Endocrine Disorders

1. Endocrine Disorders

2. Thyroid Disorders

3. “A Delicate Feedback Mechanism”

4. Thyroid Gland Hormones Thyroxine (T4) and Triiodothyronine (T3) These are responsible for • increase in metabolic rate • increase protein and bone turnover • increase responsiveness to catecholamines • Fetal and infant growth and development Calcitonin • Lowering blood calcium and phosphate levels

5. Continuum of Thyroid Dysfunction Normal

6. Hyperthyroidism An increase in release of thyroid hormone

7. Hyperthyroidism Clinical Manifestations • What are the clinical manifestations in each body system that reflect the increase in metabolism caused by the excessive release of thyroid hormones? • Cardiovascular • Respiratory • Gastrointestinal • Integumentary Musculoskeletal Nervous Reproductive Other

8. HyperthyroidismDiagnostic Studies • History • Physical examination • Ophthalmologic examination • ECG • Radioactive iodine uptake (RAIU) • Indicated to differentiate Graves’ disease from other forms of thyroiditis

9. HyperthyroidismDiagnostic Studies • Laboratory tests

10. What is the primary test used to Diagnose Hyperthyroidism?

11. HyperthyroidismCollaborative Care • Goals • Block adverse effects of thyroid hormones • Stop hormone oversecretion • Three primary treatment options • Antithyroid medications • Radioactive iodine therapy (RAI) • Subtotal thyroidectomy

12. HyperthyroidismTreatment – Drug TherapyAntithyroid Drugs • Action: • Inhibit synthesis of thyroid hormone • First-line examples • Propylthiouracil (PTU) • Also blocks conversion of T4 to T3 • Methimazole (Tapazole)

13. Antithyroid Drugs • Nursing Implications: • Instruct the patient that it will take several weeks for the drug to be effective • Improvement in 1 to 2 weeks • Good results in 4 to 8 weeks • Therapy for 6 to 15 months • Disadvantages include • Patient noncompliance • Increased rate of recurrence when medication is discontinued

14. Do these medications cure the problem?

15. HyperthyroidismDrug Therapy - Iodine • Uses: • Used with other antithyroid drugs in preparation for thyroidectomy or treatment of thyrotoxic crisis • Given several weeks preoperatively • Decrease the vascularity of thyroid gland decreasing bleeding making surgery safer • Action: • Inhibit synthesis of T3 & T4 and block release into circulation to slow metabolism • Examples • Saturated solution of potassium iodine (SSKI) • Lugol’s solution

16. HyperthyroidismDrug Therapyβ-Adrenergic blockers • Action: • Symptomatic relief of thyrotoxicosis resulting from β-adrenergic receptor stimulation • Uses: • Helps to control nervousness, tachycardia, tremor, anxiety, and heat tolerance. • Example • Propranolol (Inderal) administered with other antithyroid agents

17. HyperthyroidismRadioactive Iodine Therapy (RAI) • Uses: • Used to destroy thyroid tissue thereby limiting thyroid hormone secretion. • Effects not seen for 2-3 months • Dose of RAI is low so no radiation safety precautions are needed • Complication • High incidence of post-treatment hypothyroidism – need to be taught symptoms RAI Not an option during pregnancy

18. HyperthyroidismSurgery TherapyThyroidectomy • Indications • Unresponsive to drug therapy • Large goiters with tracheal compression • Possible malignancy

19. Thyroidectomy • Oxygen, suction equipment, tracheostomy tray available in room • Postoperative care • Every 2 hours for 24 hours • Assess for signs of hemorrhage • Assess for tracheal compression • Irregular breathing, neck swelling, frequent swallowing, choking • Semi-Fowler’s position • Support head with pillows • Avoid flexion of neck • Tension on suture lines

20. Thyroidectomy • Postoperative care • Monitor vitals • Control pain • Check for tetany • Muscle cramps or laryngeal stridor – treat with calcium gluconate • Trousseau’s and Chvostek sign should be monitored • Monitor for 72 hours • Evaluate difficulty in speaking/hoarseness • Some hoarseness for 3 to 4 days is expected

21. Thyroidectomy • Ambulatory and home care • Discharge teaching • Monitor hormone balance periodically • Decrease caloric intake to prevent weight gain • Adequate iodine • Regular exercise • Avoid ↑environmental temperature

22. HyperthyroidismNutritional Therapy • Why is the patient placed on a High-calorie diet (4000-5000 kcal/day)? • What foods are encouraged? • What foods should be avoided?

23. HyperthyroidismNursing Implementation • Change linens frequently if diaphoretic • Eye Care for exophthalmos • Apply artificial tears to prevent corneal ulceration • Elevate HOB and salt restriction for edema • Tape eyelids shut for sleep if they cannot close • Dark glasses to reduce glare and prevent environmental irritants

24. HyperthyroidismComplications Thyrotoxic crisis (Thyroid Storm) • Acute, rare condition where all manifestations of hyperthyroidism are heightened • Life-threatening emergency/death rare when treatment initiated early and is vigorous.

25. HyperthyroidismThyrotoxic crisis/ Thyroid Storm • Manifestations include: • Respiratory distress – dyspnea • Hyperthermia – up to 105.30 • Tachycardia – pulse > 130 BPM • Heart failure, chest pain • Shock • Restlessness, Agitation • Seizures • Abdominal pain, Nausea • Delirium • Coma

26. Thyrotoxic crisis/ Thyroid Storm • Goal of Treatment • ↓ Thyroid hormone levels and clinical manifestations with drug therapy • Interventions • Manage respiratory distress – oxygen • Fever reduction – with antipyretics or cooling blankets, cool room • fluid replacement – IV fluids and electrolytes, and management of stressors • Administer medications – PTU, methimazole, Iodine, β-blockers • Treatment of Heart failure

27. Review on Hyperthyroidism Case Study: Beth Minton, 43 y/o, Admitted to hospital with high fever. Following an endocrine workup she was diagnosed with Graves Disease. Objective Data: Has fever of 1040 F, B/P of 150/78, P - 11, Flushed, with hot, moist skin Has fine hand tremors and appears nervous Has 4+ deep tendon reflexes R – 24

28. Critical Thinking Questions • What is the etiology of Beth’s symptoms? • What diagnostic studies were probably ordered? What would the results have been to establish the diagnosis of Grave’s Disease? • She has a subtotal Thyroidectomy planned for 2 months later – why is surgery being delayed? • Beth is started on propylthiouracil (PTU) and propranolol (Inderal). What is the purpose of drug therapy for Beth?

29. Critical Thinking Questions • What are Beth’s immediate learning needs; pre-op needs, and post-op needs? • What are the nursing interventions for successful long-term management of Beth after the subtotal thyroidectomy? • Based on assessment data presented, write appropriate nursing diagnosis pertinent to Beth while hospitalized.

30. Hypothyroidism A condition in which the body lacks thyroid hormones

31. Hypothyroidism Clinical Manifestations • What are the clinical manifestations in each body system that reflect the decrease in metabolism caused by the lack of thyroid hormones? • Cardiovascular • Respiratory • Gastrointestinal • Integumentary Musculoskeletal Nervous Reproductive Other

32. HypothyroidismDiagnostic Studies • History and physical examination • Laboratory tests • Serum TSH • Determines cause of hypothyroidism • Other abnormal findings are ↑ cholesterol and triglycerides, anemia, and ↑ creatinekinase

33. HypothyroidismTreatment - Drug Therapy • Levothyroxine (Synthroid) • Must take regularly • Monitor for angina and cardiac dysrhythmias • Monitor thyroid hormone levels and adjust (as needed) • Patient/family teaching • Because of the impaired memory - Be sure to provide patient with written instructions and teach family as well as patient • Lifelong therapy

34. Nursing ManagementAmbulatory and Home Care • Teach measures to prevent skin breakdown • Emphasize need for warm environment • Caution patient to avoid sedatives or use lowest dose possible • Discuss measures to minimize constipation • Avoid enemas because of vagal stimulation in cardiac patient • Teach patient to notify physician immediately if signs of overdose appear • Orthopnea, dyspnea, rapid pulse, palpitations, nervousness, insomnia

35. HypothyroidismComplication • Those with severe longstanding hypothyroidism may display myxedema • Accumulation of hydrophilic mucopolysaccharides in the dermis and other tissues • Causes puffiness, periorbital edema, masklike effect

36. HypothyroidismComplicationsMyxedema Coma Medical emergency • Hypoventilation- respiratory drive is decreased resulting in alveolar hypoventilation • Mental sluggishness • Drowsiness • Lethargy progressing gradually or suddenly to impairment of consciousness or coma • Subnormal temperature • Hypotension • Decrease pulse – does not perfuse tissues

37. Myxedema ComaTreatment • Vital functions must be supported • Mechanical respiratory support • Cardiac monitoring • Administer IV thyroid hormone replacement • If hyponatremic – give Hypertonic saline solution • Close assessment • VS monitoring • Monitor core temperature

38. Think of this when comparing Hyper vs Hypo thyroidism VS. Hypothyroidism Hyperthyroidism

39. Hyperparathyroidism

40. Hyperparathyroidism • There is overproduction of parathormone which is characterized by bone decalcification. • The patient will have an increase in blood calcium. What is a complication of increase in calcium in the blood?

41. HyperparathyroidismClinical Manifestations What are the clinical manifestations of hyperparathyroidism? Hint: They Mimic those of Hypercalcemia

42. HyperparathyroidismDiagnosis • Serology • Parathyroid hormone levels -  • Serum calcium - >10 mg/dl • Serum phosphorus - < 3 mg/dl • Urine calcium, serum chloride, creatinine, amylase, alkaline phosphatase – all elevated • Bone x-rays and bone scans • Ultrasound and MRI

43. Most common way to diagnose Hyperparathyroidism is by persistent elevated _____ ______levels and PTH

44. Hyperparathyroidism Treatment and Nursing Care • Hydration Therapy – force fluids. WHY? • Avoid Immobility / Active Lifestyle • Bones subjected to normal stress give up less calcium so encourage walking • Dietary measures-avoid diet with excess calcium

45. Hyperparathyroidism: Surgery • Post – op Nursing Care • Assess for hemorrhage • Assess Fluid and Electrolytes • Assess for Tetany – occurs with sudden decrease in calcium levels • What medication should be available at the bedside?

46. HyperparathyroidismDrug Therapy • Explain the use of the following medications in treatment: • Bisphosphates • Fosamax • Calcimimetic Agent • Cinacalcet

47. Hypoparathyroidism Results from abnormally low levels of PTH low Ca level

48. HypoparathyroidismClinical Manifestations What are the clinical manifestations of hypoparathyroidism: Hint: They mimic those of hypocalcemia

49. Sign that Calcium Level is Low • Chvostek’s sign: tap on the facial nerve just below the temple. • Positive - when nose, eye, lip & facial muscles twitch

50. Signs of Low Calcium • Trousseau’s sign:temporarily occlude arterial blood flow (with BP cuff inflated) above the normal systolic pressure. • Positive Trousseau’s sign occurs when the hand and fingers contract from ischemia