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Chapter 50
Thyroid Disorder
Located in the lower neck anterior to the trachea Regulated by Thyroid-stimulating hormone (TSH)
Calcitonin
Reduce plasma level of Calcium by increasing deposition in bone
Copyright 2014 by Mosby, an imprint of Elsevier Inc.
Hyperthyroidism
A sustained increase in synthesis and release of thyroid hormones by thyroid gland Occurs more often in women, ages 20 to 40 years
Other causes
Toxic nodular goiter Thyroiditis Excess iodine intake Pituitary tumors Thyroid cancer
Hyperthyroidism
Thyrotoxicosis
Physiologic effects/clinical syndrome of hypermetabolism Results from increased circulating levels of T3, T4, or both
Accounts for 80% of hyperthyroidism cases Precipitating factors interact with genetic factors Cigarette smoking increases risk
Clinical Manifestations
Related to effect of thyroid hormone excess
Metabolism Tissue sensitivity to stimulation by sympathetic nervous system
Goiter
Inspection Auscultation: bruits
Clinical Manifestations
Ophthalmopathy
Abnormal eye appearance or function
Exophthalmos
Increased fat deposits and fluid Eyeballs forced outward
Clinical Manifestations
Cardiovascular system
Systolic hypertension Bounding, rapid pulse; palpitations Cardiac output Cardiac hypertrophy Systolic murmurs Dysrhythmias (e.g., atrial fibrillation ) Angina
Respiratory system
Increased respiratory rate Dyspnea on mild exertion
Copyright 2014 by Mosby, an imprint of Elsevier Inc.
Clinical Manifestations
GI system
Appetite, thirst Weight loss Diarrhea Splenomegaly Hepatomegaly
Clinical Manifestations
Integumentary system
Warm, smooth, moist skin Thin, brittle nails Hair loss Clubbing of fingers; palmar erythema Fine, silky hair; premature graying Diaphoresis Vitiligo
Acropachy
Clinical Manifestations
Musculoskeletal system
Fatigue Muscle weakness Proximal muscle wasting Dependent edema Osteoporosis
Clinical Manifestations
Nervous system
Nervousness, fine tremors Insomnia , exhaustion Lability of mood, delirium Hyperreflexia of tendon reflexes Inability to concentrate Stupor, coma
Clinical Manifestations
Reproductive system
Menstrual irregularities Amenorrhea Decreased libido Impotence Gynecomastia in men Decreased fertility
Clinical Manifestations
Intolerance to heat Elevated basal temperature Lid lag, stare Eyelid retraction Rapid speech
Thyrotoxicosis
Manifestations
Tachycardia, heart failure Shock Hyperthermia Restlessness, irritability Seizures Abdominal pain, vomiting, diarrhea Delirium, coma
Thyrotoxicosis
Treat by reducing circulating hormones Supportive therapy
Manage respiratory distress Reduce fever Replace fluids Eliminate or manage initiating stressor
Diagnostic Studies
TSH and free thyroxine (free T4) Total T3 and T4 Radioactive iodine uptake (RAIU)
Differentiates Graves disease from other forms of thyroiditis
Collaborative Care
Three primary treatment options
Antithyroid medications Radioactive iodine therapy (RAI) Surgery
Drug Therapy
Useful in treatment of thyrotoxic states Not considered curative
Antithyroid drugs Iodine -Adrenergic blockers
Antithyroid Drugs
Propylthiouracil (PTU) and methimazole (Tapazole) Inhibit synthesis of thyroid hormone Improvement in 1 to 2 weeks Good results in 4 to 8 weeks Therapy for 6 to 15 months
Iodine
Potassium iodine (SSKI) and Lugols solution Inhibit synthesis of T3 and T4 and block their release into circulation Decreases vascularity of thyroid gland Maximal effect within 1 to 2 weeks Used before surgery and to treat crisis
-Adrenergic Blockers
Symptomatic relief of thyrotoxicosis Block effects of sympathetic nervous stimulation Propranolol (Inderal) Atenolol (Tenormin)
Surgical Therapy
Indications
Large goiter causing tracheal compression Unresponsive to antithyroid therapy Thyroid cancer Not a candidate for RAI
Surgical Therapy
Subtotal thyroidectomy
Preferred surgical procedure Involves removal of 90% of thyroid Can be done endoscopically
Nutritional Therapy
High-calorie diet (4000 to 5000 cal/day)
Six full meals/day with snacks in between Protein intake: 1 to 2 g/kg ideal body weight Increased carbohydrate intake
Nursing Assessment
Subjective data
Past health history
Goiter, recent infection or trauma, immigration from iodinedeficient area, autoimmune disease
Medications
Thyroid hormones, herbal therapies
Weight loss Increased appetite, thirst Nausea/vomiting, diarrhea, polyuria Decreased libido - Impotence
-Amenorrhea
Nursing Assessment
Objective data
Agitation, Rapid speech, Anxiety, restlessness Enlarged or nodular thyroid gland Exophthalmos Eyelid retraction, infrequent blinking Thin, loose nails Fine, silky hair and hair loss Palmar erythema Clubbing Vitiligo Edema Warm, diaphoretic, velvety skin
Copyright 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Assessment
Objective data
Tachypnea, dyspnea on exertion Tachycardia, murmurs, dysrhythmias, HTN, bruit Bowel sounds, appetite, diarrhea, weight loss Hepatosplenomegaly
Objective data
Hyperreflexia, diplopia Fine tremors Muscle wasting
Copyright 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Assessment
Objective data
T3, T4 T3 resin uptake Or undetectable TSH Chest x-ray showing enlarged heart ECG findings of tachycardia, atrial fibrillation
Overall goals
Experience relief of symptoms Have no serious complications related to disease or treatment Maintain nutritional balance Cooperate with therapeutic plan
Copyright 2014 by Mosby, an imprint of Elsevier Inc.
Hypothyroidism
Deficiency of thyroid hormone Slow metabolic rate More common in women than in men
Secondary hypothyroidism
Caused by pituitary or hypothalamic dysfunction ( TSH or TRH)
Etiology
Iodine deficiency Atrophy of the gland Treatment for hyperthyroidism Drugs Cretinism if occurs in infancy
Clinical Manifestations
Manifestations variable Slow onset Cardiovascular system
Cardiac contractility and output Angina, heart failure, myocardial infarction Anemia Cobalamin, iron, folate deficiencies Serum cholesterol and triglycerides
Copyright 2014 by Mosby, an imprint of Elsevier Inc.
Clinical Manifestations
Respiratory system
Low exercise tolerance Shortness of breath on exertion
Neurologic system
Fatigue and lethargy Personality and mood changes Impaired memory, slowed speech, decreased initiative, and somnolence
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Clinical Manifestations
Gastrointestinal system
Decreased appetite Nausea and vomiting Weight gain Constipation Distended abdomen Enlarged, scaly tongue Celiac disease
Copyright 2014 by Mosby, an imprint of Elsevier Inc.
Clinical Manifestations
Integumentary system
Dry, thick, inelastic, cold skin Thick, brittle nails Dry, sparse, coarse hair Poor turgor of mucosa Generalized interstitial edema Puffy face Decreased sweating Pallor
Clinical Manifestations
Musculoskeletal system
Fatigue, weakness Muscular aches and pains Slow movements Arthralgia
Reproductive system
Prolonged menstrual periods or amenorrhea Decreased libido, infertility
Clinical Manifestations
Other
Increased susceptibility to infection Increased sensitivity to opioids, barbiturates, anesthesia Intolerance to cold Decreased hearing Sleepiness Goiter
Complications
Myxedema coma
Impaired consciousness Precipitated by infection, drugs, cold, trauma Subnormal temperature, hypotension, hypoventilation Cardiovascular collapse Treat with IV thyroid hormone
Diagnostic Studies
History and physical examination TSH and free T4
TSH with primary hypothyroidism TSH with secondary hypothyroidism
Collaborative Care
Levothyroxine (Synthroid)
Start with low dose Monitor for cardiovascular side effects (chest pain, dysrhythmias), weight loss, nervousness, tremors, insomnia Increase dose in 4- to 6-week intervals as needed Lifelong therapy
Nursing Assessment
Health History
Hyperthyroidism treatment Iodine-containing medications Changes in appetite, Weight gain Activity level Speech, memory, or skin changes
Physical examination
Cold intolerance Constipation Signs of depression Heart rate Gland tenderness Edema
Nursing Diagnoses
Imbalanced nutrition: more than body requirements Constipation Impaired memory
Nursing Implementation
Health promotion
Screen populations at high risk
Family history of thyroid disease History of neck irradiation Women older than 50 Postpartum women
Nursing Implementation
Most outpatient therapy Myxedema coma necessitates acute care
Mechanical respiratory support Cardiac monitoring IV thyroid hormone replacement Monitoring of core temperature
Nursing Implementation
Acute intervention
Skin care Vital signs, weight, I&O, edema Cardiovascular response to hormone Energy level Mental alertness
Nursing Implementation
Patient teaching
Written instructions important Need for lifelong therapy Thyroid medicine in morning on empty stomach Side effects of medication Signs and symptoms of hypothyroidism and hyperthyroidism
Nursing Implementation
Patient teaching
Regular follow-up care Do not switch brands Comfortable, warm environment Measures to prevent skin breakdown Emphasize need for warm environment Avoid sedatives or use lowest dose possible Measures to minimize constipation Avoid use of enemas
Copyright 2014 by Mosby, an imprint of Elsevier Inc.