THYROID GLAND

The thyroid gland is a butterfly-shaped gland located at the base of the neck and wrapped around the lateral sides of the trachea. It has two lobes joined by a thin strip of tissue (isthmus) in front of the trachea. It has a rich blood supply and is composed of :

a. Follicular cells which produce the thyroid hormones: THYROXINE (T4) and Triiothyronin
(T3)

b. Parafollicular cells preduce and secrete:

THYROCALCITONIN (calcitonin), which helps regulate serum calcium levels.

 Control of metabolism occurs through T3 & T4 both hormones increase meatbolism, which causes an increase in oxygen use and heat production in all tissues. Once in the cell, T4 is converted to T3 the most active thyroid hormone.

 The conversion of T4 & T3 is impaired by:

Stress Starvation Beta blockers Corticosteroids PTU (Propyltiuracil) Cold temperature increase the conversion

T3 & T4 causes the following effects

1. Increase the meatbolic activities of most tissues of the body (exceptions include brain, retina, spleen, testes and lungs) 2. Increase protein synthesis and catabolism 3. Increase the uptake of glucose by cells 4. Increase the mobilization of fatty acids from fat stores and subsequently increase fatty acid

5. Decrease blood levels of cholesterol, phospholipids and triglycerides. 6. Increase oxygen utilization by the cellsand the production of metabolic end products 7. Increase the rate and strength of the heart 8. Increase the depth and rate of respiration

 when circulating concentration of the thyroid hormones are low, thyrotropin - releasing hormone (TRH) is released from the nuclei in the hypothalamus. TRH stimulates the release of thyroid stimulating hormone (TSH) from the anterior pituitary. In turn TSH stimulates the release of T4 & T3

 The actions of TRH and TSH are

controlled through a negative feedback in which rising levels of of T3 & T4 inhibit the release of TRH from the hypothalamus, which, in turn, inhibits the release of TSH from the anterior pituitary.

The two factors that cause the hypothalamus to secrete TRH, which then stimulates the anterior pituitary gland to secrete TSH.

Cold & Stress

CALCITONIN
lowers plasma calcium concentrations by inhibiting the release of calcium from bone. Calcium will decrease serum phosphate. As the plasma concentration of calcium increases, the thyroid releases calcitonin, which helps to restore the plasma calcium concentration to normal.

 Conversely, decreasing plasma concentrations of calcium inhibits the release of calcitonin. This hormone works in harmony with parathyroid hormone to maintain serum calcium and phosphate concentrations within normal limits.

Thyroid hormone production involves a series of steps: 1. Dietary intake of Protein and Iodine is needed to produce thyroid hormones. Iodine is absorbed from the intestinal tract as iodide. 2. The thyroid gland withdraws iodide from the blood and concentrates it. After the iodide is in the thyroid, it enters into a series of reactions to form T4 & T3

These hormones binds to thyroglobulin and are stored in the Follicular cells of the thyroid gland. with stimulation, T4 & T3 break off from the thyroglobulin and are stored into the blood. They enter many cells, bind to the nucleus, and turn on genes important in metabolism.

The presence of T4 & T3 directly regulates basal metabolic rate (BMR).

BMR - the rate at which heat is

produced by the body at rest, 12 to 14 hours after eating, measured in kilocalories per square metre of body surface per hour.

CALCIUM AND PHOSPHORUS BALANCE

occurs through the action of Calcitonin or TCT. Calcitonin, lowers serum calcium and serum phosphorus levels by reducing bone resorption (breakdown). The serum calcium level determines calcitonin secretion. Low serum calcium levels inhibit the release of calcitonin Elevated serum calcium levels increase its secretion.

Thyroid disorders
Hyperthyroidism is excessive
thyroid hormone secretion from the thyroid gland. The manifestations of hyperthyroidism are called THYROTOXICOSIS, regardless of the origin of the thyroid hormones.

Hyperthyroidism can be temporary or permanent depending on the cause. In hyperthyroidism, the normal feedback control over thyroid hormone fails. The excessive thyroid hormones stimulate most body systems, causing hypermetabolism and increased sympathetic nervous system activity.

 Many of the manifestations are caused by the bodys response to the demands of hypermetabolism Thyroid hormone directly stimulate the heart The resulting increased heart rate and stroke volume cause increased cardiac output, increased systolic BP, and increased blood flow.

 Elevated thyroid hormone levels affect protein, lipid and carbohydrate metabolism.
1. Protein synthesis (build up) and degradation (breakdown) are increased. 2. Breakdown exceeds build up, causing a net loss of body protein known as a NEGATIVE NITROGEN BALANCE. 3. Glucose tolerance is decreased, and the patient has hyperglycemia 4. Fat metabolism is increased, and body fat decreases.

 although the patient has an increased appetite, food intake does not meet the energy demands and the patient losses weight. with prolonged hyperthyroidism, the patient has chronic nutritional deficiency.

ETIOLOGY AND GENETIC RISK

1. Graves Disease the most common cause (also called toxic diffuse goiter) Patients with GD usually manifest a. Thyrotoxicosis b. Goiter (enlargement of the thyroid gland) c. Exophthalmus (abnormal protrusion of the eyes)

 GD is an autoimmune disorder in which antibodies are made and attack to the thyroid stimulating hormone (TSH) receptor sites on the thyroid tissue. When the antibodies, known as Thyroid stimulating immunoglobulins (TSIs), bind to the thyroid gland, the gland increases in size and overproduces thyroid hormones.

2. Hyperthyroidism caused by multiple thyroid nodules is termed TOXIC MULTINODULAR GOITER.

The nodules may be enlarged thyroid tissues or benign tumors (adenoma) These patients have had goiter for years The overproduction of thyroid hormones is usually milder than that seen in Graves disease, and the patient does not have exophthalmus or pretibial edema

3. Hyperthyroidism also can be caused by excessive use of thyroid replacement hormones. This type of problem is called EXOGENOUS HYPERTHYROIDISM. a condition called Thyroid Storm or Thyroid Crisis can occur when hyperthyroidism is untreated or poorly controlled or when the patient is severely stressed. This condition is an extreme state of hyperthyroidism in which all manifestations, are more severe and life threatening. It is most common in patients who have Graves disease.

INCIDENCE AND PREVALENCE

Hyperthyroidism is a common endocrine disorder GD can occur at any age but is diagnosed most often in women between 20 and 40 years of age, affecting women 10x more often than men. Toxic multinodular goiter usually occurs after age 50 and affect women 4x as often as men.

ASSESSMENT
1. Heat intolerance hallmark of hyperthyroidism 2. May have diapheresis even when environmental temperatures are comfortable for others. Often wears lighter clothing in cold weather. 3. May report palpitations or chest pain as a result of a cardiovascular effects
Dyspnea is common with or without exertion

5. Visual changes is the earliest problem, especially exophthalmus 6. fatigue, weakness and insomia are common 7. amenorrhea is common initially both men and women may have an inccrease libido, but this changes as the patient becomes more fatigued. 8. ask about previous thyroid surgery or radiation therapy to the neck because some people remain hyperthyroid after surgery or are resistent to radiation therapy.

Clinical Manifestation
1. Exophthalmus The wide eyed or startled look is due to edema in the extraocular muscles and decreased fatty tissue behind the eye, which pushes the eyeball forward. Pressure on the optic nerve may impair vision. swelling and shortening of the muscles may cause problems with focusing. If the eyelid fails to close completely and the eye is unprotected, the eye may become overly dry and develop corneal ulcers and infection.

2. Two other type od eye problems are common in all types of HYPERTHYROIDISM a. Eyelid retraction (eye lid lag) the upper eyelid fails to descend when the patient gazes slowly downward. b. Globe (eyeball) lag the upper eyelid pulls back faster than the eyaball when the patient gazes upward. during assessment, aks the patient to look down and then up and document the response.

3. In goiter, a generalized thyroid enlargement, the thyroid gland may increase to four times its normal size. 4. Goiters are common in Graves disease and are classified by size. 5. Bruit (turbulence from increased blood flow may be heard with a stethoscope 6. fine, soft, silky hair and smooth warm and moist skin are common with hyperthyroidism. 7. The patient may have muscle weakness, hyperactive tendon reflexes, or tremors.

Auscultate the thyroid. A bruit, a sign of increased blood flow, may be heard in hyperthyroidism.

Goiter Classification
Goiter Grade
0

Description *no palpable or visible goiter *mass is not visible with neck in normal psition. *Goiter can be palpated and moves up when the patient swallows

Goiter Grade 2 Description Mass is visible, swelling when the neck is in normal position Goiter is easily palpated and is usually asymmetric

Laboratory Assessment
1. Testing for hyperthyroidism includes measurement of the following values: a. Triiothyronine (T3) b. Thyroxine (T4) c. T3 resin uptake (T3RU) d. TSH 2. Antibodies to TSH (TSH RAb) are measured to determine the presence of Graves Disease.

Other Diagnostic Assessment

1. Thyroid Scan
evaluates the position, size and functioning of the thyroid gland.

2. Radioactive Iodine (RAI [123])

is given by mouth, and the uptake iodine by the thyroid gland (RAIU) is measured. RAIU is increase in patient with hyperthyroidism any drug that contains iodine should be discontinued for 1 week before the scan.

3. Ultrasonography of the thyroid gland determine its size and the general composition of ant masses or nodules this procedure takes about 30 minutes reassure patient that it is painless 4. Electrocardiogram (ECG) Usually shows tachycardia

Interventions
NONSURGICAL MANAGEMENT 1. Monitoring a. VS b. Instruct to report any palpitations, dyspnea, vertigo or chest pain increase in temperature may indicate a rapid worsening of the patients condition and the onset of Thyroid Storm

2. REDUCING STIMULATION is important because a noisy or stressful environment can increase the manifestation of hyperthyroidism and increase the risk for cardiac complications a. Encourage patient to rest b. Keep the environment as quiet as possible by closing the door of the room c. Limit visitors

3. Promoting Comfort can be accomplished through actions such as reducing the room temperature to decrease discomfort caused by heat intolearance a. Change bed linen if it is damp with diaphoresis b. Instruct to take a cold shower several times each day

4. Drug Therapy
a. Propyltiuracil (PTU)
These drugs block thyroid hormone production by preventing iodide binding in the thyroid gland b. Iodine Preparations

may be used for short term therapy before surgery. they decrease blood flow through the thyroid gland, reducing the production and release of thyroid hormone.

3. Litium
also inhibits thyroid hormone, however its use is limited because of side effects such as depression, diabetes insipidus, tremors, nausea and vomiting. may be used for patients who cannot tolerate other antithyroid drugs.

4. Beta Adrenergic Blocking Drugs (propanolol) may be used as supportive therapy these drugs relieve diaphoresis, anxiety, tachycardia, and palpitations but do not inhibit thyroid hormone production

SURGICAL MANAGEMENT
1. Surgery to remove all or part of the thyroid gland may be needed for patients who have a large goiter causing tracheal or esophageal compression or who do not have a good response to antothyroid drugs 2. Removal of all (total thyroidectomy) or part (subtotal thyroidectomy) of the thyroid tissue decreases the production of thyroid hormones.

PREOPERATIVE CARE
1. The patient is treated first with drug therapy to have near normal thyroid function (EUTHYROID) before surgery. Iodine preparations are used to decrease thyroid size and vascularity, thereby reducing the risk for hrmorrhage and the potential for thyroid storm during surgery.

2. Teach the patient to perform coughing and deep breathing exercises. 3. Stress the importance of supporting the neck when coughing or moving by placing both hands behind the neck This action reduces the strain on the suture line. 4. Explain that hoarseness may be present for a few days as a result of endotracheal tube placement during surgery.

Operative Procedures
1. Performed under GA 2. The patients neck is extended and the surgeon makes a collar incision above the clavicle. 3. The surgeon attempts to avoid the parathyroid glands and recurrent laryngeal nerve to reduce the risk of complications and injury.

4. With a subtotal thyroidectomy, the remaining thyroid tissues are sutured to the trachea 5. With a total thyroidectomy, the entire thyroid gland is removed but the parathyroid glands are left with an intact blood supply to prevent hypothyroidism.

POSTOPERATIVE CARE
1. Monitor VS every 15 minutes until stable then every 30 minutes 2. Assess level of discomfort a. Use sandbags or pillows to support the head and neck b. While awake, place patient in semi-fowlers position c. When positioning, decrease tension on the suture line by avoiding neck extension.

3. assist patient to cough and deep breath every 30 minutes to 1 hour. 4. suction oral and trachwal secretions when necessary.

THYROID SURGERY CAN CAUSE:

1. Hemorrhage 2. Respiratory distress 3. Parathyroid gland injury (resulting in hypocalcemia and tetany) 4. Damage to the laryngeal nerves 5. Thyroid storm

Hemorrhage
is most likely to occur during the first 24 hours after surgery. a. Inspect the neck dressing and behind the neck for blood b. A drain may be present, and a moderate amount of serosanguineous drainage is normal. it may be seen as bleeding at the incision site or as a respiratory distress caused by the tracheal compression.

Respiratory Distress
can result from swelling, tetany or damage to the laryngeal nerve, causing spasms. Laryngeal stridol (harsh, highpitched respiratory sounds) is heard in acute respiratory obstruction

Hypocalcemia and Tetany

may occur if the parathyroid glands are damaged or their blood supply is impaired during thyroid surgery. These problems result when parathyroid hormone (PTH) levels decrease. a. Assess for muscle twitching as a sign of calcium deficiency Calcium Gluconate or Ca Chloride for IV should be available in an emergency situation.

Damage to the Laryngeal Nerve this problem results in hoarseness and a weak voice a. Assess the voice at 2 hour intervals b. Reassure patient that hoarseness is usually temporary.

Thyroid Storm or Thyroid Crisis

is a life threatening event that occurs in patients with uncontrolled hyperthyroidism and occurs most often with Graves Disease. a. It is often triggered by stressors such as trauma, infection, diabetic ketoacidosis, and pregnancy. b. Other conditions that can lead to thyroid storm include vigorous palpation of the goiter, exposure to iodine, and radioactive iodine (RAI) therapy.

c. The manifestation of thyroid storm are caused by excessive thyroid hormone release, which dramatically increases metabolic rate. Key manifestations include fever, tachycardia, and systolic hypertension. As the crisis progresses, patient may become restless, confused or psychotic and may have seizures, leading to coma. Even with treatment, thyroid storm may lead to death.

Hypothyroidism
Thyroid cells fail to produce sufficient levels of thyroid hormones for several reasons a. Sometimes cell are damage and no longer function normally. b. At other times the thyroid cells are functional but the person does not ingest enough of the substances needed to make thyroid hormones (iodide and tyrosine)

 when the production of thyroid hormones is too low or absent, the blood levels of TH are very low and the patient has had decreased metabolic rate. This lowered metabolism causes the hypothalamus and anterior pituitary gland to make stimulatory hormone release, especially TSH, in an attempt to trigger hormone release from poorly responsive thyroid gland

 The TSH binds to thyroid cells and causes the thyroid gland to enlarge, forming a goiter, although thyroid hormone production does not increase. Most tissues and organs are affected by the low metabolic rate Cellular energy is decreased and metabolites build up.

 Metabolites are compounds of proteins and sugars called GLYCOSAMINOGLYCANS These compounds build up inside cells, which increases the mucus and water, forms cellular edema, and changes organ texture The edema is mucinous (called MYXEDEMA) rather than edema caused by water alone.
This edema changes patients appearance

 Nonpitting edema forms everywhere, especially around the eyes, in the hands and feet, and between the shoulder blades The tongue thickens and edema forms in the larynx, making the voice husky.

Myxedema coma a rare serious complications of untreated or poorly treated hypothyroidism.

The decreased metabolism caused the heart muscle to become flabby and the chamber size to increase

 The result is decreased cardiac output and decreased perfusion to the brain and other vital organs The decreased perfusion makes the already slowed cellular meatbolism worse, resulting in tissue and organ failure.

Etiology
Most cases of hypothyroidism occur as a result of thyroid surgery and radioactive iodine (RAI) treatment of hyperthyroidism. Worldwide, hypothyroidism is common in areas where the soil and water have little natural iodide causing endemic goiter.

Physical Assesment/Clinical Manifestation

1. Common changes Coarse features Edema around the eyes and face A blank expression Thick tongue 2. The overall muscle movement is slow 3. May not spaeak clearly, and may take a longer time to respond to questions.

4. Cardiac and RR are decreased 5. Depending on the cause of hypothyroidism, the patient may have goiter. therefore the presence of goiter suggests a thyroid problem but does not indicate whether the problem is excessive or too little hormone secretion.

Laboratory Assessment
1. T3 & T4 serum levels are decreased 2. TSH levels are high in primary hypothyroidism but can be decreased or near normal in patients with secondary hypothyroidism.

Primary Causes
1. Decreased thyroid tissue Surgical removal of the thyroid Radiation-induced thyroid destruction Autoimmune thyroid destruction cancer

2. Decreased synthesis of thyroid hormone

Endemic iodine deficiency Excessive exposure to iodine Drugs a. Lithium b. Phenlybutazone c. PTU

Secondary Causes
1. Inadequate Production of Thyroid Stimulating Hormone a. Pituitary tumors, trauma, infections b. Congenital pituitary defects c. Hypothalamic tumors

Common Nursing Diagnoses

1. Ineffective Breathing Pattern related to decreased energy and fatigue 2. Decreased cardiac output: output related to altered heart rate and rhythm as a result of decreased myocardial metabolism. 3. Disturbed Thought Process related to impaired brain metabolism and edema 4. Potential for myxedema coma

Ineffective Breathing Pattern

Expected Outcomes 1. Maintenance of Spo2 of at least 90% 2. Abscence of cyanosis 3. Maintenance of cognitive orientation

Interventions
1. Observe and record the depth and rate of respirations 2. Measure O2 saturation by pulse oximetry. 3. Auscultate lungs for breath sounds

Decreased Cardiac Output

Expected outcomes 1. Maintains heart rate above 60 bpm 2. Maintain blood pressure within normal limits 3. Has no dysrhythmias, peripheral edema, or neck vein distention.

Interventions
1. Monitor BP and Heart rate and rhythm and observe closely for shock (hypotension, decreasing urine output change in mental status) 2. Lifelong thyroid replacement 3. Remind patient and family who are taking thyroid hormone replacement to take the drug exactly as prescribed and not to change change th dose or schedule

Disturbed Thought Process

Expected Outcomes 1.Demonstrates immediate memory 2.Communicates clearly and appropriately for age and ability 3.Is attentive during conversations.

Interventions
1. Observe and record the presence and severity of lethargy, consciousness, memory deficit, poor attention span, and difficulty communicating. These problems should decrease with thyroid hormone treatment, and mental awareness usually returns to the patients normal level within 2 weeks.

2. Orient patient to person, place and time and explain procedures slowly and carefully. 3. Encourage the family to accept the mood changes and mental slowness as manifestation of the disease. 4. Remind family that these problems should improve with therapy

Health teachings
1. Hormonal replacement therapy and its side effects. 2. Not to take OTC drugs Thyroid hormone preparations interact with many other drugs 3. Advise to eat well balanced diet with adequate fiber and fluid to prevent constipation caution not to use fiber supplements because it will interfere with the absorption of thyroid hormone. the drugs should be taken on an empty stomach.

4. Remind about adequate rest 5. Monitor for therapy effectiveness The two easiest parameters to check are the need for sleep and bowel elimination when the patient requires more sleep and is constipated, the dose of replacement hormone may need to be increased. when the patient has difficulty getting to sleep and has more bowel movements than normal for him/her, the dose may need to be decreased.

QUESTIONS
Which one is NOT a symptom of hypothyroidism?
fatigue weight gain feeling cold shaking

 Which hormone causes a decrease in the calcium concentration in the blood?

thyroxine Calcitonin Triiodothyronine All of the above

 Which hormone speeds up the bodys metabolism?

Triiodothyronine Calcitonin Thyroxine All of the Above

 When you feel cold, the first thing your body does is produce: A. Thyroxine B. Thyroxine Stimulating Hormones (TSH) C. Thyroxine Stimulating Hormone Releasing Factor (TSHRF) D. Oxytocin E. Heat from elevated metabolism

What does Calcitonin cause? a. A decrease in bone density b. An increase in bone density c. A decrease in calcium concentrations d. An increase in calcium concentrations

How many hormones does the thyroid gland secrete? a. seven b. two c. three d. one