Evaluating Outcomes for Clients with Thyroid and Parathyroid Problems

1
Evaluating Outcomes for Clients with Thyroid and
Parathyroid Problems
2
Hyperthyroidism

• Thyrotoxicosis
• Graves disease, the most frequent causes
  goiter, exophthalmos, pretibial myxedema
• Laboratory assessment
• Thyroid scan
• Ultrasonography
• Electrocardiography

3
Drug Therapy

• Radioactive iodine therapy not used in pregnant
  women
• Additional drug therapy may be needed.
• Implement radiation precautions.
• Monitor regularly for changes in thyroid function.

4
Surgical Management

• Surgery possible in absence of good response to
  drug therapy.
• Postoperative care for
• Hemorrhage
• Respiratory distress
• Hypocalcemia and tetany
• Laryngeal nerve damage
• Thyroid storm or thyroid crisis

5
Infiltrative Opthalmopathy

• Provide symptomatic treatment.
• Treatment of hyperthyroidism does not correct eye
  and vision problems of Graves disease.
• Elevate the head of bed at night.
• Instill artificial tears.
• Treat photophobia with dark glasses.
• (Continued)

6
Infiltrative Opthalmopathy (Continued)

• Give steroid therapy.
• Provide diuretics.

7
Hypothyroidism

• Decreased metabolism from low levels of thyroid
  hormones
• Myxedema coma a rare, serious complication
• Mostly a result of thyroid surgery and
  radioactive iodine treatment of hyperthyroidism
• Clinical manifestations

8
Decreased Cardiac Output

• Interventions
• Monitor circulatory status.
• Monitor for signs of inadequate tissue
  oxygenation.
• Monitor for changes in mental status.
• Monitor fluid status and heart rate.
• Administer oxygen or mechanical ventilation, as
  appropriate.

9
Ineffective Breathing Pattern

• Interventions
• Observe and record rate and depth of
  respirations.
• Auscultate the lungs.
• Assess for respiratory distress.
• Assess the client receiving sedation for
  respiratory adequacy.

10
Disturbed Thought Processes

• Interventions
• Assess lethargy, drowsiness, memory deficit, poor
  attention span, and difficulty communicating.
• These problems should decrease with thyroid
  hormone treatment.
• Provide a safe environment.
• Provide family teaching.

11
Myxedema Coma

• Coma, respiratory failure, hypotension,
  hyponatremia, hypothermia, hypoglycemia
• Emergency care

12
Thyroiditis

• Inflammation of the thyroid gland
• Three types of thyroiditis acute, subacute
  (granulomatous), and chronic (Hashimotos
  disease)the most common type
• Dysphagia and painless enlargement of the gland
• Nonsurgical management, drug therapy
• Surgical management

13
Thyroid Cancer

• Papillary, follicular, medullary, and anaplastic
• Collaborative management
• Surgery treatment of choice thyroidectomy
• Suppressive doses of thyroid hormone for 3 months
  after surgery
• Study performed after drugs are withdrawn

14
Hyperparathyroidism

• Parathyroid glands calcium and phosphate balance
• Hypercalcemia and hypophosphatemia
• Nonsurgical management
• Diuretic and fluid therapy
• Drug therapy phosphates, calcitonin, calcium
  chelators

15
Surgical Management

• Parathyroidectomy preoperative care
• Client stabilized calcium levels normalized
• Studies bleeding and clotting times, CBC
• Teaching coughing, deep-breathing exercises,
  neck support
• Operative procedures
• (Continued)

16
Surgical Management (Continued)

• Postoperative care includes
• Observe for respiratory distress.
• Keep emergency equipment at bedside.
• Hypocalcemic crisis can occur.
• Recurrent laryngeal nerve damage can occur.

17
Hypoparathyroidism

• Decreased function of the parathyroid gland
• Iatrogenic hypoparathyroidism
• Idiopathic hypoparathyroidism
• Hypomagnesemia
• Interventions correcting hypocalcemia, vitamin D
  deficiency, and hypomagnesemia

18
If a manifestation is caused by hyperthyroidism,
indicate HYPER. If a manifestation is caused
by hypothyroidism, indicate HYPO.

• Decreased body temperature
• Palpitations
• Apathy
• Diaphoresis
• Thinning of scalp hair
• Thick, brittle nails
• Constipation

• Tremors
• Heat intolerance
• Weight gain
• Tachycardia
• Insomnia
• Dry, coarse, brittle hair
• Decreased activity tolerance

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HYPO HypothyroidismHYPER Hyperthyroidism

• Tremors HYPER
• Heat intolerance HYPER
• Weight gain HYPO
• Tachycardia HYPER
• Insomnia HYPER
• Dry, coarse, brittle hair HYPO
• Decreased activity tolerance HYPO

• Decreased body temperature HYPO
• Palpitations HYPER
• Apathy HYPO
• Diaphoresis HYPER
• Thinning of scalp hair HYPER
• Thick, brittle nails HYPO
• Constipation HYPO

20
The pathology of Graves disease is (select one)

1. increased release of TSH (thyroid stimulating
   hormone) by the anterior pituitary.
2. an autoimmune disorder in which antibodies are
   made and attach to the TSH receptor sites on the
   thyroid tissue.
3. the development of a thyroid nodule which
   releases increased amounts of thyroid hormones.
4. a lack of dietary iodine.

21
B

• Graves disease is an autoimmune disorder in
  which antibodies are made and attach to the TSH
  receptor sites on the thyroid tissue. When these
  antibodies, known as thyroid-stimulating
  immunoglobulins (TSIs), bind to the thyroid
  gland, the gland increases in size and
  overproduces thyroid hormones.
• Clients with Graves disease also have
  exophthalmos (wide-eyed appearance) and pretibial
  myxedema.

22
How can laboratory tests help differentiate
hyperthyroidism caused by Graves disease versus
hyperthyroidism caused from hyperpituitarism?
23

• With hyperthyroidism, both the T3 and T4 blood
  levels are elevated, causing hypermetabolism. An
  elevated free thyroxine (FT4) or Free T4 index
  may be more useful as it provides information
  about the active hormone. The FT4 is also
  elevated in hyperthyroidism. In Graves disease,
  the autoantibodies bind to the TSH receptor and
  activate it, causing an overproduction of thyroid
  hormones.

24

• The increased metabolic rate negatively feeds
  back and suppresses hypothalamic secretion of
  thyrotropin hormone, which in turn suppresses
  thyroid-stimulating hormone (TSH). The TSH is
  decreased in Graves disease. When the TSH
  levels are elevated despite increased synthesis
  of thyroid hormones, hyperpituitarism is a
  possible cause.

25
If the statement is true, place a T before the
statement. If the statement is false, place a
F before the statement.

• A client is given radioactive iodine by mouth and
  scanned 24 hours later during a thyroid scan.
• Drug therapy for hyperthyroidism commonly
  includes antianxiety medications alprazolam
  (Xanax), lorazepam (Ativan) to relieve
  diaphoresis, anxiety, tachycardia, and
  palpitations.
• Results from drug therapy and from radioactive
  iodine therapy are usually seen in 48-72 hours.
• A patient with hyperthyroidism has a need for
  increased calories, carbohydrates, and especially
  proteins.

26
A client is given radioactive iodine by mouth
and scanned 24 hours later during a thyroid
scan.

• TRUE
• The thyroid scan evaluates the position, size,
  and functioning of the thyroid gland.
• The uptake of the radioactive iodine is measured.
  Normally the thyroid has an uptake of 5 35
  when measured at 24 hours.
• The uptake of radioactive iodine is increased in
  hyperthyroidism.

27
Drug therapy for hyperthyroidism commonly
includes antianxiety medications alprazolam
(Xanax), lorazepam (Ativan) to relieve
diaphoresis, anxiety, tachycardia, and
palpitations.

• FALSE
• The most commonly ordered antithyroid drugs are
  the thioamides, including propylthiouracil (PTU)
  and methimazole (Tapazole), which block thyroid
  hormone production.
• Iodine preparations decrease blood flow through
  the thyroid gland. This reduces the production
  and release of thyroid hormone.
• Lithium carbonate also inhibits thyroid hormone
  release.
• Beta-adrenergic blocking drugs, such as
  propranolol (Inderal) and atenolol (Tenormin),
  relieve diaphoresis, anxiety, tachycardia, and
  palpitations.

28
Results from drug therapy and from radioactive
iodine therapy are usually seen in 48-72 hours.

• FALSE
• The response to thioamides is delayed because the
  client may have large amounts of thyroid hormone
  stored that continues to be released.
• With the use of iodine preparations, improvement
  usually occurs within 2 weeks, but weeks may be
  needed before metabolism returns to normal.

29
A patient with hyperthyroidism has a need for
increased calories, carbohydrates, and especially
proteins.

• TRUE
• The client is hypermetabolic and has an increased
  need for calories, carbohydrates, and proteins.
  Proteins are especially important because the
  client is at risk for a negative nitrogen balance.

30
More questions
31
What should be assessed to determine if
antithyroid agents (such as propylthiouracil) are
effective? What are common side effects
associated with these drugs?
32

• Effectiveness of therapy can be demonstrated by a
  decrease in the severity of symptoms of
  hyperthyroidism.
• Of particular concern is the effect of the
  thyroid hormone activity on cardiac function.
  The drugs should lower the systolic BP, narrow
  the pulse pressure, lower the heart rate, and
  eliminate dysrhythmias if effective.
• Weight gain is another sign of effective therapy.
• The most common side effects are nausea,
  vomiting, and rash. Hypothyroidism is a possible
  side effect for which dose adjustment may be
  indicated.

33
Indicate if the statement regarding thyroidectomy
is true (T) of false (F).

• A client should avoid coughing following surgery.
• Clients are at risk for hypocalcemia following a
  thyroidectomy.
• Permanent hoarseness occurs if laryngeal nerve
  damage occurs.
• In acute respiratory obstruction, a laryngeal
  stridor will be heard.
• Neck extension should be avoided to decrease
  tension on the suture line.

34

• A client should avoid coughing following surgery.
  FALSE, BUT IT IS IMPORTANT TO SUPPORT THE NECK
  WHEN COUGHING OR MOVING. PLACING BOTH HANDS
  BEHIND THE NECK WHEN MOVING REDUCES THE STRAIN ON
  THE SUTURE LINE.
• Clients are at risk for hypocalcemia following a
  thyroidectomy. TRUE. THE PARATHYROID GLANDS CAN
  BE DAMAGED OR THEIR BLOOD SUPPLY IMPAIRED.
  HYPOCALCEMIA AND TETANY RESULT IF PARATHYROID
  HORMONE IS DECREASED. EARLY SIGNS OF
  HYPOCALCEMIA ARE NUMBNESS AND TINGLING AROUND THE
  MOUTH OR FINGERS AND TOES.
• Permanent hoarseness occurs if laryngeal nerve
  damage occurs. FALSE. THE NURSES ASSESSES THE
  CLIENTS VOICE AT 2-HOUR INTERVALS AND DOCUMENTS
  CHANGES. THE CLIENT IS REASSURED THAT HOARSENESS
  IS USUALLY TEMPORARY.
• In acute respiratory obstruction, a laryngeal
  stridor will be heard. TRUE. EMERGENCY
  TRACHEOSTOMY EQUIPMENT IS KEPT IN THE CLIENTS
  ROOM.
• Neck extension should be avoided to decrease
  tension on the suture line. TRUE. SANDBAGS AND
  PILLOWS ARE USED TO SUPPORT THE HEAD AND NECK.

35
Thyroid Storm

• What interventions are implemented prior to a
  thyroidectomy to prevent the risk of a thyroid
  storm?
• What signs and symptoms are common during a
  thyroid storm?
• What are the primary concerns during a thyroid
  storm?

36
Thyroid Storm

• Prior to surgery a clients receive antithyroid
  drugs, beta blockers, steroids, and iodides
  before to prevent thyroid crisis.
• Signs and symptoms of a thyroid storm are related
  to the increase in metabolic rate. They include
  fever, tachycardia, systolic hypertension,
  abdominal pain, NV, diarrhea, agitation,
  tremors, restlessness, confusion, psychosis, and
  seizures, It has a mortality rate of 25.
• It is important to identify the causative event.
  The primary concerns will be maintaining airway
  patency, providing adequate ventilation, and
  stabilizing the hemodynamic status.

37
Myxedema

• During hypothyroidism, cellular energy production
  is decreased and metabolites build up.
• The metabolites are compounds of proteins and
  sugars called glycosaminoglycans.
• These compounds build up inside cells, which
  increases mucous and water, forms cellular edema,
  and changes organ texture.
• The edema is mucinous edema (called myxedema)
  rather than edema caused by water alone.

38
Myxedema Coma

• A rare, serious complication of untreated or
  inadequately treated hypothyroidism.
• Decreased metabolism leads to a flabby heart
  increased chamber size
• Cardiac output decreases
• Perfusion to the brain and other organs decreases
• Decreased perfusion makes slowed cellular
  metabolism worse.
• Tissue and organ failure occurs.

39
What is the most common reason a person seeks
medical help prior to being diagnosed with
hypothyroidism? (select one)

• Weight gain
• Dyspnea
• Depression
• Hoarseness

40
C. Depression

• Depression is the most common reason for seeking
  medial attention. Family members often bring the
  client for the initial evaluation. The client
  may be too lethargic, apathetic, or drowsy to
  recognize changes in his or her condition.
• Other psychosocial changes include paranoia,
  agitation, disturbed thought process, and
  impaired memory.

41
Indicate T for a true statement and F for a
false statement.

• The client with more severe symptoms of
  hypothyroidism is started on the lowest dose of
  thyroid hormone replacement.
• A client is placed on thyroid hormone replacement
  until T3 and T4 level become normal, and is then
  gradually tapered off the medication.
• Increased mental awareness is a sign of effective
  thyroid hormone replacement therapy.
• Emergency care of the client during myxedema coma
  includes levothyroxine sodium IV.

42
True or False

• The client with more severe symptoms of
  hypothyroidism is started on the lowest dose of
  thyroid hormone replacement. TRUE. This caution
  is especially important when the client has known
  cardiac problems. Severe hypertension, heart
  failure, and myocardial infarction can occur if
  the initial dose is too high or if the dose is
  increased too rapidly.
• A client is placed on thyroid hormone replacement
  until T3 and T4 level become normal, and is then
  gradually tapered of the medication. FALSE The
  client with hypothyroidism requires lifelong
  thyroid hormone replacement.

43
True or False

• Increased mental awareness is a sign of effective
  thyroid hormone replacement therapy. TRUE Other
  signs of resolving hypothyroidism will also
  demonstrate effective therapy.
• Emergency care of the client during myxedema coma
  includes levothyroxine sodium IV. TRUE Other
  interventions include maintain a patent airway,
  replacing fluids, administering glucose IV,
  administering corticosteroids, checking
  temperature frequently, monitoring BP, covering
  client with warm blankets, and monitoring mental
  status.

44
Conditions that could lead to hyperparathyroidism
include which of the following? Indicate all
that apply.

• Congenital thyroid dysgenesis
• Parathyroid carcinoma
• Vitamin D deficiency
• Hypomagnesemia
• Chronic renal failure with hypocalcemia.
• Neck trauma

45
Causes of hyperparathyroidism include the BOLD
items

• Congenital dysgenesis
• Parathyroid carcinoma
• Vitamin D deficiency
• Hypomagnesemia
• Chronic renal failure with hypocalcemia.
• Neck trauma
• Other causes are parathyroid adenoma, congenital
  hyperplasia, neck radiation, parathyroid
  hormone-secreting carcinomas of lung, kidney , or
  GI tract.

46
Indicate T for a true statement and F for a
false statement.

• A client with hyperparathyroidism is at risk for
  pathologic fractures.
• Hypercalcemia associated with hyperparathyroidism
  is treated with dietary restriction of calcium.
• A positive Chvosteks sign and Trousseaus sign
  indicate hypercalcemia.
• Serum PTH, calcium, and phosphate levels and
  urine cyclic adenosine monophosphate (cAMP) are
  the most commonly used laboratory tests to detect
  hyperparathyroidism.

47
True or False

• A client with hyperparathyroidism is at risk for
  pathologic fractures. TRUE An increased rate of
  bone destruction occurs when the levels of PTH
  are high, resulting in pathologic fractures, bone
  cysts, and osteoporosis.
• Hypercalcemia associated with hyperparathyroidism
  is treated with dietary restriction of calcium.
  FALSE A diuretic and fluid therapy is the most
  common method used to lower calcium. Other drug
  therapy includes oral phosphates, calcitonin, and
  calcium chelators such as Mithramycin.

48
True or False

• A positive Chvosteks sign and Trousseaus sign
  indicate hypercalcemia. FALSE Low calcium levels
  are associated with increased neuromuscular
  activity. Chvosteks and Trousseaus are found
  in hypocalcemia.
• Serum PTH, calcium, and phosphate levels and
  urine cyclic adenosine monophosphate (cAMP) are
  the most commonly used laboratory tests to detect
  hyperparathyroidism. TRUE In hyperparathyroidism,
  serum PTH is increased, calcium is increased,
  phosphate is decreased, and urinary cAMP is
  increased.