Thyroid disorders.pdf

Thyroid Disorders Thyroid Overview Thyroid Gland - produces thyroid [T3, T4] hormone (hormones that regulate the body's metabolic rate, growth and development) ○ Controls heart, muscle and digestive function, brain development and bone maintenance. ○ Located in the neck on either side of the trachea...

Thyroid Disorders Thyroid Overview Thyroid Gland - produces thyroid [T3, T4] hormone (hormones that regulate the body's metabolic rate, growth and development) ○ Controls heart, muscle and digestive function, brain development and bone maintenance. ○ Located in the neck on either side of the trachea. Parathyroid Gland - Produces parathyroid hormone (regulates calcium levels in blood) ○ Calcium - help regulate muscle and nerves. Scope of Thyroid Disorders 1←→5 1. Myxedema coma 2. Hypothyroid 3. Euthyroid - normal thyroid 4. Hyperthyroid 5. Thyroid Storm Hyperthyroidism/ Graves Disease Hyperthyroidism - Excessive thyroid hormone secretion from thyroid gland ○ Reduces cellular regulation by increasing metabolism in all body organs ○ Increased sympathetic nervous system activity ○ Thyroid hormones stimulate the heart, increasing rate and stroke volume ○ Weight loss and nutritional deficits ○ Concepts Affected: Cellular regulation → increased metabolism Nutrition Graves Disease - autoimmune disorder in which a patient's immune system attacks thyroid. ○ Most common cause of hyperthyroidism ○ Make note: Problems with the airway Calcium could be affected ○ Graves Symptoms Rapid heartbeat (palpitations) Increased appetite Weight loss Feeling shaky and/or nervous Diarrhea and/or more frequent bowel movements Signs and symptoms ○ Overall Dryness, corneal erosion, pain in the eyes, lacrimation Dysrhythmia, tachycardia Thirst, copious urination Increased appetite, indigestion, diarrhea, abdominal pain Thirst, copious rumination Increased appetite, indigestion, diarrhea, abdominal pain Splenomegaly: Enlarged spleen Hypotrophy of muscles, tremors in the body and limbs, development of osteoporosis Infertility, meager menstruation, decreased potency Sweating, early gray Irritability, anxiety, depression, insomnia ○ Other: AGES Amenorrhea - absence of menstrual period Goiter - enlarged thyroid gland. Exophthalmos (Proptosis) - bulging or protruding eyeballs. Signs and Symptoms by Systems Cardiopulmonary Symptoms PCT DR Palpitations Chest pain increased systolic BP Tachycardia Dysrhythmias Rapid shallow respirations Metabolic Symptoms HILF Smooth moist warm skin Thinning of scalp hair Fine, soft silky body hair Skin symptoms STF Heat intolerance Increased basal metabolic rate Low grade fever Fatigue Neuro Symptoms BE HIT GI Symptoms WII Weight loss Increased appetite Increased stools (diarrhea) Blurred/double vision (diplopia) Eye fatigue Hyperactive deep tendon reflexes Insomnia Tremors Psych Symptoms DREM Decreased attention span Restlessness / irritability Emotional instability Manic behavior Note: This patient can present as a psych patient Secondary Prevention ○ CBC → increased WBC with infection ○ TSH - produced by pituitary gland. Prompts thyroid gland to make thyroid hormones. ○ T3, T4 - thyroid hormones. ○ EKG → checks for arrhythmias due to increased heart rate ○ Urinalysis → checks for proteinuria or damage to kidneys because of weight loss. Tertiary Prevention ○ Pharmacology (in order of given) Beta-Blockers - decreases sympathetic hyperactivity (heart rate) Partially blocks peripheral conversion of T4 to T3. Ex: Propranolol Suffix = “-olol” Propylthiouracil (PTU) - blocks synthesis of thyroid hormone Decreases conversion of T4 to T3. Faster onset of action than methimazole Preferred in pregnancy. Methimazole [Tapazole] - blocks synthesis of thyroid hormone Teratogenic - can cause abnormalities or birth defects in a developing fetus ○ Teaching: Note symptoms of hyper/hypothyroidism; report these to the MD Dose of medication may need to be changed Stay away from crowds and people who are ill Lowers immune response / increases chance of infection Let MD know if she wishes to get pregnant The drug should NOT be used in pregnancy ○ Nutrition Education: Small, frequent meals High protein Can have high calorie meals Weight checks Iodide - inhibits release of stored thyroid hormone. Administer only after the synthetic pathway has been blocked by PTU or methimazole. Steroids - decrease peripheral conversion of T4 to T3. May treat the autoimmune process in Graves Disease. ○ Radioactive Iodine Therapy (RAI) - Given orally. Thyroid picks up RAI and it destroys cells producing thyroid hormone. Can be done as an outpatient Contraindicated in pregnancy Takes 6 - 8 weeks to work → May not work completely / may need more doses Radioactivity in patient’s stool / body fluids for months Before RAI, many doctors order low iodine diet to increase uptake Implications: Use separate toilet for 2 weeks Avoid splashing urine on walls, floor, seat Use laxative on 2nd or 3rd day to excrete contaminated stool faster Wear only machine washable clothes and wash them separately After washing clothing, run machine through complete cycle on empty before washing others’ clothes Remain at least 3 ft away from pregnant women, infants, and young children for 1 week DO NOT share toothbrushes or toothpastes Use disposable tissues, dishes, and utensils Surgery → Thyroidectomy - Surgical removal of all or part of your thyroid gland ○ Types: Thyroid lobectomy - removes 1 of 2 thyroid lobes, leaving the other intact. Subtotal thyroidectomy - removal of the majority of the thyroid gland but leaves approximately 4-8 g of thyroid tissue to achieve an euthyroid state. Total thyroidectomy - involves the removal of the entire thyroid gland Thyroidectomy After-Care: ○ Vitals every 15 minutes in the 1st hour, then every 30 minutes ○ Deep breathing every 30 - 60 minutes ○ Check for laryngeal nerve damage → Assess voice every 2 hours ○ Inspect for signs of hemorrhage in the first 24 hours ○ Monitor for respiratory distress (keep emergency trach kit at bedside) Stridor heard in acute respiratory obstruction Stridor - high-pitched due to obstructed airflow through a narrowed airway. ○ Monitor for hypocalcemia and tetany Parathyroid glands are responsible for making calcium Low calcium can cause tetany. Tetany - involuntary, intermittent muscular spasms and caused by malfunction of the parathyroid glands and a consequent deficiency of calcium Check For: Chvostek’s and Trousseau’s signs → indicates hypocalcemia. Chvostek’s Sign - Contraction of the ipsilateral facial muscles elicited by tapping the facial nerve just anterior to the ear. ○ Response: Twitching of the lip to spasm of all facial muscles Trousseau’s Sign - induction of the carpopedal spasm by inflation of sphygmomanometer above SBP for 3 minutes. ○ Response: Adduction of the thumb Flexion of the metacarpophalangeal joints Extension of the interphalangeal joints Flexion of the wrist Thyroid storm ○ Thyroid Storm - Life threatening uncontrolled hyperthyroidism. Caused by release of too much thyroid hormone TIP DM ○ Triggers: Trauma Infection Pregnancy Diabetic ketoacidosis (DKA) Medication mismanagement (Pts stop taking medications b/c they feel fine). Signs and Symptoms: V FART ○ Vomiting, diarrhea ○ Fever ○ Abdominal pain ○ Restlessness, confusion, delirium ○ Tachycardia, hypertension Treatment: C-CRIP ○ Close monitoring of vitals ○ Cooling (air-conditioning, cooling mattress, sponge bath) ○ Reducing stimulation ○ Immediate IV fluids (avoid dehydration/start IV immediately) ○ Pharmacology → same as above. Hyperthyroidism Questions to Ask Patient/Significant Other ○ ○ ○ ○ ○ ○ ○ ○ How long has the mass in the neck been present? Has she been feeling overheated? Is the mass painful? Was she ever diagnosed with thyroid problems? Does she take any medications? Has her urine been tested for infection? Does she have any vision problems? Family history? Hypothyroidism Hypothyroidism - low thyroid hormones ○ Causes Decreased thyroid tissue Thyroidectomy Autoimmune destruction of thyroid Cancer Decreased synthesis of thyroid hormone: Severe iodine deficiency Drugs such as lithium Inadequate production of thyroid stimulating hormone (TSH): Pituitary tumor / defects Hypothalamic tumors Trauma Infection ○ Concepts Affected: Cell regulation Gas exchange Nutrition Signs and symptoms ○ Overall Brittle nails and hair Hair loss Receding hairline Lethargy Muscle aches and weakness Extreme fatigue Dry skin (coarse and scaly) Intolerance to cold Thick tongue → slow speech Anorexia ○ Late Clinical Manifestations BTS CDW ○ Bradycardia Thickened skin Subnormal temperature Cardiac complications Decreased level of consciousness Weight gain Other: PHACED DG Puffy face (Facial and eyelid edema) Hoarseness - changes in the pitch or quality of the voice, which may sound weak, scratchy or husky Amenorrhea or prolonged periods (Menstrual disturbances) Constipation Easy bruising Depression/apathy Decreased libido Signs and Symptoms by Systems Cardiopulmonary Symptoms HD BD HD Hypoventilation Dyspnea Metabolic Symptoms DD CW Decreased basal metabolic rate Decreased body temperature Bradycardia Dysrhythmias Hypotension Decreased activity level Skin symptoms CT DDP Cool, pale, dry, scaly skin Thick brittle nails Dry, coarse, brittle hair Decreased hair growth, loss eyebrow Poor wound healing Cole intolerance Weight gain Neuro Symptoms CLIPSS MD Confusion lethargy/ somnolence (sleepiness) Impaired memory Paresthesia Slowing of intellectual functions Slow/Sometimes slurred speech Muscle aches and pains Decreased tendon reflexes Secondary Prevention ○ T3, T4 ○ EKG ○ CBC ○ TSH Goiter Tertiary Prevention ○ Lifelong thyroid hormone replacement = Levothyroxine [Synthroid, Levoxyl, Tirosint] Synthetic preparation of T4 identical to naturally occurring hormone Route: Oral IV for Myxedema Side Effects: CAT CJ Changes in appetite, weight loss/gain Alopecia - Hair loss Tachycardia Changes in menstruation Joint pain Nursing Implications: Take on an empty stomach for 30-60 min Before breakfast / take late at night before sleeping Dose adjusted as frequent blood work determines hormone levels Observe for symptoms of hypo/hyperthyroidism ○ Nutrition Control Weight control Exercise Add iodine in diet (Iodine - makes thyroid hormone) Examples: ○ Saltwater fish ○ Seaweed, cod, yogurt, shrimp, eggs, iodized salt, tuna, dried prunes ○ Most Americans get iodine in diet by using iodized salt ○ Depression Assessment Note: Patients older than 80 may have lower than normal levels of thyroid hormone without symptoms of hypothyroidism and usually are not treated with hormone replacement unless symptoms appear Myxedema Coma ○ Myxedema Coma - Serious complication of untreated or poorly treated hypothyroid. Reduced cardiopulmonary function/few adults become comatose Decreased cardiac output creates problem with gas exchange LIFE THREATENING EMERGENCY ○ Causes: U CADS Use of sedatives/opioids Chemo Acute illness Discontinuation of thyroid replacement hormone Surgery ○ Problems Involved: Respiratory failure Hypotension Hyponatremia Hypoglycemia Hypothermia ○ Treatments: MITCH M Maintain airway / Oxygen with pulse ox below 93 Aspiration precautions = Glucose, Normal Saline, Hypertonic Saline IV Turn every 2h Corticosteroids - helps reduce recovery time by decreasing inflammation “-sone” and “-lone” Examples: Hourly temperature check Warm with blankets Monitor changes in mental status Hypothyroidism Questions to Ask Patient/Significant Other ○ How long has she been feeling this way? ○ ○ ○ ○ ○ Has she ever had thyroid trouble? Is she on medication? What medications do you take? Has she been feeling cold? How long has she been tired?