Topic 1 Thyroid Problems

hyperthyroidism

hyperactivity of the thyroid gland with sustained inrease in synthesis and release of thyroid hormones; MC in women 20-40 y/o

Graves disease

what is the MC form of hyperthyroidism

Graves disease, toxic nodular goiter, thyroiditis, excess iodine intake, pituitary tumors, thyroid cancer

what are the causes of hyperthyroidism

thyrotoxicosis

the physiologic effects or clinical syndrome of hypermetabolism resulting from excess circulating levels of T4, T3, or both; usually occurs with hyperthuroidism

subclinical hyperthyroidism

TSH level below 0.4 mU/L but normal T4 and T3 levles

overt hyperthyroidism

low or undetectable TSH and increased T4 and T3

Graves disease

An autoimmune disease characterized by thyroid enlargement and excess thyroid hormone secretion, accounted for 75% of all hyperthyroidism; exact cause is unknown but RF are lack of iodine, smoking, infection, stress, genetic factors and associated with the presence of other autoimmune disorders, rheumatoid arthritis, pernicious anemia, systemic lupus erythematosus, Addison disease, celiac disease, and vitiligo

• increased metabolism and tissue sensitivity to sympathetic nervous system stimulation

• goiter

• Bruits from increased blood supply

• ophthalmopathy

• exophthalmos (Graves diseases)

• corneal ulcers

• loss of vision

• diplopia

• elderly in early stages may have weight loss and increased nervousness

• acropachy

• palpitations

• tremors

• weight loss

what are the clinical manifestations of hyperthyroidism

ophthalmopathy

a S/S of hyperthyroidism that describes abnormal eye appearance or function

exophthalmos

a classic finding in Graves’ disease; protrusion of the eyeballs from the orbits that results from increased fat deposits and fluid (edema) in the orbital tissues and ocular muscles causes the eyeballs to press outward, the upper lids retract and elevate, the sclera is visible above the iris, the eyes cannot close completely caused the corneal surfaces to become dry and irritated

acropachy

clubbing of the digits that may occur with advanced hyperthyroidism

acute thyrotoxicosis

an acute, severe, rare condition that occurs when excess amounts of thyroid hormones are released into the circulation; results from stressors like infection, trauma, or surgery in a patient with preexisting hyperthyroidism; manifestations include severe tachycardia, HF, shock, hyperthermia, agitation, delirium, seizures, abdominal pain, vomiting, diarrhea, and coma

aka. thyrotoxic crisis or thyroid storm

low/undetectable TSH levels and increased free T4 levels

What are the primary lab findings used to diagnose hyperthyroidism

RAIU test

can distinguish Graves disease from other forms of thyroiditis; if Graves disease, the patient should have a diffuse, homogenous uptake of 35-95%, if thyroiditis the uptake will be less than 2%, if a nodular goiter uptake in the high-normal range

antithyroid drugs, iodine, B-adrenergic blockers, radiation therapy

what meds are used to treat hyperthyroidism

propylthiouracil and methimazole (Tapazole)

The first line of antithyroid drugs that are used to treat hyperthyroidism; they inhibit thyroid hormone synthesis

propylthiouracil

the antithyroid drug that is generally used for patients who are in the 1st trimester of pregnancy, have had an adverse reaction to methimazole, or need a rapid reduction in symptoms; the first like therapy of thyrotoxicosis and achieves a therapetuic goal of being euthyroid more quickly, however must be taken 3x a day (nonadherence)

• HTN

• Tachycardia

• bounding, rapid pulse

• increased cardiac output and force of cardiac contractions

• systolic mururs

• dysrhythmias

• palpitations

• angina

how is the CV system impacted by hyperthyroidism

• increased capillary fragility

• decreased rate and force of contractions

• varied changes in BP

• cardiac hypertrophy

• distant heart sounds

• anemia

• HF

• angina

how is the CV system impacted by hypothyroidism

• increased appetite and thirst

• weight loss

• increased peristalsis and bowel sounds

• diarrhea, frequent defecation

• splenomegaly

• hepatomegaly

how is the GI system impacted by hyperthyroidism

• decreased appetite

• weight gain

• N/V

• constipation

• distended abdomen

• enlarged, scaly tongue

• celiac disease

how is the GI system impacted by hypothyroidism

• fatigue

• weakness

• proximal muscle wasting

• dependent edema

• osteoporosis

how is the MSK system impacted by hyperthyroidism

• fatigue

• weakness

• muscular aches and pain

• slow movements

• arthralgia

how is the MSK system impacted by hypothyroidism

• hyperactive DTR

• depression

• lack of ability to concentrate

• rapid speech

• insomnia

• difficulty focusing eyes

• nervousness

• fine tremor of fingers and tongue

• lability of mood, delirium

• restlessness

• personality changes of irritabiilty and agitation

• stupor, coma

how is the nervous system impacted by hyperthyroidism

• prolonged relaxation of DTR

• anxiety and depression

• slowed mental processes

• slow and slurred speech

• sleepiness

• apathy

• lethargy

• forgetfulness

• hoarseness

• stupor and coma

• paresthesias

how is the nervous system impacted by hypothyroidism

dyspnea on mild exertion and increased respiratory rate

how is the respiratory system impacted by hyperthyroidism

dyspnea and decreased breathing capacity

how is the respiratory system impacted by hypothyroidism

• warm, smooth, moist skin

• thin, brittle nails detached from nail beds (onycholysis)

• hair loss

• clubbing or fingers

• palmar erythema

• fine, silky hair

• premature graying in men

• diaphoresis

• vitiligo

• pretibial myxedema (infiltrative dermopathy)

• goiter

• eyelid retraction, exopthlamos, lid lag/stare

• increased temp and intolerance to heat

• l

how is the skin impacted by hyperthyroidism

• dry, thick, inelastic, cold skin

• thick, brittle nails

• dry, sparse, coarse hair

• poor turgor of mucosa

• generalized interstitial edema

• puffy face

• decreased sweating, intolerance to cold

• pallor

• goiter

• hearing problems

• increased risk of infection

• increased sensitivity to opioids, barbiturates, and anesthesia

how is the skin impacted by hypothyroidism

iodine

given as a saturated solution of potassium iodine (SSKI) and Lugol solution and used with other antithyroid drugs to prepare the patient for thyroidectomy or for treatment of thyrotoxicosis because in large doses it inhibits T3 and T4 synthesis and blocks the release of these hormones into circulation, and decreases the vascularity of the thyroid gland making surgery safer and easier; long term is not effective in controlling hyperthyroidism

swelling of the buccal mucosa and other mucous membranes, excess salivation, N/V, skin reaction

what are S/S of iodine toxicity

B-adrenergic blockers

used for symptomatic relief of thyrotoxicosis as they block the effects of sympathetic nervous stimulation → decreases tachycardia, nervousness, irritability, and tremorr

ie. propranolol and atenolol

propranolol

B adrenergic blocker that is usually given with other antithyroid agents

atenolol

the preferred B adrenergic blocker for use in the hyperthyroid patient with asthma or heart disease

decreases TSH

how does hyperthyroidism impact TSH levels

increases TSH

how does hypothyroidism impact TSH levels

increases T4

how does hyperthyroidism impact T4 (thyroxine) levels

decreases T4

how does hypothyroidism impact T4 (thyroxine) levels

normal cholesterol

how does hyperthyroidism impact total cholesterol levels

increases total cholesterol

how does hypothyroidism impact total cholesterol levels

decreases LDLs

how does hyperthyroidism impact LDL levels

increases LDLs

How does hypothyroidism impact LDL levels

normal triglycerides

how does hyperthyroidism impact triglyceride levels

increases triglycerides

how does hypothyroidism impact triglyceride levels

normal CK

how does hyperthyroidism impact creatine kinase (CK) levels

increases CK

how does hypothyroidism impact creatine kinase (CK) levels

increases BMR

how does hyperthyroidism impact basal metabolic rate (BMR)

decreases BMR

how does hypothyroidism impact basal metabolic rate (BMR)

radioactive iodine therapy (RAI)

The treatment of choice for most nonpregnant adults; damages/destroys thyroid tissues, limited thyroid hormone secretion, but has a delayed response with effect not being seen for up to 3 months, so usually used in conjunction with antithyroid drugs and propranolol until effects are seen. become apparent; can result in posttreatment hypothyroidism; side effects include dryness and irritation of the mouth

• older adults: anorexia, weight loss, apathy, lassitude, depression, confusion

• younger adult: nervousness, irritability, weight loss, heat intolerance, warm moist skin

what are the difference of symptoms of hyperthyroidism in young and older adults

• use private/separate toilet facilities if possible

• flush 2-3 times after each use

• separately laundering towels, bed linens, and clothes daily at home

• do not prepare food for others that needs prolonged handling with bare hands

• avoid being close to pregnant women and kids for 7 days after therapy

what teaching should the nurse provide to patients undergoing RAI to limit radiation exposure to others at home

thyroidectomy

surgical therapy for hyperthyroidism for those who have a large goiter causing tracheal compression, a lack of response to antithyroid drugs, or thyroid cancer

acute thyrotoxicosis

caused by infection, surgery trauma in a patient with hyperthyroidism, or a thyroidectomy

s/s include abdominal pain, agitation, delirium, diarrhea, fever, HF<seizures, severe tachycardia, shock, vomiting

Often requires aggressive treatment in the ICU, give meds that block thyroid products and SNS effects, monitor heart, provide oxygen, give IV fluids, ensure rest with a calm, cool, and quiet room, encourage and assist with exercise

apply artificial tears to soothe/moisten conjunctival membranes, restricting salt may reduce periorbital edema, sit upright to promote fluid drainage, dark glasses reduce glare and irritations from allergic, can light take eyes shit for sleep, exercise the intraocular muscles several times a day, corticosteroids, radiation, orbital decompression, corrective lid/muscle surgery

What are interventions to treat or relieve pain/discomfort due to exophthalmos

laryngeal stridor

harsh, vibratory sound that may occur because of edema of the laryngeal nerve related to tetany from hypocalcemia, which occurs if the parathyroid glands were removed/damaged during surgery; Tx: IV calcium salts

hypothyroidism

a deficiency of thyroid hormone that causes a general slowing of the metabolic rate, MC in women

subclinical hypothyroidism

occurs when the TSH is greater than 4.5 mU/L but the T4 levels are normal

primary hypothyroidism

caused be destruction of thyroid tissue or defective hormone synthesis

Iodine deficiency (worldwide) and atrophy of the thyroid glands as a result of Hashimoto thyroiditis (US)

what is the MCC of hypothyroidism worldwide and in the US

• slowing of body processes

• tired and lethargic

• impaired memory

• slowed speech

• decreased initiative

• somnolence

• appear depressed

• weight gain

• decreased cardiac contractility and output

• low exercise tolerance

• SOB on exertion

• high cholesterol and triglycerides

• myxedema

• myxedema coma

• older adults: fatigue, cold and dry skin, hair loss, constipation, cold intolerance, confusion, lethargy, depression

what are the clinical manifestations of hypothyroidism

myxedema

S/S of hypothyroidism that results from the accumulation of hydrophilic mucopolysaccharides in the dermis and other tissues, altering the physical appearance of the skin and sub-q tissues with puffiness, facial and periorbital edema, and a mask-like effect

Levothyroxin (Synthroid); monitor HR and report pulse > 100 bpm or irregular heartbeats, report chest pain, weight loss, nervousness, tremors, or insomnia

what is the drug of choice to treat hypothyroidism and what are nursing considerations for this medication