Transcript 21 L.Interventions for Clients with Problems of the Thyroid

Evaluating Outcomes
for Clients with Thyroid
and Parathyroid
Problems
Hyperthyroidism
 Thyrotoxicosis
 Graves’
disease, the most
frequent causes: goiter,
exophthalmos, pretibial
myxedema
 Laboratory assessment
 Thyroid scan
 Ultrasonography
 Electrocardiography
Drug Therapy
 Radioactive
iodine therapy; not
used in pregnant women
– Additional drug therapy may be
needed.
– Implement radiation precautions.
– Monitor regularly for changes in
thyroid function.
Surgical Management
 Surgery
possible in absence of
good response to drug therapy.
 Postoperative care for:
– Hemorrhage
– Respiratory distress
– Hypocalcemia and tetany
– Laryngeal nerve damage
– Thyroid storm or thyroid crisis
Infiltrative Opthalmopathy
 Provide
symptomatic treatment.
 Treatment of hyperthyroidism
does not correct eye and vision
problems of Graves’ disease.
 Elevate the head of bed at night.
 Instill artificial tears.
 Treat photophobia with dark
glasses.
(Continued)
Infiltrative Opthalmopathy
(Continued)
 Give
steroid therapy.
 Provide diuretics.
Hypothyroidism
 Decreased
metabolism from low
levels of thyroid hormones
 Myxedema coma a rare, serious
complication
 Mostly a result of thyroid surgery
and radioactive iodine treatment
of hyperthyroidism
 Clinical manifestations
Decreased Cardiac Output
 Interventions:
– Monitor circulatory status.
– Monitor for signs of inadequate
tissue oxygenation.
– Monitor for changes in mental
status.
– Monitor fluid status and heart rate.
– Administer oxygen or mechanical
ventilation, as appropriate.
Ineffective Breathing Pattern
 Interventions:
– Observe and record rate and depth
of respirations.
– Auscultate the lungs.
– Assess for respiratory distress.
– Assess the client receiving sedation
for respiratory adequacy.
Disturbed Thought Processes
 Interventions:
– Assess lethargy, drowsiness,
memory deficit, poor attention
span, and difficulty communicating.
– These problems should decrease
with thyroid hormone treatment.
– Provide a safe environment.
– Provide family teaching.
Myxedema Coma
 Coma,
respiratory failure,
hypotension, hyponatremia,
hypothermia, hypoglycemia
 Emergency care
Thyroiditis
 Inflammation
of the thyroid
gland
 Three types of thyroiditis: acute,
subacute (granulomatous), and
chronic (Hashimoto’s disease)—
the most common type
 Dysphagia and painless
enlargement of the gland
 Nonsurgical management, drug
therapy
Thyroid Cancer
 Papillary,
follicular, medullary,
and anaplastic
 Collaborative management
 Surgery treatment of choice:
thyroidectomy
 Suppressive doses of thyroid
hormone for 3 months after
surgery
 Study performed after drugs are
withdrawn
Hyperparathyroidism
 Parathyroid
glands: calcium and
phosphate balance
 Hypercalcemia and
hypophosphatemia
 Nonsurgical management:
– Diuretic and fluid therapy
– Drug therapy: phosphates,
calcitonin, calcium chelators
Surgical Management
 Parathyroidectomy
care:
preoperative
– Client stabilized; calcium levels
normalized
– Studies: bleeding and clotting
times, CBC
– Teaching: coughing, deep-breathing
exercises, neck support
 Operative
procedures
(Continued)
Surgical Management
(Continued)
 Postoperative
care includes:
– Observe for respiratory distress.
– Keep emergency equipment at
bedside.
– Hypocalcemic crisis can occur.
– Recurrent laryngeal nerve damage
can occur.
Hypoparathyroidism
 Decreased
function of the
parathyroid gland
 Iatrogenic hypoparathyroidism
 Idiopathic hypoparathyroidism
 Hypomagnesemia
 Interventions: correcting
hypocalcemia, vitamin D
deficiency, and hypomagnesemia
If a manifestation is caused by hyperthyroidism,
indicate “HYPER”. If a manifestation is caused
by hypothyroidism, indicate “HYPO.”
Tremors
 Heat intolerance
 Weight gain
 Tachycardia
 Insomnia
 Dry, coarse,
brittle hair
 Decreased
activity tolerance

Decreased body
temperature
 Palpitations
 Apathy
 Diaphoresis
 Thinning of scalp
hair
 Thick, brittle nails
 Constipation
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HYPO = Hypothyroidism
HYPER = Hyperthyroidism
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Tremors: HYPER
Heat intolerance:
HYPER
Weight gain: HYPO
Tachycardia: HYPER
Insomnia: HYPER
Dry, coarse, brittle
hair: HYPO
Decreased activity
tolerance: HYPO

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
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Decreased body
temperature: HYPO
Palpitations: HYPER
Apathy: HYPO
Diaphoresis: HYPER
Thinning of scalp hair:
HYPER
Thick, brittle nails:
HYPO
Constipation: HYPO
The pathology of Graves’ disease
is (select one)
A.
B.
C.
D.
increased release of TSH (thyroid
stimulating hormone) by the anterior
pituitary.
an autoimmune disorder in which
antibodies are made and attach to the
TSH receptor sites on the thyroid tissue.
the development of a thyroid nodule
which releases increased amounts of
thyroid hormones.
a lack of dietary iodine.
B
Graves’ disease is an autoimmune
disorder in which antibodies are made and
attach to the TSH receptor sites on the
thyroid tissue. When these antibodies,
known as thyroid-stimulating
immunoglobulins (TSIs), bind to the
thyroid gland, the gland increases in size
and overproduces thyroid hormones.
 Clients with Graves’ disease also have
exophthalmos (wide-eyed appearance)
and pretibial myxedema.

How can laboratory tests
help differentiate
hyperthyroidism caused
by Graves’ disease
versus hyperthyroidism
caused from
hyperpituitarism?
With hyperthyroidism, both the T3
and T4 blood levels are elevated,
causing hypermetabolism. An
elevated free thyroxine (FT4) or
Free T4 index may be more useful
as it provides information about the
active hormone. The FT4 is also
elevated in hyperthyroidism. In
Graves’ disease, the autoantibodies
bind to the TSH receptor and
activate it, causing an
overproduction of thyroid hormones.
 The
increased metabolic rate
negatively feeds back and
suppresses hypothalamic secretion of
thyrotropin hormone, which in turn
suppresses thyroid-stimulating
hormone (TSH). The TSH is
decreased in Graves’ disease. When
the TSH levels are elevated despite
increased synthesis of thyroid
hormones, hyperpituitarism is a
possible cause.
If the statement is true, place a “T” before the
statement. If the statement is false, place a “F”
before the statement.
 A client is given radioactive iodine by
mouth and scanned 24 hours later during
a thyroid scan.
 Drug therapy for hyperthyroidism
commonly includes antianxiety
medications [alprazolam (Xanax),
lorazepam (Ativan)] to relieve diaphoresis,
anxiety, tachycardia, and palpitations.
 Results from drug therapy and from
radioactive iodine therapy are usually seen
in 48-72 hours.
 A patient with hyperthyroidism has a need
for increased calories, carbohydrates, and
especially proteins.
A client is given radioactive iodine
by mouth and scanned 24 hours
later during a thyroid scan.
TRUE
 The thyroid scan evaluates the position,
size, and functioning of the thyroid gland.
 The uptake of the radioactive iodine is
measured. Normally the thyroid has an
uptake of 5 – 35% when measured at 24
hours.
 The uptake of radioactive iodine is
increased in hyperthyroidism.

Drug therapy for hyperthyroidism commonly
includes antianxiety medications [alprazolam
(Xanax), lorazepam (Ativan)] to relieve
diaphoresis, anxiety, tachycardia, and palpitations.
– FALSE
– The most commonly ordered antithyroid drugs
are the thioamides, including propylthiouracil
(PTU) and methimazole (Tapazole), which
block thyroid hormone production.
– Iodine preparations decrease blood flow
through the thyroid gland. This reduces the
production and release of thyroid hormone.
– Lithium carbonate also inhibits thyroid
hormone release.
– Beta-adrenergic blocking drugs, such as
propranolol (Inderal) and atenolol (Tenormin),
relieve diaphoresis, anxiety, tachycardia, and
palpitations.
Results from drug therapy and from radioactive
iodine therapy are usually seen in 48-72 hours.
FALSE
 The response to thioamides is delayed
because the client may have large
amounts of thyroid hormone stored that
continues to be released.
 With the use of iodine preparations,
improvement usually occurs within 2
weeks, but weeks may be needed before
metabolism returns to normal.

A patient with hyperthyroidism has a need
for increased calories, carbohydrates, and
especially proteins.
 TRUE
 The
client is hypermetabolic and has
an increased need for calories,
carbohydrates, and proteins.
Proteins are especially important
because the client is at risk for a
negative nitrogen balance.
More questions
What should be
assessed to determine if
antithyroid agents (such
as propylthiouracil) are
effective? What are
common side effects
associated
with these drugs?
Effectiveness of therapy can be
demonstrated by a decrease in the
severity of symptoms of
hyperthyroidism.
 Of particular concern is the effect of the
thyroid hormone activity on cardiac
function. The drugs should lower the
systolic BP, narrow the pulse pressure,
lower the heart rate, and eliminate
dysrhythmias if effective.
 Weight gain is another sign of effective
therapy.
 The most common side effects are
nausea, vomiting, and rash.
Hypothyroidism is a possible side effect
for which dose adjustment may be
indicated.

Indicate if the statement regarding
thyroidectomy is true (T) of false (F).
A client should avoid coughing following
surgery.
 Clients are at risk for hypocalcemia
following a thyroidectomy.
 Permanent hoarseness occurs if laryngeal
nerve damage occurs.
 In acute respiratory obstruction, a
laryngeal stridor will be heard.
 Neck extension should be avoided to
decrease tension on the suture line.
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A client should avoid coughing following surgery. FALSE, BUT
IT IS IMPORTANT TO SUPPORT THE NECK WHEN COUGHING
OR MOVING. PLACING BOTH HANDS BEHIND THE NECK
WHEN MOVING REDUCES THE STRAIN ON THE SUTURE LINE.
Clients are at risk for hypocalcemia following a thyroidectomy.
TRUE. THE PARATHYROID GLANDS CAN BE DAMAGED OR
THEIR BLOOD SUPPLY IMPAIRED. HYPOCALCEMIA AND
TETANY RESULT IF PARATHYROID HORMONE IS DECREASED.
EARLY SIGNS OF HYPOCALCEMIA ARE NUMBNESS AND
TINGLING AROUND THE MOUTH OR FINGERS AND TOES.
Permanent hoarseness occurs if laryngeal nerve damage
occurs. FALSE. THE NURSES ASSESSES THE CLIENT’S VOICE
AT 2-HOUR INTERVALS AND DOCUMENTS CHANGES. THE
CLIENT IS REASSURED THAT HOARSENESS IS USUALLY
TEMPORARY.
In acute respiratory obstruction, a laryngeal stridor will be
heard. TRUE. EMERGENCY TRACHEOSTOMY EQUIPMENT IS
KEPT IN THE CLIENT’S ROOM.
Neck extension should be avoided to decrease tension on the
suture line. TRUE. SANDBAGS AND PILLOWS ARE USED TO
SUPPORT THE HEAD AND NECK.
Thyroid Storm
 What
interventions are implemented
prior to a thyroidectomy to prevent
the risk of a thyroid storm?
 What signs and symptoms are
common during a thyroid storm?
 What are the primary concerns
during a thyroid storm?
Thyroid Storm
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Prior to surgery a clients receive
antithyroid drugs, beta blockers,
steroids, and iodides before to prevent
thyroid crisis.
Signs and symptoms of a thyroid storm are
related to the increase in metabolic rate. They
include fever, tachycardia, systolic
hypertension, abdominal pain, N&V, diarrhea,
agitation, tremors, restlessness, confusion,
psychosis, and seizures, It has a mortality
rate of 25%.
It is important to identify the causative event.
The primary concerns will be maintaining
airway patency, providing adequate
ventilation, and stabilizing the hemodynamic
status.
Myxedema
During hypothyroidism, cellular energy
production is decreased and metabolites
build up.
 The metabolites are compounds of
proteins and sugars called
glycosaminoglycans.
 These compounds build up inside cells,
which increases mucous and water, forms
cellular edema, and changes organ
texture.
 The edema is mucinous edema (called
myxedema) rather than edema caused by
water alone.

Myxedema Coma
A rare, serious complication of untreated
or inadequately treated hypothyroidism.
 Decreased metabolism leads to a flabby
heart increased chamber size
 Cardiac output decreases
 Perfusion to the brain and other organs
decreases
 Decreased perfusion makes slowed cellular
metabolism worse.
 Tissue and organ failure occurs.

What is the most common reason a person
seeks medical help prior to being diagnosed
A.
B.
C.
D.
with hypothyroidism? (select one)
Weight gain
Dyspnea
Depression
Hoarseness
C. Depression
Depression is the most common reason
for seeking medial attention. Family
members often bring the client for the
initial evaluation. The client may be too
lethargic, apathetic, or drowsy to
recognize changes in his or her condition.
 Other psychosocial changes include
paranoia, agitation, disturbed thought
process, and impaired memory.

Indicate “T” for a true statement
and “F” for a false statement.
The client with more severe symptoms of
hypothyroidism is started on the lowest
dose of thyroid hormone replacement.
 A client is placed on thyroid hormone
replacement until T3 and T4 level become
normal, and is then gradually tapered off
the medication.
 Increased mental awareness is a sign of
effective thyroid hormone replacement
therapy.
 Emergency care of the client during
myxedema coma includes levothyroxine
sodium IV.

True or False
The client with more severe symptoms
of hypothyroidism is started on the
lowest dose of thyroid hormone
replacement. TRUE. This caution is
especially important when the client has
known cardiac problems. Severe
hypertension, heart failure, and
myocardial infarction can occur if the
initial dose is too high or if the dose is
increased too rapidly.
 A client is placed on thyroid hormone
replacement until T3 and T4 level
become normal, and is then gradually
tapered of the medication. FALSE The
client with hypothyroidism requires
lifelong thyroid hormone replacement.

True or False
Increased mental awareness is a sign of
effective thyroid hormone replacement
therapy. TRUE Other signs of resolving
hypothyroidism will also demonstrate
effective therapy.
 Emergency care of the client during
myxedema coma includes levothyroxine
sodium IV. TRUE Other interventions
include maintain a patent airway,
replacing fluids, administering glucose
IV, administering corticosteroids,
checking temperature frequently,
monitoring BP, covering client with
warm blankets, and monitoring mental
status.

Conditions that could lead to
hyperparathyroidism include which of the
following? Indicate all that apply.
 Congenital thyroid dysgenesis
 Parathyroid carcinoma
 Vitamin D deficiency
 Hypomagnesemia
 Chronic renal failure with
hypocalcemia.
 Neck trauma
Causes of hyperparathyroidism include the BOLD
items:
 Congenital
dysgenesis
 Parathyroid carcinoma
 Vitamin D deficiency
 Hypomagnesemia
 Chronic renal failure with
hypocalcemia.
 Neck trauma

Other causes are parathyroid
adenoma, congenital hyperplasia,
neck radiation, parathyroid
hormone-secreting carcinomas of
lung, kidney , or GI tract.
Indicate “T” for a true statement
and “F” for a false statement.
A client with hyperparathyroidism is at risk
for pathologic fractures.
 Hypercalcemia associated with
hyperparathyroidism is treated with
dietary restriction of calcium.
 A positive Chvostek’s sign and Trousseau’s
sign indicate hypercalcemia.
 Serum PTH, calcium, and phosphate levels
and urine cyclic adenosine
monophosphate (cAMP) are the most
commonly used laboratory tests to detect
hyperparathyroidism.

True or False
A client with hyperparathyroidism is at
risk for pathologic fractures. TRUE An
increased rate of bone destruction
occurs when the levels of PTH are high,
resulting in pathologic fractures, bone
cysts, and osteoporosis.
 Hypercalcemia associated with
hyperparathyroidism is treated with
dietary restriction of calcium. FALSE A
diuretic and fluid therapy is the most
common method used to lower calcium.
Other drug therapy includes oral
phosphates, calcitonin, and calcium
chelators such as Mithramycin.

True or False
A positive Chvostek’s sign and
Trousseau’s sign indicate
hypercalcemia. FALSE Low calcium
levels are associated with increased
neuromuscular activity. Chvostek’s and
Trousseau’s are found in hypocalcemia.
 Serum PTH, calcium, and phosphate
levels and urine cyclic adenosine
monophosphate (cAMP) are the most
commonly used laboratory tests to
detect hyperparathyroidism. TRUE In
hyperparathyroidism, serum PTH is
increased, calcium is increased,
phosphate is decreased, and urinary
cAMP is increased.
