYROTOXICOSIS/ THYROID STORM  MEDICAL TREATMENT: 2. Diet ✔ High CHON, Ca supplement ✔ Low calorie diet ✔ Decrease cholesterol intake ✔ Increase fiber  CRETINISM ▪ Congenital hypothyroidism ▪ Generally caused by failure in the embryonic development of the thyroid gland EARLY CLINICAL MANIFESTATIONS: Prolonged physiologic jaundice Feeding problems (impaired GI secretions) Excessive sleeping, minimum crying Hypotonic abdominal musculature (constipation, protruding abdomen) – umbilical hernia LATE CLINICAL MANIFESTATIONS: Impaired development of Nervous System precipitating mental retardation Slow awkward movement Severe stunted skeletal development Short forehead, protruding tongue Dentition is delayed/defective CV changes (bradycardia, decreased pulse pressure) MEDICAL MANAGEMENT: Before 3 months old 🡪 normal physically & intellectually, if given with proper treatment Oral Thyroxine & Vitamin D - to prevent mental retardation & bone development) HYPERTHYROIDISM BASIC CONCEPTS: 1. Increased metabolic rate 2. Increased body heat production 3. Hypocalcemia  GRAVES’ DISEASE Excessive T3 & T4 Other names: – Parry’s Disorder – Basedow’s Disorder – Exophthalmic Goiter – Toxic Diffuse Goiter CLINICAL MANIFESTATIONS: 1. THYROIDAL DISTURBANCES ▪ Restlessness, nervousness, irritability, tremors ▪ Tachycardia, HTN ▪ Increased appetite BUT weight loss ▪ Heat intolerance ▪ Diaphoresis ▪ Amenorrhea ▪ Irritability, mood swings, agitation ▪ Fine, silky hair, smooth skin ▪ Pliable nails CLINICAL MANIFESTATIONS: 2. OPHTHALMOPATHY ▪ Exophthalmos – accumulation of fluid at the fat pads behind the eyeballs, pushing the eyeballs forward. ▪ Von Graefe’s Sign (Lid Lag) – if the patient looks down, there is long and deep palpebral fissure ▪ Dalrymple's Sign (Thyroid Stare) – bright-eyed stare; infrequent blinking ▪ Joffroy’s Sign – forehead remains smooth when one looks up CLINICAL MANIFESTATIONS: 3. DERMOPATHY ▪ Clubbing of fingers and toes ▪ Skin is raised, thickened, very itchy and hyperpigmented COLLABORATIVE MANAGEMENT: 1. Rest 2. Diet 3. Safety 4. Protect the eyes 5. Replace F&E losses  PHARMACOTHERAPY: 1. Beta-blockers (Propranolol, Inderal) 2. Iodides (Lugol’s Solution/ KISS/ SSKI) ✔ decreases activity of TG ✔ decreases vascularity ✔ decreases the size of the TG ▪ Mix with fruit juice with ice or glass of water to remove palatability ▪ Provide drinking straw to prevent permanent staining of teeth ▪ S/E: Allergic rxn, Increased salivation, Coryza  PHARMACOTHERAPY: 3. Thioamides ▪ PTU (Propylthiouracil), Tapazole (Methimazole) ▪ Inhibit the synthesis of TH ▪ S/E: Agranulocytosis/ Neutropenia, Fever, Sore Throat, Skin Rashes 4. Calcium Channel Blockers 5. Dexamethasone  RADIATION THERAPY (I131/I132) ▪ A radioactive isotope given per orem ▪ 3 weeks to take effect, signs of hyperthyroidism will subside ▪ More than 2 months for thyroid function to become normal ▪ Isolation – few days ▪ Pregnancy – avoided 6 months after  SURGERY Partial Thyroid Lobectomy – only part of one thyroid is removed; a rare procedure Thyroid Lobectomy – all of the one thyroid lobe is removed Thyroid Lobectomy with Isthmusectomy – all of one thyroid lobe is removed together with the thyroid isthmus Subtotal Thyroidectomy – one thyroid lobe, the isthmus and part of the second lobe is removed; 5/6 is removed; usually done Pre-Op Care: Euthyroid state – to prevent occurrence of thyrotoxicosis during the surgery Administer iodides & thioamides ECG  Post-Op Care: 1. Positioning 2. Prevent hemorrhage 3. Tracheostomy Set – first 48 hrs 4. Ask pt to speak every hour 5. Calcium gluconate readily available 6. Monitor body temperature 7. Steam inhalation to soothe irritated airway 8. Support neck with interlaced fingers when getting up POTENTIAL COMPLICATIONS: Hemorrhage Airway obstruction Tetany Recurrent laryngeal nerve damage Thyroid crisis/storm / Thyrotoxicosis CLIENT TEACHING: ROM exercises of neck 3-4 times a day after discharge Massage incision site with cocoa butter lotion to minimize scarring Regular follow-up care  THYROID STORM 1. Monitor T, I&O, neurologic status, CV status every hour. 2. Administer increasing dosage of oral PTU (200 to 300 mg every 6hr) as ordered following a loading dose of 800 to 1200 mg, per orem, as ordered. 3. Iodide preparation 4. Dexamethasone 5. Propranolol  THYROID STORM 6. Implement measures to lower fever (cooling devices, cold baths, acetaminophen) due to hyperthermia. 7. Administer oxygen as needed. 8. Maintain quiet, calm, cool, private environment until crisis is over.  GOITER ▪ Enlargement of the thyroid gland. ▪ May occur in euthyroid, hypothyroid, hyperthyroid states. PATHOLOGY: Iodine deficiency Congenital defects preventing thyroid hormones synthesis Chemical agents (goitrogens) Drugs (thiocarbamates, sulfonylureas, lithium) MANIFESTATIONS: Enlarged gland, not weightful Mild discomfort Trachea & esophagus may be compressed – stridor, dysphagia Laryngeal nerve compression – may lead to hoarseness DIAGNOSTIC TESTS: THs – low, normal, high RAIU – normal or increased MANAGEMENT: ✔Drug therapy ✔Avoidance of goitrogens ✔Surgery ✔Iodized salt  THYROIDITIS Inflammation of TG; painful swelling TYPES: I. ACUTE THYROIDITIS – De Quervain’s Thyroiditis II. CHRONIC THYROIDITIS – Hashimoto’s Thyroiditis  ACUTE THYROIDITIS (De Quervain’s Thyroiditis) Associated with URTI o Left lobe: children o Right Lobe: adult Signs & symptoms: Hyperthyroid state 1. Unilateral pain radiates to the ear, aggravated by hyperextension of neck 2. Swelling 3. Fever, chills, sore throat, hoarseness, dysphagia TREATMENT: Control of infection Bed rest Steroids N = in weeks or months  CHRONIC THYROIDITIS (Hashimoto’s Thyroiditis) AUTOIMMUNE disorder Leading to underactive TG; Thyroid is infiltrated with lymphocytes and plasma cells Signs & Symptoms: Hypothyroid State MANAGEMENT: ▪ Steroid therapy – Prednisone - To reduce inflammation ▪ PTU - suppress TSH (negative feedback) 🡪 May have HYPERTHYROIDISM PARATHYROID GLANDS AFFECT: CALCIUM (Ca) – Cation; bone formation; nerve impulse transmission; skeletal muscles N= 4.5 – 5.5 meq/L or 8.2 – 10.2 mg/dl PHOSPHOROUS (P) – important in bone formation, energy storage, & release urinary acid base buffering, CHO metabolism N= 2.5 – 4.5 mg/dl or 1.8-2.6 mEq/L  Parathyroid Glands Decrease serum Calcium ↓ Parathormone release ↓ Withdraws Calcium from the bones ↓ Increase serum Calcium levels HYPERPARATHYROIDISM: HYPERCALCEMIA HYPOPARATHYROIDISM: HYPOCALCEMIA  HYPERPARATHYROIDISM May lead to BONE DECALCIFICATION & RENAL CALCULI (KIDNEY STONES) Depression of muscular activity SIGNS & SYMPTOMS 1. Apathy 2. Fatigue, muscle weakness 3. N/V 4. Constipation 5. HTN & cardiac dysrhythmias 6. Kidney stones (alkaline stones) 7. Bone deformities; bone demineralization; pathologic fractures 8. Skeletal pain (esp. on weight bearing joints) 9. Psychological manifestation  COMPLICATION HYPERCALCEMIC CRISIS 🡪 occurs when serum Ca reaches 15 mg/dL 🡪 results in neuro, cardio and renal symptoms that can be life threatening  DIAGNOSTICS 1. ____serum Ca; ____ parathormone; ____ P 2. Bone x-ray / scan – reveal bone demineralization 3. UTZ, MRI, thallium scan & fine needle biopsy  MANAGEMENT 1. Hydration therapy 2. Mobility 3. Diet – meat, eggs, fish, poultry, grapes, citrus fruits, bread, cereals 🡪 ACID-ASH DIET 4. Medications: MITHRAMYCIN 5. Surgery: PARATHYROIDECTOMY  HYPOPARATHYROIDISM CAUSES: Interruption of blood supply; surgical removal; radical neck dissection Atrophy Idiopathic – less common  MANIFESTATIONS 1. TETANY A. LATENT tetany - elicited by the application of electrical & mechanical stimulation (numbness, tingling, paresthesia, cramps) B. OVERT tetany - bronchospasm, laryngeal spasm, cardiac dysrhythmias, seizures 2. Anxiety, irritability, depression, delirium 3. ECG changes, HYPOtension TROUSSEAU’S SIGN CHVOSTEK’S SIGN  NURSING RESPONSIBILITIES 1. Serum Ca & Phosphate level -> ↓Ca ; ↑PO 3− 4 2. Prepare @ bed side: a. Tracheostomy set b. 02; bronchodilator c. Suction d. Ca gluconate  MANAGEMENT GOAL: to increase Ca to 9 – 10 mg/dl 1. Calcium gluconate (IV) 2. Pentobarbital agents 🡪 to decrease neuromuscular irritability 3. Parenteral parathormone 4. Vit D (Ergocalciferol) 🡪 to increase GI absorption of Ca 5. Amphojel (aluminum hydroxide) – binds phosphate & facilitate excretion thru GIT  NURSING MANAGEMENT 1. detect early signs of hypocalcemia 2. Calcium gluconate/ Ca salts 3. Cardiac monitoring ECG READINGS DIET