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Nursiswati, M.Kep.,Sp.KMB
Titis Kurniawan, MNS
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OutlineAnatomy & physiology Thyroid Gland
Thyroid Hormone Regulation
Hyperthyroid Patophysiology (etiology, clinical
manifestation, complication, & Nursingproblem)
Diagnostic test
NCP
Hypothyroid Patophysiology (etiology, clinical
manifestation, complication, & Nursingproblem)
Diagnostic test
NCP
Case Review
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Anatomy of Thyroid GlandSingle, bi-lobed gland in the anterior neck, shape of
butterfly
Largest of all endocrine gland (weight = 25 30g)
Regulation; low level of thyroidTRH (thyrotropin
releasing hormone) pituitary gland release TSH(thyroid-stimulating hormone) anterior pituitary
gland release thyroid (T3 and T4)
Hormone produced:
Thyroxine (T4) & tri-iodothyronin (T3)
dependent on iodine & BMR responsible for
cell metabolism (oxidasi & termogenesis), growth
& development
Calcitonin regulating blood calcium level
Isthmus
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Thyroid Regulation
T3 & T4Blood >>
TSH
TRH
Negativefeedback
T3 & T4Blood
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Hyperthyroidism
Excess thyroid hormone production
2nd most common endocrine disorder, after
diabetes mellitus.
Women; 8 x more often (age = 3050 years)
Etiology: Graves disease, toxic multinodular
goiter, thyroiditis, adenoma thyroid gland, &
excess iodine/thyroid intake
Graves disease; autoimmune disorder (Ig
stimuli TSH), most cause of hyperthyroid
Risk factors:pregnancy, trauma, stress,
amiodarone therapy, and age
(Tierney et al., 2001)
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Clinical Manifestations
Thyrotoxicosis; Loss weight, >> appetite
Rapid pulse/Palpitationatrialfibrilation/decompensatio cordis
Blood pressure (systolic) M>> Warm & moist skin
Heat intolerance, fatigue
Hand/tongue tremor
Nervousness, irritable
Hyperactive
Exopthalmus/bulging eye
Amenorhea
Osteoporosis/fracture
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PatofisiologiGraves DiseaseThyroiditis Goiter Adenoma
Autoimmune
TSH >>
>> T3 & T4
Thyrotoxicosis
>> metabolism
Prot & Fat > heat
>> sweat
DeComp/Atrial Fibrilation
Enlargmentthyroid gland
Change body image
Substance like TSH
CardiovascularSystem
Fibroblas & folikel
mata
Change
Jar. Obital & otot mata
Exophthalmus
Iritation
Risk of Injury
Nutrition problem
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Diagnostic TestTest Nature of test Normal Range Use in Diagnosis Nx Implication
TSH test Laboratory Bloodtest
Adults: 2-12microinternationalunit/ml
Differentiate primary &secondary hypothyroid.Primary THS >>,secondary TSH
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Diagnostic TestTest Nature of test Normal Range Use in Diagnosis Nx Implication
Thyroxine(T4) screen Laboratory Bloodtest Adults: 4 -11 mcg/dl Identify T4 blood level .Increase T4(Hyperthyroidism), lowlevel of T4 (hypothyroid)
Preparation, resultmay be affected iodinecontrast scans,medications(estrogen, oralcontraception, seizuremedication, opiates, &antithyroid drug
Tyroxineindex (freeT4 index)
Laboratory Bloodtest
Identify T4 or T3 bloodlevel . Increase level(Hyperthyroidism), lowlevel (hypothyroid)
Explain the procedure
Triiodothyronineradioimmunoassay
Laboratory Bloodtest
Accurately measurethyroid function. Whenlevel less than normal hypothyroid
Fasting is notrequired. May beaffected by pregnancy,recent radioisotopeadministration.
Iodineuptake scan
Patient takes oraldose of radioactiveiodine on anempty stomach(Iodine uptake by
thyroid gland)
Measure how muchiodine is taken bythyroid gland
Hypothyroid takes uplittle iodineHyperthyroidtakes upa lot of iodine
NPO, usually done inconjunction withthyroid lab studies
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Diagnostic TestTest Nature of test Normal Range Use in Diagnosis Nx Implication
Thyroid scan A radioactivesubstance is givento enhancevisualization of
the gland.
Reveal normal size,shape, position, &function
Differentiate thyroidnodule, Graves disease
from Plummers disease
Contraindicated forpregnancy & allergiesto iodine
Thyroidultrasound
Ultrasound Reveal normal size,shape & position ofgland
Differentiate cystic fromsolid thyroid nodules.Can be used to aid inplacement of needle forbiopsy.
Explain theprocedures
Needlebiopsy
Biopsy Differentiate malignantor benigna
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Medical ManagementTreatment ; directed to reduce thyroid hyperactivity to
relieve symptoms & remove the cause ofcomplications.
Depends on the cause of the hyperthyroidism andmay require a combination of therapeutic approaches.
Antithyroid drugs; inhibit production of active thyroidhormone, initial & long term treatment
PTU (Propilthiouracil); 3 divided doses
Methimazole; one daily dose, rapid improvement in T3& T4 serum & better patients compliance
Radioactive iodine; destrys all/part thyroid glandreduce excessive thyroid hormone
Subtotal thyroidectomy; most of thyroid glandremoved reduce thyroid hormone production
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Medical ManagementMedication Action Side Effects Nx Care
PTU Slowing TH production.
Given several months &
may cause temporary/long-term remission of
hyperthyroidism
Allergic (rash, hives, fever,
joint pain),
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Recurrent Hyperthyroidism
No treatment for thyrotoxicosis without side
effects, and all three treatments (radioactive
iodine therapy, antithyroid medications, and
surgery) share the same complications:
relapse or recurrent hyperthyroidism andpermanent hypothyroidism.
The rate of relapse increases in patients who
had very severe disease, a long history ofdysfunction, ocular and cardiac symptoms,
large goiter, and relapse after previous
treatment.
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Nursing ManagementNursing diagnoses: Imbalanced nutrition, less than body requirements, related to
exaggerated metabolic rate, excessive appetite, and increasedgastrointestinal activity
Anxiety, restlessness, hand tremor, insomnia secondary tohypermetabolism
Ineffective coping related to irritability, hyperexcitability, apprehension,and emotional instability
Body image (change/disruption) related to changes in physicalappearances (weight loss, exophthalmus, thyroid enlargement)
Risk for injury (eye) secondary to exophthalmus & inability to closeeyelids properly
Risk for decrease cardiac output related to hypermetabolic state
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Nursing Interventions Improving nutritional status;
Diet consultation
Nutritional supplements
Information supports (effect of hypo/hyperthyroid on
body weight); Administer antithyroid as prescribed
Monitor patients body weight
Enhancing coping;
Restful environment
Social support
Information supports (effect of hypo/hyperthyroid);
Administer antithyroid as prescribed
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Nursing Interventions Risk for injury
Encourage patients to flush eyes with warm water atinterval while awake
Use artificial tears
Cover eye while sleeping
Decrease Cardiac output
Monitor vital signs frequently
Administer antythyroid & cardiac medication as prescribed
Maintain restful & calm environment
Assess toleration of physical activity Monitoring and managing potential complications
Promoting home and community-based care
Teaching patients self-care
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Hypothyroidism
Results from suboptimal levels of thyroid
hormone.
Thyroid deficiency can affect all bodyfunctions range from mild, subclinical
forms to an advanced form (myxedema).
The most common cause of hypothyroidism
in adults is autoimmune thyroiditis(Hashimotos disease)
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Pathophysiology More than 95% hypothyroidism primary orthyroidal hypothyroidism dysfunction of the
thyroid gland.
Central hypothyroidismthyroid dysfunctioncaused by failure of the pituitary gland, the
hypothalamus, or both decreased stimulation ofTRH
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Pathophysiology Myxedema the accumulation of
mucopolysaccharides in subcutaneous and other
interstitial tissues.
Myxedema occurs in long-standing hypothyroidism,
the term is used appropriately only to describe the
extreme symptoms of severe hypothyroidism.
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Clinical Manifestations Early symptoms nonspecific, but extreme fatigue
makes it difficult for the person to complete a full dayswork or participate in usual activities.
Integuments: Reports of hair loss, brittle nails, and dryskin are common, and numbness and tingling of thefingers may occur.
The voice may become husky, and the patient maycomplain of hoarseness.
Menstrual disturbances; menorrhagia or amenorrheaoccur, in addition to loss of libido.
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NURSING DIAGNOSES
Risk for imbalanced body temperature;
hypothermia secondary to metabolic
dysfunction
Activity intolerance and fatigue secondary to
hypometabolic state with decrease cardiac
output
Constipation secondary to lethargy, activityintolerance, & hypometabolic state
Risk for impaired skin integrity secondary to
TH deficiency
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Life Threatening Complications
Myxedema coma Thyroid Storm
Life threatening Occurs when precipitating event trauma,
infection, sedation compromises the hypothyroidpatients (older adults with long-standing primary
thyroid diseases)
Occurs when there is failure of the compensatory
metabolic, thermoregulatory, & cardiovascular systemin hyperthyroid patients
Early symptoms Weight gain, extreme fatigue, bradycardia,
lethargy, mental dullness, memory impairment,
cold intolerance
Significant unexplained weight loss, warm, moist skin,
heat intolerance, cardiac palpitation, tachycardia,
tachypneu, & dyspneu on exertion
Signs & synptoms Very low body temperature (32,8 35C), skin cold
& dry, seizure, severe bradycardia, delayed deep
tendon reflexes, non pitting edema (face and
around eyes), enlarged tongue, loss of
consiousness, mood disturbance, & psychosis
Tachycardia (> 14x/mnt), atrial fibrilation, arrhytmias,
increase stroke volume, synptoms of high output
hearth failure with pulmonary edema.
Very high body temperature > 40 C, restlessness,
agitation, abdominal pain, nausea, vomiting, coma,
emotional lability, exophthalmus, goiter, coma
Laboratory values Low TSH (if pituitary is involved) & very high TSH
(thyroid gland is affected tissue), low serum FT4,
hyponatremia, hypoglycemia, hyperlipidemia,respiratory acidosis, ECG; prolong QT intervals,
pleural/pericardial effusions, presence antithyroid
antibodies
Low level TSH, high serum FT4, elevated liver
function test, elevated alkaline phosphatase
Assessment Vital signs, level of consciousness Body temperature, blood glucose level
Treatment Hormone replacement therapy Antithyroid drugs, surgery
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Nursing InterventionsRisk for imbalanced body temperature
Goal: Maintenance of normal body temperature
1. Provide extra layer of clothing or extra blanket.2. Avoid and discourage use of external heat
source (eg, heating pads, electric or warming
blankets).
3. Monitor patients body temperature and reportdecreases from patients baseline value.
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Nursing InterventionsActivity intolerance and fatigue secondary tohypometabolic state with decrease cardiac output
Goal: Increased participation in activities
1. Assess patient ability/activities tolerance level
2. Include patients in the low impact ativities
3. Helps patients conducting ADL
4. Include families during intervention
5. Instruct patient on administration of hormonereplacement
6. Avoid sadatives
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Nursing Intervention
Nursing Dx: Constipation secondary to lethargy, activity
intolerance, & hypometabolic state
Goal: Return of normal bowel function
1. Encourage increased fluid intake within limits of fluid restriction.2. Provide foods high in fiber.
3. Instruct patient about foods with high water content.
4. Monitor bowel function.
5. Encourage increased mobility within patients exercise tolerance.
6. Encourage patient to use laxatives and enemas sparingly.
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Nursing Intervention
Nursing Dx:Risk for impaired skin integrity secondary to TH
deficiency
Goal: improve skin condition (intact, soft, moist, no
itching/breaking)1. Avoid use of soap, astringents, or alcohol
2. Liberally apply emollient skin lotion
3. Cut patients nails properly
4. Monitor skin integrity
5. Consider air mattress if needed
6. Administer replacing hormone therapy as prescribed