NURSING CARE OF PATIENTS WITH ALTERATIONS IN THYROID GLAND FUNCTION

•HYPOTHYROIDISM

•HYPERTHYROIDISM

General overview

• Hypothalamus: corticotropin-RH; thyrotropin-RH; growth H-RH; gonadotropin-RH

• Anterior pituitary: GH; ACH; TSH; FST; LT• Posterior pituitary: prolactin; ADH; oxytocin• Adrenal cortex: aldosterone; cortisol• Adrenal medulla: dehydroepiandrosteron; epinephreine; norepinephrine• Thyroid: triiodothyronine T3; thyroxin T4; calcitonin• Parathyroid: parathormone PTH• Kidney: renin, erythroppoietin• Ovaries: estrogen; progesterone• Testes: androgens--testosterone

Thyroid hormones

• Thyroid hormones, T3 &T4 are amino acids containing iodine• They are synthesized & stored in the cells of the thyroid gland until

needed• Iodide absorbed in GIT—blood stream—uptake by the thyroid—

converted to iodine—react with tyrosine, an amino acid-to form thyroid hormones

• Hypothalamus releases thyrotropin-releasing hormone—pituitary gland releases thyroid-stimulating hormone—thyroid gland to secret T3 & T4

• The primary function of thyroid hormones is control of cellular metabolic activity—increase levels of specific enzymes that contribute to O2 consumption

• Calcitonin is secreted when calcium serum level increases; increases deposition of calcium in bone

Thyroid hormones

• Thyroid gland is located in the lower neck region between sternocleidomastoid muscles

• Inspection: instruct to extend the neck and swallow• Palpation from posterior or anterior• Auscultate using the diaphragm of the stethescope• A localized systolic or continuous bruit indicates increased blood flow—

hyperthyroidism• Tenderness, enlargement, and nodularity require further assessment• Blood test for TSH, T3, T4; needle biopsy• Free T4 is a direct measure of thyroxine , the only active fraction of T4• T3 is 5 times as potent as T4, has rapid metabolic action; more accurate• Nursing action: check if the patient is receiving iodine-containing drugs

Alteration in thyroid hormone level, decreasedhypothyroidism

• Hypothyroidism results from suboptimal level of thyroid hormones• Range from mild, subclinical to myxedema• The most common cause is autoimmune thyroiditis• Also, common in those with previous hyperthyroidism—been treated• Can be primary, secondary & tertiary; or cretinism• Early symptoms: -extreme fatigue—unable to complete a full day’s work -Hair loss, brittle nails, dry skin -husky voice; hoarseness -menstrual disturbances• Affects women 5 times more than men

Hypothyroidismclinical manifestations

• In severe hypothyroidism: -subnormal temp. & pulse rate; wt gain without increased food intake -thickened skin-accumulation of mucopolysaccharides; -hair thins & falls, cold in warm environment -as progress; mental process becomes dulled, apathetic; slow speech, -in most extreme severe stage, myxedema coma• Advanced form: dementia; myxedema in which: The respiratory drive is depressed; elevated cholesterol Cardiovascular collapse; atherosclerosis, CAD These changes require intensive therapy Myexdema coma: the patient becomes hypothermic & unconscious Effects of analgesics, sedatives are prolonged Read chart 42-3; P.

1256

Nursing care

• Objective: restore normal metabolic rate

• Administer / instruct taking of prescribed medications -synthetic levothyroxine (Levothroid) -the dose is based on serum level of TSH

• Prevention of cardiac dysfunction -thyroid replacement—increased O2 demand—but no increase in O2

delivery unless atherosclerosis improves—angina -angina & dysrhytmias may occur because thyroid replacement enhance

catcholamines effect on cardiovascular system

• Nursing Alert: Monitor signs of myocardial ischemia in response to Levothyroxine

Nursing care

• If these changes occur; discontinue thyroid therapy• Later; is administered at low dose cautiously

• Prevention of drug interaction: Thyroid replacement increases blood glucose—adjustment of insulin or

anti-diabetic agents Increases actions of digoxin, anticoagulant agents, indocin Hypnotic & sedative agents produce profound somnolence; respiratory

depression—dose adjustment is needed Bone loss & osteoporosis may occur Phenytoin & tricyclic antidepressant increases effects of thyroid

hormone

Nursing care

• Supportive therapy: in severe hypothyroidism & myxedema coma Monitoring of O2 & CO2 status; pulse oximetry, ABGs to guide assisted

ventilation to combat hypoventilation Cautious administration of fluid—to prevent water toxication Avoid external heating pads—they increase O2 demand Concentrated glucose if hypoglycemia without fluid overload If mxedema coma—Levothyroxine IV; then oral drugs are continued • Modifying activity: Assist the patient with care and hygiene Encourage participation in activities, as tolerated, to prevent immobility

complicationsREAD NURSING CARE PLAN; Chart 42-2; PP: 1259-1260 AND chart 42-5

Specific Nursing care

• Monitoring physical status: monitor VSs & cognitive level to detect -deterioration in physical & mental status -S&S of metabolic rate that exceeds ability of cardiopulmonary system -continued limitations & complications of myxedema• Promoting physical comfort -provide extra clothing and blankets -avoid heating pads & electrical blankets; may cause increased peripheral

dilatation , vascular collapse & further loss of heat -the patient could be burned because of unawareness—delayed response• Enhancing coping mechanisms: patients may experience severe emotional

reactions to changes in appearance & body image -inform patients and families that inability to recognize symptoms is

common -provide assistant & counseling

Teaching self-care

• Instruct how to monitor the patient condition and responses to therapy• Stress the importance of adherence to medication prescribed• Involve family in teaching because of slowed mental process• Provide written instructions for patients & families• Dietary instructions to promote weight loss once medications are

initiated• COMMON NURSING DIAGNOSES: activity intolerance related to fatigue & depressed cognitive process risk for imbalanced body temperature constipation related to depressed GIT function ineffective breathing pattern related to depressed ventilation disturbed thought processes related to depressed metabolism

Alteration in thyroid hormone level, increasedHyperthyroidism

• Graves’ disease is the most common type of hyperthyroidism• Results from excessive output of thyroid hormone by abnormal

stimulation of thyroid by circulating immunoglobulins• Affects women 8 times more than men• In well-developed hyperthyroidism patients exhibit a group of S& S,

referred to as thyrotoxicosis• The presenting symptom is nervousness; are often emotionally

hyperexcitable, irritable, they can not sit quietly• Palpitation, rapid pulse at rest & exertion• Tolerate heat poorly, perspire freely• Skin is flushed; likely to be warm, soft, moist

Assessment / clinical manifestations

• Fine tremor of hands; exophthalmos• Increased appetite & dietary intake, progressive weight loss• Muscular fatigability & weakness; amenorrhea; changes in bowel

function

• Cardiac effects: heart rate 90-160; elevate systolic Bp not diastolic; atrial fibrillation; cardiac decompensation—H failure in brief: sinus tachycardia; increased pulse pressure; palpitations related

to increased sensitivity to catecholamines The course of the disease may be mild, characterized by remissions and

excacerbations

Nursing management

• The thyroid gland is enlarged; soft & pulsate• A thrill can be palpated, a bruit is heard• A decrease in TSH, increased free T4; increased radioactive iodine

uptake

Nursing care: integration of medical management• Goal of treatment:• reducing thyroid hyperactivity to relieve symptoms; prevent

complications• A combination of therapy is used; antithyroid, radioactive iodine

Management

• Pharmacological therapies:

• Radioactive iodine therapy; iodine 131, to destroy overactive thyroid cells—resulting in reduction of hyperthyroidism

• 95% of patients cured by a single dose of radioactive iodine; the 5% may require 2 doses more

• symptoms are relived in 3-4 weeks; monitor for hypothyroidism

Radioactive Iodine is contraindicated: during pregnancy, while breast-feeding

Nursing management

Ablative dose: Initially causes acute release of thyroid hormone—thyroid storm

Manifested• Hyperpyrexia;• Extreme tachycardia• Exaggerated symptoms of hyperthyroidism• GIT: Wt. loss, diarrhea, abdominal pain• Altered neurologic or mental state: delirium, somnolence, coma• Beta adrenergic blocking agents (Inderal) to relieve symptoms

Close follow-up for hypothyriodism; 20% develop hypothyroidism after 2 years

Management

Anti-thyroid medications:• The objective is to inhibit one or more stages in thyroid hormone

synthesis or hormone release• They block the utilization of iodine• The most common are: propylthiouracil (PTU); methimazole• Take several weeks for symptoms to be relieved; maintenance dose• Withdrawal over several months

Anti-thyroid medicationsnursing considerations

• Periodic follow-up is necessary: fever, rash, thrombocytopenia may occur

• With signs of infection: pharyngitis, fever, mouth ulcer; advise to stop medications, notify physician

• Agranulocytosis in 5% of the patients• Instruct patients not to use nasal decongestants ; they are poorly

tolerated• PTU is the treatment of choice in pregnancy• Antithyroid medications are contraindicated in late pregnancy—may

affect the fetus• Relapse may occur after 3-6 months of stopping medication

Integration of adjunctive therapy

• Potassium iodide can be used in combination with anti-thyroid agents or beta adrenergic blockers to prepare the patient for surgery

• They reduce the activity of the thyroid hormone & vascularity of the thyroid gland—safer surgery

• Solution of iodine, iodide are more palatable in milk or fruit juice; administered through straw to prevent staining of teeth

• Beta adrenergic blockers (propranolol) to control SNS effect of hyperthyroidism; used to control nervousness, tachycardia, tremor anxiety

• The patients continue taking Propranolol until T4 and TSH within normal range

Surgical management

• Previously, surgical removal of thyroid was the primary method of management

• Today it is used for special cases; pregnant women, allergic to antithyroid drugs, in those with large goiter, unable to take antithyroid

• Excision of 5-sixth results in prolonged remission Preoperative management:• PTU is given until S & S have disappeared• Propranolol may be given to reduce H rate• Medication that prolong clotting, aspirin, are stopped weeks before

surgery

Nursing diagnoses

• Imbalanced nutrition, less than body requirement• Ineffective coping related to irritability, hyperexcitability, emotional

instability• Low self-esteem related to changes in appearance, weight loss• Altered body temperature• Potential complications -thyrotoxicosis/thyroid storm -hypothyroidism

Improving nutritional status

• GIT changes—increased peristalsis—diarrhea; increased appetite• Rapid movement of food may result in nutritional deficiencies & weight

loss• Several meals a day up to 6; small well-balanced• Encourage high-caloric, high protein foods• Food & fluid are selected to replace fluid lost• Discourage stimulants: coffee, tea, cola, alcohol• A quiet environment may aid digestion• Record weight & food intake to monitor nutritional status

Enhancing coping measures

• Assurance that emotional reactions are a result of the disorder; can be controlled by effective treatment

• Also assurance of family for these reactions• Use a calm unhurried approach• Minimize stressors; hospitalization is not with very sick or talkative

patients• Avoid noisy environment; loud sounds• Encourage relaxing activities; if not stimulants• If assigned for surgery; encourage taking drugs to prepare for the surgery• May require repetition of information because of hyperexcitability &

shortened attention span

Improving self-esteem

• Changes, because of the disorder, may result in low self-esteem• Convey understanding of the patient’s concern &• Assist in developing effective coping strategies• If appearance is disturbing; remove mirrors• Advise nurses & family not to bring the changes to the patient attention• Explain that most of the changes disappear with effective treatment• Eye care & protection is necessary; instruct on instillation of eye drops• Discourage smoking• Meet the need of the patient with respect to food intake

Maintain normal body temperatureTeaching self-care

• Maintain the room cool & comfortable• Change bedding & clothes as needed• Cool baths, cool fluid may provide relief

• Managing complications: thyroid storm; hypothyroidism• Cardiac and respiratory changes; O2 therapy; fluid replacement

• Teach about medications• Provide written information• Advise to avoid stressful situations• Instruction about expectation of the surgery