Compl - Thyroid & Parathyroid

NURSING 304 NURSING CARE OF THE CLIENT AND FAMILY WITH THYROID/PARATHYROID HEALTH DEVIATIONS Endocrine Disorders are generally due to hyper or hypofunction of the glands. PARATHYROID GLANDS Influenced by: Influenced by nothing. Senses calcium levels.

1. Secretions/Functions: secretes parathormone, keeps calcium levels normal. serum calcium levels ↓ = bone resorption (breakdown). calcium levels are ↑ = stops bone resorption Responsible for metabolism & growth. Euthyroid – normal thyroid.

2. Health Deviations of Parathyroid Gland a. Hypoparathyroidism 1. Patho: causes hypocalcemia (irritability), hyperphosphatemia 2. Etiology/Predisposing Factors a. iaotrogenic cause – we did it to them. Surgical removal of thyroid gland. Thyroidectomy surgical removal of thyroid. b. Radiation therapy – cancer of thyroid. Iatrogenic cause c. Hyperphosphatemia

d. Hypomagnesiemia – (usually alcoholics & malnourished). Need to watch ca levels b/c hypomagnesemia inhibits the parathyroid functioning. 3. S&S of Hypoparathyroidism Hypocalcemia (irritability) – Early sign - paresthesias – numbness & tingling of toes & hands. Late sign – largynospasms & tetany - we have let it gone too far.

4. Medical/Nursing Management of Hypoparathyroidism •

Get calcium levels ↑ - calcium supplements. Critical situation – IV calcium gluconate – mix w/ D5W (D5W makes body hand on to calcium)

• At risk for laynogospasms (tetany of larynx) – need to have artificial airway near, very close by (trachestomy set). Airway will get blocked b/c laryngospasms. • Diet – high calcium supplements, vitamin D supplements, low phosphorus • Diuretics – patient w/ heart problem, give thiazide – help retain calcium.

b. Hyperparathyroidism 1. Etiologies: caused by overproduction of parathormone by parathyroid 2. S&S of Hyperparathyroidism

• Hypercalcemia (weakness) – lethargy, sluggish, constipation. Fluids – NS, fluids (no surgery stuff b/c they will hang on to calcium). Infuse several liters of NS over 24 hour period. • Pulling calcium out of bones – high risk for pathologic fractures. • Kidney stones – calcium in urine. Trying to excrete Calcium & Phosphorus in urine. Flank pain, excruciating pain. • Hypercalciuria –excess calcium in urine. Elevated Calcium & Phosphorus levels in urine.

3. Dx Test Results of Hyperparathyroidism Elevated serum calcium levels

4.

Medical/Nursing Mgt of Hyperparathyroidism

• Lower calcium • Calcitonin – inhibits bone resorption, Miacalcin (exogenous calcitonum), nasal spray, lowers calcium, flush w/ lots of fluid. *Parathyroid is much stronger than miacalcin – cannot by only treatment * • Flush them with fluids • Surgery - total or sub-total • Steroids blocks absorption of calcium in GI tract • Diuretics – loops lose calcium • Diet - low calcium

• Weakness – constipated: prunes, fluids, fiber, activity (hypoactive bowel sounds b/c hyperparathyroidism

5. Nursing Diagnoses for Hyperparathyroidism Injury, high risk RT demineralization of bone--safety precautions Cardiac Output, impaired RT myocardial irritability secondary to increased calcium Must watch cardiac rhythm and monitor vs. Urinary elimination, altered RT renal involvement secondary to elevated calcium and phosphorous in urine a. Must maintain hydration up to 3,000 cc per day b. Cranberry and prune juice to acidify urine--Ca more soluble in acidic urine c. Strain urine looking for stones Nutrition < BR RT anorexia, nausea, GI upset Constipation RT effects of hypercalcemia on GI tract

THYROID GLAND • Responsible for growth & metabolism. • Euthyroid – normal thyroid. Difficult growing & developing. • Function of thyroid depends on adequate amounts of protein & iodine. 1. Influenced by: PITUITARY & HYPOTHALAMUS

Hypothalamus (tertiary) (TRH – thyroid releasing hormone) ↓ Pituitary (secondary) (TSH – thyroids stimulating hormone) ↓ Thyroid (primary) (Thyroid hormone, T3 & T4) 2. Secretes: a. Calcitonin – inhibits bone resorption (breakdown). Exogenous form – miacalcin. Nasal spray, rotate nostrils. b. T 3 – much more potent c. T 4 – “more 4 than 3, but 3 is more potent”. T 7 (free T 4, not bound to protein)

3. Diagnostic Tests for Thyroid Function • Levels for T 3 & T 4 – elevated or decreased will tell you if they are hypo or hyper • TSH – comes from pituitary – hyperfunctioning (ex. tumor of pituitary gland) and sending tons of TSH – thyroid will make tons of thyroid hormone = person will be hyperthyroid – was not thyroid gland fault. Secondary hyperthyroidism. If problem comes directly from thyroid – primary hyperthyroidism.

• T 7 - free T 4 Elevated T 3 & T 4, also have elevated TSH – secondary problem unless there is more data to support tertiary problem If have low T 3 & T 4 but high TSH – thyroid not doing what it needs to do, so pituitary is trying to compensate • Radioactive iodine uptake test – give patient radioactive iodine, need adequate protein & iodine in diet to make thyroid hormone. Iodine is attracted to thyroid – go to thyroid gland. Healthy profused tissue of thyroid will pick up and glow. Dead, necrotic, nonfunctioning, damaged, diseased areas will not glow – “cold spots”. Low dose radiation – flush toilet several times for couple of days. • Fine needle biopsy – stick needle into thyroid gland & aspirate out some tissue. • Cholesterol levels – cannot be used to diagnose hypo or hyperthyroidism. Look at in relationship, if highly suspected – confirms. Hyper – cholesterol will be low b/c they are burning everything off. Hypo – cholesterol will be high b/c can’t metabolize fats. 4. Health Deviations of Thyroid Gland a. Enlargement Goiter – enlarged thyroid gland. Does not indicate hypothyroid or hyperthyroid or euthyroid. Need further assessment. Palpate goiter – DO NOT PALPATE GOITER AGGRESSIVELY, could send into thyroid storm – release excessive amounts of thyroid hormone – s/s: hypermetabolism, tachycardia, fever, HTN Highly vascular (gland) – feel a thrill & hear a bruit

1. Types/Causes of thyroid gland enlargement • Tumor – cancerous growth on thyroid gland-gets bigger. Need radiation, then surgery. • Hypothyroidism – pituitary tries to stimulate thyroid w/ TSH, but thyroid can’t send out thyroid hormone, may get larger – reason for goiter. • Simple goiter – lack of iodine in diet. Get in salt & seafood. Iodine is available but is not being ingested – hypo or hyper. Pituitary tries to secrete more TSH and thyroid gets bigger b/c does not have adequate iodine. • Endemic goiter – occurs in certain geographic regions • Sporadic goiter – genetic defect, plenty of iodine in area, but person develops goiter b/c of genetic malfunction. • Ingestion of excessive goitrogens – rutabaga, cabbage, soybeans, spinach, radish, peaches, strawberries • Medications that inhibit thyroid hormone production – goitrogenic • Excessive iodine 2. S&S of Thyroid Enlargement May show up physically: Problem w/ eating (swallowing) & breathing Nursing/Medical Mgt of goiter/ thyroid enlargement: • Aimed at stopping progression of enlargement and promoting regression of gland • Iodine preparations – SSKI saturated solution of potassium iodide – potassium in it, so it must be diluted. Decreases size & vascularity of thyroid gland

• If eating too many goitrogens – stop eating the food that causes it – rudabaga, radish, etc.. • Surgery – if causing body image disturbance, problem eating or breathing. Cause iaotrogenic hypothyroidism ***If they have a goiter – they may be hypothyroidism, hyperthyroidism, or euthyroidism You cannot tell the state of thyroid by simply looking at goiter*** 3. Dx testing--thyroid hormones in serum, radioactive iodine uptake. b.

Hypofunction of Thyroid Gland—Hypothyroidism

2. Types of Hypothyroidism a. Primary Hypothyroidism thyroid’s fault 1. Congenital defects person born with thyroid problem – cretinism – genetic defect, hypothyroid. Important for growth & metabolism – will be morphed & retarded. Test every baby at birth – exogenous thyroid hormones for rest of life (getting from outside) 2. Iodine deficiency (still very common in Zaire and Nepal) • if hypothyroid – give iodine • hypothyroid b/c excessive goitrogens – stop food or meds causing it • iaotrogenic hypothyroid – we took thyroid gland out or damaged it w/ radiation • secondary hypothyroidism – pituitary (TSH) tertiary – problem is with hypothalamus

3. Excessive ingestion of exogenous goitrogens a. Foods b. Drugs 4. Iatrogenic causes of hypothyroidism: 5. Atrophy of thyroid as a result of chronic inflammatory autoimmune diseases which destroy the gland b. Secondary Hypothyroidism Pituitary gland c. Tertiary Hypothyroidism--Hypothalamus does not release Thyroid Releasing Hormone (TRH) and so does not stimulate pituitary to release Thyroid Stimulating Hormone (TSH) 1. S&S of hypothyroidism • hypometabolc • gain weight – slow metabolism •

↓HR

•

↓BP

•

↓temperature

• bowel sounds will be hypoactive: constipated

• intolerance to cold – want room warm • fatigue • hair loss – b/c decreased blood flow • decreased memory • depression • anemia – decreased blood flow = low profusion to kidneys, make erythropoietn – bone marrow stops making RBCs = decreased oxygenation •

cholesterol levels – go ↑ = blocked blood vessels. Someone that is hypothyroidism, will not have s/s of chest pain or MI b/c everything is slow. When you treat them for hypothyroidism, you speed everything up. At risk for angina & heart attacks

• FVE – profusion if poor- kidney and renin-angiotensin system holds on to sodium & water • Fertility problems • Reduced dosages of sleeping meds & pain meds – not metabolizing normally d. Myxedema hypothyroidism to the max – everything is slow. At risk of dying, most severe form of hypothyroidism 1. S&S of Myxedema • FVE - swelling of hands, feet, face, periorbital tissues. Not perfusing. • HR slow • BP low • Respiration low • Acidosis – not breathing fast leads to CNS depression – coma & death

• Anemia – kidney makes erthropoietn, stimulates bone marrow to make RBCs. Decreased oxygenation • Person hypothyroidism – ran out of medicine, or abruptly stopped taking meds. • Severe stress can cause myxedema 2. Medical/Nursing Mgt of Myxedema • Teach – do not come off meds abruptly, make sure you have back-up supply • Need IV thyroid hormone, airway, breathing, circulation • Warm them w/ blankets • Get HR up • BP up • Temperature up • Intubated -may need to be put on breathing machine

Diagnostic findings for hypothyroidism: • T 3 & T 4 – low • TSH – high • Cholesterol & trigylcerides – high • RBCs – low (anemia) • Radioactive iodine uptake – not normal, poor profusion

Treatment of hypothyroidism: • Give them low doses of sleeping & pain meds – not metabolizing properly • Start low and go slow with treatment • Exogenous hormones – Synthroid. B/c body is used to operating slow – speed everything up, HR goes up to keep up with oxygen demand – at risk for myocardial ischemia or infarction (heart attack) • Diabetics – if hypothyroid, speed up metabolism, increase insulin & calories • Cold intolerant – need heat on, ac off • Diet – low calories • Monitor GI status – constipation, impaction, hypoactive bowel sounds, fiber, fluids, laxatives, increase activity • I & O – increase their metabolism, output should increase • Cardiac symptoms – teach about chest pain, down left arm or left side of face – repot to MD immediately • Pain meds & sedatives carefully • Teach – need to repeat teaching • Take thyroid meds in 3. Nursing Diagnoses for Hypothyroidism Altered comfort RT cold intolerance Altered nutrition > BR RT hypometabolism Constipation RT decreased GI motility Activity intolerance RT decreased MR, decreased RBCs Altered thought processes RT diminished cerebral blood flow secondary to decreased CO

c. Hyperfunction of Thyroid Gland--Hyperthyroidism 1. Etiologies a. Primary disorder 1. Graves Disease--Diffuse toxic goiter autoimmune problem – develop immunoglobulins that act like TSH but much stronger with much longer effect. Acting like overactive pituitary gland sending out too much TSH, stimulating thyroid. NOT PITUITARY’S FAULT. b. Secondary causes of hyperthyroidism

2. S&S of hyperthyroidism • hypermetabolism •

↑ HR - tachycardiac

•

↑ BP - hypertensive

• heat intolerant – ac on • bowel sounds – hyperactive, diarrhea • skinny – burning everything off • can’t sleep or rest • depressed b/c they can’t sleep • skin is warm & moist • greasy hair b/c increased circulation • exophthalmos (bulging eyes) – increased retention of fluid around eyes • May have goiter – hypo or hyper 3. DX of hyperthyroidism

• thyroid is soft & may pulsate • thrill can often be palpated • bruit heard over thyroid arteries •

↓ TSH

•

↑ TSH

•

↑ free T 4

•

↑ radioactive iodine uptake

4. Medical/Nursing Mgt of Hyperthyroidism • Antithyroid meds – PTU – proplythiouracil – decrease synthesis or production of thyroid hormone. Take 4-8 weeks to start working. Elderly – may not tolerate surgery – keep them on PTU for maintenance for rest of life. PTU major side effect – agranulocytis – without WBCs, at risk for infection •

Iodine therapy – SSKI – reduce size & vascularity of thyroid gland. Given prior to surgery, can only use 10-14 days w/o causes other problems. Before surgery to reduce size & vascularity so when we cut out, don’t have profuse bleeding.

• Radioactive iodine therapy – iodine attracted to thyroid gland. Can give in higher doses to kill thyroid tissue. Higher dose than diagnostic procedure. Need to sleep alone for couple of nights b/c of radioactive material. Flush toilet. • Thyroidectomy – surgical removal of thyroid

5. Surgical Management of Hyperthyroidism a. Potential complications – nursing management • Monitor VS carefully – were hyper, now at risk for hypo • May go into thyroid storm (thyrotoxicosis) – especially if done sub-total thyroidectomy (partial removal). Hyperthyroidism to the max: dangerously tachycardiac, HTN, stroke, increase temp, can die • Monitor weight • Diet – lots of calories • Alternate rest & activity • Exophthalmos – saline drops, shields when they sleep to protect eyes b. Post-Op Thyroidectomy Nursing Care • assessment of VS - potential thyroid storm • hemorrhage – hypotension, loss of body fluids • head of bed up 30 degrees – helps reduce swelling in area, keep head in neutral position – good venous flow • cough & deep breath – teach before, during, after • good pain control • trachestomy set handy – as close to patient as possible • calcium gluconate handy • oxygen humidified – to help thin secretions, cough up secretions • check bleeding behind patient • check dressing for tightness – should not be tight, swelling going on

• assess for paresthesias – numbness & tingling around mouth, toes & fingers • check quality of voice - laryngeal nerve damage • thyroid storm (thyrotoxicosis) – HR up , need to bring HR down…beta blocker (-olol). HTN – give drugs to bring BP down. If hyperthermic – tylenol will not help, need cooling blanket. Report & take care of all of their symptoms. Thyroid storm is short lived, may last 12-24 hours, 2 days…as long as they have it, we need to treat them symptomatically.