Transcript Disorders of the Thyroid Gland

Management of Patients With Thyroid
Disorders
Dr. Belal M. Hijji, RN. PhD
May 7th & 9th, 2012
Learning Outcomes
At the end of this lecture, students will be able to:
• Describe the thyroid gland, its functions, and hormones
• Examine relevant assessment and diagnostic studies.
• Recognise the outcomes related to abnormal thyroid function.
• Define hypothyroidism, its causes; discuss its
pathophysiology, clinical manifestations, medical and nursing
management
• Define hyperthyroidism and its causes; discuss its clinical
manifestations, diagnostic evaluation, medical and nursing
management
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Management of Patients With Thyroid Disorders
• The thyroid gland:
– Is a butterfly-shaped organ located in the lower neck anterior to
the trachea.
– Is about 5 x 3 cm2 , weighs about 30 g.
– Has a very high blood supply (about 5 mL/min per gram of
thyroid tissue).
– Produces thyroxine (T4), triiodothyronine (T3), and
calcitonin. T4 & T3 are referred to collectively as thyroid
hormone.
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Thyroid Function and Dysfunction
• Various hormones and chemicals are responsible for normal
thyroid function.
• Key among them are thyroid hormone, calcitonin, and iodine.
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Thyroid Hormone
• The two separate hormones, thyroxine (T4) and
triiodothyronine (T3) are produced by the thyroid gland and
that make up thyroid hormone, are amino acids that regulate
the cellular metabolic activity. They influence cell replication,
are important in brain development, and necessary for normal
growth.
The thyroid gland and surrounding structures
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Calcitonin
• Is another important hormone secreted by the thyroid gland.
• It is secreted in response to high plasma levels of calcium. It
reduces the plasma level of calcium by increasing its
deposition in bone.
Iodine
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Is essential to the synthesis of the thyroid gland hormones.
Is mainly used by the thyroid.
Deficiency alters thyroid function.
Iodide is ingested in the diet, absorbed & its ions are converted
to iodine molecules.
• Molecules react with tyrosine (an amino acid) to form the
thyroid hormones.
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Assessment and Diagnostic Findings
• Inspection: Identification of landmarks.
• Look for swelling or asymmetry.
• Palpation: Palpate the gland for size, shape, consistency,
symmetry, and the presence of tenderness.
• Auscultate the enlarged gland to identify localized audible
vibration of a bruit. This indicates increased blood flow
necessitates referral to a physician.
Continued…..
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Thyroid Function Tests
• Thyroid function tests, TSH and free thyroxine (FT4), are
elevated in hyperthyroidism and decreased in hypothyroidism.
• Thyroid scanning.
• Biopsy.
• Ultrasonography.
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Nursing Implications for Thyroid tests
• Determine whether the patient has taken drugs or agents that
contain iodine. These include:
– Contrast agents (radiopaque, dye-like substances that may
contain iodine) and medications used to treat thyroid
disorders.
– Topical antiseptics, multivitamin preparations, cough
syrups; and amiodarone, an antiarrhythmic agent.
– Estrogens, salicylates, amphetamines (drugs that produce
increased wakefulness and focus such as dextrostat),
chemotherapeutic agents, antibiotics, and corticosteroids.
• Ask the patient about the use of these drugs and note their use
on the laboratory requisition.
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Abnormal Thyroid Function
• In infancy: Hypothyroidism results in stunted physical and
mental growth because of general depression of metabolic
activity.
• In adults: Hypothyroidism manifests as lethargy, slow
mentation, and generalized slowing of body functions.
• Hyperthyroidism is manifested by a greatly increased
metabolic rate.
• Oversecretion of thyroid hormones is usually associated with
an enlarged thyroid gland (goiter).
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Hypothyroidism
• Suboptimal levels of thyroid hormone.
• Thyroid deficiency can affect all body functions.
Causes of Hypothyroidism
• Chronic lymphocytic thyroiditis (Hashimoto’s thyroiditis).
• Atrophy of thyroid gland.
• Therapy for hyperthyroidism:
– Radioactive iodine (131I) & thyroidectomy
• Medications.
– Lithium (controversal), iodine rich compounds
(amiodarone), and antithyroid drugs (propylthiouracil).
• Radiation to head and neck.
• Infiltrative diseases of the thyroid (amyloidosis, scleroderma)
• Iodine deficiency and iodine excess.
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Why Does High Iodine Intake Induce Hypothyroidism?
• Thyroid disorder? (Monaco, Satta, & Shapiro, 1993).
• The thyroid gland has a capacity to reduce thyroid hormone
production in the presence of excess iodine (Wolff-Chaikoff
effect). This effect is usually temporary and within a few days
thyroid hormone synthesis returns to normal through the socalled 'escape' phenomenon. However in a few normal
individuals and in some susceptible patients, the escape does
not occur. (Wémeau, 2002)
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Pathophysiology of Hypothyroidism
• Thyroidal hypothyroidism is responsible for more than 95% of
patients with hypothyroidism.
• Central hypothyroidism causes thyroid dysfunction due to
failure of the pituitary gland, the hypothalamus, or both.
• Secondary hypothyroidism is caused entirely by a pituitary
disorder.
• Neonatal thyroid deficiency is known as cretinism.
• The term myxedema, advanced case of hypothyroidism, refers
to the accumulation of mucopolysaccharides in subcutaneous
and other interstitial tissues.
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Clinical Manifestations of Hypothyroidism
• Early symptoms are nonspecific.
• Extreme fatigue.
• Hair loss, brittle nails, dry skin, and numbness and tingling of
the fingers may occur.
• Voice may become husky [hoarse and dry].
• Menstrual disturbances & loss of libido.
• In severe hypothyroidism:
– Hypothermia & bradycardia.
– Weight gain even without ↑ in food intake.
– Thick skin, thin hair that falls out.
– Expressionless and masklike face.
Continued…
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Subdued emotional responses, and dull mental processes.
Slow speech and enlarged tongue, hands, and feet.
Constipation.
Sleep apnea, pleural effusion, and pericardial effusion.
↑cholesterol level, atherosclerosis, coronary artery disease, and
poor left ventricular function.
Intraoperative hypotension and postoperative heart failure may
occur to undiagnosed patients.
Myxedema coma describes the most extreme, severe stage of
hypothyroidism, in which the patient is hypothermic and
unconscious.
The patient would develop respiratory complications
culminating in coma.
Cardiovascular collapse and shock. Mortality rate is high.
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• The aim of medical management is to:
– restore a normal metabolic state by replacing the missing
hormone.
Pharmacologic Therapy
– Synthetic levothyroxine (Synthroid or Levothroid) is the
preferred preparation for treating hypothyroidism and
suppressing nontoxic goiters.
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Nursing Management
Modifying Activity
• The patient experiences decreased energy and lethargy. As a
result, the risk for complications from immobility increases.
• The patient has decreased ability to exercise and participate in
activities due to changes in cardiovascular and pulmonary
status.
• The nurse’s role is to assist with care and hygiene while
encouraging the patient to participate in activities as tolerated
to prevent the complications of immobility.
Continued….
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Monitoring Physical Status
• Close monitoring of the vital signs and cognitive level to
detect the following:
– Deterioration of physical and mental status
– Signs and symptoms indicating that treatment has resulted
in the metabolic rate exceeding the ability of the
cardiovascular and pulmonary systems to respond
– Continued limitations or complications of myxedema
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Promoting Physical Comfort
• Extra clothing and blankets are provided.
• Use of heating pads and electric blankets is avoided. This is
because the patient could be burned by these items without
being aware of it because of delayed responses and decreased
mental status.
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Providing Emotional Support
• The patient may experience severe emotional reactions. The
nonspecific, early symptoms may produce negative reactions
by family members and friends, who may have labeled the
patient mentally unstable, uncooperative, or unwilling to
participate in self-care activities.
• The nurse informs the patient and family that the symptoms
and inability to recognize them are common but treatment is
successful and symptoms are reversible. The patient and
family may require assistance and counseling to deal with the
emotional concerns and reactions that result.
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Promoting Home and Community-Based Care
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Teaching Patients Self-Care
The patient and family require information and instruction that
will enable them to monitor the patient’s condition and
response to therapy.
The nurse instructs the patient and a family member about
medications.
The nurse provides written instructions and guidelines for the
patient and family.
Dietary instruction is provided to promote weight loss once
medication has been initiated.
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Continuing Care
• Before discharge, arrangements are made to ensure that the
patient returns to an environment that will promote adherence
to the prescribed treatment plan. The nurse:
– Assists in devising a schedule or record to ensure accurate
and complete administration of medications.
– Reinforces the importance of continued thyroid hormone
replacement and periodic follow-up testing and instructs
the patient and family members about the signs of
overmedication and undermedication.
– May refer the patient for home care.
– Documents and reports to the patient’s primary health care
provider, subtle signs and symptoms that may indicate
either inadequate or excessive thyroxine hormone.
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Hyperthyroidism
• Hyperthyroidism: The second most prevalent endocrine
disorder.
• Graves’ disease: Excessive output of thyroid hormones.
• It affects women eight times more frequently than men.
• It may appear after an emotional shock, stress, or an infection.
• Other common causes of hyperthyroidism include thyroiditis
and excessive ingestion of thyroid hormone.
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Clinical Manifestations
• Patients exhibit a characteristic group of signs and symptoms
(thyrotoxicosis). The presenting symptom is often
nervousness.
• Emotionally hyperexcitable, irritable, and apprehensive;
cannot sit quietly; palpitations; tachycardia at rest and on
exertion.
• Poor heat tolerance and unusual perspiration.
• The skin is flushed continuously.
• Skin is dry and diffuse pruritus.
• Exophthalmos.
Continued…..
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• Increased appetite and dietary intake, weight loss, abnormal
muscular fatigability and weakness, amenorrhea, and changes
in bowel function.
• Elevation of systolic blood pressure
• Atrial fibrillation.
• Osteoporosis and fracture.
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Assessment and Diagnostic Findings
• Enlarged thyroid.
• It is soft and may pulsate; with a bruit.
• Diagnosis is made on the basis of the symptoms and ↑ in
serum T4 and an increased 123I or 125I uptake by the thyroid in
excess of 50%.
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Medical Management
• Aims at reducing thyroid hyperactivity to relieve symptoms
and remove the cause of important complications.
• Treatment depends on the cause of the hyperthyroidism and
may require a combination of therapeutic approaches. These
are discussed next.
Continued….
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Pharmacologic Therapy
• Radioactive iodine therapy
– Destroys the overactive thyroid cells.
– Is the most common treatment in elderly patients.
• Antithyroid medications
– The overall aim of pharmacotherapy is to decrease thyroid
hormone production.
– The most commonly used medications are propylthiouracil
(Propacil, PTU) or methimazole (Tapazole) until the patient
is euthyroid.
– Medications may take several weeks for relief of
symptoms. Withdrawal of the medication is gradual.
– Toxic complications of antithyroid medications are
relatively uncommon.
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Surgical Management
• Surgery is reserved for special circumstances.
• Subtotal thyroidectomy ensures a prolonged remission in most
patients with exophthalmic goiter.
• Before surgery, propylthiouracil is administered until signs of
hyperthyroidism have disappeared.
• Propranolol may be used to reduce the heart rate.
• Iodine (Lugol’s solution or potassium iodide) may reduce
blood loss.
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Nursing Management of Patient with Hyperthyroidism
• Assessment: Focus should be on the patient’s:
– and family’s report of irritability and increased emotional
reaction.
– ability to cope with stress.
– nutritional status.
– changes in vision and appearance of the eyes.
– cardiac status.
– emotional & psychological status.
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Nursing Diagnoses
• Imbalanced nutrition, less than body requirements, related to
exaggerated metabolic rate, excessive appetite, and increased
gastrointestinal activity.
• Ineffective coping related to irritability, hyperexcitability,
apprehension, and emotional instability.
• Low self-esteem related to changes in appearance, excessive
appetite, and weight loss.
• Altered body temperature.
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Planning and Goals
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Improved nutritional status.
Improved coping ability.
Improved self-esteem.
Maintenance of normal body temperature.
Absence of complications.
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Nursing Interventions
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Improving Nutritional Status
Up to six well-balanced meals of small size are offered daily.
Foods and fluids are selected to replace fluid lost through
diarrhea and diaphoresis.
To reduce diarrhea, highly seasoned foods and stimulants such
as coffee, tea, cola, and alcohol are discouraged.
High-calorie, high-protein foods are encouraged.
Monitor weight, dietary intake, and nutritional status.
Continued….
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Enhancing Coping Measures
Reassure the patient that the emotional reactions will be
controlled with effective treatment.
Similar reassurance needs to be made to family and friends.
Minimise stressful experiences for the patient.
Keep the patient’s environment quiet and noiseless.
The nurse encourages relaxing activities if they do not
overstimulate the patient.
Educate patient about medications to be taken in anticipation
for surgical intervention.
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Improving Self-esteem
The patient with hyperthyroidism may lose self-esteem due to
changes in appearance, appetite, and weight, and due to his
inability to cope well with family and the illness.
Cover or remove mirrors.
Remind family members and personnel to avoid bringing these
changes to the patient’s attention.
Explain the temporary nature of these changes.
Provide eye care as appropriate. Instruct the patient on how to
use eye preparations.
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Maintaining Normal Body Temperature
• The patient with hyperthyroidism frequently finds a normal
room temperature too warm because of an exaggerated
metabolic rate and increased heat production.
• The nurse maintains the environment at a cool, comfortable
temperature and changes bedding and clothing as needed. Cool
baths and cool or cold fluids may provide relief.
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Teaching Patients Self-Care
Provide instruction and written plan about the medications.
Provide verbal and written instruction about the actions and
possible side effects of the medications.
Identify adverse effects that should be reported.
Provide information to the patient about what to expect if total
or subtotal thyroidectomy is anticipated.
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Evaluation
Expected Patient Outcomes
1. Improves nutritional status
a. Reports adequate dietary intake and ↓ hunger
b. Identifies foods with high-calorie, high-protein and those to be
avoided
c. Avoids use of alcohol and other stimulants
d. Reports decreased episodes of diarrhea
2. Achieves increased self-esteem
a. Verbalizes feelings about self and illness
b. Describes feelings of frustration and loss of control
c. Describes reasons for increased appetite
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