Transcript Hypoythyroidism

Hypoythyroidism
Mexedema
Definition
O Hypothyroidism results from
suboptimal levels of thyroid hormone.
O It is a condition in which there is an
inadequate amount of
triiodothyronine (T3) and thyroxine
(T4), leading to decrease in
metabolic rate.
Types of hypothyroidism
O According to the cause:
1. primary, which refers to dysfunction of the thyroid gland
(more than 95% of cases)
2. Secondary, due to failure of the pituitary gland
3. Tertiary, results from hypothalamus disorders.
Note: secondary and tertiary also called central
hypothyroidism
Types of hypothyroidism
According to the age of onset.
1. Cretinism –severe hypothyroidism found in infants, resulting
in retardation of physical growth, mental growth, or both.
2. Juvenile hypothyroidism (usually caused by chronic
autoimmune thyroiditis ) and affects the growth and sexual
maturation of the child.
S&Sx like adult hypothyroidism, and Rx reverses most of them
3. Adult hypothyroidism
The disorder is most prevalent in women, with the incidence
rising significantly in persons age 40 to 50.
Facts and etiology
O Hypothyroidism occurs most often in older women.
O Its causes include :
O Autoimmune thyroiditis (Hashimoto’s thyroiditis,
O Therapy for hyperthyroidism (radioiodine, surgery, or
antithyroid drugs);
O Radiation therapy for head and neck cancer;
O Iodine deficiency; and iodine excess.
Diagnostic Procedures and Nursing
Interventions
O T3 and T4 – low
O (TSH) – determines etiology. (
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with primary
hypothyroidism , in secondary hypothyroidism).
Thyrotropin-releasing hormone (TRH)
Free thyroxine index (FTI) and thyroxine (T4) levels –
decreased
Skull x-ray, CT scan, MRI
Radioisotope (131 I) scan and uptake – will be less than
10% in a 24-hr period.
ECG – sinus bradycardia, flat or inverted T waves
Serum cholesterol – elevated
CBC – anemia
Clinical Manifestations
O Extreme fatigue
O Hair loss, brittle nails, dry skin, and numbness and
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tingling of fingers
Husky voice and hoarseness
Menstrual disturbances (eg, menorrhagia or
amenorrhea); loss of libido
Joint or muscle pain
Hypothermia,
Bradypnea,
Weight gain without corresponding increase in food
intake;
Clinical Manifestations
O Thickened skin, thinning hair or alopecia;
O masklike facial features
O Cold intolerance
O Dulled mental processes and apathy
O Slowed speech; enlarged tongue, hands, and feet;
O Constipation;
O Decreased taste and smell
O Thinning of eyebrows
O Advanced hypothyroidism: personality and cognitive
changes, pleural effusion, pericardial effusion, and
respiratory muscle weakness
NANDA Nursing Diagnoses
O Decreased cardiac output
O Ineffective breathing pattern
O Activity intolerance
O Imbalanced nutrition: More than body
requirements
O Risk for constipation
Nursing Interventions
O Caution: Barbiturates or sedatives are contraindicated.
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Also, external warming measures are contraindicated
Administer thyroid hormone therapy, as ordered.
Synthetic levothyroxine (Synthroid) is the medication
most frequently prescribed.
Monitored for cardiovascular compromise with early
medication (palpitations, chest pain, SOB, tachycardia)
Treatment begins slowly and the dosage increases
every 2 to 3 weeks. The treatment is considered to be
lifelong,
Ongoing medical assessment of thyroid function is
required.
Nursing Interventions
O Teach the client about S&Sx of hyperthyroidism
O Increase the client’s activity level gradually, and provide
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frequent rest periods.
Apply anti-embolism stockings and elevate the client’s
legs
Encourage the client to cough and breathe deeply
Provide a high-bulk, low-calorie diet and encourage
activity
Administer cathartics and stool softeners, as needed.
The client’s intolerance to cold may extend to cold foods,
making meal planning more difficult
Nursing Interventions
O Change the client \s position every 2 hr.
O Use alcohol-free skin care products and an emollient lotion
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after bathing.
Provide extra clothing and blankets for clients with
decreased cold tolerance.
Dress the client in layers, adjust room temperature, and
encourage warm liquids if possible.
Caution the client against using electric blankets or other
electric heating devices.
Encourage the client to verbalize feelings and fears about
changes in body image.
Return to the euthyroid state takes some time. The client
may need frequent reassurance that most of the physical
manifestations are reversible.
Complications and Nursing Implications
O Myxedema Coma;
“myxedema” refers to the accumulation of mucopolysaccharides in
subcutaneous and other interstitial tissue and is used only to
describe
the extreme symptoms of severe hypothyroidism.
O A life-threatening condition that occurs when hypothyroidism is
untreated or when a stressor such as infection affects an individual
with hypothyroidism.
O Clients with myxedema coma experience:
O Significantly depressed respirations, so PaCO2 levels may rise.
O Decreased cardiac output.
O Worsening cerebral hypoxia.
O Stupor.
O Hypothermia.
O Bradycardia.
O Hypotension.
Nursing Responses to Myxedema
Coma
O Maintain airway patency with ventilatory support if
necessary.
O Maintain circulation through IV fluid replacement.
O Provide continuous EKG monitoring.
O Monitor ABGs to detect hypoxia and metabolic acidosis.
O Warm the client with blankets.
O Monitor body temperature until stable.
O Replace thyroid hormone by administering large IV
levothyroxine
O Monitor vital signs because rapid correction of
hypothyroidism can cause adverse cardiac effects.
Nursing Responses to Myxedema Coma
O Monitor I&O and daily weight.
O Replace fluids and other substances, such as glucose, as
needed.
O Administer corticosteroids, as ordered.
O Check for possible sources of infection. Treat underlying
illness
O Meeting the Needs of Older Adults
O hypothyroidism is often undiagnosed in older adult clients,
which can lead to potentially serious side effects.
O When starting thyroid hormone replacement, care must be
taken with older
O adult clients and with those who have coronary artery disease
to avoid coronary ischemia because of increased oxygen
demands of the heart.
O Polypharmacy is a significant concern for the hypothyroid client.
Hyperthyroidism
O Hyperthyroidism is the second most common endocrine
disorder, and Graves’ disease is the most common type.
O It results from an excessive output of thyroid hormones
due to abnormal stimulation of the thyroid gland by
circulating immunoglobulins.
O The disorder affects women eight times more frequently
than men
It may appear after an emotional shock, stress, or
infection
O Other common causes include thyroiditis and excessive
ingestion of thyroid hormone
Diagnostic Procedures and Nursing Interventions
O Serum TSH test – decreased in the presence of disease.
O Free thyroxine index (FTI) and T3 – elevated in the
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presence of disease.
TRH stimulation test – failure of expected rise in TSH.
Radioiodine (123 I) uptake and thyroid scan – clarifies
size of gland and detects presence of hot or cold
nodules.
Take a medication history to determine the use of
iodides.
Severe illness, malnutrition, and use of aspirin,
corticosteroids, and phenytoin sodium may cause a
false decrease in serum thyroid hormone levels.
Clinical Manifestations
O Nervousness (emotionally hyperexcitable), irritability,
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apprehensiveness;
Palpitations; tachycardia on rest and exertion.
Heat intolerance
Skin that is flushed, with a characteristic salmon color, and
likely to be warm, soft, and moist.
Dry skin and diffuse pruritus.
Fine tremor of the hands.
Exophthalmos (bulging eyes) in some patients.
Increased appetite and dietary intake, progressive loss of
weight,
Abnormal muscle fatigability, weakness,
Amenorrhea,
Clinical Manifestations
O Insomnia, interrupted sleep.
O Frequent stools, diarrhea.
O Tremor, hyperkinesias, hyperreflexia.
O Goiter.
O Bruits over the thyroid gland.
O Atrial fibrillation;
O Osteoporosis and fracture.
O Cardiac effects may include sinus tachycardia or
dysrhythmias,
O May include remissions and exacerbations, terminating
with spontaneous recovery in a few months or years.
O May progress relentlessly, causing emaciation, intense
nervousness, delirium, disorientation, and eventually
HF.
NANDA Nursing Diagnoses
Hyperthermia
Activity intolerance
Disturbed thought processes
Imbalanced nutrition: Less than body requirements
related
to exaggerated metabolic rate, excessive appetite, and
increased gastrointestinal activity
O Ineffective coping related to irritability, hyperexcitability,
apprehension, and emotional instability
O Low self-esteem related to changes in appearance,
excessive appetite, and weight loss
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Nursing Interventions
O Administer antithyroid medications as prescribed, which
may include:
O Propylthiouracil (PTU) or methimazole (Tapazole) – blocks
thyroid hormone synthesis.
O Beta-adrenergic blockers – treats sympathetic nervous
system effects (tachycardia, palpitations).
O Iodine-containing medications – inhibits the release of
stored thyroid hormone and retards hormone synthesis.
Use of these medications is contraindicated in
pregnancy & breastfeeding .
O Clients receiving antithyroid medications should be
monitored for signs of hypothyroidism, which can occur
with overmedication.
Nursing Interventions
O Promote a calm environment.
O Minimize the client’s energy expenditure by assisting
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with activities as necessary
Monitor nutritional status. Provide increased calories,
protein, and other nutritional support as necessary.
Assess the client’s mental status and decision-making
ability; ensure safety.
Provide eye protection (patches, eye lubricant, taping
eyelids closed) for a client with exophthalmos.
Monitor vital signs and hemodynamic parameters (for
an acutely ill client) for signs of heart failure.
Nursing Interventions
O Reassure the family that any abrupt changes in the
client’s behavior likely are disease related and should
subside with antithyroid therapy.
O Prepare the client for total/subtotal thyroidectomy, if the
client is unresponsive to antithyroid medications or has
an airway-obstructing goiter.
Complications and Nursing Implications
O Thyroid Storm (thyrotoxic crisis), results from a sudden surge of
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large amounts of thyroid hormones into the bloodstream, causing
an even greater increase in body metabolism.
This is a medical emergency with a high mortality rate.
Precipitating factors include: infection, trauma, and emotional
stress (increase demands on body metabolism).
It can also occur following subtotal thyroidectomy because of
manipulation of the gland during surgery.
Symptoms include:
O hyperthermia,
O hypertension,
O delirium,
O vomiting,
O abdominal pain, and
O tachydysrhythmias.
Nursing Responses to Thyroid Storm
O Maintain a patent airway.
O Monitor continuously for dysrhythmias
O As prescribed, administer acetaminophen to decrease
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temperature. (Aspirin is contraindicated; because it releases
thyroxine from protein-binding sites and increases free
thyroxine levels.)
Provide cold compresses,
Administer propylthiouracil (PTU) as prescribed to prevent
further synthesis and release of thyroid hormones.
Administer propranolol (Inderal) as prescribed to block
sympathetic nervous system effects.
Administer IV fluids as prescribed to provide adequate
hydration and prevent vascular collapse.
Fluid volume deficit may occur because of increased fluid
excretion by the kidneys or excessive diaphoresis. Carefully
monitor I&O/H to prevent fluid overload or inadequate
replacement.
Nursing Responses to Thyroid Storm
O Administer small doses of insulin as prescribed to
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control hyperglycemia.
Because O2 demands are increased as the metabolism
increases, administer prescribed supplemental O2 as
necessary.
Meeting the Needs of Older Adults
Symptoms in older adult clients are often more subtle
than those in younger people and the classic signs may
be absent.
Occasionally an older adult client with hyperthyroidism
demonstrates apathy or withdrawal instead of the more
typical hypermetabolic state.
Older adult clients with hyperthyroidism often present
with heart failure and atrial fibrillation.