Stressors of the Thyroid and Parathyroid Glands

1. Stressors of the Thyroid and Parathyroid Glands JBorrero 3/09

2. Thyroid Physiology • Regulates rate of metabolism/caloric requirements • Stimulates consumption of O2 by the tissues • Influences rate of growth • Affects metabolism of protein, CHO and lipids • Stimulates myocardium to increase force and rate of contraction • Affects resistance to infection • Affects brain and nervous system function • Some influence an sex organ development

3. Thyroid Hormones 1. T3- triiodothyronine 2. T4- thyroxine Both synthesis and release is regulated by TSH in the pituitary gland through a negative feedback mechanism • Calcitonin- made by thyroid, but not controlled by TSH Iodine is an essential element in the production of thyroid hormone

4. Hypothyroidism • Primary- Decreased thyroid hormone production, most common • Causes: • Hashimoto’s thyroiditis • Result of thyroid surgery • Radioactive iodine treatment of hyperthyroidism • Overtreatment of hyperthyroidism • Iodine deficiency

5. Hypothyroidism • 2. Secondary- Originates from anterior pituitary gland not producing TSH • 3. Myxedema Coma- rare, serious complication

6. CLINICAL MANIFESTATIONSEVERYTHING SLOWS DOWN SUBJECTIVE: • Weakness, fatigue, lethargy • Headaches • Slowed memory, psychotic behavior • Loss of interest in sexual activity • Menstrual disturbances • Depression

8. Hypothyroidism Objective Data • Neurological • CV • Pulmonary • Metabolic • GI • Integumentary • Psychological • Reproductive • Goiter

9. Lab Data • TSH • T4 and T3 • RAIU- Radioactive Iodine Uptake Test

10. ManagementGoal: Euthroid state 1. Administer thyroid hormone therapy as ordered. levothyroxine (Synthroid) Monitor for SE: tremors, HA, insomnia, palpitations, tachycardia 2. Monitor pulmonary function 3. Monitor Cardiac function 4. Monitor metabolism 5. Monitor for infection or trauma 6. Provide warmth and prevent heat loss 7. Health Teaching

11. Health Teaching • Diet teaching • Review signs of Hypo/Hyper thyroidism • Lifelong medication therapy- desired and side effects • Medication adjustments and interactions • Stress management techniques • Exercise program

12. Myxedema Coma • Coma, respiratory failure, hypotension, hyponatremia, hypothermia, hypoglycemia • Emergency care: ABC

13. HyperthyroidismEVERYTHING SPEEDS UP • Clinical syndrome caused by excessive circulating thyroid hormones • AKA Thyrotoxicosis , Graves’ Disease • Graves’ disease, the most frequent cause. Signs: goiter, exophthalmos, pretibial edema • Thyroid scan • Ultrasonography • Electrocardiography

14. Risk Factors/ Causes • Graves’ Disease is most common cause • Possible autoimmune repsonse • Occurs in 3rd or 4th decade • Affects women > men • Emotional trauma, infection, increased stress • Overdose of meds to tx hypothyroidism • Use of certain weight loss products

15. Signs & Symptoms • Nervousness, mood swings, irritability, hyperactivity, decreased attention span • Insomnia, interrupted sleep • Increased appetite, weight loss • Palpitations, widened pulse pressure, increased SBP • Heat intolerance, increased perspiration • Dyspnea • Weakness, exercise intolerance • Vision changes, exophthalmos, staring gaze • Goiter • Bruits over thyroid gland • Irregular menses

17. Diagnostic Studies • T3 & T4: elevated • TSH- decreased • RAI Uptake Test- High uptake with hyperthyroidism • Thyroid Scan • EKG

18. Exophthalmus • Provide symptomatic treatment. • Treatment of hyperthyroidism does not correct eye and vision problems of Graves’ disease. • Elevate the head of bed at night. • Instill artificial tears. • Treat photophobia with dark glasses/patches • Give steroid therapy. • Provide diuretics.

19. Health Teaching • Minimize energy expenditure • Stress reduction techniques • Diet: High caloric, high protein • Avoid stimulants: coffee, tea, chocolate, colas, tobacco • Medications as ordered. Teach SE and desired effects. • Provide eye protection • S&S Thyroid Storm • Possible Preop

20. Thyroid StormAKA Thyrotoxic Crisis S&S • Tachycardia >1 30/min • Hyperpyrexia Up to 106 • Exaggerated symptoms of Hypertension

21. Thyroid Storm - Tx • Goals: • Maintain airway • Prevent CV collapse • Reduce body temp • Reduce metabolic demands • Airway • EKG monitor • Acetominophen • Cool sponge baths • PTU • Propanalol • IVF • Insulin • Sodium iodide • Insulin • O2

22. Thyroiditis Inflammation of the Thyroid Gland. Three types A. Acute B. Subacute C. Chronic (Hashimoto’s disease)

23. Thyroid Tumors Classification: A. Benign- associated with thyrotoxicosis or glandular enlargement (goiter) B. Malignaat 1. Papillary, 2. Follicular 3. Medullary 4. Anaplastic.

24. Patient Education • Thyroid hormone replacement for life • CXR and total body scan yearly x 3 years • Assess for signs of recurrence • Follow up with T4, T3, serum Ca and Phos

25. Thyroidectomy • Pre Op: • Antithyroid hormone and SSKI Iodine to reduce activity and decrease vascularity • Nutritional assessment • Expalnation of procedure and post op course • Teach support of neck incision to prevent strain

26. Surgical Management • Postoperative care: • Hemorrhage • Respiratory distress • AIRWAY, SUCTION AND TRACH SET AT BEDSIDE • Humidified O2 • Semi-fowlers with pillows on either side of neck • Hypocalcemia and tetany • Laryngeal nerve damage

27. Surgical Management • Pain Management • Nutrition • Rest, relaxation, and avoidance of stress • Thyroid storm or thyroid crisis- uncontrolled hyperthyroidism triggered by stressors

28. Hyperparathyroidism • Parathyroid glands: calcium and phosphate balance • Hypercalcemia (Norm 9.0-10.5 mg/dL) and hypophosphatemia • Sign & Symptoms • Nonsurgical management: • Diuretic and fluid therapy • Drug therapy: phosphates, calcitonin, calcium chelators (Mithramycin) • Nutrition

29. Surgical Management • Parathyroidectomy preoperative care: • Client stabilized; calcium levels normalized • Studies: bleeding and clotting times, CBC • Teaching: coughing, deep-breathing exercises, neck support • Operative procedures- transverse incision in lower neck. All 4 glands are check for enlargement • Minimal Parathyroid Surgery http://www.parathyroid.com/MIRP-Surgery.htm )

30. Surgical Management • Postoperative care includes: • Observe for respiratory distress. • Keep emergency equipment at bedside. • Hypocalcemic crisis can occur. • Recurrent laryngeal nerve damage can occur. • Lifetime Ca and Vitamin D supplements

31. Hypoparathyroidism • Decreased function of the parathyroid gland • CAUSES: • Iatrogenic hypoparathyroidism • Idiopathic hypoparathyroidism • Hypomagnesemia (Norm 1.6-2.6 mg/dL) • INTERVENTIONS: • Correct hypocalcemia, vitamin D deficiency, and hypomagnesemia • Tx: Rocaltrol – Vitamin D compound • PO Calcium intake up to 2Gm /day

32. NCLEX TIME Following thyroid resection, the nurse frequently assesses the client's ability to speak. What is the nurse evaluating with this intervention? A.Changes in level of consciousness B.Recovery from anesthesia C.Injury to parathyroid gland D.Spasm or edema of the vocal cords

33. NCLEX TIME In reviewing laboratory results in the client with Hashimoto's thyroiditis, the nurse expects which of the following? A.Elevated thyroxine B.Elevated triiodothyronine C.Elevated thyroid-stimulating hormone D.Elevated plasma catecholamines

34. NCLEX TIME • The nurse correlates which clinical manifestations with the diagnosis of hyperthyroidism? A.Fatigue, weight gain, cold intolerance B.Decreased pulse rate, slurred speech, anorexia C.Abdominal pain, constipation, heat intolerance D.Nervousness, weight loss, tachycardia

35. NCLEX TIME • The nurse monitors for which of the following as indicative of effective treatment of hypothyroidism? • A.Decreased sweating • B.Weight gain • C.Decreasing heart rate • D.Increasing energy level

36. NCLEX TIME • The nurse recognizes that the client with Graves' disease is at risk for which of the following complications? • A.Corneal ulceration • B.Pitting edema • C.Hypotension • D.Urinary retention

37. NCLEX TIME • Which of the following statements by the client on thyroid replacement therapy indicates the need for further teaching? A.“I should take this every morning.” B.“If I continue to lose weight, I may need to have the dose increased.” C.“I should have more energy with this medication.” D.“If I gain weight and feel tired all the time, I may need the dose increased.”