SIADH-until-Hypothyroidism.pdf

SIADH (syndrome of inappropriate antidiuretic hormone secretion) ⩥ Excessive ADH secretion from the pituitary gland ⩥ Dilutional hyponatremia 1 Causes ⩥ CNS disturbances: head injury, brain surgery or tumor, infection ⩥ Malignancies ⩥ Drugs: carbamazepine, oxcarbazepine, chlorpropamide, and selectiv...

SIADH (syndrome of inappropriate antidiuretic hormone secretion) ⩥ Excessive ADH secretion from the pituitary gland ⩥ Dilutional hyponatremia 1 Causes ⩥ CNS disturbances: head injury, brain surgery or tumor, infection ⩥ Malignancies ⩥ Drugs: carbamazepine, oxcarbazepine, chlorpropamide, and selective serotonin reuptake inhibitors (SSRI) ⩥ Surgery ⩥ Pulmonary disease ⩥ HIV infection: hyponatremia 2 Signs and Symptoms ⩥ ⩥ ⩥ ⩥ ⩥ ⩥ ⩥ Loss of appetite Weight loss Nausea and vomiting Headache Muscle weakness, spasm and cramps Fatigue Restlessness and irritability 3 The Schwartz and Bartter Clinical Criterion ⩥ ⩥ ⩥ ⩥ ⩥ ⩥ ⩥ Serum sodium less than 135mEq/L Serum osmolality less than 275 mOsm/kg Urine sodium greater than 40 mEq/L (due to ADH-mediated free water absorption from renal collecting tubules) Urine osmolality greater than 100 mOsm/kg The absence of clinical evidence of volume depletion - normal skin turgor, blood pressure within the reference range The absence of other causes of hyponatremia - adrenal insufficiency, hypothyroidism, cardiac failure, pituitary insufficiency, renal disease with salt wastage, hepatic disease, drugs that impair renal water excretion. Correction of hyponatremia by fluid restriction 4 Medical management ⩥ Interventions include eliminating the underlying cause, if possible, and restricting fluid intake ⩥ Diuretic agents such as furosemide (Lasix) may be used along with fluid restriction if severe hyponatremia is present. 5 Nursing management ⩥ Close monitoring of fluid intake and output, daily weight, urine and blood chemistries, and neurologic status 6 Diabetes insipidus ⩥ The most common disorder of the posterior pituitary lobe and is characterized by a deficiency of ADH. 7 Causes ⩥ Head trauma, brain tumor or irradiation of the pituitary gland ⩥ Infections of the CNS (meningitis, encephalitis) ⩥ Tumors (e.g. lymphoma of the breast or lung) ⩥ Failure of the renal tubules to respond to ADH (nephrogenic DI) 8 Signs and symptoms ⩥ urine contains no abnormal substances such as glucose or albumin ⩥ Intense thirst - 2 to 20 L of fluid daily (preferably cold water) 9 Assessment and diagnostic findings ⩥ Fluid deprivation test ⊳ Fluids are withheld for 8-12 hours or 3% to 5% of the body ⊳ ❖ ❖ ❖ weight is lost Plasma and urine osmolality studies are performed at the beginning and end of test Inability to increase the specific gravity and osmolality of the urine Large volume of urine with low specific gravity Increasing serum osmolality and elevated Na levels 10 Medical management ⩥ Objectives: ⊳ To replace ADH ⊳ To ensure adequate fluid replacement ⊳ To identify and correct the underlying intracranial pathology ⩥ Desmopressin (DDAVP) ⩥ Chlorpropamide (Diabinese) and thiazide diuretics ⩥ If renal in origin- Thiazide diuretics, mild salt depletion, and prostaglandin inhibitors (ibuprofen [Advil, Motrin], indomethacin [Indocin], and aspirin) 11 Nursing management ⩥ Verbal and written instructions should include the dose, actions, side effects, and administration of all medications ⩥ Teach the patient and the family about signs of hyponatremia ⩥ Allow the patient to return demonstrate medication administration ⩥ Advise the patient to wear a medical identification bracelet and carry required medication 12 Disorders of the thyroid gland 13 Thyroid hormones ⩥ Thyroxine (T4): 5.4-11.5 mcg/dL ⩥ Triiodothyronine (T3): 80-200 ng/dL ⊳ euthyroid ⊳ Iodine ⩥ Calcitonin ⊳ High plasma levels of calcium ⩥ Functions: ⊳ Body metabolism ⊳ Brain development ⊳ Normal growth ⊳ Cholesterol levels Hypothyroidism ⩥ results from suboptimal levels of thyroid hormone ⩥ range from mild, subclinical forms to myxedema, an advanced life-threatening form 16 Causes ⩥ Autoimmune disease (Hashimoto thyroiditis, post-Graves disease) ⩥ Atrophy of thyroid gland with aging ⩥ Therapy for hyperthyroidism ⊳ Radioactive iodine (131I) ⊳ Thyroidectomy 17 Causes ⩥ Medications ⊳ Lithium ⊳ Iodine compounds ⊳ Antithyroid medications ⩥ Radiation to head and neck in treatment for head and neck cancers, lymphoma ⩥ Infiltrative diseases of the thyroid (amyloidosis, scleroderma, lymphoma) ⩥ Iodine deficiency and iodine excess 18 ⩥ ⩥ ⩥ ⩥ ⩥ Primary or thyroidal hypothyroidism Central hypothyroidism Pituitary or secondary hypothyroidism Hypothalamic or tertiary Neonatal hypothyroidism 19 Signs and symptoms Extreme fatigue hair loss, brittle nails, and dry skin numbness and tingling of the fingers Menstrual disturbances such as menorrhagia or amenorrhea Weight gain even without an increase in food intake patient often complains of being cold even in a warm environment ⩥ Speech is slow, hoarse voice, and deafness may occur ⩥ Constipation ⩥ Dull mentation, apathetic, cognitive changes (dementia) ⩥ ⩥ ⩥ ⩥ ⩥ ⩥ 20 Signs and symptoms ⩥ Severe hypothyroidism ⊳ associated with an elevated serum cholesterol level, atherosclerosis, coronary artery disease, and poor left ventricular function ⩥ Myxedema coma ⊳ The decompensated state of severe hypothyroidism in which the patient is hypothermic and unconscious ⊳ initially show signs of depression, diminished cognitive status, lethargy, and somnolence 21 Myxedema coma ⩥ Undiagnosed hypothyroidism ⩥ Forget to take thyroid replacement medication ⩥ Depression, diminished cognitive status, lethargy and somnolence ⩥ Respiratory drive is depressed 22 Medical management ⩥ Synthetic levothyroxine (Synthroid or Levothroid) ⩥ IV administration of T4 and T3- myxedema coma ⩥ high-dose glucocorticoids (hydrocortisone) every 8 to 12 hours for 24 hours followed by low-dose therapy 23 Medication interactions ⩥ magnesium-containing antacids- decrease in thyroid hormone absorption ⩥ Thyroid hormones may also decrease the pharmacologic effects of digitalis glycosides ⩥ Anticoagulant agents- dose must be decreased because of the increased risk of bleeding ⩥ hypnotic and sedative agents may induce profound somnolence and lead to narcosis ⊳ ½ or 1/3 of the typical prescribed dose 24 Nursing diagnoses ⩥ Activity intolerance r/t insufficient physiologic energy ⩥ Risk for imbalanced body temperature ⩥ Constipation r/t diminished GIT peristalsis ⩥ Deficient knowledge about the therapeutic regimen for lifelong thyroid replacement therapy ⩥ Ineffective breathing pattern r/t depressed ventilation 25 Hyperthyroidism INCREASED THYROID HORMONES: ⩥ Hypermetabolism ⩥ sympathetic nervous system activity ⩥ Effects protein, lipid and carbohydrate metabolism 26 EFFECTS ON PROTEIN METABOLISM ⩥ Protein synthesis and degradation ⩥ More breakdown than buildup ⩥ Leads to loss of protein ⩥ Called negative nitrogen balance 27 EFFECTS ON GLUCOSE ⩥ Glucose tolerance decreased ⩥ Leads to hyperglycemia 28 EFFECTS ON FAT METABOLISM fat metabolism body fat appetite food intake; food intake does not meet energy demands ⩥ weight ⩥ nutritional deficiencies with prolonged disease ⩥ ⩥ ⩥ ⩥ 29 causes GRAVES DISEASE: ⩥ Client has a goiter (enlarged thyroid gland ⩥ Autoimmune problem ⩥ Antibodies attach to gland causing it to enlarge ⩥ SYMPTOMS: ⊳ exophthalmos (protrusion of the eyes) ⊳ Pretibial myxedema (dry, waxy swelling of the frontal surfaces of the lower legs) 30 31 causes 1. 2. 3. TOXIC MULTINODULAR GOITER: multiple thyroid nodules, milder disease EXOGENOUS HYPERTHYROIDISM: excessive use of thyroid replacement hormones THYROID STORM: untreated or poorly controlled hyperthyroidism; life threatening 32 ASSESSMENT Recent weight loss Increased appetite Increase in the number of bowel movement per day heat intolerance Diaphoresis even when temperatures comfortable for others ⩥ Palpitations/chest pain ⩥ Dyspnea with or without exertion ⩥ ⩥ ⩥ ⩥ ⩥ 33 ASSESSMENT VISUAL PROBLEMS MAY BE EARLIEST PROBLEM: ⩥ Infiltrative Exophthalmopathy (abnormal eye appearance or function) ⩥ Blurring/double vision/tiring of eyes ⩥ Increased tears ⩥ Photophobia ⩥ Eyelid retraction(eyelid lag) ⩥ Globe lag (eyeball lag) 34 35 goiter ⩥ Thyroid gland may be 4 X normal ⩥ Bruits (turbulence from increased blood flow) heard with stethoscope 36 Cardiac problems ⩥ ⩥ ⩥ systolic BP tachycardia dysrhythmia 37 Other manifestations ⩥ ⩥ ⩥ ⩥ ⩥ ⩥ ⩥ ⩥ Fine, soft, silky hair Smooth, moist skin Muscle weakness Hyperactive deep tendon reflexes Tremors of hands Restless, irritable, mood swings Decreased attention span Fatigued, inability to sleep 38 LABORATORY ASSESSMENT IN HYPERTHYROIDISM: ⩥ T3 ⩥ T4 ⩥ TSH in Graves disease ⩥ Radioactive Thyroid Scan ⩥ Ultrasonography: used to determine goiter or nodules ⩥ EKG: note tachycardia 39 Drug therapy ⩥ Antithyroid drugs: thioamides ⊳ propylthiouracil (PTU) ⊳ methimazole (Tapazole) ⊳ carbimazole (Neo-Mercazole) ⩥ ACTION: blocks thyroid hormone production; takes time ⩥ Need to control cardiac manifestations (tachycardia, palpitations, diaphoresis, anxiety) until hormone production reduced: use beta-adrenergic blocking drugs: propranolol (Inderal, Detensol) 40 Drug therapy ⩥ Iodine preparations: ⊳ Lugol’s Solution ⊳ SSKI (saturated solution of potassium iodide) ⊳ Potassium iodide tablets, solution, and syrup ⩥ ACTION: ⊳ decreases blood flow through the thyroid gland ⊳ This reduces the production and release of thyroid hormone ⊳ Takes about 2 weeks for improvement ⊳ Leads to hypothyroidism 41 Radioactive iodine therapy (Radioisotope 131I) ⩥ ⩥ ⩥ ⩥ CI: pregnancy Not conceive for at least 6 months following treatment Eliminate the hyperthyroid state Pretreatment: Methimazole ⊳ 4-6 weeks prior to administration ⊳ Stopped 3 days before and restarted 3 days after administration ⊳ Thyroid hormone replacement: 4-18 weeks after antithyroid medication 42 Drug therapy RADIOACTIVE IODINE THERAPY: ⩥ Receives RAI in form of oral iodine ⩥ Takes 6-8 Weeks for symptomatic relief ⩥ Additional drug therapy used during this type of treatment ⩥ Not used on pregnant women 43 Patient Teaching ⩥ Contaminate their household & other persons thru saliva, urine or radiation emitting from their body ⩥ Avoid sexual contact, sleeping in the same bed with other persons ⩥ Avoid close contact with children and pregnant women, and sharing utensils and cups 44 Drug therapy ⩥ Lithium Carbonate ⩥ ACTION: inhibits thyroid hormone release ⩥ NOT USED OFTEN BECAUSE OF SIDE EFFECTS: depressions, diabetes insipidus, tremors, nausea and vomiting 45 Thyroid Storm (thyrotoxic crisis, thyrotoxicosis) ⩥ Severe hyperthyroidism with an abrupt onset ⩥ Precipitated by stress, abrupt withdrawal of antithyroid meds, extreme emotional stress ⩥ Characteristics: ⊳ High fever : > 38.5 degrees centigrade ⊳ Extreme tachycardia: > 130bpm ⊳ Exaggerated symptoms of hyperthyroidism ⊳ Altered neurologic or mental state 46 ⩥ Reduction of body temperature, heart rate and prevention of vascular collapse ⊳ Hypothermia mattress/blanket, ice packs, cool environment, acetaminophen, hydrocortisone ⊳ Humidified oxygen ⊳ IV fluids containing dextrose ⊳ Propylthiouracil (PTU) or methimazole 47 Surgical management TWO TYPES OF SURGERIES: 1. Total thyroidectomy (must take lifelong thyroid hormone replacement) 2. Subtotal thyroidectomy 48 Preoperative care 1. 2. 3. Antithyroid drugs to suppress function of the thyroid Iodine prep (Lugols or K iodide solution) to decrease size and vascularity of gland to minimize risk of hemorrhage, reduces risk of thyroid storm during surgery Tachycardia, BP, dysrhythmias must be controlled preoperatively 49 Preoperative teaching ⩥ Teach C&DB ⩥ Teach support neck when C&DB ⩥ Support neck when moving reduces strain on suture line ⩥ Expect hoarseness for few days (endotracheal tube) 50 Postoperative nursing care ⩥ ⩥ ⩥ ⩥ ⩥ VS, I&O, IV Semifowlers position Support head Avoid tension on sutures Pain meds, analgesic lozenges 51 Postoperative nursing care ⩥ ⩥ ⩥ ⩥ Humidified oxygen, suction First fluids: cold/ice, tolerated best, then soft diet Limited talking , hoarseness common Assess for voice changes: injury to the recurrent laryngeal nerve 52 Postoperative nursing care ⩥ CHECK FOR HEMORRHAGE 1st 24 hrs: ⩥ Look behind neck and sides of neck ⩥ Check for c/o pressure or fullness at incision site ⩥ Check drain ⩥ REPORT TO THE PHYSICIAN ⩥ CHECK FOR RESPIRATORY DISTRESS ⩥ Laryngeal stridor (harsh highpitched respiratory sounds) ⩥ Result of edema of glottis, hematoma, or tetany ⩥ Tracheo set/airway/ O2, suction ⩥ CALL physician for extreme hoarseness 53 Tetany ⩥ accidental removal of the parathyroid gland during surgery can happen ⩥ This disturbs the Ca metabolism ⩥ low blood calcium: see hyper-irritability of the nerves, spasms of the hands and feet, muscle twitchings occur, tingling, around mouth/toes/fingers ⩥ RISK: laryngospasm, airway obstruction ⩥ TREAT: IV calcium gluconate or calcium chloride 54 Postoperative nursing care CHECK FOR THYROID STORM: 25% mortality rate ⩥ result of release of TH during surgery ⩥ Observe for fever, tachycardia, systolic hypertension, agitation leading to seizures, delirium and coma, heart failure and shock TREAT: ⩥ Patent airway, cardiac monitor ⩥ Antithyroid drugs IV: PTU, propyl-Thyracil, Tapazole, sodium iodide solution ⩥ Inderal, Detensol for cardiac symptoms ⩥ Glucocorticoids (hydrocortisone IV) ⩥ Antipyretics and cooling blanket for fever 55