MSEM103.pdf

11/20/23, 1:00 AM Realizeit for Student Medical Management The objectives in the management of hypothyroidism are to restore a normal metabolic state by replacing the missing hormone, as well as prevention of disease progression and complications. Prevention of Cardiac Dysfunction Any patient who...

11/20/23, 1:00 AM Realizeit for Student Medical Management The objectives in the management of hypothyroidism are to restore a normal metabolic state by replacing the missing hormone, as well as prevention of disease progression and complications. Prevention of Cardiac Dysfunction Any patient who has had hypothyroidism for a long period usually has associated elevated serum cholesterol, atherosclerosis, and coronary artery disease. As long as metabolism is subnormal and the tissues (including the myocardium) require relatively little oxygen, a reduction in blood supply is tolerated without overt symptoms of coronary artery disease. When thyroid hormone is given, the oxygen demand increases, but oxygen delivery cannot be increased unless, or until, the atherosclerosis improves. This occurs very slowly, if at all. The occurrence of angina and acute coronary syndrome is the signal that the oxygen needs of the myocardium exceed its blood supply. Angina or arrhythmias can occur when thyroid replacement is initiated because thyroid hormones enhance the cardiovascular effects of catecholamines. Quality and Safety Nursing Alert The nurse must monitor for signs and symptoms of cardiac dysfunction, which can occur in response to therapy in patients with severe, long-stand especially during the early phase of treatment. Acute coronary syndrome must be aggressively treated to avoid morbid complications (e.g., myocar If angina or arrhythmias occur, thyroid hormone administration must be discontinued immediately. Later, when it can be resumed safely, it should be prescribed cautiously at a lower dosage and with close monitoring by the primary provider and the nurse. Supportive Therapy Severe hypothyroidism and myxedema coma require prompt, aggressive management to maintain vital functions. Arterial blood gases may be measured to determine carbon dioxide retention and to guide the use of assisted ventilation to combat hypoventilation. Oxygen saturation levels should be monitored using pulse oximetry. Fluids are given cautiously because of the danger of water intoxication. Passive rewarming with a blanket is recommended versus active rewarming such as application of external heat (e.g., heating pads). The latter should be avoided to prevent increased oxygen demands and hypotension. Nursing Management Nursing care of the patient with hypothyroidism and myxedema is summarized in the plan of nursing care in Chart 45-4. In patients with hypothyroidism, the effects of analgesic, sedative, and anesthetic agents are prolonged. The nurse should carefully monitor patients who are prescribed these agents for adverse effects. Older patients are at increased risk because of age-related changes in liver and renal function. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IZN5n24G8UktHULazYLeTIBFBizuuh93swtew1H3xVYA2sj… 1/6 11/20/23, 1:00 AM Realizeit for Student https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IZN5n24G8UktHULazYLeTIBFBizuuh93swtew1H3xVYA2sj… 2/6 11/20/23, 1:00 AM Realizeit for Student https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IZN5n24G8UktHULazYLeTIBFBizuuh93swtew1H3xVYA2sj… 3/6 11/20/23, 1:00 AM Realizeit for Student Quality and Safety Nursing Alert Medications are given to the patient with hypothyroidism with extreme caution because of the potential for altered metabolism and excretion, as we respiratory status. Promoting Home, Community-Based, and Transitional Care Educating Patients About Self-Care The patient and family require education and support to manage this complex disorder at home. Oral and written instructions should be provided regarding the following: https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IZN5n24G8UktHULazYLeTIBFBizuuh93swtew1H3xVYA2sj… 4/6 11/20/23, 1:00 AM Realizeit for Student •The importance of life-long therapy and the need to take thyroid medication everyday •Desired actions and side effects of medications •Correct medication administration (“Take first thing in the morning with a full glass of water on an empty stomach.”) •Importance of continuing to take the medications as prescribed even after symptoms improve •When to seek medical attention •Importance of nutrition and diet to promote weight loss and normal bowel patterns •Importance of periodic follow-up testing The patient and family should be educated that the symptoms observed during the course of the disorder will disappear with effective treatment Continuing and Transitional Care If indicated, a referral is made for home, community-based or transitional care. The nurse monitors the patient’s recovery and ability to cope with changes, and assesses the patient’s physical and cognitive status and the patient’s and family’s understanding of previous education. The nurse documents and reports to the patient’s primary provider subtle signs and symptoms that may indicate either inadequate or excessive thyroid hormone. Gerontologic Considerations The prevalence of hypothyroidism increases with age, most often among women (Calsolaro, Niccolai, Pasqualetti, et al., 2019). The higher prevalence of hypothyroidism among older adults may be related to age-related alterations in immune function and complicated by multiple comorbidities. Most patients with primary hypothyroidism present with long-standing mild to moderate hypothyroidism. Subclinical disease is common among older women and can be asymptomatic or mistaken for other medical conditions. Subtle symptoms of hypothyroidism, such as fatigue, muscle aches, and mental confusion, may be attributed to the normal aging process by patients, families, and health care providers; therefore, these symptoms require close attention (Calsolaro et al., 2019). In addition, signs and symptoms of hypothyroidism in older adults are often atypical, and manifestations of hypothyroidism and hyperthyroidism may blur. Patients may have few or no symptoms until dysfunction is severe. Depression, apathy, and decreased mobility or activity may be the major initial symptoms and may be accompanied by significant weight loss. Constipation affects one fourth of older patients. In those with mild to moderate hypothyroidism, thyroid hormone replacement is individually tailored and must be started with low dosages and increased gradually to prevent serious cardiovascular side effects (Calsolaro et al., 2019). Angina, for example, may occur with rapid thyroid replacement in the presence of coronary artery disease secondary to the hypothyroid state. Heart failure and tachyarrhythmias may worsen during the transition from the hypothyroid state to the normal metabolic state. Dementia may become more apparent during early thyroid hormone replacement in older patients with concomitant dementia. Older patients with severe hypothyroidism and atherosclerosis may become confused and agitated if their metabolic rate is increased too quickly. Marked clinical improvement follows the administration of hormone replacement; such medication must be continued for life, even though signs of hypothyroidism disappear within 3 to 12 weeks. Older patients require periodic follow-up monitoring of serum TSH levels, because poor adherence with therapy may occur or the patient may take the medications erratically. A careful history can identify the need for further education about the importance of the medication. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IZN5n24G8UktHULazYLeTIBFBizuuh93swtew1H3xVYA2sj… 5/6 11/20/23, 1:00 AM Realizeit for Student https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IZN5n24G8UktHULazYLeTIBFBizuuh93swtew1H3xVYA2sj… 6/6