Objectives of the Lecture

• Describe functions of thyroid,

parathyroid and pituitary glands
• Identify diagnostic tests used to
determine alterations in functions if
those glands
• Use the nursing process, including
education, as a framework for care of
patients with hypothyroidism,
hyperthyroidism hypoparathyroidism
and hyperparathyroidism
• Explain nursing care of patients
undergoing thyroidectomy

Hormones
• Triiodothyronine T3
• 3 iodine atoms
• Serum thyroxine T4
• 4 iodine molecules
• Calcitonin

Negative feedback
• Decrease in T3 and T4 = increase
in TSH
• Increase in T3 and T4 = decrease in
TSH
• Increase calcitonin = increase
serum calcium levels
• Decrease serum calcium =
decrease calcitonin is released
• Hypothalamus
• Anterior pituitary

• Euthyroid

Thyroid function

• Euthyroid
• Metabolism
• Goiter
• Hyperfunction
• Hypofunction

Hyperthyroidism
• Exogenous thyroid hormone
• Excessive use of thyroid
replacement hormones
• Endogenous thyroid hormone
• Excessive secretory activity of
thyroid gland

Incidence
• Highest incidence in women
between 20-40 years of age
• Women 8 – 10 X more than men
• High incidence among family
members
• genetic component

Etiology
• Graves Disease
• TRAB
• TSI
• Iodine deficiency
• Toxic nodular goiter
• Metastatic thyroid carcinoma
• Shock
• Stress
• Infection
Pathophysiology
• Normal feedback control over
thyroid hormone secretion fails
• Increased thyroid hormones
• Hypermetabolism
• Increase SNS activity

Clinical Manifestations
• Fine tremors
• Heat intolerance
• Many loose stools daily
• Weight loss
• Diaphoresis
• Warm moist skin
• Skin salmon color
• Palpitations
• Rapid pulse at rest and with exertion
• Hyperactive DTR

• Increased appetite
• Abnormal muscle fatigue
• Weakness
• Menstrual abnormalities
• Insomnia
• Nervousness
• Restlessness
• Emotional hyperexcitability
• Irritable
• Apprehensive
• Rapid speech

Pretibial myxedema

Exophthalmos

Eyelid lag
Globe lag
 Clinical Manifestations

A. Goiter: classified by size

Goiter Grade:

0= no palpable or visible goiter

1=mass is not visible with neck in normal position. Goiter can

be palpated and moves up with swallowing

2=mass is visible as swelling of the neck in normal position.

Goiter is easy to palpate; usually asymmetrical

B. Bruits: turbulence from increase blood flow

Clinical Manifestations
Progression of Disease
• Atrial fibrillation
• BP: increase in systolic and decrease in
diastolic (widened pulse pressure)
• Cardiac decompression
• Osteoporosis
• Fractures

• Cardiac effects
• Sinus Tachycardia
• Dysrhythmias
• Increased pulse pressure
• Palpitations
• Myocardial hypertrophy
• Heart failure

Diagnostics
• TRH stimulation test
• Serum TSH
• Free T3 and T4
• Radioactive iodine uptake with
thyroid scan
• Ultrasound of thyroid gland
• Clinical manifestations
• Medical and surgical history
Management goals
• Remove cause of disease
• Reduce thyroid hyperactivity
• Provide effective symptomatic relief
• Prevent complications

Anti-thyroid medications
• Propranolol (Inderal)
 • decreased heart rate/nervousness

• Contraindicated with
• bleeding disorders

• diabetes

• lithium therapy

• late pregnancy

• Iodides
• Blocks thyroid hormones

• Short term use

• Can stain teeth

• SSKI (saturated solution of potassium iodide) -

take with water

• Lugols solution - take with milk

• Use a straw with both

• Patients with small goiters
• Initial control of thyrotoxicosis
• Pregnant and under 18 y/o
• Patients not wanting to take l-131
• Surgical removal
• Thionamide
• Propylthiouracil (PTU)
• suppress thyroid hormone

• used for severely ill

• Methimazole
• blocks iodine

Nursing Management
• Side effects of Anti-thyroid
medications
• agranulocytosis
• most serious

• report fever, chills, sore throat

• pruritus
• dermatitis
• arthralgia
• mouth ulcers
• nausea

• Iodide compounds
• goiter
• no OTC medications that contain iodides
 • expectorants

• bronchodilators

• salt substitute

• Iodism
• swelling of the buccal mucosa
• excessive salivation coryza

Treatment
• Radioactive iodine (l-131)
• Check allergy to iodine before
administration
• Radiation precautions not needed
• Most become euthyroid after 3 to 6
months
 • Eye related symptoms
• Start gluccosteroids if on RAI
• Contraindicated in those under 18
y/o and pregnancy
• May develop hypothyroidism

Management / Treatment
Surgery

Preoperative Management
• Takes 2 – 3 months
• Euthyroid
• PTU
• Beta blocker
• Iodide
• High protein, high carbohydrate diet
• Teach coughing/deep breathing
• Teach to support neck when
coughing/moving
• Hoarse for a few days
• Discourage unnecessary talking
• Life-long thyroid replacement therapy

Postoperative Management
• High Fowlers position
• Avoid hyperextension of neck
• Pillows or sandbags

• Airway humidification
• Coughing/deep breathing
• Patent IV line
• Suction
• Laryngeal damage
• Respiratory obstruction
• Laryngeal stridor

• Monitor hypocalcemia
• Calcium gluconate

• Pain
• Hemorrhage
• Edema
• Tracheostomy set

Nursing Care
Post-operative Thyroidectomy
• Nutrition
• Increase calories, protein, carbohydrates
• Avoid foods causing diarrhea
• Small frequent meals
• Vitamins and minerals
 • Monitor weight
• Measure I and O

• Calm environment
• Comfortable temperature and clothing

Complications

• All three treatment, radioactive iodine

therapy, antithyroid medications,
surgery, have the potential for the same
complications
• Relapse or recurrent hyperthyroidism
• Permanent hypothyroidism
• Thyroid storm/crisis
• Hemorrhage
Thyroid Storm/Thyrotoxic Crisis
• Life threatening
• Sudden surge of large amounts of
thyroid hormone in the blood
stream
• Abrupt onset
• After surgery of the thyroid gland
• antithyroid drugs are not given
• Trauma, MI, pulmonary
embolism, infection, stress, etc.
Thyroid Storm
• High fever
• Severe agitation
• Dehydration
• Abdominal pain
• Nausea, vomiting, diarrhea
• Confusion
• Malignant exophthalmos
• Edema

• Tachycardia
• Systolic Hypertension
• Chest pain
• Dyspnea
• Palpitations
• Cardiovascular collapse
• Coma

Management
Thyroid Storm
• Maintain airway patency/adequate
ventilation
• Reduce body temperature
• Stabilize the hemodynamic status
• Treat Respiratory Failure
• Antithyroid medications
• Hydrocortisone
• Anti-arrhythmics

Nursing Care for

hyperthyroidism
• Monitor side effects of
medications
• RAI
• Nausea and vomiting

• PTU and Tapazole

• pruritus, rash, arthralgia, fever, sore
throat, mouth ulcers, nausea, hepatitis,
vasculitis, agranulocytosis

• Monitor thyroid crisis

• Private room
• V/S
• Sleep medication
• Avoid stimulus
• Modify daily routine

Nursing Care
Exophthalmos
• Corticosteroids
• For less severe symptoms such as dry eyes
• methylcellulose eye drops during the day or gel at
night

• Application of cool compress

• Correct double vision with eyeglasses fitted
with prisms
• Protect the eyes from bright light and
ultraviolet ray with sunglasses
• Relieve pressure at night by decreasing fluid
by elevating the head while sleeping
• Restrict salt intake
• Tape eyelids shut at night or when at rest if
they do not close completely
• Teach patient to avoid smoking

Nursing Care
Pretibial Myxedema:

• Hydrocortisone ointments
• Compression wraps
 Patient Education for
Hyperthyroidism
• Rationale for treatment
• Dosage and side effects of medications
• Medication is to be taken for about two years
• Do not abruptly discontinue meds
• At first sign of infection or fever notify
physician
• Therapeutic effect of medication is not
usually evident for about three weeks
• If on antithyroid medication no decongestants
• Nutrition
• high carbohydrate, high caloric diet until
medication take effect

• avoidance of stimulants such as caffeine

• Symptoms of thyroid storm
• Symptoms of hypothyroidism

Nursing considerations
• Nutrition imbalanced, less than body
requirements
• Cardiac output: decreased
• Sleep pattern disturbance
• Diarrhea
• Anxiety
• Thought processes: disturbed

Hypothyroidism
• Decreased, deficient, or absent thyroid
hormone
• Primary: glandular dysfunction
• 95% have primary or thyroidal hypothyroidism

• Hashimoto’s disease

• Secondary: pituitary insufficiency

• Tertiary: hypothalamic disorder
• inadequate secretions of TSH

• Can affect all body functions

• Can range from mild, subclinical forms to
Myxedema coma

Incidence of Hypothyroidism
• More prevalent in women 30-60 years-old
• history of auto-immune thyroiditis
• previously treated for hyperthyroidism
 • treated with lithium or para-
aminosalicylic acid
• coexistent autoimmune disorders
• rheumatoid arthritis, lupus, pernicious
anemia, diabetes

• Occurs in all ages

• In elderly
• Atrophy of thyroid gland
• In the United States
• most cases occur from thyroid surgery and RAI
treatments

• Worldwide
• common in areas where the soil and water have
little natural iodide
 Etiology and risk factors
• Autoimmune thyroiditis (Hashimoto’s
disease)
• Diabetes Type 1 and Rheumatoid Arthritis
• Atrophy of the thyroid gland with aging
• Therapy for hyperthyroidism
• Radioactive iodine (1-131)

• Thyroidectomy

• Medications
• Lithium (has antithyroid effect)

• Iodine compounds

• Antithyroid medications

• Radiation to head and neck

• Scleroderma
 Pathophysiology
• Insufficient levels of thyroid
hormones
• Cells damaged and no longer function
normally
• Not ingesting enough of substances to
produce thyroid hormones (iodide and
tyrosine)
• Decrease thyroid hormone = decrease
metabolic rate

Diagnostic Findings
• Decreased T3
• Decreased Free thyroxine index (FTI) or T4
• TSH elevated
 • When T4 and T3 fall, pituitary gland releases TSH
to trigger the thyroid gland to secrete these two
hormones

• Normal T4 and Elevated TSH with mild

hypothyroidism
• Thyrotropin releasing hormone (TRH)
stimulation
• CBC
• Cholesterol

Hypothyroidism
Clinical Manifestations - Elderly
• Sub-clinical
• asymptomatic

• fatigue and muscle aches

 • mental confusion may be attributed to the
normal aging process
• Initial atypical signs and symptoms
• depression, apathy, deceased mobility, weight loss,
constipation

• Annual screening of TSH levels for >60

years old
• Cardiac symptoms

Symptoms
• Lethargy
• Fatigue
• Edema of eyelids, hands and face
• Hoarse voice
• Menstrual disorder
• Loss of libido
 Clinical Manifestations
As disease progresses
• Subnormal temperature
• Intolerance to cold
• Decreased BMR
• Skin dry, coarse, thick, cool, pale, carotene
• Thick, brittle nails
• Hair thins/falls out
• Cardiovascular
• Bradycardia

• Hypotension

• Pulmonary
• Face expressionless
• Constipation/ Flatulence
• Weight gain
• Paresthesia of fingers
• Muscle ache
• Dull mental processes
• Depression/paranoia
• Apathy
• Slow speech
• Tongue enlarges
• Drooling
• Deafness
• Massive goiter
 Clinical Manifestations
Advance Stage
Myxedema
• Personality and cognitive changes
• Inadequate ventilation
• Sleep apnea
• Pleural effusion
• Pericardial effusion
• Respiratory muscle weakness
• Subnormal temperature
• Increase cholesterol
• Atherosclerosis
• Coronary artery disease
• Poor ventricular function
• Abnormal sensitivity to sedatives,
opioids, anesthetic agents
• Myxedema coma

Myxedema
• Hypothermia
• Cardiovascular
• bradycardia

• Respiratory
• pleural effusion

• Abdominal
• ascites, decreased bowel sounds

• Neuromuscular
 • slow or delayed deep tendon reflexes
• cerebellar ataxia
• dementia - myxedema madness
• hallucinations, paranoid ideation, and
hyperactive delirium)

• pseudomyotonia, carpal tunnel syndrome

Management for Myxedema

• Hospitalization for suspected
myxedemic coma
• Care for symptoms of myxedema
coma
• Hypothermia
• Decreased mentation
• Hypoventilation
 • Respiratory acidosis
• Relative hypotension
• Hyponatremia
• Hypoglycemia
• Respiratory failure

• Coma

Myxedema Coma
• Extreme, severe stage of hypothyroidism
• Hypothermia
• Progressive mental deterioration
• Decreased metabolism in cardiac tissues
• Decreased perfusion to the brain and other
organs
• Multiple organ failure
• Alveolar hypoventilation
• Narcosis
• Coma
• Triggers
• illness, infection, trauma, anesthesia,
surgery, hypothermia, chemotherapy, etc.
• older women during cold weather
• 50% mortality rate

Myxedema Coma
• Hypothermia
• Maintain vital functions
• Arterial blood gases
• Pulse oximetry
• IV glucose
• Thyroid hormone replacement PO
• Corticosteroids
• Blankets
Medical Management for
Hypothyroidism
• Dose titrated slowly
• elderly patients
• cardiovascular disease

• Initial effects not seen for at least 2

weeks
• initially decrease in facial edema and
increased in urination, etc.
• Take same brand of medication
• Monitor for potential levothyroxine
side effects
• tachycardia, dyspnea, hyperactivity,
insomnia, dizziness, and GI upset

Nursing Care of elderly with

Hypothyroidism
• Hormone replacement with low
dosages and increase gradually
• Monitor cardiovascular and neurologic
side effects
• Angina
• Heart failure
• Dementia
• Confused
 • Agitated

Patient Education for

Hypothyroidism
• Signs and symptoms of disease
• Medications
• Rationale, dosage, side effects, toxic
effects
• Lifelong therapy
• Take same time each day
• Take on an empty stomach
• Notify MD of side effects
• palpitations, chest pain, dyspnea, anxiety,
etc.
 Patient Education for
Hypothyroidism
• Signs of hypothyroidism and
hyperthyroidism
• Recognize signs of under or over
medication
• Manage symptoms
• Fatigue
• Dry Skin
• Constipation
• Intolerance to cold
• Activity intolerance and mental
functioning

• Be alert for signs of complications

 • Angina, cardiac failure, myxedema coma

Nursing considerations
Hypothyroidism
• Imbalanced nutrition : More than body
requirement related to excessive intake in
relation to metabolic need
• Hypothermia related to decreased metabolic
rate
• Constipation related to decreased motility of
the GI tract
• Disturbed Body image related to illness,
edema
• Deficient Knowledge of condition, diagnosis
and treatment to cognitive limitation
• Cardiac output: Decreased
• Trauma: Risk for