Thyroid & Parathyroid Gland Conditions

Hypothyroidism

Reduced or absent hormone secretion from the thyroid gland that results in decreased metabolism from inadequate cellular regulation

Onset is gradual

Symptoms can mimic other diseases

Myxedema: Changes in the appearance of the patient

• tongue is thick and enlarged (macroglossia)

• inputting edema form in multiple places, especially in the perineal areas or on top of the feet bilaterally

• hands, elbows, and face can also be affected

Myxedema Coma

•Rare, but serious complication of u treated or poorly treated hypothyroidism with reduced cardiopulmonary and neurologic functioning

• Heart muscle becomes flabby

• Chamber sizes increases

• Decreased cardiac output, perfusion, & gas exchange in the brain ultimately leading to organ failure

Hypothyroidism Etiology & Genetic Risk

Autoimmune problems called Hashimoto Thyroiditis (HT):

• body provides autoantibodies that attack the thyroid tissue

• inflammation, extensive tissue destruction & reduced secretion of thyroid hormones

• thyroid surgery

• radioactive iodine (RA) tx of hyperthyroidism

• common in areas where soil & water have little natural iodine ( endemic goiter)

— Genetic:

• congenital hypothyroidism

• present @ birth

• down syndrome & turner syndrome

Causes of Hypothyroidism: Primary

— Primary:

• decreased thyroid tissue

• surgical or radiation- induced thyroid destruction

• autoimmune thyroid destruction

• congenital ( poor thyroid development)

• cancer (thyroidal or metastatic)

Causes of Hypothyroidism: Secondary

•Decreased synthesis of thyroid hormone: endemic iodine deficiency

Drugs: amiodarone, guaifenesin, lithium

• Inadequate production of thyroid stimulating hormone:

— congenital pituitary defects

— pituitary tumors, trauma, infections, or infarcts

— hypothalamic tumors, trauma, infection or infarcts

Hypothyroidism: Health Promotion/ Disease Prevention

• no knows ways to prevent hypothyroidism

• recommended that patients stay alert for symptoms

Hypothyroidism: Signs & Symptoms

• coarse skin

• edema around the eyes and face

• weight gain, can occur even when person isn’t overeating

• dyspnea of exertion

•hoarseness

• muscle movement is slow

• tongue thickening may impair speaking

• reduced cognitive function

• may have a goiter, suggest a thyroid problem

Hypothyroidism: Cardiac & Respiratory S/S

• decreased leading to gas exchange being impaired

• HR below 60

• low body temperature

Hypothyroidism: Assessment

• ask or to compare activity now with that of a year ago

• increased sleeping time

• generalized weakness, muscle aches, and paresthesia

• constipation & cold intolerance are common

• changes may be subtle

• decreased libido

• women may have difficulty getting pregnant or have changes in menses

• men report problems with impotence & fertility

• ask about previous or current use of drugs (lithium & amiodarone)

• history of COVID-19 which can affect the thyroid

Hypothyroidism: Respiratory Management

• Their management is a priority!

• observe rate and depth of respirations

• oxygen saturation

• auscultation of lungs for decrease in breath sounds/ crackles

Hypothyroidism: Cardiac Management

• causes increased BP and dysrhythmias

• monitoring B/P, HR, & rhythm for changes and preventing complications

Hypothyroidism: what medication are they required to take for a lifetime?

What teaching is required ?

*Require lifelong thyroid hormone replacement (Levothyroxine)

•Take the drug exactly as prescribed & don’t change the dose or schedule

• Taken with water on an empty stomach, 30 to 60 minutes before a meal in the morning

• Iron, calcium supplements, and antacids —> should be taken separately by at least 4 hours

Factors Leading to Myxedema Coma

• acute illness

• surgery

• chemotherapy

• discontinuation of thyroid replacement therapy

• use of sedatives or opioids

Myxedema Coma Leads To?

• reduced LOC

• respiratory failure

• hypotension

• hyponatremia

• hypothermia

• hypoglycemia

• bradycardia

Hypothyroidism: Discharge Teaching/ Management

• usually chronic condition

• don’t require changes in the home unless cognition is decreased

• patient may need help with medication

• review both hypo/hyperthyroid symptoms that may occur

• maintain nutrition with adequate fiber and fluid intake

Hyperthyroidism:

• What is it?

• What does it cause ?

• Excessive hormone stimulates ?

• What other things does it stimulate & affect?

— excessive thyroid hormone secretion from the thyroid gland

• increases metabolism in all body organs

• can be temporary or permanent, depending on the cause

• excessive hormone stimulates the body system causing hypermetabolism

• increased sympathetic nervous system

• stimulates the heart, increasing rate and stoke volume

• affects protein, fat, and glucose metabolism and protein buildup

Hyperthyroidism: Etiology & Genetic

• glucose intolerance is decreased, develop hyperglycemia

• Fat metabolism is increased and body fat decreases

• Most common for us Graves Disease:

  — occurs after an episode of thyroid inflammation

  — exophthalmos & pretibial myxedema ( extrusion of the eye balls)

  — multiple nodules ( toxic multinodular goiter)

Hyperthyroidism: Assessment/ History

• Nutrition

• Intolerance to?

• Energy level?

• Cardiovascular?

• Other?

• History of?

• Nutrition: unplanned weight loss, increased appetite, increase # of bowel movements per day

• Heat intolerance: increased sweating

• Palpitations or chest pain

• Dyspnea is common

• Visual changes may be an early problem

• Changes in energy level: fatigue & insomnia is common

• Changes in libido

• Hx of thyroid surgery or radiation therapy to the neck

Hyperthyroidism: Signs & Symptoms r/t Eyes

• expothalmos is common in Graves’ disease d/t edema in the extraocular muscles and increased fatty tissue behind the eyes, which pushes the eyeballs forward

• Pressure on the optic nerve may impair vision

• Eyes may become dry

• Blood shot appearance

• Sensitivity to light (photophobia)

• Eyelid retraction (eyelid lag): upper lid fails to descent when gazes slowly downward

• Globe (eyeball): lag upper lid pulls back faster than the eyeball when the patient gazes upward

Hyperthyroidism: Signs & Symptoms

Observe for?

What can be heard within the gland?

Cardiovascular problems?

Hair and skin?

Muscles ?

• observe for size & symmetry of the thyroid gland

• Bruits (turbulence from increased blood flow) may be heard within the gland

• cardiovascular: increased systolic blood pressure, tachycardia, & dysrhythmias

• Inspect the hair & skin: find soft, silky hair & smooth, warm, moist skin are common

• Muscle weakness, and hyperactive deep tendon reflexes are common

• Motor movements of the hand, restless and irritable

Hyperthyroidism: what do we not palpate on assessment?

• do not palpate a goiter as it can stimulate the sudden release of excessive thyroid hormones

Hyperthyroidism: Psychosocial Assessment/ Signs & Symptoms See

• wide mood swings

• Decreased attention span

• Anxiety

• Hyperactivity leads to fatigue

• Cry or laugh without cause or have difficulty concentrating

• Change in mental or emotional status

Hyperthyroidism: Laboratory Assessment

Measurement of blood levels for?

Antibodies to what receptor to diagnose what?

What is given to measure the uptake of iodine by the thyroid gland?

• measurement of blood levels for triiodothyronine (T3) and thyroxine (T4) & thyroid stimulating hormone (TSH)

• Antibodies to the TSH receptor to diagnose Graves Disease

• Radioactive iodine (RA-123), given by mouth, and the uptake of iodine by the thyroid gland (radioactive uptake) is measured

• Ultrasound

Hyperthyroidism: Nonsurgical Management

• monitoring includes measuring vital signs every 4 hours

• Teach to report any palpitations, dyspnea, vertigo, or chest pain

• Reducing stimulation

• Promoting comfort

Hyperthyroidism: what indicates a rapid worsening of the condition?

• Increases in temperature may indicate a Thyroid Storm

• Rare, life threatening event that occurs in patients with uncontrolled hyperthyroidism (more intense)

Antithyroid Medications

• Thionamides, especially Methimazole

• Iodine Preparation

• Beta Adrenergic blocking drugs

Antithyroid Medications (Hyperthyroidism): Thionamides

• Methimazole

• Propylthiouracil is less common because of its toxic effects on liver

Antithyroid Medications (Hyperthyroidism): Iodine Preparation

• decreases blood flow through the thyroid gland

• Radioactive iodine therapy

Antithyroid Medications (Hyperthyroidism): Beta Adrenergic Blocking Agents

• Atenolol or Propranolol

• Relives symptoms such as diaphoresis, anxiety, tachycardia, & palpitations

Hyperthyroidism: Surgical Management

• removal of all parts of the thyroid gland is used to manage Graves’ disease

• Total thyroidectomy or subtotal thyroidectomy

Hyperthyroidism: Thyroidectomy Preoperative Teaching

• treated with thionamide drug therapy first before thyroid function (euthyroid)

• Hypertension, dysrhythmias, & tachypnea must be controlled before surgery

• Teach turn, cough, & deep breath

• Have to support the pt’s neck before they’ve just had a neck procedure

Hyperthyroidism: Thyroidectomy Operative Procedure

• minimally invasive & traditional open approach

• Parathyroid glands & recurrent laryngeal nerves are avoided

Hyperthyroidism: Thyroidectomy Post Operative Care

• V/S every 15 minutes until pt is stable, then ever 30 minutes

• LOC

• Pain control

• Deep breath every 30 minutes to an hour

• Check temperature often, may indicate impending thyroid storm activity

• Tingling around the mouth or of the toes & fingers, muscle twitching

• Tetany- low calcium if parathyroid glands are removed resulting in decreased in PTH

Hyperthyroidism: Thyroidectomy Post Operative Complications

• Hemorrhage during the first 24 hours

• Respiratory distress and reduced gas exchange

• Eye and vision problems associated with Graves Disease

• Ischemia & Blindness can occur

• Laryngeal nerve damage resulting in hoarseness

• Thyroid storm: increased metabolic rate, fever, tachycardia, n/v, diarrhea

Thyroiditis

• group of conditions that cause inflammation of the thyroid gland Radioactive

• Acute or chronic

Infectious Thyroiditis

Caused by bacterial invasion

Subacute or Granulomatous Thyroiditis

• results from a viral infection after a cold or upper respiratory infection ( neck pain & gland feels hard)

Radiation Thyroiditis

• occurs 5 to 10 days after treatment with radioiodine

Most Common Type of Hypothyroidism

• chronic autoimmune thyroiditis (Hashimoto Thyroiditis)

• Dysphagia & painless enlargement of the gland

Palpation/ Trauma induced thyroiditis

4 Major Types of Thyroid Cancer

• Papillary Carcinoma

• Follicular Carcinoma

• Medullary Carcinoma

• Anaplastic Carcinoma

Thyroid cancer: Papillary Carcinoma

• The most common type

• Slow growing

Thyroid Cancer: Follicular Carcinoma

• between age 40 to 60 years old

• In countries where iodine is not found

• Invades blood vessels and spreads to bone and lung tissue

Thyroid Cancer: Medullary Carcinoma

Occur due to multiple endocrine neoplasia type 2

Thyroid Cancer: Anaplastic Carcinoma

• rapidly growing, aggressive tumor that invades nearby tissues

Thyroid Cancer: Collaborative Care

• surgery

• Total thyroidectomy is usually performed with dissection of lymph nodes in the neck

• Radioactive iodine

• External beam radiation/ chemotherapy ( cancer usually metastasis at diagnosis)

• Radiation used to shrink the tumor prior to surgery

Hypoparathyroidism

• PTH acts directly on the kidney, causing increased kidney reabsorption of calcium and increased phosphorus excretion

• Rate disorder, function is decreased and calcium levels cannot be maintained, resulting in hypocalcemia

• Occurs most often post surgically after removal of the thyroid gland

Hypoparathyroidism: Assessment

• ask about head and neck surgery or radiation therapy

• Neck injury

• Check trousseau and Chvostek signs

• Excessive or inappropriate muscle contractions that cause finger, hand, and elbow flexion (tetany)

Hypoparathyroidism: Signs & Symptoms

• tingling & numbness to muscle tetanus

• Tingling and numbness around the mouth or in the hands and feet reflect mild to moderate hypocalcemia

• Severe muscle cramps

• Spasms of the hands and feet and seizures

Hypoparathyroidism: Interventions

• correcting hypocalcemia

• Preventing kidney stones

• IV calcium gluconate

• Oral calcitroil and calcium carbonate

• Oral vitamin D

• Lifelong therapy

Hyperparathyroidism

• disorder in which parathyroid secretion of parathyroid hormone is increased, resulting in hypercalcemia and hypophosphatemia

• Excessive PTH in the bone increases bone resorption by decreasing osteoblastic activity & increasing osteoclastic activity

• Releases calcium and phosphorus into the blood stream and reduces bone density

Hyperparathyroidism: Assessment

• Symptoms from excessive PTH or the accompanying hypercalcemia

• Ask about bone fractures, recent weight loss, arthritis or psychological stress

• Recent radiation treatment

• High levels of PTH cause kidney stones

• Bone lesions from increased bone destruction

• Psychosis with confusion, followed by coma and death

Hyperparathyroidism: GI Assessment

• elevated gastric levels from hypercalcemia leading to peptic ulcer formation

• Fatigue & lethargy when serum calcium is greater than 12 mg/dl

Hyperparathyroidism: Interventions

Routine monitoring of?

Lifestyle changes?

Avoid?

• surgical management

• Routine monitoring of calcium

• Regular exercise, adequate hydration & avoiding lithium ther, as these raise calcium levels

• Avoid prolonged bed rest and diet with vitamin D & calcium

• Preventing injury due to decreased bone density

Hyperparathyroidism: Medications

• Use of Cinacalcet, a calcimimetic (reducing PTH) production

• Biphosphonates for those with osteoporosis

Hyperparathyroidism: Interventions- Surgical Management

• parathyroidectomy (calcium level return to normal)

• Minimally invasive or with traditional transverse incision in the lower neck

• All 4 parathyroid glands are examined for enlargement during exploration

• Laryngeal nerve can be damaged during surgery

• Monitor for hypocalcemia crisis requiring more frequent monitoring of calcium levels