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DISORDERS OF THE THYROID AND PARATHYROID GLANDS. HYPERTHYROIDISM  ETIOLOGY/PATHOPHYSIOLOGY Also called Graves’ disease, or exophthalmic goiter, or thyrotoxicosis.

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Presentation on theme: "DISORDERS OF THE THYROID AND PARATHYROID GLANDS. HYPERTHYROIDISM  ETIOLOGY/PATHOPHYSIOLOGY Also called Graves’ disease, or exophthalmic goiter, or thyrotoxicosis."— Presentation transcript:

1 DISORDERS OF THE THYROID AND PARATHYROID GLANDS

2 HYPERTHYROIDISM  ETIOLOGY/PATHOPHYSIOLOGY Also called Graves’ disease, or exophthalmic goiter, or thyrotoxicosis DUE TO: Overproduction of the thyroid hormones T3 and T4  Exaggeration of metabolic processes

3 HYPERTHYROIDISM ETIOLOGY/PATHOPHYSIOLOGY cont. Exact cause unknown – Possible genetic factors with precipitive factors of: » Infection, ↓ iodine, or extreme physical or emotional stress Affects females more than males May occur during adolesence or pregnancy

4 HYPERTHYROIDISM CLINICAL MANIFESTATIONS: Edema of the anterior portion of the neck Exophthalmos (bulging eyeballs) – SUBJECTIVE ASSESSMENT : Pt. C/o: Inability to concentrate; memory loss Dysphagia Hoarseness Increased appetite Weight loss, insomnia Nervousness, jittery, excitable

5 EXOPTHALMUS http://www.bing.com/images/search?q=exopthalmus+picture&id=910B1504DB452992E34365F19E0BE4C2EE3594 1E&FORM=IQFRBA#view=detail&id=36C1A29E6D537F51942094844C162CBA347F5CC6&selectedIndex=164 http://www.bing.com/images/search?q=exopthalmus+picture&id=910B1504DB452992E34365F19E0BE4C2EE3594 1E&FORM=IQFRBA#view=detail&id=36C1A29E6D537F51942094844C162CBA347F5CC6&selectedIndex=164 Internet picture

6 HYPERTHROIDISM

7 CLINICAL MANIFESTATIONS – OBJECTIVE ASSESSMENT Tachycardia; hypertension; bruit over thyroid Warm, flushed skin Fine hair Amenorrhea Elevated temperature/heat intolerance Diaphoresis Hand tremors, clumsiness Hyperactivity for some

8 HYPERTHYROIDISM DIAGNOSTIC TESTS – Confirmed by: ↓ TSH and ↑ Free T4 RAIU – radioactive iodine uptake – uptake of 35-95% of the drug

9 HYPERTHYROIDISM MEDICAL MANAGEMENT – Medications – Block production of thyroid hormone – Propylthiouracil / PTU – Methimazole/ Tapazole Meds reduce symptoms in 6-8 wks.

10 HYPERTHYROIDISM MEDICAL MANAGEMENT – Medication may be followed by: Radioactive iodine/ ablation therapy – Destroys some of the hypertrophied thyroid tissue – Low dose – no “radiation” precautions needed

11 HYPERTHYROIDISM MEDICAL MANAGEMENT cont. – Radioactive iodine/ Ablation therapy cont. Outcome: in most pts.  hypothyroidism  treat with Levothyroxine Adequate medical supervision follow up is important!

12 HYPERTHYROIDISM MEDICAL MANAGEMENT cont. – Surgery: for pts. who cannot tolerate antithyroid drugs; are not good candidates for radiation tx.; have a poss. malignancy; or have large goiters causing tracheal compression – Most common surgery: Subtotal Thyroidectomy Removal of 5/6ths of the thyroid gland If too much thyroid tissue is removed  gland will not regenerate  hypothyroidism

13 HYPERTHYROIDISM MEDICAL MANAGEMENT cont. – Surgery: usually delayed until pt in a normal thyroid state d/t the risk of bleeding during surgery and thyroid crisis (thyroid storm) post op.

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15 HYPERTHYROIDISM NURSING ASSESSMENT AND INTERVENTIONS: – Post-operative Subtotal Thyroidectomy Assess for s/sx internal or external bleeding Assess for tetany: – Chovstek’s Sign: is + when abnormal spasm of facial muscles occurs when elicited by light tapping on facial nerve in the pt. with low calcium – Trousseau’s Sign: is + if there is carpal spasm in the hypocalcemic and hypomagnesemia pt. When BP cuff inflated above pt. normal systolic pressure and held there for 3 min. http://www.bing.com/videos/search?q=thyroid+storm+youtube&qpvt=thyroid+storm+youtube&FORM=V DRE#view=detail&mid=0B08D370F3270FFF14820B08D370F3270FFF1482 (3 min 5 sec) http://www.bing.com/videos/search?q=thyroid+storm+youtube&qpvt=thyroid+storm+youtube&FORM=V DRE#view=detail&mid=0B08D370F3270FFF14820B08D370F3270FFF1482 (3 min 5 sec) http://www.bing.com/videos/search?q=youtube+partial+thyroidectomy+personal+story&FORM=VIRE1#vi ew=detail&mid=613D00F1A54228D31139613D00F1A54228D31139 (9 min 49sec) http://www.bing.com/videos/search?q=youtube+partial+thyroidectomy+personal+story&FORM=VIRE1#vi ew=detail&mid=613D00F1A54228D31139613D00F1A54228D31139

16 HYPERTHYROIDISM NURSING ASSESSMENT AND INTERVENTIONS: – Post-op Subtotal Thyroidectomy (cont.) Assess for Thyroid Crisis/Storm – May occur as a result of manipulation of the thyroid gland during surgery releasing large amts of thyroid hormone  bloodstream – Occurs within the first 12 hrs. – S/SX: exaggerated s/sx of hyperthyroidism + n/v, severe tachycardia, severe HTN, severe hyperthermia (106F+), extreme restlessness, dysrhythmias, delirium, heart failure  death – http://www.bing.com/videos/search?q=thyroid+storm&FORM=HDRSC3#view=detail&mi d=8A8572C304A26127A35A8A8572C304A26127A35A(5 min 38 sec)Thyroid Storm part 1 http://www.bing.com/videos/search?q=thyroid+storm&FORM=HDRSC3#view=detail&mi d=8A8572C304A26127A35A8A8572C304A26127A35A – http://www.bing.com/videos/search?q=thyroid+storm&FORM=HDRSC3#view=detail&mi d=CEB5AB156B2998E95407CEB5AB156B2998E95407 (5 min 47 sec) Thyroid Storm part 2 http://www.bing.com/videos/search?q=thyroid+storm&FORM=HDRSC3#view=detail&mi d=CEB5AB156B2998E95407CEB5AB156B2998E95407

17 HYPERTHYROIDISM – Thyroid Storm cont.: DIAGNOSTIC TESTS – ↑FT4, ↓TSH MEDICAL MANAGEMENT goals during thyroid storm: – 1. induce a normal thyroid state – 2. prevent cardio-vascular collapse – 3. prevent ↑ hyperthermia

18 HYPERTHYROIDISM NURSING ASSESSMENT AND INTERVENTIONS: – Post-op Subtotal Thyroidectomy (cont.) Voice rest x48 hrs – provide communication tool Voice checks – q 2-4 hrs. “ahh”; note hoarseness or other changes Bed – semifowler’s position; pillow support for head and shoulders

19 HYPERTHYROIDISM NURSING ASSESSMENT AND INTERVENTIONS: – Post-op Subtotal Thyroidectomy (cont.) Avoid hyperextension of neck; support head during position change Reinforce DB exercises; check with MD re: coughing Tracheotomy tray at bedside and suction Cool mist humidifier prn Nutrition care – watch for dysphagia

20 HYPERTHYROIDISM NURSING DIAGNOSES: – Pre-op Risk for hyperthermia, related to increased metabolism Imbalanced nutrition:less than body requirements r/t increased metabolism – Post-op Impaired swallowing, r/t edema Ineffective breathing,risk for, r/t post-op edema and pain

21 HYPERTHYROIDISM PATIENT EDUCATION – Post op: follow up with medical supervision Thyroid function tests Care incision site Diet: high calorie, CHO’s, and protein PROGNOSIS: normal life with appropriate medical or surgical tx. – Expophthalmos may remain to lesser degree

22 HYPOTHYROIDISM – Etiology/pathophysiology Due to insufficient secretion of thyroid hormones Decreased hormones cause slowing of all metabolic processes R/T Failure of thyroid or insufficient secretion of thyroid-stimulating hormone from pituitary gland Hashimoto talks: (Just to be funny-hehe) http://www.bing.com/videos/search?q=youtube+hashimoto&qpvt=youtube+hashimoto &FORM=VDRE#view=detail&mid=BC6F61D1587C03368265BC6F61D1587C03368265 http://www.bing.com/videos/search?q=youtube+hashimoto&qpvt=youtube+hashimoto &FORM=VDRE#view=detail&mid=BC6F61D1587C03368265BC6F61D1587C03368265 Personal Story (5 minutes) http://www.bing.com/videos/search?q=youtube+hashimoto&qpvt=youtube+hashimot o&FORM=VDRE#view=detail&mid=0A19B271B30370332C210A19B271B30370332C21 Personal Story (5 minutes) http://www.bing.com/videos/search?q=youtube+hashimoto&qpvt=youtube+hashimot o&FORM=VDRE#view=detail&mid=0A19B271B30370332C210A19B271B30370332C21

23 HYPOTHYROIDISM – Myxedema refers to severe hypothyroidism in adults Will see edema in hand’s face, feet, and periorbital tissues Inflammation and thickening of the skin – Cretinism – congenital hypothyroidism Floppy infant Thick,protruding tongue Poor feeding Choking episodes Constipation Prolonged jaundicejaundice Short stature Depression Loss of hair Rough voices Swollen eyelids Hearing problem Fatigue Weight gain

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25 HYPOTHYROIDISM Clinical Manifestations: – Because all metabolism processes slow  Hypothermia; intolerance to cold Weight gain ASHD/CAD  ↓exercise tolerance + dyspnea on exertion

26 HYPOTHYROIDISM SUBJECTIVE ASSESSMENT: Mental and emotional assessment may include: – Depression; paranoia – Impaired memory; slow thought process – Hearing/speech impairment – Lethargic, forgetful, irritable – Anorexia – Constipation – Cold intolerance – Decreased libido; reproductive difficulties

27 HYPOTHYROIDISM OBJECTIVE ASSESSMENT Menstrual irregularities Thin hair, falls out Skin thick and dry Enlarged facial appearance Low, hoarse voice Bradycardia Hypotension Weakness, clumsiness, ataxia

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29 HYPOTHYROIDISM Diagnostic tests : TSH, T3, T4, FT4 (low levels of these are the underlying stimuli for TSH) – For hypothyroidism: expect ↑TSH (compensatory); ↓T3, T4, and FT4

30 HYPOTHYROIDISM MEDICAL MANAGEMENT – Medications: replacement therapy; titration needed – Synthroid – Levothyroid – Proloid – Cytomel Symptomatic treatment

31 HYPOTHYROIDISM NURSING INTERVENTION/PT. TEACHING: – For the hospitalized pt. with severe hypothyroidism  focus on symptom relief Watch for s/sx hyperthyroidism while adjusting doses of replacement medication Watch for chest pain or dyspnea Keep room 70-74⁰F Avoid the pt. getting chilled BM monitor/protocol

32 HYPOTHYROIDISM – NURSING INTERVENTIONS/PT. TEACHING cont. Diet : ↑protein, fiber, fluid ↓ calories Adequate iodine intake – Instruct pt. to take med daily and not to stop without consulting his MD – Instruct pt./family – to anticipate clearing of mental slowness as pt. adjusts to dose of med

33 HYPOTHYROIDISM NURSING DIAGNOSES: – Decreased cardiac output r/t decreased metabolism – Constipation r/t decreased peristalsis – Risk for noncompliance r/t therapy – Risk for disturbed body image, r/t altered physical appearance (goiter)

34 HYPOTHYROIDISM PROGNOSIS: Pt. will do well with medication and medical supervision. In children, if the T4 replacement begins before the epiphyseal fusion, chance for normal growth is greatly improved – https://www.youtube.com/watch?v=sVa0L1Rka4Y https://www.youtube.com/watch?v=sVa0L1Rka4Y (Hypo/hyper/goiter symptoms & treatment 4 min 3 sec)

35 SIMPLE (COLLOID) GOITER ETIOLOGY/PATHOPHYSIOLOGY – Enlarged thyroid due to low iodine levels or the gland’s inability to use the iodine properly – Enlargement is caused by the accumulation of colloid in the thyroid follicles When blood level of T3 is too low to signal the pituitary gland to reduce TSH secretion, the thyroid gland responds by increased formation of thyroid globulin (colloid)  accumulates in the thyroid follicles  gland enlargement – Usually caused by insufficient dietary intake of iodine  overgrowth of thyroid tissue

36 GOITER

37 SIMPLE (COLLOID) GOITER CLINICAL MANIFESTATIONS/ASSESSMENT – Assessment based on physical manifestations: – SUBJECTIVE ASSESSMENT: Enlargement of the thyroid gland – Pt. emotional response to the enlargement Interview to determine pt. need for medication, diet, and medical follow up May c/o: Dysphagia, Hoarseness. Dyspnea

38 SIMPLE (COLLOID) GOITER CLINICAL MANIFESTATIONS/assessment – OBJECTIVE DATA: Assess increase of goiter Voice changes Adequate food/fluid intake MEDICAL MANAGEMENT Potassium iodide Diet high in iodine Surgery—thyroidectomy

39 SIMPLE (COLLOID) GOITER NURSING INTERVENTIONS/GOALS – Post Thyroidectomy: prevent complications such as bleeding, tetany, and thyroid crisis – Interventions: (discussed previously) NSG. DIAGNOSES – Risk for non-compliance with therapeutic regimen – Risk for disturbed body image r/t physical appearance

40 Figure 51-10 Simple goiter.

41 Thyroid Cancer ETIOLOGY/PATHOPHYSIOLOGY Malignancy of thyroid tissue; rare About 75% are papillary well-differentiated adeno carcinoma- grows slowly, usually contained, doesn’t spread beyond adjacent lymph nodes; cure rates are excellent. CLINICAL MANIFESTATIONS – Firm, fixed, small, rounded mass or nodule on thyroid

42 CANCER OF THYROID

43 Thyroid Cancer Assessment – SUBJECTIVE ASSESSMENT Pt. coping method and support system Pt. understanding of importance of medical follow up – OBJECTIVE ASSESSMENT Progressive enlargement of tumor area Response to 131I tx. Skin care post radiation

44 Thyroid Cancer DIAGNOSTIC TESTS: Thyroid scan Thyroid function tests Needle bx. MEDICAL MANAGEMENT Total thyroidectomy Thyroid hormone replacement If metastasis is present: radical neck dissection; radiation, chemotherapy, and radioactive iodine

45 CANCER OF THE THYROID

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47 Thyroid Cancer NURSING INTERVENTIONS/Pt. TEACHING – Per thyroidectomy (previously discusses) – Post op: Risk for respiratory distress Risk for laryngeal damage Bleeding S/sx hypothyroidism

48 Thyroid Cancer NURSING DX. – Anxiety r/t situational crisis – Ineffective coping r/t personal vulnerability in a crisis Pt. Teaching: – Proper medical follow up – Monitor thyroid replacement therapy – Proper care of surgical incision

49 PARATHYROID GLANDS Website written information resource for students: http://www.parathyroid.com/hypoparathyroidism.htm http://www.parathyroid.com/hypoparathyroidism.htm

50 HYPERPARATHYROIDISM ETIOLOGY/PATHOPHYSIOLOGY – Overactivity of the parathyroid glands, with increased production of parathyroid hormone (PTH) – Hypertrophy of one or more of the parathyroid glands (usually in the form of an adenoma) – Also from: CRF, Pyelonephritis, glomerulonephritis http://www.youtube.com/watch?v=sD9st1ZPFrQ

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52 HYPERPARATHYROIDISM CLINICAL MANIFESTATIONS – Hypercalcemia – primary clinical manifestation Calcium leaves the bone  serum calcium increases Bones become demineralized  formation of renal calculi, pathological fx. Skeletal pain; pain on weight-bearing

53 HYPERPARATHYROIDISM SUBJECTIVE ASSESSMENT – As a result of neuromuscular dysfunction, pts. c/o: Fatigue, drowsiness nausea, anorexia; severe skeletal pain, muscle weakness constipation personality changes, disorientation

54 HYPERPARATHYROIDISM OBJECTIVE ASSESSMENT – Skilled observation for: Skeletal deformity Abnormal movement Urine results Vomiting, weight loss HTN Cardiac dysfunction Bradycardia ↓ LOC

55 HYPERPARATHYROIDISM DIAGNOSTIC TESTS – RADIOGRAPHS/XRAYS – PTH blood level (usually ↑) – Ca++ levels – Bone Density measurements – MRI, CT, and US to localize an adenoma

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57

58 Hyperparathyroidism

59 HYPERPARATHYROIDISM MEDICAL MANAGEMENT Removal of tumor Removal of one or more parathyroid glands Autotransplantation NURSING INTERVENTIONS/Pt. TEACHING – Assess for hypercalcemia – Restore fluid and electrolyte imbalance – Diet: low in calcium

60 HYPERPARATHYROIDISM NURSING INTERVENTIONS/Pt. TEACHING cont. – Postoperatively, assess for hypocalcemia Tetany, cardiac dysrhythmia, carpo-pedal spasms – Pain management – skeletal, renal stones NURSING DIAGNOSES – Activity intolerance r/t neuromuscular dysfunction – Acute pain r/t skeletal – joint pain, renal colic

61 HYPERPARATHYROIDISM PATIENT TEACHING – Body mechanics to prevent pathological fx – Mild exercise – Urine checks for blood and stones PROGNOSIS: can lead a normal life with proper med-surg tx. With cancer dx. – prognosis is poor

62 HYPOPARATHYROIDISM Etiology/pathophysiology – Decreased parathyroid hormone  Decreased serum calcium levels – Most common causes: Inadvertent removal or destruction of one or more parathyroid glands during thyroidectomy Also, can be autoimmune or familial in origin http://www.youtube.com/watch?v=E9QvAdxeap0 http://www.youtube.com/watch?v=E9QvAdxeap0 (2 min 42 sec)

63 HYPOPARATHYROIDISM CLINICAL MANIFESTATIONS – Lab results show: ↓serum Ca++ and ↑ serum phosphorus  Neuromuscular hyperexcitability Involuntary and uncontrollable muscle spasms Hypocalcemic tetany

64 HYPOPARATHYROIDISM CLINICAL MANIFESTATIONS cont. – Severe hypocalcemia: Laryngeal spasms Stridor Cyanosis/asphyxia Parkinson-like syndrome Chvostek’s and Trousseau’s signs

65 TROUSSEAU’S SIGN

66 HYPOPARATHYROIDISM ASSESSMENT – SUBJECTIVE DATA – evidence of and/or c/o: Dysphagia Numbness/tingling lips, fingertips Increased muscle tension Parasthesis and stiffness c/o anxiety, irritability, depression Headaches nausea

67 HYPOPARATHYROIDISM ASSESSMENT – OBJECTIVE DATA + Chvostek’s and Trousseau signs Laryngeal spasm, stridor, cyanosis Decreased cardiac output, dysrhythmias Tetany

68 HYPOPARATHYROIDISM DIAGNOSTIC TESTS – Serum PTH, Phosphorus, Calcium – Urinary calcium and phosphorus –  if + for hypoparathyroidism, results will be: ↓ PTH, and serum Ca++ and ↑ urinary Ca++, with ↑ serum phosphorus and ↓ urinary phosphorus

69 HYPOPARATHYROIDISM MEDICAL MANAGEMENT – Blood tests r/t ca levels Calcium gluconate or calcium chloride will be given IV for hypoparathyroid tetany – NURSING: if IV rate is too rapid  ↓ BP, serious cardiac dysrhythmias/ cardiac arrest – IV may be irritating to vessel wall; watch for s/sx extravasation – EKG monitoring Vitamin D orally – improves GI absorption of Ca++

70 HYPOPARATHYROIDISM NURSING INTERVENTIONS – Monitor for hypercalcemia: Vomiting, disorientation, anorexia, abdominal pain, weakness – Assess for: Respiratory function VS – bradycardia, syncope, hypotension Renal involvement

71 HYPOPARATHYROIDISM NURSING INTERVENTIONS cont. – Preferred medications: Hytakerol Calcitriol (Rocaltrol) – Diet: ↑ dairy, dark green leafy veg., soybeans, tofu, canned fish with bones

72 HYPOPARATHYROIDISM NURSING DIAGNOSES: – Risk for injury r/t postop hypocalcemia – Imbalanced nutrition, less than body requirements, r/t calcium intake Nearly all interventions r/t ca levels


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