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