Transcript Chapter 19
Care of Patients with Problems of the Thyroid and Parathyroid Glands Excessive delivery of TH to the tissue Signs and symptoms ◦ Increased metabolic rate ◦ Cardiac increased workload ◦ Nutritional and caloric deficiency Causes ◦ Autoimmune excess stimulation of TSH by the pituitary gland Graves Disease ◦ Thyroiditis ◦ Neoplasms (toxic multi-nodular goiter) ◦ Side effects of certain drugs ◦ Excessive intake of thyroid medications Enlarged thyroid or goiter ◦ Can occur in hypothyroidism or hyperthyroidism Proptosis- forward displacement of the eye ◦ Exophthalmos ◦ Results from an accumulation of inflammation by products in the retro orbital space ◦ S/S eye pain, blurred vision, diplopia, lacrimation, and photophobia ◦ Treatment of graves disease does not reverse this condition Fatigue Difficulty sleeping Hand tremors Changes in menstruation Atrial fibrillation, angina, or CHF Nodules that excrete excessive amounts of TH Genetic Mutation is one suspected cause No pathology involving eyes or skin Commonly 60-70 year old woman that has had the goiter for several years Results from viral infection of the thyroid Acute condition that can become chronic If chronic the condition can result in hypothyroidism from destruction of thyroid tissue Life Threatening Condition Usually occurs from untreated Graves disease Or Hyperthyroidism plus stress ◦ ◦ ◦ ◦ Infection Trauma Untreated DKA Manipulation of the thyroid gland during surgery Temperature >102-106 Tachycardia Dyspnea GI Agitation, restlessness and tremors Confusion, lethargy, coma Treatment ◦ ◦ ◦ ◦ ◦ ◦ Cool Replace fluids Electrolytes Glucose Respiratory stabilization Cardiac monitoring Beta blockers ◦ Reduce TH synthesis and secretion Medication (page 497) Radioactive iodine Surgery Elevated TH T3, T4, Elevated radioactive iodine T3 RU Thyroid scan MRI ◦ Looks for nodules ◦ Thyroid tumors Consents Euthyroid ◦ Medications ◦ Iodine Patient Teaching ◦ Positioning neck ◦ Scar ◦ Hoarseness Total thyroidectomy Monitor for Postoperative Complications ◦ subtotal thyroidectomy ◦ ◦ ◦ ◦ ◦ ◦ Hemorrhage Respiratory distress Hypocalcemia and tetany Laryngeal nerve damage Thyroid storm or thyroid crisis Eye and vision problems of Graves’ disease Risk for Decreased Cardiac Output Interventions ◦ ◦ ◦ ◦ Monitor vital signs Cool environment Quiet Periods of rest Visual Disturbances ◦ Monitor visual acuity ◦ Teach measures to protect the eye from injury Use glasses for protection Artificial tears Cool moist compresses To report pain or changes in vision Decreased metabolism from low levels of thyroid hormones(TH) Myxedema ◦ Chronic untreated low TH ◦ Non pitting edema in the connective tissues Primary ◦ ◦ ◦ ◦ ◦ ◦ Congenital defects of the thyroid gland Post treatment for hyperthyroidism Anti-thyroid medications Endemic iodine deficiency Thyroiditis Some medications Amiodarone (Cordarone) contains iodine and has been linked to hypothyroidism Secondary Hypothyroidism Pituitary TSH deficiency Peripheral resistance to thyroid hormones History Physical assessment Clinical manifestations Psychosocial assessment ◦ Long term ◦ Page 501 ◦ Page 501 Risk for Decreased Cardiac Output Constipation Risk for Impaired Skin Integrity Inflammation of the thyroid gland Three types of thyroiditis— ◦ acute ◦ subacute (granulomatous) ◦ chronic (Hashimoto’s disease) the most common type. Antibodies destroy thyroid tissue. Initially gland enlarges to compensate Papillary ◦ ◦ ◦ ◦ ◦ Single nodule Multi-nodular goiter Childhood exposure to radiation Radiation fallout Family history Follicular Medullary ◦ 40-60 years of age ◦ Cells of the thyroid that produce calcitonin Airway Usually do not have elevated TH levels Diagnosis ◦ Scan ◦ Needle biopsy Treatment ◦ Surgery ◦ TSH suppression with Levothyroxine prior to surgery ◦ 131I radioactive iodine and or chemotherapy Control calcium blood levels Hyperparathyroidism ◦ Hypercalcemia Hypoparathyroidism ◦ Hypocalcemia Hyperparathyroidism ◦ Hyperplasia or adenoma of one of the parathyroid glands ◦ Compensatory response to chronic hypocalcemia CRF ◦ ◦ ◦ ◦ ◦ ◦ Asymptomatic Pathologic Bone fractures Renal calculi GI- constipation Cardiac HTN-dysrhythmias Avoid calcium supplements Avoid vitamins A and D Drink fluids Keep active Hospitalization ◦ IV 0.9% NS pamidronate (Aredia) ◦ alendronate (Fosamax) Surgical removal of parathyroid gland Postoperative care includes: ◦ Observe for respiratory distress. ◦ Keep emergency equipment at bedside. ◦ Hypocalcemic crisis can occur. ◦ Recurrent laryngeal nerve damage can occur. Decreased function of the parathyroid gland Most Common Cause Diagnosis ◦ Low levels of PSH ◦ High phosphate levels ◦ Low calcium levels ◦ Inadvertent removal of the parathyroid glands during a thyroidectomy ◦ Low calcium levels and high phosphate levels in the absence of renal failure, absorption disorder or a nutritional disorder Monitor for tetany ◦ Chvostek’s sign ◦ Trousseau’s sign See Box on page 507 Emergent treatment ◦ Replace calcium – calcium gluconate IV ◦ Long term Calcium replacements Vitamin D therapy Increased dietary calcium 50 year old woman presents with enlargement of left anterior neck. She has noted increased appetite over the past month with no weight gain, and more frequent bowel movements over the same period. Patients reports feeling, “jittery at times, experiences palpitations and feels hot a lot recently” She is 5’8”tall and weighs 150lbs BP110/76 HR 110 What might be wrong with this patient? What lab tests might you anticipate being ordered? Which hormone is affected? Is the hormone action hyper or hypo? What other symptoms might this client be experiencing What a re treatment options? Is this condition temporary or lifelong? Jane Lee is a 60 year old retired nurse living with her husband and daughter on a farm that has been in the family for 4 generations. Mrs. Lee has gained 10lbs (4.5kg) in the past few months, even though she is rarely hungry and eats much less than her normal. She is always tired and weak- so tired that she has not been able to help with the chores on the farm or do housework. She is concerned about her appearance and the way she sounds when she talks Her face is puffy, and her tongue always feels thick Mr. Lee convinces his wife to make an appointment at a health center in a nearby town You complete the health assessment for Mrs. Lee at the health center ◦ ◦ ◦ ◦ 10 lb weight gain over the past 6 months C/O constipation Difficulty remembering things Looks different “puffy” Thyroid exam palpate the thyroid ◦ Findings include a palpable and bilaterally enlarged thyroid ◦ Dry yellowish skin ◦ Nonpitting edema of the face and lower legs ◦ Slow slurred speech Diagnostic tests ◦ T3 56ng/dl Normal range: 80-200ng/dl ◦ T4 3.1 mg/dl Normal range: 5-12mg/dl ◦ THS- increased What diagnosis is made? What is important to teach Mrs. Lee about her new medication ◦ Levothyroxine 0.05mg daily What are some nursing diagnosis based on your assessment and data collection? Evaluation 2 months later Mrs. Lee reports that she is no longer constipated but is continuing to drink at least 6 glasses of water and eating oatmeal every day She no longer feels cold, is regaining her normal energy and even feels well enough to plant her garden. Her speech is clear and easy to understand. “ it’s hard to believe that I have changed so much- now I look and feel like the old me”