Thyroid Disorders 2023/2024 PDF

Thyroid disorders Prepared by Assist.Lect. Sara Yousef 2023/2024 1 Objectives At the end of this presentation , the students will be able to : 1. Explain anatomy and physiology of thyroid gland 2. Illustrate role of calcitonin and parathyroid hor...

Thyroid disorders Prepared by Assist.Lect. Sara Yousef 2023/2024 1 Objectives At the end of this presentation , the students will be able to : 1. Explain anatomy and physiology of thyroid gland 2. Illustrate role of calcitonin and parathyroid hormone (PTH) in regulating the blood calcium level in the body. 3. Clarify Hypothalamic-Pituitary-Thyroid Axis 4. Discuss different thyroid disorders regarding to :  Definition  Signs and symptoms  Causes  Diagnostic procedure  Complications 5. Discuss management of thyroid disorders Medical Surgical Nursing  Outlines 1. Anatomy and physiology of thyroid gland 2. Role of calcitonin and parathyroid hormone (PTH) in regulating the blood calcium level in the body. 3. Hypothalamic-Pituitary-Thyroid Axis 4. Different thyroid disorders inform of :  Definition  Signs and symptoms  Causes  Diagnostic procedure  Complications Outlines 5. Management of Thyroid disorders in form of : Medical Surgical Nursing 6. References Anatomy of thyroid gland A butterfly shaped organ Thyroid gland is located anterior to the trachea ,inferior to larynx. The medial region is called isthmus , it is flanked by wing shaped left and right lobes. Each of thyroid lobes are embedded with parathyroid glands , on the posterior surface. 5 Thyroid gland hormones 1. Triiodothyronine, also known as T3. 2. Tetraiodothyronine, also called thyroxine or T4. 3. Calcitonine Iodine is one of the main building blocks of both hormones. it is eventually used to make thyroid hormones. The bodies cannot produce this trace element, so it is important to get enough iodine in diet. 6 Hypothalamic-Pituitary-Thyroid Axis 7 Effect of thyroid hormones 1. T3 & T4 Effect growth and development Control basal metabolic rate Regulate heat production Regulate metabolism of carb, protein and fats Effect on CNS Control body temperature, heart rate and blood pressure Effect on weight Effect on sexual ability 8 Effect of thyroid hormones 2-Effect of calcitonin It effect bone cell and kidney to reduce blood calcium levels when increased. It promotes storage of calcium in bones It inhibits reabsorption of calcium by renal tubules 9  Role of calcitonin and parathyroid hormone (PTH) in regulating the blood calcium level in the body. 10 11  Thyroid disorders Hyperthyroidism Hypothyroidism Hyperthyroidism Hypothyroidism (overactive thyroid) (underactive thyroid) Too much thyroid Thyroid gland does hormone in the body. not make enough thyroid hormones to meet body needs.  Causes of thyroid disorders Hyperthyroidism Hypothyroidism Hashimoto’s disease (autoimmune Graves’ disease (autoimmune disease). disease). Overactive thyroid nodules (lumps in Thyroiditis (inflammation of the thyroid). your thyroid, usually not cancerous). Congenital hypothyroidism. Thyroiditis (inflammation of the thyroid Surgical removal of part or all of the gland). thyroid. Pituitary gland tumor. Radiation treatment of the thyroid. Thyroid tumor. Pituitary gland or hypothalamus diseases. Common causes of hyperthyroidism Graves' disease 14  Signs and Symptoms Hyperthyroidism Hypothyroidism Signs and symptoms Hyperthyroidism 16  Complications Hyperthyroidism Hypothyroidism Thyroid storm, rare Myxedema is an (thyrotoxic crisis) due to emergency situation untreated and requires prompt hyperthyroidism. medical treatment. Complications Thyroid storm Management Block synthesis (i.e. antithyroid drugs) Block release (i.e. iodine) Block T4 into T3 conversion (i.e. propranolol, propylthiouracil [PTU]) Block enterohepatic circulation (i.e. cholestyramine) Myxedema Management Thyroid Hormone injections Glucocorticoid therapy Fluid replacement Diagnostic procedure 1. Physical examination  Examine thyroid for enlargement or nodules.  Assess signs of too much thyroid hormone like fast heart rate, shakiness/tremor of the hands, warm and moist skin.  Assess signs of thyroid eye disease like eye redness, swelling, or bulging of the eyes 19 Diagnostic procedure , con.. 2. Thyroid test (T3, T4 and TSH) T3(total): 70-204 ng/dl T4(total): 5-11 ng/dl TSH: 0.4 -4.2 mIU/L 3. Thyroid antibodies may help diagnose an autoimmune thyroid disorder 20 Diagnostic procedure , con.. 4. Ultrasound 21 Diagnostic procedure , con.. 5. Thyroid scan :This test uses a small amount of radioactive iodine. The scan takes place after 30 minutes of an injection, or up to 24 hours after swallowing the substance, so the thyroid has enough time to absorb it. 22  Hyperthyroidism Management Medical Surgical Nursing Anti-thyroid Preoperative Postoperative drugs Total / partial thyroidectomy Assessment Assessment Common Health teaching B-Adrenergic nursing blockers diagnosis Common nursing Wound diagnosis care Radioactive Iodine Therapy (RAI) Health teaching Diet Complications Follow-up 23 Nursing management Pre-operative Preoperative assessments. Prepare the patient for thyroidectomy surgery. Ensuring proper informed consent. 24 Nursing diagnosis (Bio-psychosocial) Actual nursing diagnosis according to priority (ABC) 1. Fluid volume deficit related altered bowel elimination (diarrhea) 2. Insomnia related to fatigue 3. Disturbed body image related to weight loss 4. Anxiety relayed to knowledge deficit about medical diagnosis 5. Low self-esteem related to disturbed body image 25 Nursing diagnosis (Bio-psychosocial) Potential nursing diagnosis according to priority (ABC) 1. High risk for fluid volume deficit related to altered bowel elimination (diarrhea( 2. High risk for pain related to surgical incision 3. High risk for fatigue related to insomnia 4. High risk for disturbed body image related to weight loss 5. High risk for anxiety related to knowledge deficit about surgical procedure 6. High risk for Low self-esteem related to disturbed body image 26 Goals Realize therapeutic needs. Understand surgical procedure , prognosis and potential complications. Follow the treatment regimen. 27 Pre-operative health teaching Cough and deep breathing. Support of neck (to avoid pressure on the suture lines) Possible hoarseness (is temporary and may last a few days). Educate the patient on postoperative care, including wound care , activity restrictions and dietary modifications 28 Post-operative Assessment Assess vital signs and the patient’s pain. Assess site of surgical incision. Monitor any signs of complications such as : o Laryngeal edema o Hemorrhage o Respiratory obstruction (stridor sound) 29 Nursing diagnosis (Bio-psychosocial) Actual nursing diagnosis according to priority (ABC) 1. Ineffective air way clearance related to surgical Incision 2. Insomnia related to Pain 3. Anxiety related to knowledge deficit about surgical procedure 4. Low self-esteem related to disturbed body image 30 Nursing diagnosis (Bio-psychosocial) Potential nursing diagnosis according to priority (ABC) 1. High risk for ineffective air way clearance related to surgical incision 2. High risk for fluid volume deficit related to bleeding 3. High risk for altered nutritional status less than body requirement related to incisional Pain 4. High risk for infection related to surgical incision 5. High risk for anxiety related to impaired verbal communication 6. High risk for low self-esteem related to disturbed body image 31 Goals 1. Maintain a patent airway. 2. Control of pain. 3. Maintain effective way of communication 4. Prevent occurrence of injury 32 1. Maintaining a Patent Airway Clearance Monitor respiratory rate, depth and auscultate breath sounds, noting the presence of rhonchi. Assess for dyspnea, stridor and cyanosis. Keep tracheostomy tray at the bedside in case of laryngeal edema occur. Suction mouth and trachea as indicated, noting the color and characteristics of sputum 33 1. Maintaining a Patent Airway Clearance, con.. Encourage patient to avoid bending the neck and support the head with pillows. Assist patients with repositioning, deep breathing exercises, and/or coughing. Check dressing frequently, especially the posterior portion. 2-Managing Post-operative Acute Pain Assess verbal and nonverbal reports of pain, noting location, intensity (0–10 scale), and duration. keep patient in semi-Fowler’s position and support head and neck with small pillows. Instruct patient to use hands to support the neck during movement and to avoid hyperextension of the neck. Provide cool liquids or soft foods, such as ice cream or popsicles. 35 2-Managing Post-operative Acute Pain, con.. Administer analgesics as necessary. Provide an ice collar if indicated. 3-Prevent occurrence of Injury Monitor vital signs and serum calcium levels to detect signs of hypocalcaemia like muscle twitching, numbness, paresthesias, positive Chvostek’s and Trousseau’s signs. Chvostek Sign: it is an abnormal response of the facial nerve to stimulation. This can be obtained by tapping on the cheek of the patient and observing for facial twitching. Trousseau’s Sign: it occurs when applying pressure on the arm causes an abnormal reaction of the hand. 37 3-Prevent occurrence of Injury, cont.. 3-Prevent occurrence of Injury, cont.. Evaluate patient’s ability to swallow to avoid aspiration , choking. Keep side rails raised and padded, the bed in a low position, and the airway at the bedside. Facilitate early ambulation and mobility, with assistance. Administer medications as calcium gluoconate and analgesic if needed. 39 4-Promoting Effective Communication Assess speech periodically to detect any changes in voice. Keep communication simple and ask yes or no questions, to promotes voice rest. Provide alternative methods of communication as appropriate: slate board, and picture board. Visit the patient frequently to reduces anxiety and to assess patient’s need. Maintain a quiet environment to reduces the necessity for the patient to raise voice to be heard. 40 Health Teaching Identify signs and symptoms requiring medical help like fever, chills, purulent wound drainage, erythema, nausea and vomiting, insomnia, constipation, drowsiness, intolerance to cold, and fatigue. Encourage patient to have a well-balanced diet with inclusion of iodized salt like sea food, dairy product and egg. Identify foods high in calcium and vitamin D like Spinach kale, Okra, Some fish like sardines, salmon, Beef liver, Cheese, Egg yolks , orange juice and oatmeal. 41  Health Teaching, cont.. Review postoperative neck exercises to be started after the incision heals. Instruct patient about incisional care Recommend the use of loose-fitting scarves to cover the scar Avoid lifting anything over 10pounds, stretching neck for first 2 weeks. Approximately, After 6 weeks following surgery ,perform blood test to evaluate thyroid hormone level. 42 Health Teaching , cont.. Instruction regarding thyroxine pills : Take the pills on the morning on empty stomach or at bedtime. Don’t have anything to eat or drink for one hour after taking it. Avoid taking calcium, iron or multivitamins within 4hours of taking it. Don’t miss the time of taking the pill. Schedule follow-up appointments to monitor healing, assess thyroid hormone levels, and adjust medication dosage if needed. 43  Hypothyroidism Management Medical Nursing Thyroid Common hormone Assessment nursing Health teaching replacement diagnosis 44 Medical Management Hypothyroidism can’t be cured. But it can be controlled. It is treated by replacing the amount of hormone that thyroid cannot make, to restore T4 and TSH levels back to normal levels. Synthetic thyroxine pills (levothyroxine). 45  Nursing management Assessment Assess the thyroid gland and palpate it. Assess signs, symptoms that appear on the patient Assess serum thyroid-stimulating tests (TSH) and assess serum T3 and T4. Assess psychological status 46 Nursing diagnosis (Bio-psychosocial) Actual nursing diagnosis according to priority (ABC) 1. discomfort related to ineffective breathing pattern 2. Abdominal pain related to altered bowel elimination (constipation) 3. Insomnia related to fatigue 4. Disturbed body image related to weight gain 5. Anxiety related to knowledge deficit about medical diagnosis 6. Low self-esteem related to disturbed body image 7. Activity intolerance related to fatigue 47 Nursing diagnosis (Bio-psychosocial) Potential nursing diagnosis according to priority (ABC) 1. High risk for discomfort related to ineffective breathing pattern 2. High risk for Abdominal pain related to altered bowel elimination (constipation) 3. High risk for insomnia related to fatigue 4. High risk for disturbed body image related to weight gain 5. High risk for anxiety related to knowledge deficit about medical diagnosis 6. High risk for low self-esteem related to disturbed body image 7. High risk for Activity intolerance related to fatigue 48 Goals Improve respiratory status. Maintenance of normal breathing pattern. Increase patients participation in activities. Increase independence. Maintenance of normal body temperature. Return of normal bowel function. Weight reduction. Emphasize on medication compliance. Follow-up visits: State the importance of regular follow-up visits with health care provider. 49  Nursing intervention Manage respiratory symptoms. Monitor respiratory depth, rate, pattern, pulse oximetry, and ABG. Pulmonary exercises. Encourage deep breathing, coughing. Increase fluid intake. Encourage increased fluid intake within the limits of fluid restriction & Provide foods high in fiber. Protect against coldness. Provide extra layer of clothing or extra blanket. Control body temperature. Monitor patient’s body temperature. Promote rest. Space activities to promote rest. 50  Nursing intervention , cont.. Weight reduction. Identify strategies for weight reduction and prevention of constipation such as high-fiber, low-calorie intake and adequate fluid intake. Ensure patients adherence to medication. State that compliance to medical regimen is life-long. Follow-up visits. State the importance of regular follow-up visits with health care provider. State the importance of regular follow-up visits with health care provider. Health teaching TSH checked 6 to 10 weeks after starting a thyroxine dose. Ask medical help in these conditions : If symptoms return or get worse. In case of needing to change your thyroxine dose. In case of gaining or losing a lot of weight (as little as a 10-pound difference) In case of starting or stopping take a drug that can interfere with absorbing thyroxine (such as calcium supplements and iron tablets). In case of missing many thyroxine pills. 52 References Hinkle, J. L., Cheever, K. H., & Hinkle, J. L. (2010). Brunner & Suddarth's textbook of medical-surgical nursing. 12th edition. Philadelphia, Wolters Kluwer. https://www.thyroid.org/hypothyroidism/ American thyroid association. availabe at https://www.thyroid.org/post- operative-expectations/ Carroll, R., & Matfin, G. Endocrine and metabolic emergencies: thyroid storm. Therapeutic advances in endocrinology and metabolism, 1(3), 139– 145. https://doi.org/10.1177/2042018810382481 53 References ,con.. Pandey, R., Kumar, S., & Kotwal, N. (2020). Thyroid Storm: Clinical Manifestation, Pathophysiology, and Treatment. IntechOpen. doi: 10.5772/intechopen.89620 https://www.entspecialtycare.com/provider-physician/instructions- postoperative_care_after_thyroidectomy https://nurseslabs.com/thyroidectomy-nursing-care-plans/ https://www.mountsinai.org/locations/head-neck-institute/postoperative/thyroidectomy https://www.thenursingjournal.com/post/thyroidectomy-pre-operative-nursing-care https://www.healthcentral.com/condition/hypothyroidism/morning-still-best-time-take- levothyroxine