Post on 05-Jan-2016
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Thyroxine (T4)
andTriiodothyronine (T3)
These are responsible for increase in metabolic rate increase protein and bone turnover increase responsiveness to catecholamines Fetal and infant growth and development Calcitonin Lowering blood calcium and phosphate
levels
Normal
An increase in release of thyroid hormone
What are the clinical manifestations in each body system that reflect the increase in metabolism caused by the excessive release of thyroid hormones? Cardiovascular
Respiratory Gastrointestinal
Integumentary Musculoskeletal Nervous Reproductive Other
History
Physical examination
Ophthalmologic examination
ECG
Radioactive iodine uptake (RAIU)◦ Indicated to differentiate Graves’ disease
from other forms of thyroiditis
Laboratory tests
Goals◦Block adverse effects of thyroid hormones ◦Stop hormone oversecretion
Three primary treatment options◦Antithyroid medications◦Radioactive iodine therapy (RAI)◦Subtotal thyroidectomy
Action:◦Inhibit synthesis of thyroid hormone
◦ First-line examples Propylthiouracil (PTU)
Also blocks conversion of T4 to T3
Methimazole (Tapazole)
Nursing Implications: Instruct the patient that it will take several
weeks for the drug to be effective◦ Improvement in 1 to 2 weeks ◦Good results in 4 to 8 weeks◦Therapy for 6 to 15 months
◦ Disadvantages include Patient noncompliance Increased rate of recurrence when
medication is discontinued
Uses:◦ Used with other antithyroid drugs in
preparation for thyroidectomy or treatment of thyrotoxic crisis
◦ Given several weeks preoperatively◦ Decrease the vascularity of thyroid gland
decreasing bleeding making surgery safer
◦ Action: Inhibit synthesis of T3 & T4 and block release
into circulation to slow metabolism
◦ Examples Saturated solution of potassium iodine
(SSKI) Lugol’s solution
Action:◦Symptomatic relief of thyrotoxicosis
resulting from β-adrenergic receptor stimulation
Uses:◦Helps to control nervousness, tachycardia,
tremor, anxiety, and heat tolerance.
Example◦Propranolol (Inderal) administered with
other antithyroid agents
Uses: Used to destroy thyroid tissue thereby limiting
thyroid hormone secretion. Effects not seen for 2-3 months Dose of RAI is low so no radiation safety
precautions are needed
Complication High incidence of post-treatment
hypothyroidism – need to be taught symptoms
RAI Not an option during pregnancy
Indications◦Unresponsive to drug therapy◦Large goiters with tracheal compression◦Possible malignancy
Oxygen, suction equipment, tracheostomy tray available in room
Postoperative care◦Every 2 hours for 24 hours
Assess for signs of hemorrhage Assess for tracheal compression
Irregular breathing, neck swelling, frequent swallowing, choking
◦Semi-Fowler’s position Support head with pillows Avoid flexion of neck Tension on suture lines
◦Postoperative care Monitor vitals Control pain Check for tetany
Muscle cramps or laryngeal stridor – treat with calcium gluconate
Trousseau’s and Chvostek sign should be monitored
Monitor for 72 hours
Evaluate difficulty in speaking/hoarseness Some hoarseness for 3 to 4 days is expected
Ambulatory and home care◦Discharge teaching
Monitor hormone balance periodically Decrease caloric intake to prevent
weight gain Adequate iodine
Regular exercise Avoid ↑environmental temperature
Why is the patient placed on a High-calorie diet (4000-5000 kcal/day)?
What foods are encouraged?
What foods should be avoided?
◦Change linens frequently if diaphoretic
◦Eye Care for exophthalmos◦Apply artificial tears to prevent corneal
ulceration◦Elevate HOB and salt restriction for
edema◦Tape eyelids shut for sleep if they cannot
close◦Dark glasses to reduce glare and prevent
environmental irritants
Thyrotoxic crisis (Thyroid Storm)
Acute, rare condition where all manifestations of hyperthyroidism are heightened
Life-threatening emergency/death rare when treatment initiated early and is vigorous.
◦Manifestations include: Respiratory distress – dyspnea Hyperthermia – up to 105.30
Tachycardia – pulse > 130 BPM Heart failure, chest pain Shock Restlessness, Agitation Seizures Abdominal pain, Nausea Delirium Coma
Goal of Treatment◦↓ Thyroid hormone levels and clinical
manifestations with drug therapy
Interventions◦Manage respiratory distress – oxygen◦Fever reduction – with antipyretics or cooling blankets, cool room
◦fluid replacement – IV fluids and electrolytes, and management of stressors
◦Administer medications – PTU, methimazole, Iodine, β-blockers
◦Treatment of Heart failure
Case Study:
Beth Minton, 43 y/o, Admitted to hospital with high fever. Following an endocrine workup she was diagnosed with Graves Disease. Graves Disease.
Objective Data:Objective Data:•Has fever of 1040 F, B/P of 150/78, P - 11, •Flushed, with hot, moist skin•Has fine hand tremors and appears nervous•Has 4+ deep tendon reflexes
R – 24
1. What is the etiology of Beth’s symptoms?
2. What diagnostic studies were probably ordered? What would the results have been to establish the diagnosis of Grave’s Disease?
3. She has a subtotal Thyroidectomy planned for 2 months later – why is surgery being delayed?
4. Beth is started on propylthiouracil (PTU) and propranolol (Inderal). What is the purpose of drug therapy for Beth?
5. What are Beth’s immediate learning needs; pre-op needs, and post-op needs?
6. What are the nursing interventions for successful long-term management of Beth after the subtotal thyroidectomy?
7. Based on assessment data presented, write appropriate nursing diagnosis pertinent to Beth while hospitalized.
A condition in which the body lacks A condition in which the body lacks thyroid hormonesthyroid hormones
What are the clinical manifestations in each body system that reflect the decrease in metabolism caused by the lack of thyroid hormones? Cardiovascular
Respiratory Gastrointestinal
Integumentary Musculoskeletal Nervous Reproductive Other
History and physical examination Laboratory tests
◦Serum TSH Determines cause of hypothyroidism
◦Other abnormal findings are ↑ cholesterol and triglycerides, anemia, and ↑ creatine kinase
Levothyroxine (Synthroid)◦Must take regularly◦Monitor for angina and cardiac
dysrhythmias◦
Monitor thyroid hormone levels and adjust (as needed)
Patient/family teaching◦Because of the impaired memory - Be sure
to provide patient with written instructions and teach family as well as patient
◦Lifelong therapy
◦Teach measures to prevent skin breakdown◦Emphasize need for warm environment◦Caution patient to avoid sedatives or use
lowest dose possible◦Discuss measures to minimize constipation
Avoid enemas because of vagal stimulation in cardiac patient
◦Teach patient to notify physician immediately if signs of overdose appear Orthopnea, dyspnea, rapid pulse,
palpitations, nervousness, insomnia
Those with severe longstanding hypothyroidism may display myxedema
◦ Accumulation of hydrophilic mucopolysaccharides in the dermis and other tissues
◦ Causes puffiness, periorbital edema, masklike effect
Medical emergency Hypoventilation- respiratory drive is
decreased resulting in alveolar hypoventilation
Mental sluggishness Drowsiness Lethargy progressing gradually or suddenly
to impairment of consciousness or coma Subnormal temperature Hypotension Decrease pulse – does not perfuse tissues
Vital functions must be supported Mechanical respiratory support Cardiac monitoring
Administer IV thyroid hormone replacement
If hyponatremic – give Hypertonic saline solution
Close assessment
VS monitoring Monitor core temperature
Hyperthyroidism
Hypothyroidism
There is overproduction of parathormone which is characterized by bone decalcification.
The patient will have an increase in blood calcium.
What is a complication of increase
in calcium in the blood?
What are the clinical manifestations of hyperparathyroidism?
Hint: They Mimic those of Hypercalcemia
Serology◦Parathyroid hormone levels - ◦Serum calcium - >10 mg/dl◦Serum phosphorus - < 3 mg/dl◦Urine calcium, serum chloride, creatinine, amylase, alkaline phosphatase – all elevated
Bone x-rays and bone scans
Ultrasound and MRI
Most common way to diagnose Hyperparathyroidism is by persistent elevated _____ ______levels and PTH
Hydration Therapy – force fluids. WHY?
Avoid Immobility / Active Lifestyle◦Bones subjected to normal stress give up
less calcium so encourage walking
Dietary measures- avoid diet with excess calcium
Post – op Nursing Care◦Assess for hemorrhage
◦Assess Fluid and Electrolytes
◦Assess for Tetany – occurs with sudden
decrease in calcium levels
What medication should be available at the bedside?
Explain the use of the following medications in treatment:
◦Bisphosphates Fosamax
◦Calcimimetic Agent Cinacalcet
Results from abnormally low levels of PTH low Ca level
What are the clinical manifestations of hypoparathyroidism:
Hint: They mimic those of hypocalcemia
Chvostek’s sign: tap on the facial nerve just below the temple.
Positive - when nose, eye, lip & facial muscles twitch
Trousseau’s sign: temporarily occlude arterial blood flow (with BP cuff inflated) above the normal systolic pressure.
Positive Trousseau’s sign occurs when the hand and fingers contract from ischemia
IV calcium such as calcium gluconate – infuse slowly
Prevent hypotension, cardiac dysrhythmia, cardiac arrest
ECG monitoring Rebreathing using paper bag – increases
carbonic acid in blood lowering blood pH.
Other Drugs◦ Calcium◦ Vitamin D – promotes intestinal calcium
absorption and bone resorption
Diet Therapy◦Encourage high-calcium
◦What are examples of foods high in calcium?
Use a gait belt when assisting a patient with muscle weakness
Collaborate with dietitian to teach patients about diets that are restricted in calcium
Use a lift sheet to move or reposition a patient with hypocalcemia
Keep environment of a patient with risk for thyroid storm cool, dark, quiet.
Keep emergency suctioning and trach tray in room of patient who has had thyroid or parathyroid surgery.
Monitor the hydration status of patients who have hypercalcemia
Teach patients that hormone replacement therapy for hypothyroidism is lifelong
Teach patients to use clinical manifestations such as number of bowel movements, ability to sleep as indicators of therapy effectiveness