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1 Jean A. Trost, RN, BSN Alverno College – MSN 621 May 2010 Start

2 By the end of this tutorial, you will be able to:  Demonstrate accurate knowledge involving the pathophysiology of hyper-/hypothyroidism  Have basic knowledge of treatments for hyper- /hypothyroidism  Have accurate knowledge of the signs and symptoms of the disease process of hyper-/hypothyroidism to include the effects of thyroid disease on the patient population  Be able to effectively teach the patient population the differences between hyper-/hypothyroidism

3  Use the following buttons to help you navigate  To advance forward click the left mouse key or the enter key  To move backward one slide  To end the tutorial  To go to the home page  To hyperlink segment (click on “Thyroid Gland and Negative Feedback”) H

4 Hyoid Bone Cricothyroid Ligament Largest Endocrine Gland (Weight 20-25g—just under one ounce) (Martini, F., 1992)

5  Arises from the root of the embryonic tongue (located on the back of tongue) and descends into the neck  Is wrapped around the anterior and lateral aspects of the trachea right below the larynx  Consists of two large lobes, one on each side of the trachea, connected by a narrow anterior isthmus (Martini, F., 1992)

6  The thyroid is composed mostly of sacs called thyroid follicles  A network of capillaries, which accept secretory products and metabolic wastes and deliver nutrients and regulatory hormones to the glandular cells, surrounds each follicle  Each follicle is filled with a protein-rich colloid and is lined with a simple cuboidal epithelium of follicular cells, which aids in secretion Endocrine_System/histology_jpgs/thyroid_400x_P2252255lbd.JPG (Matfin, Porth, 2009)

7  Thyroid follicles release several hormones into the circulation  These hormones are derivatives of the amino acid tyrosine to which 3 or 4 iodine atoms have been attached (Goodson, no date provided)

8 Larynx Right lobeLeft lobe Isthmus Trachea Thyroid follicle Larynx Right Lobe Left Lobe Isthmus Trachea Thyroid Follicle AAAAIM/NQ10fthQwfY/s400/ethereal-Thyroid-Gland.jpg

9  To control the rate and method of tissues’ utilization of food and natural chemicals for creation of energy  To take iodine trapped in circulating blood and convert it to thyroid hormones  To use the above energy in the creation of muscle energy and body heat Microsoft Clipart

10  To combine iodine and the amino acid tyrosine to make Thyroxine (T4), which contains 4 iodine atoms, and Triiodothyronine (T3), which contains 3 iodine atoms and possess four times the hormone strength of T4  The normal thyroid gland produces 90% T4 cells and 10% T3 cells  T3 and T4 are released into the blood and transported throughout the body where they control metabolism—the conversion of oxygen and calories to energy (Matfin, Porth, 2009)

11  T3 and T4 have complimentary effects ◦ T3 produces a strong, immediate, and temporary increase in cellular metabolism ◦ T4 slowly and gradually diffuses into peripheral tissues and produces a long-term response  T4 is converted to T3 in the cytoplasm of the cell; thus, the effects of T3 and T4 are the same Microsoft Clipart (Matfin, Porth, 2009)

12  Incorrect  The parathyroid gland (PTH) raises blood calcium levels when needed  Correct  The thyroid gland increases the metabolic rate, which in turn creates energy  Correct  The thyroid gland regulates growth and development  Incorrect  The chief cells in the stomach create HCL (stomach acid) To create energy Raises the circulating concentration of calcium Regulates growth and developmentTo create stomach acid

13  Occurs as either an acquired or congenital defect  Acquired hypothyroidism is related to either primary disease of thyroid gland or to disorders of the pituitary or hypothalamic source and develops in later life Microsoft Clipart (Matfin, Porth, 2009)

14  Loss of appetite  Chronic fatigue/Tiredness  Constipation  Depression  Dry skin/other skin conditions  Hair loss  Infections  Sensitivity to cold/low body temperature  Muscle weakness  Weight gain  Painful/heavy premenstrual period  Slow speech Microsoft Clipart (Matfin, Porth, 2009)

15 Treatment:  Thyroid function improves with: ◦ Proper balance of nutrients ◦ Thyroid hormone replacement medication  Synthroid/levothyroxine/levoxyl/levothroid Management:  Follow up blood work to monitor TSH (Thyroid Stimulating Hormone) levels  Regular visits with M.D.  Balanced nutrition Microsoft Clipart (Matfin, Porth, 2009)

16  Incorrect  An increase in the metabolic rate creates increased energy; hypothyroid activity means the thyroid gland is not very active. Therefore, the metabolic rate decreases  Incorrect  The chief cells in the stomach create hydrochloric acid (HCl) Correct The thyroid gland’s job is to increase the metabolic rate; hypothyroidism means the gland is underactive and not working to create increased energy Incorrect The parathyroid gland monitors blood calcium levels Increase in metabolic processIncrease in stomach acid Decrease in metabolic process Decrease in circulating calcium in blood

17  Occurs when tissues are exposed to elevated levels of circulating hormone  Hyperactivity of thyroid gland which increases metabolism (overactive thyroid gland) pulmonar/pdself/Goiter1.jpg (Moore, no date provided)

18  Hypoactivity of thyroid gland causes a decrease in metabolic processes (underactive thyroid gland)  Most common cause: Hashimoto thyroiditis (an autoimmune disorder in which the thyroid may be totally destroyed—a disease found predominantly in women with a female to male ratio of 5:1) (Matfin, Porth, 2009)

19  Most common: ◦ Graves disease (autoimmune disorder, abnormal stimulation of thyroid gland TSH/receptor antibodies) ◦ Multinodular goiter (swelling of the thyroid gland related to inability to uptake iodine) ◦ Adenoma of thyroid gland ◦ Thyroiditis (iodine-containing agents can cause hyperthyroidism) (Goodson, Moore, no date provided; Matfin, Porth, 2009)

20  Increased anxiety/nervousness  Diarrhea  Hair loss  Hand tremors  Heat intolerance  Insomnia  Muscle weakness  Palpitations/ tachycardia  Shortness of breath  Excessive sweating  Bulging of eye balls/abnormal retraction of eyelids and frequent blinking  Thin skin  Weight loss  Separation of nails from nail bed (Matfin, Porth, 2009)

21 Treatment:  Obtains reduced levels of thyroid hormone ◦ Eradication of thyroid gland (with radioactive dye, surgical removal of gland, use of medication to reduce thyroid function) Management:  Balanced nutrition  Regular M.D. visits  Follow up blood work to monitor TSH (Thyroid Stimulating Hormone) levels  If treated with medication, monitor specific pharmacological levels (Matfin, Porth, 2009)

22 Thyroid Storm: What is it? Thyroid Storm: Is a crisis with high mortality rate Is a life threatening form of thyrotoxicosis (Over activity of thyroid gland: excessive thyroid hormones in blood, Graves disease) Precipitating factors: Diabetic Ketoacidosis Infection Physical/emotional trauma Surgical manipulation of thyroid gland Signs/Symptoms: High fever Tachycardia/chest pain Congestive heart failure Agitation Delirium Restlessness Microsoft Clipart(Matfin, Porth, 2009)

23 Thyroid Storm: what do you do? Treatment: Rapid Diagnosis Cooling of the body (shivering response must be prevented) General support IV fluids Glucose and electrolytes to be provided B-adrenergic blocking drugs (blocks effects of T4 on cardiovascular function) Glucocorticodids to be given to correct adrenal insufficiency Microsoft Clipart (Matfin, Porth, 2009)

24  Correct  An overactive thyroid gland produces increased energy, which creates excess heat from that energy production, making people intolerant to environmental heat Correct  This is reflective of an overactive thyroid gland that is overproducing thyroid hormone— remember the job of the thyroid is to produce energy  Correct  An overactive thyroid gland creates an increased metabolism; therefore, the body utilizes stored fat (energy) to keep pace with the increased metabolic rate, which results in weight loss Incorrect  Hypothyroidism will cause a decrease in the metabolic rate, which slows metabolism (energy production is significantly decreased) High fever/high body temperature Increased weight loss Slow speech Intolerance to heat

25  Located below the thalamus just above the brain stem  Controls the autonomic functions of the body ◦ Autonomic nervous system is the part of the nervous system that affects:  Glands  Smooth and cardiac muscle  There is no voluntary control /1/5/C/hypothalamus.jpg (Bowen, 2003)

26  Produces thyroid releasing hormone (TRH) which informs the pituitary gland to stimulate thyroid stimulating hormone (TSH)  Is the “grand poobah”: regulates the body’s thermostat by informing the pituitary gland at what level the thyroid should be set troubleshoot-thermostat-800X800.jpg images/GrandPoobah160.jpg (Bowen, 2003)

27 CorrectIncorrect Below the thalamus just above the brain stem Cerebral cortex Frontal lobeCerebellum

28 Incorrect Eye movement to track objects is initiated by a small cortical region of the frontal lobe of the brain Incorrect Voluntary muscle activity is controlled by the central nervous system and the cerebellum Correct The hypothalamus links the autonomic nervous system to the endocrine system via the pituitary gland, which controls body temperature Incorrect The cerebral cortex is outer neural tissue of the cerebrum which controls memory, attention, and thought process Thought processMuscle movement Eye movementThermoregulation

29  Is suspended from the hypothalamus and is under its control  Secretes 6 principle hormones: ◦ Follicle stimulating hormone(FSH) ◦ Luteinizing hormone (LH) ◦ Adrenocorticotropic hormone (ACTH) ◦ Growth hormone (GH) ◦ Thyroid stimulating hormone (TSH) ◦ Prolactin (PRL) (Matfin, Porth, 2009; Bowen, 2003)

30  Hormonal relationship between the pituitary gland and the hypothalamus (“grand poobah”) and the thyroid gland creates a negative feedback loop to maintain homeostasis 1)Hypothalamus secrets thyroid releasing hormone— thyrotropin releasing hormone (TRH) 2)Then TRH stimulates anterior pituitary to secrete TSH 3)The TSH will then stimulate the thyroid gland to secrete T3 and T4 4)T3 and T4 stimulate metabolism of most cells in body 5)T3 and T4 also inhibit the release of TSH by the pituitary gland 6)T3 and T4 will inhibit the release of TRH by the hypothalamus (Matfin, Porth, 2009; Bowen, 2003)

31  Steps 5 and 6 are negative feedback inhibition of the pituitary and hypothalamus  This ensures that when the TH levels are high, TSH secretion remains low  If TH levels drop, then TSH secretion climbs and stimulates the thyroid to secrete more TH  This negative feedback loop helps to ensure that TH levels remain at a typical homeostatic state H Hyperlink: (Matfin, Porth, 2009; Bowen, 2003)

32 Central Nervous system Neurochemical stimuli Hypothalamus Releases (TRH) Anterior Pituitary Positive feedback Releases (TSH) Thyroid Gland Stimulates the release of T3 &T4 Negative feedback loop T3 & T4 stimulate metabolism T3 T4 T3 Inhibit release of TSH and TRH

33 Thyroid production/function: What comes next? Body requires thyroid hormone TRH released from hypothalamus TSH secreted by anterior pituitary gland TSH stimulates the release of T3 and T4 Regulate growth and development TRH released from hypothalamus TSH stimulates the release of T3 and T4 TSH secreted by anterior pituitary gland Stimulates central nervous system Press ‘Enter’ to advance to next slide when activity is completed.

34  Thyroid agents for replacement can be synthetic or natural and contain T3, T4, or both  Medications: ◦ Levothroxine—contains T4Dose: 100 mcg ◦ Liothyronine—contains T3Dose: 25 mcg Liotrix—contains T4 and T3 Dose: 62.5-75 mcg in a 4:1 ratio ◦ Thyroglobulin—contains T4 Dose: 65 mg and T3 in a 2.5:1 ratio ◦ Thyroid USP contains T4 and Dose: 65 mg T3 variable ratio Microsoft Clipart (Baer, Williams, 1992)

35  Natural agents come from animal thyroid ◦ Thyroid USP ◦ Thyroglobulin  Synthetic agents are sodium salts of the L- isomers of the hormones ◦ Levothyroxine sodium ◦ Liothyronine sodium ◦ Liotrix Both contain T3 and T4 Microsoft Clipart (Baer, Williams, 1992)

36  Thyroid replacement hormones: ◦ Increase metabolic rate in the body’s tissues ◦ Stimulate protein synthesis ◦ Stimulate the heart to increase cardiac output Microsoft Clipart (Baer, Williams, 1992)

37 Correct Protein synthesis is the process of cells’ building proteins in the body—if the metabolism is slow, so is the building process. Thyroid replacement hormones help to increase the metabolism; therefore, they increase protein synthesis Correct Thyroid replacement hormones will increase metabolism, which results in the need for more fuel to run the body Incorrect Anti-thyroid medications destroy thyroid tissues. Thyroid hormones will add to hormone levels Incorrect Thyroid replacement hormones only add to hormone levels What do thyroid replacement hormones do? (Pick all that apply) Increase protein synthesisIncrease appetite Destroys thyroid tissuesInhibit hormone production

38 What medication would a patient with hypothyroidism receive? Correct This is a thyroid replacement hormone and will increase the metabolic rate in body tissues Incorrect This is a thyroid antagonist. It interferes with the thyroid’s ability to concentrate iodide ions and therefore reduces the signs and symptoms of hyperthyroidism Incorrect This is an anti-thyroid drug. This medication inhibits the conversion of T4 to T3 and acts as an immunosuppressant Incorrect This is an anti-thyroid medication; it destroys thyroid tissues by inducing acute radiation thyroiditis, which shrinks the thyroid gland Levothyroxine PropranololPropylithiouracil Radioactive iodine

39 Adverse drug reactions:  Most adverse drug reactions are from drug toxicity  Adverse effects will subside when drug is temporarily removed  What to look for: GI signs/symptoms -Diarrhea -Abdominal cramps -Weight loss -Increased appetite Cardiovascular signs/symptoms -Heart palpitations -Tachycardia/aryhythmias -Sweating -Increased blood pressure -Chest pain Other signs/symptoms -Headache -Insomnia -Tremors -Nervousness -Heat intolerance -Fever -Menstrual irregularities (Baer, Williams, 1992)

40  Antithyroid agents (thyroid antagonists): ◦ Used for people with hyperthyroidism and Graves disease ◦ Thyroid antagonists function by  Interfering with hormone synthesis  Modifying body tissues’ response to hormones  Destroying the thyroid gland Microsoft Clipart (Baer, Williams, 1992)

41  Antithyroid agent medications: ◦ Thionamides  Propylthiouracil  Methimazole ◦ Iodides  Stable iodine  Radioactive iodine Biohazard Microsoft Clipart (Baer, Williams, 1992)

42  How do these medications work? ◦ Thionamides  Inhibit hormone production by reducing binding of iodine and tyrosine  Act as immunosuppressants ◦ Propylthiouracil  Inhibits conversion of T4 to T3 ◦ Stable iodine  Quickly produces critical levels of iodide in the thyroid gland, which temporarily decreases the rate of hormone production (Baer, Williams, 1992)

43  Radioactive iodine ◦ Works two ways:  Induces acute radiation thyroiditis which produces chronic shrinking of the thyroid gland  Destroys thyroid tissues  Adverse drug reactions ◦ Most serious reaction to thionamide therapy:  Fatal—granulocytopenia (appears 4-8 weeks after treatment)  Drop in white blood cell (WBC) count (Baer, Williams, 1992)

44  What to look for: ◦ Sore throat ◦ Fever ◦ Hypersensitivity—rash/puritis  What to do: ◦ Obtain WBC count ◦ Obtain throat culture Microsoft Clipart (Baer, Williams, 1992)

45  Iodides can cause chronic toxicity (dose dependent)  What to look for: ◦ Brassy taste/burning sensation in mouth ◦ Increased salivation ◦ Swelling of parotid and submaxillary glands ◦ Headache ◦ Rhinitis ◦ Conjuctivitis ◦ Gastric irritation ◦ Bloody diarrhea ◦ Anorexia ◦ Depression (Baer, Williams, 1992)

46  What to look for (Potassium iodide): ◦ Tooth discoloration ◦ Feeling of fullness in neck ◦ Metallic taste in mouth ◦ High risk for birth defects ◦ Leukemia products-small/potassiumiodide.jpg (Baer, Williams, 1992)

47 Other Antithyroid Agents (Thyroid Antagonists):  Not used as first line drug therapy  Interfere with the thyroid’s ability to concentrate iodide ions  Reduce signs and symptoms of hyperthyroidism  Ionic inhibitors (adrenergic blocking agents) ◦ Propranolol ◦ Ipodate—used to decrease serum T3 levels (Baer, Williams, 1992)

48 Incorrect Correct A patient diagnosed with hyperthyroidism calls and complains of brassy taste and burning sensation in his mouth. What category of medication is he taking? Thyroid replacement agentAce inhibitor Thyroid antagonistAntithyroid agent

49 Aging:  Thyroid gland shrinks and shifts to lower neck  T3 and T4 levels decrease slightly  Thyroid function decreases (hypothyroidism)  Thyroid gland may enlarge or produce nodules (goiter) Microsoft Clipart (Matfin, Porth, 2009)

50 Inflammation:  Caused by Infection/Autoimmune response can result in Thyroiditis (Hashimotos-hypothyroidism)  Hyperthyroidism (Graves disease) Genetics:  Polymorphisms (multiple forms of gene expression with different phenotypes) are associated with variations in serum hormone levels appear to contribute to alterations in thyroid activity.  Defect in immune systems response leads to alteration in thyroid function. Microsoft Clipart (Matfin, Porth, 2009)

51 Stress Response: (Biological or environmental)  TSH increases  Corticosteroids are elevated during stress  Elevated corticosteroids inhibit immune response  Opportunity for infection occurs  Defect in immune response leads to decreased or increased thyroid function ( the specific alteration depends on which thyroid antibodies are produced during altered immune response) Microsoft Clipart (Matfin, Porth, 2009)

52  Mrs. Jones is a 44 year-old woman who came into the clinic with complaints of just not feeling well. As you interview her, she states that she is feeling tired lately and that she is cold and needs to wear an extra sweater even on nice days. She also complains that lately her monthly menstrual cycles have been very heavy, and she’s been constipated even though she has increased her daily fiber intake. Upon your initial exam, you take her vital signs and find that her temperature is 96.4F; pulse is 54 bpm; blood pressure is 90/54. She is 5’2” tall, and her weight today was 172 lb. You observe she has gained 15 lb. from her last exam about a year ago. Upon your objective observation, you notice that her skin is very dry and her hair seems much thinner since her exam last year.

53  What diagnosis would you attribute to Mrs. Jones’s signs and symptoms? Incorrect Hyperthyroidism Incorrect Vitamin D deficiency Incorrect Seasonal allergies Correct!!! Hypothyroidism

54 Incorrect This a thyroid antagonist, it interferes with the thyroid’s ability to concentrate iodide ions and causes hypothyroidism  Now that you know Mrs. Jones has an underactive thyroid gland (hypothyroidism), how will you treat her? Correct Thyroid replacement hormones will increase metabolism and therefore create energy through an increase in protein synthesis Give her levothyroxine Incorrect This is an anti-thyroid medication and will destroy thyroid tissues by shrinking the thyroid gland causing increased hypothyroidism Give her radioactive iodine Incorrect Although constipation is a symptom of hypothyroidism and Metamucil and exercise can help, Mrs. Jones is suffering from hypothyroidism and needs replacement therapy Send her home with Metamucil and tell her to increase exercise Give her propranolol

55  Hypothyroidism is an overactive thyroid. Incorrect Hyperthyroidism causes increased metabolic processes (overactive thyroid) Correct Hypothyroidism causes decreased metabolic processes TrueFalse

56  Now that Mrs. Jones is on levothyroxine (thyroid replacement medication), how will you manage her care? (pick all answers that apply) Correct Balanced nutrition will help Mrs. Jones maintain a healthy weight Minimize green leafy vegetables Correct Thyroid replacement medication will increase Mrs. Jones’ metabolic rate and will create increased energy and protein synthesis Correct Mrs. Jones must have TSH levels monitored for medication dose regulation to keep her metabolic rate at an optimum level Correct To monitor Mrs. Jones’ ongoing health and wellness Proper balance of nutrients Thyroid replacement medication Follow up blood work to monitor TSH levels Regular visits to the doctor

57 You have successfully completed this tutorial Microsoft Clipart

58  OHSU Objectives Wiki, n.d. Anatomy of thyroid, slide 4. Retrieved from  Analgesia Database, n.d. Chemical Formula—T3 and T4, slide 7. Retrieved from  Poineer Laboratories, n.d. Chemical formula—potassium iodide, slide 46. Retrieved from  Patient UK, n.d. Exophthalmos, slide 17. Retrieved from  Clermont College Biology Home Page, n.d. Follicle of thyroid, slide 6. Retrieved from tology_jpgs/thyroid_400x_P2252255lbd.JPG  Index of Sight Flash Images, n.d. Fred Flintstone, slide 26. Retrieved from  Loyola University, n.d. Goiter, slide 17. Retrieved from  Hyperlink. Used with permission from Dr. Saul. Retrieved from , n.d. Hypothalamus, slide 25. Retrieved from  Microsoft Clipart , n.d. Negative feedback, slide 31. Retrieved from  eHow, n.d. Thermostat, slide 26. Retrieved from  ABC Australia, n.d. Thyroid gland, slide 5. Retrieved from , n.d. Thyroid quiz, slide 8. Retrieved from al-Thyroid-Gland.jpg

59 Baer, C. L., Williams, B. R. (1992). Clinical Pharmacology and Nursing. Springhouse, PA: Springhouse Corporation. Bowen, R. A. (2003). Functional Anatomy of the Hypothalamus and Pituitary Gland. Retrieved March 6, 2010, from ocrine/hypopit/anatomy.html Bowen, R. Overview of Hypothalamic and Pituitary Hormones. Retrieved March 6, 2010, from ocrine/hypopit/overview.html

60 Bowen, R. Thyroid-Stimulating Hormone (Thyrotropin). Retrieved March 6, 2010, from docrine/hypopit/tsh.html Goodson, Deanna Couras. What Causes Thyroid Dysfunction? Retrieved February 28, 2010, from problems.htm Goodson, Deanna Couras. Your Thyroid: What it is and What it does. Retrieved February 28, 2010, from gland.htm

61 How Your Thyroid Works. Retrieved February 28, 2010, from Martini, F. (1992). Fundamentals of Anatomy and Physiology. Englewood Cliffs, NJ: Prentice-Hall, Inc. Matfin, G., Porth, C. M. (2009). Pathophysiology: Concepts of Altered Health States. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. Moore, Elaine. Thyroid Disease Triggers. Retrieved April 9, 2010, from thyroiddiseasetriggers

62 Thyroid Gland Function Hormones. Retrieved February 28, 2010, from Thyroid Hormone Levels Strongly Genetic. Retrieved April 9, 2010, from forum/thyroid-hormone-levels-strongly- 134286971.html

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