Disorders of the Thyroid and Parathyroid

ACC, RNSG 1247

Created by Lydia Seese, RN

Thyroid Enlargement/Goiter

Maybe caused by: Increased TSH stimulationGrowth-stimulating immunoglobulins &

other growth factorsGoitrogensIodine-deficiency areas (endemic goiter)

Thyroid nodules

Mostly benignMalignant nodules: usually hard &

painlessDiagnostics: US, US-guided FNA,

thyroid scan Treatment: unilateral to total

thyroidectomy

Thyroiditis

Subacute and acute thyroiditis: Subacute - viral (as in subacute granulomtous thyroiditis)

Acute fungal or bacterial

Chronic autoimmune thyroiditis

Silent painless thyroiditis

Hashimoto’s thyroiditis

Chronic autoimmune diseaseMost common cause of hypothyroidism in

US

Diagnostics: T3 T4 usually low, TSH high, (+) for antithyroid antibodies

HYPERTHYROIDISM

Graves’ DiseaseToxic nodular goitersThyroiditis (hyper) – usually caused by virus

as in viral subacute granulomatous thyroiditis

Thyrotoxic crisis (thyroid storm)

Graves Disease

Autoimmune, unknown etiologyAntibodies attach to the TSH receptors

and stimulate the thyroid to release T3 & T4

May lead to destruction of thyroid tissue , thus hypothyroidism

Toxic Nodular Goiters

Release thyroid hormones independent of TSH stimulation

Maybe single or multinodular

Diagnostics for Hyper/Hypothyroid Dysfunction

1. History and PE

2. Most reliable blood tests are: TSH Free T4

Diagnostics Continued

T3, T4Radioactive iodine uptake (RAIU ) TRH stimulation testECGUSThyroid scanAntibody assay

Hyperthyroidism: Manifestations

S/sx of increased metabolism & stimulation of SNS

Goiter Opthalmopathy; exophthalmus in

Graves’

Exopthalmus

Thyroid storm

Rare but dangerous Systemic symptoms: examples

HyperthermiaTachycardia, esp. atrial arrhythmiasAgitation or delirium

Hyperthyroidism: Collaborative Care

Medications/Drugs Radioactive Iodine Nutritional Surgical

Drug Therapy: Antithyroid drugs

Preferred Tx for pregnant women Methimazole - tapazole PTU - prophylthiouracil Improvement begins 1-2 weeks Good results in 4-8 weeks Remission in 6-15 mos. in < 50% of casesPatient concern: noncompliance

Drug Therapy: B adrenergic blockers

Symptomatic relief of thyrotoxicosisPropranolol - InderalAtenolol - Tenormin

Drug Therapy: Iodine

Maximal effect in 1-2 weeks Saturated solution of potassium iodine

(SSKI) Lugol’s solution

Radioactive Iodine Therapy

Preferred for most nonpregnant women Damages thyroid hormone Effect in 2-3 mos.

Acute Intervention

Support ABC’sRest, minimal stimulationEye care

Pre/Post operative Care

CDB, turning, ambulate w/in hrs post opROM of neckAirway and incision site monitoringSemi fowlers to prevent tension on suture

linesVS monitoring including tetanyPain managementFluids if tolerated, soft diet day after

Post operative & home care

Remaining thyroid tissue is allowed to regenerate post-op

Reduced caloric intake, adequate iodineRegular exerciseAvoid temperature extremesRegular follow up to monitor for

hypothyroidism

HYPOTHYROIDISM

Primary – RT destruction of thyroid tissue or defective hormone synthesis

Secondary – RT pituitary disease

Hypothyroidism: Manifestations

Slowing of body process which develops over months to years

Exs: fatigue, cold intolerance, weight gain, systemic symptoms

Myxedema

Myxedema Coma

Rare but life threateningSevere metabolic disorders, hypothermia,

cardiovascular collapse, comaFactors: infection, trauma, failure to take

thyroid replacements

Hypothyroidism: Collaborative care

Goal – euthyroid stateLow calorie dietThyroid hormoneNatural hormones

Hypothyroidism: Acute Intervention

IV thyroid hormone Hypertonic saline solution Close assessment VS monitoring

Thyroid malignancies

Occur more often in people who have undergone radiation of the head, neck or chest.

Symptoms of thyroid cancer include hoarseness, dysphagia

Most Common Types of Thyroid Cancer

Papillary thyroid cancerFollicular thyroid cancer

The parathyroid glands

Disorders of the parathyroid glands

Hyperparathyroidism (hypercalcemia)Hypoparathyroidism (hypocalcemia)Tumors

Hyperparathyroidism

PrimarySecondaryTertiary

Hyperparathyroid

Major S/Sx: depression, fatigue, loss of appetite, constipation, osteoporosis, fractures, kidney stones

DX: bone x-rays, Ca & PTH levelsTX: decrease high serum levels, surgical

removal of parathyroid

Hyperparathyroidism: Nonsurgical Treatment

Close follow upActive lifestyle. Dietary measures Drugs

Common Medications used in Hyperparathyroidism

PhosphorusBiphosphatesEstrogen or progestinOral phosphateDiureticsCalcimimetic agents

Signs that indicate calcium levels are abnormal

Trousseau’s sign: temporarily occlude arterial blood flow (with BP cuff inflated) above the normal systolic pressure. A + Trousseau”s sign occurs when the hand and fingers contract from ischemia

Chvostek’s sign: tap on the facial nerve just below the temple. Sign is + when nose, eye, lip & facial muscles twitch

HypoparathyroidismResults from abnormally low levels of

PTH low Ca level Symptoms: painful spasms of face, hands,

arms, and feet; seizuresTX: IV Calcium; CalMag & vit D;

Rebreathing

Parathyroid Tumors

Grow inside the gland itselfMay cause levels of PTH leading to

hyper states.Most are benign adenomas;

malignancies are very rare

Nursing Diagnosis for thyroid/parathyroid patients

Imbalanced nutrition: _______ r/t hypermetabolic or hypometabolic state

Disturbed body image: r/t changes in appearance AEB exopthalmus (myxedema), skin changes, facial edema, presence of goiter

Risk for constipation r/t slowed metabolic states and decreased activity tolerance

Risk for fluid/electrolyte imbalance r/t changes in production of thyroid hormones 2° hypothyroidism

Nursing Diagnosis, cont.

Electrolyte imbalance r/t decreased/increased levels of calcium AEB….

Knowledge deficit: dietary, r/t decreased parathyroid function AEB calcium serum levels of_____, facial twitching, muscle cramps, …..

R/F impaired cardiac outputR/F Imbalanced body temperatureRF acute pain RT effects of renal stone