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DISORDERS OF THE THYROID AND PARATHYROID GLANDS

DISORDERS OF THE THYROID AND PARATHYROID GLANDS. HYPERTHYROIDISM. ETIOLOGY/PATHOPHYSIOLOGY Also called Graves’ disease, or exophthalmic goiter, or thyrotoxicosis DUE TO : Overproduction of the thyroid hormones T3 and T4  Exaggeration of metabolic processes. HYPERTHYROIDISM.

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DISORDERS OF THE THYROID AND PARATHYROID GLANDS

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  1. DISORDERS OF THE THYROID AND PARATHYROID GLANDS

  2. HYPERTHYROIDISM • ETIOLOGY/PATHOPHYSIOLOGY • Also called Graves’ disease, or exophthalmic goiter, or thyrotoxicosis • DUE TO: Overproduction of the thyroid hormones T3 and T4  Exaggeration of metabolic processes

  3. HYPERTHYROIDISM • ETIOLOGY/PATHOPHYSIOLOGY cont. • Exact cause unknown • Possible genetic factors with precipitive factors of: • Infection, ↓ iodine, or extreme physical or emotional stress • Affects females more than males • May occur during adolesence or pregnancy

  4. HYPERTHYROIDISM • CLINICAL MANIFESTATIONS: • Edema of the anterior portion of the neck • Exophthalmos (bulging eyeballs) • SUBJECTIVE ASSESSMENT : Pt. C/o: • Inability to concentrate; memory loss • Dysphagia • Hoarseness • Increased appetite • Weight loss, insomnia • Nervousness, jittery, excitable

  5. EXOPHLALMUS

  6. HYPERTHROIDISM

  7. HYPERTHROIDISM • CLINICAL MANIFESTATIONS • OBJECTIVE ASSESSMENT • Tachycardia; hypertension; bruit over thyroid • Warm, flushed skin • Fine hair • Amenorrhea • Elevated temperature/heat intolerance • Diaphoresis • Hand tremors, clumsiness • Hyperactivity for some

  8. HYPERTHYROIDISM • DIAGNOSTIC TESTS • Confirmed by: • ↓ TSH and ↑ Free T4 • RAIU – radioactive iodine uptake – uptake of 35-95% of the drug

  9. HYPERTHYROIDISM • MEDICAL MANAGEMENT • Medications – Block production of thyroid hormone • Propylthiouracil / PTU • Methimazole/ Tapazole • Meds reduce symptoms in 6-8 wks.

  10. HYPERTHYROIDISM • MEDICAL MANAGEMENT • Medication may be followed by: • Radioactive iodine/ ablation therapy • Destroys some of the hypertrophied thyroid tissue • Low dose – no “radiation” precautions needed

  11. HYPERTHYROIDISM • MEDICAL MANAGEMENT cont. • Radioactive iodine/ Ablation therapy cont. • Outcome: in most pts.  hypothyroidism treat with Levothyroxine • Adequate medical supervision follow up is important!

  12. HYPERTHYROIDISM • MEDICAL MANAGEMENT cont. • Surgery: for pts. who cannot tolerate antithyroid drugs; are not good candidates for radiation tx.; have a poss. malignancy; or have large goiters causing tracheal compression • Most common surgery: Subtotal Thyroidectomy • Removal of 5/6ths of the thyroid gland • If too much thyroid tissue is removed  gland will not regenerate hypothyroidism

  13. HYPERTHYROIDISM • MEDICAL MANAGEMENT cont. • Surgery: usually delayed until pt in a normal thyroid state d/t the risk of bleeding during surgery and thyroid crisis (thyroid storm) post op.

  14. HYPERTHYROIDISM • NURSING ASSESSMENT AND INTERVENTIONS: • Post-operative Subtotal Thyroidectomy • Assess for s/sx internal or external bleeding • Assess for tetany: • Chovstek’s Sign: is + when abnormal spasm of facial muscles occurs when elicited by light tapping on facial nerve in the pt. with low calcium • Trousseau’s Sign: is + if there is carpal spasm in the hypocalcemic and hypomagnesemia pt. When BP cuff inflated above pt. normal systolic pressure and held there for 3 min.

  15. HYPERTHYROIDISM • NURSING ASSESSMENT AND INTERVENTIONS: • Post-op Subtotal Thyroidectomy (cont.) • Assess for Thyroid Crisis/Storm • May occur as a result of manipulation of the thyroid gland during surgery releasing large amts of thyroid hormone  bloodstream • Occurs within the first 12 hrs. • S/SX: exaggerated s/sx of hyperthyroidism + n/v, severe tachycardia, severe HTN, severe hyperthermia (106F+), extreme restlessness, dysrhythmias, delirium, heart failure  death

  16. HYPERTHYROIDISM • Thyroid Storm cont.: • DIAGNOSTIC TESTS • ↑FT4, ↓TSH • MEDICAL MANAGEMENT goals during thyroid storm: • 1. induce a normal thyroid state • 2. prevent cardio-vascular collapse • 3. prevent ↑ hyperthermia

  17. HYPERTHYROIDISM • NURSING ASSESSMENT AND INTERVENTIONS: • Post-op Subtotal Thyroidectomy (cont.) • Voice rest x48 hrs – provide communication tool • Voice checks – q 2-4 hrs. “ahh”; note hoarseness or other changes • Bed – semifowler’s position; pillow support for head and shoulders

  18. HYPERTHYROIDISM • NURSING ASSESSMENT AND INTERVENTIONS: • Post-op Subtotal Thyroidectomy (cont.) • Avoid hyperextension of neck; support head during position change • Reinforce DB exercises; check with MD re: coughing • Tracheotomy tray at bedside and suction • Cool mist humidifier prn • Nutrition care – watch for dysphagia

  19. HYPERTHYROIDISM • NURSING DIAGNOSES: • Pre-op • Risk for hyperthermia, related to increased metabolism • Imbalanced nutrition:less than body requirements r/t increased metabolism • Post-op • Impaired swallowing, r/t edema • Ineffective breathing,risk for, r/t post-op edema and pain

  20. HYPERTHYROIDISM • PATIENT EDUCATION • Post op: • follow up with medical supervision • Thyroid function tests • Care incision site • Diet: high calorie, CHO’s , and protein • PROGNOSIS: nml life with appropriate medical or surgical tx. • Expophthalmos may remain to lesser degree

  21. HYPOTHYROIDISM • Etiology/pathophysiology • Due to insufficient secretion of thyroid hormones • Decreasedhormones cause slowing of all metabolic processes • R/T Failure of thyroid or insufficient secretion of thyroid-stimulating hormone from pituitary gland

  22. HYPOTHYROIDISM • Myxedema refers to severe hypothyroidismin adults • Will see edema in hand’s face, feet, and periorbital tissues • Cretinism – congenital hypothyroidism

  23. HYPOTHYROIDISM • Clinical Manifestations: • Because all metabolism processes slow  • Hypothermia; intolerance to cold • Weight gain • ASHD/CAD  ↓exercise tolerance + dyspnea on exertion

  24. HYPOTHYROIDISM • SUBJECTIVE ASSESSMENT: • Mental and emotional assessment may include: • Depression; paranoia • Impaired memory; slow thought process • Hearing/speech impairment • Lethargic, forgetful, irritable • Anorexia • Constipation • Cold intolerance • Decreased libido; reproductive difficulties

  25. HYPOTHYROIDISM • OBJECTIVE ASSESSMENT • Menstrual irregularities • Thin hair, falls out • Skin thick and dry • Enlarged facial appearance • Low, hoarse voice • Bradycardia • Hypotension • Weakness, clumsiness, ataxia

  26. HYPOTHYROIDISM • Diagnostic tests : TSH, T3, T4, FT4 (low levels of these are the underlying stimuli for TSH) • For hypothyroidism: expect ↑TSH (compensatory); ↓T3, T4, and FT4

  27. HYPTHYROIDISM • MEDICAL MANAGEMENT • Medications: replacement therapy; titration needed • Synthroid • Levothyroid • Proloid • Cytomel • Symptomatic treatment

  28. HYPOTHYROIDISM • NURSING INTERVENTION/PT. TEACHING: • For the hospitalized pt. with severe hypothyroidism  focus on symptom relief • Watch for s/sx hyperthyroidism while adjusting doses of replacement medication • Watch for chest pain or dyspnea • Keep room 70-74⁰F • Avoid the pt. getting chilled • BM monitor/protocol

  29. HYPOTHYROIDISM • NURSING INTERVENTIONS/PT. TEACHING cont. • Diet : ↑protein, fiber, fluid ↓ calories Adequate iodine intake • Instruct pt. to take med daily and not to stop without consulting his MD • Instruct pt./family – to anticipate clearing of mental slowness as pt. adjusts to dose of med

  30. HYPOTHYROIDISM • NURSING DIAGNOSES: • Decreased cardiac output r/t decreased metabolism • Constipation r/t decreased peristalsis • Risk for noncompliance r/t therapy • Risk for disturbed body image, r/t altered physical appearance (goiter)

  31. HYPOTHYROIDISM • PROGNOSIS: Pt. will do well with medication and medical supervision. • In children, if the T4 replacement begins before the epiphyseal fusion, chance for normal growth is greatly improved

  32. SIMPLE (COLLOID) GOITER • ETIOLOGY/PATHOPHYSIOLOGY • Enlarged thyroid due to low iodine levels or the gland’s inability to use the iodine properly • Enlargement is caused by the accumulation of colloid in the thyroid follicles • When blood level of T3 is too low to signal the pituitary gland to reduce TSH secretion, the thyroid gland responds by increased formation of thyroid globulin (colloid)  accumulates in the thyroid follicles  gland enlargement • Usually caused by insufficient dietary intake of iodine  overgrowth of thyroid tissue

  33. GOITER

  34. SIMPLE (COLLOID) GOITER • CLINICAL MANIFESTATIONS/ASSESSMENT • Assessment based on physical manifestations: • SUBJECTIVE ASSESSMENT: • Enlargement of the thyroid gland • Pt. emotional response to the enlargement • Interview to determine pt. need for medication, diet, and medical follow up • May c/o: Dysphagia, Hoarseness. Dyspnea

  35. SIMPLE (COLLOID) GOITER • CLINICAL MANIFESTATIONS/assessment • OBJECTIVE DATA: • Assess increase of goiter • Voice changes • Adequate food/fluid intake • MEDICAL MANAGEMENT • Potassium iodide • Diet high in iodine • Surgery—thyroidectomy

  36. SIMPLE (COLLOID) GOITER • NURSING INTERVENTIONS/GOALS • Post Thyroidectomy: prevent complications such as bleeding, tetany, and thyroid crisis • Interventions: (discussed previously) • NSG. DIAGNOSES • Risk for non-compliance with therapeutic regimen • Risk for disturbed body image r/t physical appearance

  37. Figure 51-10 Simple goiter.

  38. Thyroid Cancer • ETIOLOGY/PATHOPHYSIOLOGY • Malignancy of thyroid tissue; rare • About 75% are papillary well-differentiated adeno carcinoma- grows slowly, usually contained, doesn’t spread beyond adjacent lymph nodes; cure rates are excellent. • CLINICAL MANIFESTATIONS • Firm, fixed, small, rounded mass or nodule on thyroid

  39. CANCER OF THYROID

  40. Thyroid Cancer • Assessment • SUBJECTIVE ASSESSMENT • Pt. coping method and support system • Pt. understanding of importance of medical follow up • OBJECTIVE ASSESSMENT • Progressive enlargement of tumor area • Response to 131I tx. • Skin care post radiation

  41. Thyroid Cancer • DIAGNOSTIC TESTS: • Thyroid scan • Thyroid function tests • Needle bx. • MEDICAL MANAGEMENT • Total thyroidectomy • Thyroid hormone replacement • If metastasis is present: radical neck dissection; radiation, chemotherapy, and radioactive iodine

  42. CANCER OF THE THYROID

  43. CANCER OF THE THYROID

  44. Thyroid Cancer • NURSING INTERVENTIONS/Pt. TEACHING • Per thyroidectomy (previously discusses) • Post op: • Risk for respiratory distress • Risk for laryngeal damage • Bleeding • S/sx hypothyroidism

  45. Thyroid Cancer • NURSING DX. • Anxiety r/t situational crisis • Ineffective coping r/t personal vulnerability in a crisis • Pt. Teaching: • Proper medical follow up • Monitor thyroid replacement therapy • Proper care of surgical incision

  46. PARATHYROID GLANDS

  47. HYPERPARATHYROIDISM • ETIOLOGY/PATHOPHYSIOLOGY • Overactivity of the parathyroid glands, with increased production of parathyroid hormone (PTH) • Hypertrophy of one or more of the parathyroid glands (usually in the form of an adenoma) • Also from: CRF, Pyelonephritis, glomerulonephritis

  48. HYPERPARATHYROIDISM • CLINICAL MANIFESTATIONS • Hypercalcemia – primary clinical manifestation • Calcium leaves the bone  serum calcium increases • Bones become demineralized formation of renal calculi, pathological fx. • Skeletal pain; pain on weight-bearing

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