ENDOCRINE DISORDERS-
THYROID AND PARATHYROID
GLAND DISORDERS
MED SURG 11
Nup 223
Sept 2018
Mildred Odhiambo
THYROID GLAND
Butterfly shaped organ
Largest single endocrine gland in
the body (15-20g)
Located anterior to the trachea and
inferior to larynx
Medial region called the isthmus-
with right and left lobes
Tissue composed of thyroid follicles
THYROID GLAND
Originates from Ratke’s pouch at
the base of the tongue at 4-8wks
(Intrauterine life)
Secretes hormones by 11wks-
critical to neurological
development
THYROID GLAND
Follicleshas a sticky fluid in the
central cavity called colloid
The colloid is center of thyroid
hormone production
Productionis dependent on the
hormones essential and unique
component iodine
THYROID GLAND
The thyroid gland
produces three
hormones:
1- Thyroxin (T4),
2- Calcitonine.
3- Triiodthyronine(T3),
THYROID GLAND
BLOOD SUPPLY
Superior thyroid artery is a branch of the
external carotid artery
It supplies the superior and anterior portions
The inferior thyroid artery arises from the
thyrocervical trunk
Supplies the postero-inferior aspect
10% of people have an additional artery- the
thyroid ima artery
Comes from the brachiocephalic trunk of the
arch of aorta
Supplies the anterior surface of the isthmus
BLOOD SUPPLY
Venous drainage- superior,
middle and inferior thyroid veins
form a venous plexus
Superior and middle veins drain
into the internal jugular veins
Inferior drains into
brachiocephalic vein
NERVE SUPPLY
Nerve supply is by branches
derived from sympathetic trunk
SYNTHESIS AND RELEASE OF THYROID
HORMONES
Thyroglobulin a glycoprotein is
secreted into the colloid by the
follicle cells
Atoms of the mineral iodine attach
to thyroglobulin and produce
hormones
SYNTHESIS AND RELEASE OF
THYROID HORMONES
Hormones T3 and T4 are bound
to specialized transport proteins
called thyroxine binding
globulins(TBGs), or albumin or to
other plasma proteins
Release of T3 and T4 from the
thyroid gland is regulated by
thyroid stimulating hormone
(TSH)
REGULATION OF THYROID
HORMONE LEVELS
FUNCTIONS OF THYROID
HORMONE
Influence basal metabolic rate
Raise body temperature
Protein synthesis
Fetal and childhood tissue
development & growth
Normal development of nervous
system in utero and early childhood
Support adult neurological function
FUNCTIONS OF THYROID
HORMONE
Deficiencies of thyroid hormones
can influence libido, fertility and
other aspects of reproductive
function
Increase body’s sensitivity to
catecholamines (epinephrine and
norepinephrine) from the adrenal
medulla
Excessive T3 and T4 accelerates the
heart rate, strengthens the heart
Thyroid Hormones
Hormone Function Stimulated by
T3/T4 h metabolic rate i metabolic rate
h protein synthesis i T3/T4
h energy production h TSH
Most important hormone in day
today regulation of metabolic rate
Calcitonin
i blood calcium concentration
i the reabsorption of Ca and Ph
h blood Ca levels
from bones to blood
Calcitonin “tones” down serum
Ca levels
29/11/2010 16
PATHOPHYSIOLOGY
Thyroid hormone secretion leads
to hyperthyroidism
hence thyrotoxicosis
EFFECT OF THYROID
HORMONES
Metabolism in all body organs
Stimulate the heart
heart rate stroke volume
cardiac output blood flow
GOITRE
A condition that increases the
size of your thyroid
More common in women.
May affect thyroid functions.
A person with goiter can have
normal levels of thyroid hormone
(euthyroidism), excessive levels
(hyperthyroidism) or levels that
are too low (hypothyroidism).
Colloid Goiter (Endemic)
A colloid goiter develops from the lack of
People who get this type of goiter usually live in
areas where iodine is scarce.
Nontoxic (Sporadic)
The cause of a nontoxic goiter is usually
unknown
May be caused by medications like lithium.
Lithium is used to treat mood disorders such as a
bipolar disorder.
Nontoxic goiters don’t affect the production of
thyroid hormone
Thyroid function is healthy. They are also benign.
Endemic (Iodine-Deficient)
Goiter
CAUSES
Iodine deficieny
Grave’s disease
Hashimoto’s disease
thyroiditis
Thyroid nodules (cysts)
Thyroid cancer
Pregnancy
Clinical features
Neck swelling
difficulty swallowing or breathing
coughing
hoarseness in your voice
dizziness when you raise your
arm above your head
DIAGNOSIS
Physical examination
Blood tests
Thyroid scan
Thyroid ultrasound
Biopsy
Management
Many goiters of this type decreased after
correction of iodine insufficiency.
When surgery is recommended, post
operative complications can be minimized
by pre operative iodide administration to
reduce the size & vascularity of goiter.
Prevention
Providing children in iodine-poor region with
iodine compounds.
Use of iodized salt.
THYROTOXICOSIS
Hyper-metabolic clinical syndrome
resulting from serum elevation of
thyroid hormone levels (T3&T4)
CAUSES
GRAVE’S disease
Multinodular goitre
Toxic adenoma
GRAVE’SDISEASE is the most
common form
GRAVE’S DISEASE
Autoimmune disease
Female : Male ratio- 5:1 or 10:1
Has a strong hereditary
component
Diagnosis is mainly made by the
symptoms
SIGNS AND SYMPTOMS
Skin is warm and moist, palms are
warm, moist and hyperemic and
Plummer’s nails (separation of nail
from nail bed )are seen
Peritibial myxedema
Alopecia and vitiligo
Severe cases of proptosis
(Exopthalmus)
Excessive sweating & heat
intolerance
Peritibial myxedema Proptosis/exopthalmus
Vitiligo
SIGNS AND SYMPTOMS
Cardiovascular symptoms:-
palpitations, Congestive cardiac
failure (CCF), systolic
hypertension
Metabolic symptoms- weight loss
despite of increased in appetite
GIT (gastrointestinal): - hyper-
defecation
Exacercebate bronchial asthma
Cont.
CNS (central nervous system)-
nervousness, irritability, tremor,
insomnia, proximal muscle
weakness
In females: amenorrhea,
oligomenorrhea
Oligomenorrhea is a condition
that involves having light or
infrequent menstrual periods
Males: impotence and loss of libido
Eye signs
VON GRAFFE’S
SIGN- lid lag
JOFFROY’S SIGN-
absence of
winking of
forehead on
looking up
cont
STELLWAG’S SIGN- reduced
frequency of blinking
DALRIMPLE’S SIGN- Lid retraction
exposing upper sclera- widened
opening of eye lid
MOBIUS SIGN- absence of
convergence
COMPLICATIONS
Thyroid crisis (storm)
A sudden worsening of
hyperthyroidism symptoms that
may occur with infection or
stress.
Characterized by -Fever,
decreased mental alertness, and
abdominal pain
Immediate hospitalization is
needed.
Cont. COMPLICATIONS
Heart-related complications
including:
◦ Rapid heart rate
◦ Congestive heart failure
◦ Atrial fibrillation
Increased risk for osteoporosis, if
hyperthyroidism is present for a
long time
INVESTIGATIONS
Thyroid-stimulating hormone (TSH) assay
reveals a decrease in result (normal TSH:
0.5–1.5 mU/L).
Elevation of thyroid hormones decreased
TSH secretion by negative feedback.
Elevated Thyroxine (T4) radioimmunoassay
(normal values: 5.0–12.0 μg/dL).
Elevation reflects overproduction of thyroid
hormones; monitors response to therapy.
INVESTIGATIONS
Elevated Tri-iodothyronine (T3)
radioimmunoassay (normal values:
80–230 ng/dL).
Elevation reflects overproduction of
thyroid hormones.
Other Tests: 24-hr radioactive iodine
uptake;
thyroid autoantibodieS
antithyroglobulin
electrocardiogram (ECG)
MANAGEMENT
GOAL of treatment:
Reducing thyroid hyperactivity for
symptomatic relief
Removing the cause of complications.
Three forms of treatment are available:
Irradiation
Pharmacotherapy
Surgery with the removal of most of
the thyroid gland
Radio iodine treatment
Radio iodine ablation
postmenopausal women and
elderly men
pharmacotherapy
Objectiveis to inhibit hormone synthesis or release
and reduce the amount of thyroid tissue.
Most commonly used medications are
propylthiouracil (Propacil, PTU)
methimazole (Tapazole)
until patient is euthyroid.
Maintenance dose is established
followed by gradual withdrawal of the medication
over the next several months.
Antithyroid drugs are contraindicated in late
pregnancy because of a risk for goiter and cretinism
in the fetus.
Thyroid hormone may be administered to put the
thyroid to rest.
pharmacotherapy
Immediate control: propranolol
40mg/6hr orally
Long term control:
Antithyroid drugs- carbimazole
15mg tid initially and then
reducing it to 5mg tid for 12-18
months
pharmacotherapy
Adjunctive Therapy
Potassium iodide, Lugol’s solution, and
saturated solution of potassium iodide
(SSKI) may be added.
Beta- adrenergic agents may be used to
control the sympathetic nervous system,
effects that occur in hyperthyroidism;
for example, propranolol is used for
nervousness, tachycardia, tremor,
anxiety, and heat intolerance
Pharmacologic Highlights
1. Propylthiouracil (PTU) an antithyroid
agent is given to return the patient to the
euthyroid (normal) state.
PTU inhibits use of iodine by thyroid
gland
blocks oxidation of iodine
inhibitis thyroid hormone synthesis
2. Methimazole (Tapazole) an antithyroid
agent is given to return the patient to the
euthyroid (normal) state by inhibiting use
of iodine by thyroid gland.
Pharmacologic Highlights
3. Other Drugs: Beta-adrenergic
blockers, corticosteroids,
radioactive iodine
Exopthalmos: corticosteroids,
tarsorrhaphy, orbital
decompression
Cardiac arrythmias- beta
blockers; cardioversion done in
euthyroid state
Nursing Interventions
Provide adequate rest.
Administer sedatives as prescribed.
Provide a cool and quiet
environment.
Obtain weight daily.
Provide a high-calorie diet.
Avoid the administration of
stimulants.
Administer antithyroid medications
(propylthiouracil [PTU]) that block thyroid
synthesis, as prescribed.
Administer iodine preparations that inhibit
the release of thyroid hormone as prescribed.
Administer propranolol (Inderal) for
tachycardia as prescribed.
Prepare the client for radioactive iodine
therapy, as prescribed, to destroy thyroid
cells.
Prepare the client for thyroidectomy if
prescribed
SURGICAL MANAGEMENT
Why use surgery?
Used to remove large goiter causing
tracheal or esophageal compression
Used for patients who do not have
good response to antithyroid drugs
TWO TYPES OF SURGERIES:
1. Total thyroidectomy (must take
lifelong thyroid hormone
replacement)
2. Subtotal thyroidectomy
PREOPERATIVE CARE
Patient should become euthyroid
before surgery to prevent thyroid
crisis.
Assessment of vocal cord
condition
Low weight:
High protein, high carbohydrate
diet for days/weeks before
PRE-OPERATIVE CARE
1. Antithyroid drugs to suppress function
of the thyroid
2. Iodine prep (Lugols or potassium
iodide solution)
To decrease size and vascularity of
gland
To minimize risk of hemorrhage,
Reduce risk of thyroid storm during
surgery
3. Tachycardia, BP, dysrhythmias must
be controlled preop
PREOPERATIVE TEACHING
Teach coughing and deep
breathing exercises
Teach support neck when coughing
& deep breathing
Support neck when moving
reduces strain on suture line
Expect hoarseness for few days
(endotracheal tube)
29/11/2010
POST-OP THYROIDECTOMY
NURSING CARE
1. Vital signs
2. Intravenous fluids
3. Intake – output monitoring
4. Semifowlers
5. Support head
6. Avoid tension on sutures
5. Pain meds, analgesic lozengers
6. Humidified oxygen, suction
Cont. POST-OP THYROIDECTOMY
NURSING CARE
7. First fluids: cold/ice, tolerated
best, then soft diet
8. Limited talking , hoarseness
common
9. Assess for voice changes: injury
to the recurrent laryngeal nerve
POSTOP THYROIDECTOMY
NURSING CARE
CHECK FOR CHECK FOR
HEMORRHAGE 1st 24 RESPIRATORY DISTRESS
hrs: Laryngeal stridor
Look behind neck and (harsh high pitched
sides of neck respiratory sounds)
Check for c/o pressure Result of edema of
or fullness at incision glottis, hematoma or
site tetany
Check drain Tracheostomy
Report if bleeding is set/airway/ O2, suction
high Call doctor for extreme
hoarseness
Complication of operation
Hemorrhage
Recurrent laryngeal nerve damage.
Superior laryngeal nerve damage
Hypoparathyrodism
Hypothyroidism
Sepsis
Postoperative infection
Hypertrophic scaring (keloid)
56
Toxic Single Adenoma
(TSA)
TSA is a single hyper functioning follicular
thyroid adenoma.
Benign monoclonal tumor that usually is larger
than 2.5 cm
Itis the cause in 5% of patients who are
thyrotoxic
Nuclear Scintigraphy scan shows only a single
hot nodule
TSH is suppressed by excess of thyroxines
So the rest of the thyroid gland is suppressed
Toxic Single Adenoma
(TSA)
Nucleotide
Scintigraphy
Age and Sex
Age
◦ Graves disease 20 to 40
◦ Toxic multinodular goitre > 50 yrs
◦ Toxic Single Adenoma 35 to 50
◦ Sub Acute Thyroiditis Any age
Sex M : F ratio
◦ Graves Disease 1: 5 to 1:10
◦ Toxic MNG 1: 2 to 1: 4
Nucleotide Scintigraphy
Clinical Features
1. Those that occur with any type of
thyrotoxicosis
2. Those that are specific to Graves
disease
3. Non specific changes of hyper
metabolism
Thyroid hormone levels
Normal TSH levels range from 0.4 ‑ 4.0
mIU/L for the average adult
High TSH levels for the average adult are
4.2 mIU/L and over.
This reading typically indicates an
underactive thyroid.
Low TSH levels for the average adult are
less than 0.2 mIU/L.
This reading indicates an overactive
thyroid
Note: mIU/L- milli-international units per
liter
Thyroid hormone levels
Normal ranges for adults
generally fall between these
values
Total T4 5.0-12 μg/dL
(micrograms per decilitre)
Total T3 80-190 ng/dL
(nannogram per decilitre)
Free T4 1.0-3.0 ng/dL
Free T3 0.25-0.65 ng/dL
INVESTIGATIONS
LABORATORY TESTS
-serum T3, T4.
-serum TSH.
-serum LATS: (Long Acting Thyroid
Stimulator)
in grave’s disease
-thyroid antibodies:
in hashimoto’s disease.
-serum cholesterol
increase cholesterol level in hypothyroidism
INVESTIGATIONS
IN HYPERTHYROIDISM:
T3
T4
TSH in Graves disease
Radioactive Thyroid Scan
Ultrasonography: used to determine goiter or
nodules
ECG (electrocardiogram): note tachycardia
29/11/2010 65
Radiological Investigation
-chest and neck x-ray:
Show descend of thyroid gland
to thorax and mediastanal
shifting in retrosternal goitre.
-iodine isotopes
By i.v injection of I131. Then,
use gamma rays to show hot
and cold nodules.
-CT scan
Show thyroid size and if there is
compression to trachea
INVESTIGATIONS
Endoscopic investigation:
-bronchoscopy: show compression
and infiltration of trachea by
tumer
Biopsy:
-fine needle aspiration biopsy.
-true-cut biopsy.
MANAGEMENT
Depending on clinical features
Toxic Multinodular Goiter (TMG)
TMG is the next most common hyperthyroidism -
20%
More common in elderly individuals – long
standing goiter
Lumpy bumpy thyroid gland
Milder manifestations (apathetic hyperthyroidism)
Mild elevation of FT4 and FT3
Progresses slowly over time
Clinically multiple firm nodules (called Plummer’s
disease)
Scintigraphy shows - hot and normal areas
Toxic Multinodular Goiter (TMG)
Toxic Multinodular Goiter (TMG)
Toxic Multinodular goitre
Huge Toxic MNG Huge Toxic MNG
MULTINODULAR GOITRE
Excess production of thyroid
hormones from TSH
Occurs in individual over 60yrs
Females are mostly affected
SYMPTOMS
Large goitre with or without
tracheal compression
Goitre is nodular and palpable
Large goitre- Mediastinal
compression
With stridor, dysphagia, obstruction
of superior venacava
hoarseness
MANAGEMENT
Small goitre- no treatment-
Annual review
Large goitres: partial
thyroidectomy
Radioactive
iodine
Recurrence is common in 10-20
yrs
THYROID STORM (CRISIS)
Rare but life threatening sudden
severe exarcerbation of
hyperthyroidism
CAUSES
Precipitated by stress or infection
Or Unrecognized thyrotoxicosis
Or inadequately treated
thyrotoxicosis
Following subtotal
thyroidectomy/radio active iodine
Trauma
Pregnancy
Emotional stress
SIGNS AND SYMPTOMS
Elevation of temperature
Increase in heart rate
Irritable
Delirius / comatose
Hypotension
Vomiting
Diarrhoea
MANAGEMENT
Treatment started immediately with
Propanolol 80mg/6hrs orally (dose
of 1-5mg/6hrs given IV)
Potassium iodide 60mg daily
orally/sodium iopodate 5oomg daily
orally
Carbimazole 60-120mg daily
Dexamethasone 2mg/6hrs IV
Fluid replacement
antibiotics
NURSING MANAGEMENT
ASSESSMENT
NURSING DIAGNOSIS
INTERVENTION
NURSING MANAGEMENT
Acute Care Patient
Management
Nursing Diagnosis:
Decreased cardiac output
related to increased cardiac work
secondary to increased
adrenergic activity
Deficient fluid volume secondary
to increased metabolism and
diaphoresis.
NURSING MANAGEMENT
Outcome Criteria
Patient alert and oriented
Peripheral pulses palpable
Lung clear to auscultation
Urine output 30 ml/hr
Absence of life-threatening
dysrhythmias
NURSING MANAGEMENT
1. Patient Monitoring
Continuously monitor ECG for
dysrhythmias or HR ? 140
beats/min that can adversely
affect cardiac output and monitor
for ST segment changes
indicative of myocardial
ischemia.
Continuously monitor oxygen
saturation with pulse oximetry.
NURSING MANAGEMENT
CONT. MONITORING
Continuously monitor pulmonary
artery pressure.
Monitor fluid volume status;
measure urine output hourly and
determine fluid balance every 8
hours.
NURSING MANAGEMENT
2. Patient Assessment
Assess cardiovascular status; extra
heart sounds, complaints of
orthopnea or dyspnea on exertion.
Assess hydration status because
dehydration can further decrease
circulating volume and compromise
cardiac output.
Assess for pressure ulcer
development secondary to
hypoperfusion.
NURSING MANAGEMENT
3. Diagnostic Assessment
REVIEW THYROID STUDIES AS AVAILABLE.
Review serial serum electrolytes, serum
glucose, and serum calcium levels to
evaluate the patient’s response to therapy.
Review serial ABGs for hypoxemia and
acid-base imbalance, which can adversely
affect cardiac function.
Review serial chest radiographs for cardiac
enlargement and pulmonary congestion.
NURSING MANAGEMENT
4. Patient Management
Administer dextrose-containing
intravenous fluids as ordered to
correct fluid and glucose deficits.
Carefully assess the patient for heart
failure or pulmonary edema.
Dopamine may be used to support
blood pressure.
Provide supplemental oxygen to help
meet increased metabolic demands.
NURSING MANAGEMENT
Once the patient is hemodynamically stable,
provide pulmonary hygiene to reduce pulmonary
complications.
If the patient is in heart failure, typical
pharmacologic agents for treatment of heart
failure may also be indicated.
Reduce oxygen demands by decreasing anxiety,
reduce fever, decrease pain, and limit visitors if
necessary.
Anticipate aggressive treatment of precipitating
factor.
Institute pressure ulcer strategies.
INFLAMMATORY GOITRE-(Thyroiditis)
Acute: rare and due to
suppurative infection of the
thyroid
Sub acute: also termed de
Quervains thyroiditis/
granulomatous thyroiditis –
mostly viral origin
Chronic thyroiditis: mostly
autoimmune (Hashimoto’s and
Acute Thyroiditis
Bacterial – Staph, Strep
Fungal – Aspergillus, Candida,
Histoplasma, Pneumocystis
Radiation thyroiditis
Amiodarone (acute/ sub acute)
Painful thyroid, ESR usually
elevated, thyroid function normal
Sub Acute Thyroiditis
Viral (granulomatous) – Mumps,
coxsackie, influenza, adeno and
echoviruses
Mostly affects middle aged
women, Three phases, painful
enlarged thyroid, usually complete
resolution
Rx: NSAIDS and glucocorticoids if
necessary
Sub Acute Thyroiditis (cont)
Silent thyroiditis
No tenderness of thyroid
Occur mostly 3 – 6 months after
pregnancy
3 phases: hyperhyporesolution,
last 12 to 20 weeks
ESR normal, TPO Abs present
Usually no treatment necessary
DEFINITION OF TERMS
ESR- Erythrocyte sedimentation
rate is a blood test that can
reveal inflammatory activity in
the body.
DEFINITION OF TERMS
Thyroperoxidase (TPO) is an enzyme
involved in thyroid hormone
synthesis, catalyzing the oxidation of
iodide on tyrosine residues in
thyroglobulin for the synthesis of
triiodothyronine and thyroxine
(tetraiodothyronine).
TPO is a membrane-associated
hemoglycoprotein expressed only in
thyrocytes and is one of the most
important thyroid gland antigens.
TPO VALUE <9.0 IU/mL
Reference values apply to all
ages.
Values above 9.0 IU/mL generally
are associated with autoimmune
thyroiditis, but elevations are also
seen in other autoimmune
diseases.
Clinical Course of Sub Acute
Thyroiditis
Chronic Thyroiditis
Hashimoto’s
◦ Autoimmune
◦ Initially goiter later very
little thyroid tissue
◦ Rarely associated with
pain
◦ Insidious onset and
progression
◦ Most common cause of
hypothyroidism
◦ TPO abs present (90 –
95%)
Chronic Thyroiditis
Reidel’s
◦ Rare
◦ Middle aged women
◦ Insidious painless
◦ Symptoms due to compression
◦ Dense fibrosis develop
◦ Usually no thyroid function
impairment
◦ Rule out thyroid cancer
Thyroiditis
The most common form of
thyroiditis is Hashimoto
thyroiditis, this is also the most
common cause of long term
hypothyroidism
The outcome of all other types of
thyroiditis is good with eventual
return to normal thyroid function
HYPOTHYROIDISM
Chronic deficiency of T4 and T3
Hypothyroidism results
from suboptimal levels of
thyroid hormone.
CLASSIFICATION
1. Central hypothyroidism.
Failure of the pituitary gland,
the hypothalamus or
both to stimulate production of thyroid hormones.
2. Secondary or pituitary hypothyroidism.
Due to pituitary disorder in secondary
hypothyroidism.
3. Tertiary or hypothalamic hypothyroidism.
Due to a disorder of the hypothalamus resulting in
inadequate secretion of TSH due to decreased
stimulation of TRH.
4. The thyroid disorder is already present at
birth in cretinism
CAUSES
Autoimmune diseases-autoimmune
thyroiditis or Hashimoto’s disease (most
common cause of hypothyroidism in adults)
Atrophy of the thyroid gland. The thyroid
gland shrinks in size as a result of aging.
Therapy for hyperthyroidism- such
as radioactive iodine and surgery
(thyroidectomy)
Medications- lithium, iodine compounds,
and anti-thyroid medications- decrease
production of TSH.
Cont. CAUSES
Iodine deficiency or excess. Imbalance
in the iodine levels in the body also
affects the thyroid gland.
In adequate release of TRH or TSH from
hypothalamic –pituitary axis
(hypophysectomy or pituitary radiation)
PREVENTION
Increase in iodine intake.
Early detection. Undergoing
thyroid tests after a
thyroid surgery or therapy could
result in early detection and
prompt treatment of
hypothyroidism.
COMPLICATIONS
Hypothyroidism can be a life-
threatening disease if left
unchecked.
Myxedema coma-
decompensated state of severe
hypothyroidism
Patient is hypothermic and
unconscious.
ASSESSMENT AND DIAGNOSIS
Physical examination-inspect and
palpate routinely in all patients.
Serum thyroid-stimulating tests.
Serum T3 and T4. Measurement of
total T3 or T4 includes protein-bound
and free hormone levels that occur in
response to TSH secretion.
Thyroid antibodies- anti-thyroid
antibodies are positive in
Hashimoto’s thyroiditis (100%).
MEDICAL MANAGEMENT
Pharmacologic therapy.
Synthetic levothyroxine- the preferred
preparation for treating hypothyroidism
and suppressing nontoxic goiters.
Prevention of cardiac dysfunction- As
long as metabolism is subnormal and
the tissues require relatively little
oxygen, a reduction in the blood supply
is tolerated without overt symptoms
of coronary artery disease.
MEDICAL MANAGEMENT
Supportive therapy
Monitor oxygen saturation levels
Administer fluids cautiously
Avoid application of external
heat
Continue oral thyroid hormone
therapy
NURSING MANAGEMENT
Nursing Assessment
Assessment of the thyroid from an
interior or posterior position.
Auscultation of the lobes of the
thyroid gland using the diaphragm
of the stethoscope if there are
abnormalities palpated.
Assess thyroid gland for firmness
(Hashimoto’s) or tenderness
(thyroiditis).
NURSING MANAGEMENT
Nursing diagnoses:
Activity intolerance related to fatigue and
depressed cognitive process.
Risk for imbalanced body
temperature related to cold intolerance.
Constipation related to depressed
gastrointestinal function.
Ineffective breathing pattern related to
depressed ventilation.
Disturbed thought processes related to
depressed metabolism and altered
cardiovascular and respiratory status.
NURSING MANAGEMENT
Planning & Goals
To achieve a successful nursing care plan,
the following goals should be realized:
Increase in participation in activities.
Increase in independence.
Maintenance of normal body
temperature.
Return of normal bowel function.
Improve respiratory status.
Maintenance of normal breathing pattern
Improve thought processes
NURSING MANAGEMENT
Nursing Interventions
Promote rest. Space activities to promote rest and
exercise as tolerated.
Protect against coldness. Provide extra layer of clothing
or extra blanket.
Avoid external heat exposure. Discourage and avoid the
use of external heat source.
Mind the temperature. Monitor patient’s body
temperature.
Increase fluid intake. Encourage increased fluid intake
within the limits of fluid restriction.
Provide foods high in fiber.
Manage respiratory symptoms. Monitor respiratory
depth, rate, pattern, pulse oximetry, and ABG.
Pulmonary exercises. Encourage deep breathing,
coughing, and use of incentive spirometry.
Orient to present surroundings. Orient patient to time,
place, date, and events around him or her.
NURSING MANAGEMENT
Evaluation
A successful nursing care plan has
achieved the following goals:
Increased participation in activities.
Increased independence.
Maintained normal body temperature.
Return of normal bowel function.
Improved respiratory status.
Maintained normal breathing pattern.
Improved thought processes.
NURSING MANAGEMENT
Discharge and Home Care Guidelines
At the completion of the home care instruction, the
patient or caregiver will be able to:
Medication compliance. State that compliance
to medical regimen is life-long.
Cold intolerance. State the need to avoid
extreme cold temperature until condition is stable.
Follow-up visits. State the importance of regular
follow-up visits with health care provider.
Weight reduction. Identify strategies for weight
reduction and prevention of constipation such as
high-fiber, low-calorie intake and adequate fluid
intake.
PATHOPHYSIOLOGY
Hashimoto’s disease( autoimmune
thyroiditis)
A form of primary hypothyroidism.
The thyroid tissue is attacked by the
person’s own immune system.
Occurs through cell and antibody-
mediated destruction of the tissue
The thyroid tissue is invaded by
lymphocytes and thyroid
autoantibodies which destroy the
cells of the thyroid
PATHOPHYSIOLOGY
The damaged thyroid tissue is no longer
able to synthesize and secrete thyroid
hormones resulting in low T3 and T4
levels.
This stimulates the hypothalamus and
anterior pituitary to release TRH and TSH
in an attempt to elevate these levels
resulting in higher than normal levels.
Process occurs over months to years and
the resulting damage affects most of the
bodies systems
PREDISPOSING FACTORS
Genetic predisposition
Increased iodine intake
Decreased selenium
Smoking
Hepatitis C
CLINICAL FEATURES
fatigue, malaise, and weight gain
Non-pitting edema particularly in the face
Cold intolerance
Hoarse voice
Dry skin and hair
Constipation
Irregular menses
Sexual dysfunction
Impaired fertility
Difficulty with concentration and memory
CLINICAL FEATURES
Myalgias and arthralgias
Depression
Outward signs:
Goiter
Non-pitting edema
Coarse hair, dry skin and brittle nails
Slowed relaxation of reflexes
Psychosis
Bruising/bleeding
Pericardial or pleural effusion
Ascites
MANAGEMENT
The treatment of choice for
Hashimoto thyroiditis is thyroid
hormone replacement.
The drug of choice is orally
administered levothyroxine
sodium
Given for life.
MANAGEMENT
Goal of therapy is to restore a
clinically and biochemically
euthyroid state.
The standard dose is 1.6-1.8
mcg/kg lean body weight per
day, but the dose is patient
dependent.
CRETINISM
Hypothyroidism during birth (deficiency
of thyroid hormone) leading to stunted
physical and mental growth.
CAUSES
Iodine deficiency
Impaired thyroid gland
Hereditary condition interrupting
thyroid synthesis
Intake of antithyroid drugs
during pregnancy (uncommon)
SIGNS AND SYMPTOMS
SUBJECTIVE FINDINGS OBJECTIVE FINDINGS
Gradual development of a coarse, Foreshortened base of the skull
dry skin
Mild inflammation of face and Low hair line
tongue
Umbilical hernia Short and wide face
Drooling from an open mouth Pallor
Underdeveloped mandible/
Listlessness Overdeveloped maxill
a
Slow movement Large, thick and protruding tongue
(Macroglossia
Constipation Delayed eruption of primary and
permanent teeth
Feeding difficulties and choking Short and thickened long bones
Myxedema Late appearing of epiphyses
MANAGEMENT
Goal of treatment is to correct
hypothyroidism and ensure normal
growth and neuropsychological
development.
Early diagnosis and thyroid
hormone replacement essential
Optimal care includes diagnosis
before age 10-13 days and
normalization of thyroid hormone
blood levels by age 3 weeks
MANAGEMENT
Only levothyroxine is recommended for
treatment.
It has been established as safe, effective,
inexpensive, easily administered, and easily
monitored.
Initial dosages of 10-15 mcg/kg/day,
equivalent to a starting dose of 50 mcg in
many newborns, have been recommended.
However, in up to 43% of infants and 10% of
older children with congenital
hypothyroidism, TSH elevation fails to
normalize despite appropriate LT4 treatment.
MYXEDEMA COMA
A state of extreme
hypothyroidism with a very high
mortality rate (approaching 60%).
Patients with this condition
usually present with an acute
precipitating condition
CAUSES
Acute deficiency of T4 and T3
Long-standing, undiagnosed
hypothyroidism
Discontinuation of T4
replacement therapy
Failure to institute T4
replacement after radioactive
iodine ablation of the thyroid in
Graves disease or after total
thyroidectomy
PRECIPITATING CAUSES
Infection
Cardiovascular accident
Pulmonary infection
Congestive cardiac failure
Drugs such as narcotics,
sedatives, anesthetic agents,
antidepressants, and tranquilizers
(all of which depress the
respiratory drive).
SIGNS AND SYMPTOMS
Subjective findings Objective findings
Diminished hearing Anasarca
Cold intolerance Hoarsness
Fatigue Pericardial & pleural effusions
Lethargy Diminished hearing
Complaints of constipation Paralytic ileus
Unresponsiveness
Decreased breathing
Hypotension
Hypoglycemia
hypothermia
Definition of terms
Anasarca affects the whole body
and is more extreme than regular
edema
MEDICAL MANAGEMENT
Levothyroxine is administered
intravenously in a loading dose of
4 mcg/kg of lean body weight; this
is about 300-600 mcg, which
should be administered by rapid IV
injection.
The daily maintenance dose is 50-
100 mcg/d, administered
intravenously until the patient can
take it orally.
MEDICAL MANAGEMENT
Steroids, preferably
hydrocortisone in stress doses
Treatment of infection or any
other precipitating causes
Lasix to promote water diuresis
SURGICAL MANAGEMENT
Indications for surgery include the
following:
A large goiter with obstructive
symptoms, such as dysphagia, voice
hoarseness, and stridor, caused by
extrinsic obstruction of airflow
Evaluate patients with these
symptoms with a barium swallow study
and pulmonary function tests, including
flow volume loops and a neck
computed tomography (CT) scan
SURGICAL MANAGEMENT
Presence of a malignant nodule - As
found by cytologic examination via
fine-needle aspiration
Presence of a lymphoma diagnosed
on fine-needle aspiration - Thyroid
lymphoma responds very well to
radiotherapy and is the treatment
modality of choice in this situation
Cosmetic reasons - For large,
unsightly goiters
NURSING MANAGEMENT
IN ACU TE CARE UNIT (ICU)
Ventilatory support for
hypoventilation and carbon
dioxide retention
Monitor oxygenation
Electrocardiographic
monitoring and a Swan-Ganz
catheter for hemodynamic
monitoring of vital signs
NURSING MANAGEMENT
Judicious rewarming to avoid
excessive vasodilatation, which
would increase oxygen
consumption and could lead to
worsening of hypotension and
vascular collapse
NURSING MANAGEMENT
Assess level of consciousness
Restrict IV fluids
Vasopressors to improve blood
pressure
Thyroid replacement hormone
SICK EUTHYROID SYNDROME
Underproduction of thyroid
stimulating hormone from
anterior pituitary(which
stimulates the production and
release of T4 and T3)
CAUSE
Acute illness
SIGNS AND SYMPTOMS
Subjective findings Objective findings
none Normal or low TSH
Abnormal T4 (low or high)
Low T3
Absence of thyroid symptoms
MANAGEMENT
Treatment of acute illness
