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Chapter 45

Thyroid and Parathyroid Disorders

QuestionAnswer
What are the hormones produced by the thyroid gland? Thyroid hormone, triiodothyronine, and calcitonin.
Thyroid hormone is also called... Thyroxine, tetraiodothyronine or T4.
Triiodothyronine is referred to as... T3
T3 and T4 Increase the body's metabolic rate.
Calcitonin (thyrocalcitonin) Plays a role in regulating the serum calcium level. Secreted when serum calcium levels are high and limits the shift of calcium from the bones into the blood.
Age related changes in thyroid function Increased incidence of nodules, T3 decline, increase incidence of hypothyroidism (especially in women), and increased risk for thyroid dysfunction.
Health history Ask the patient if they have experienced any changes in energy level, sleep patterns, personality, weight loss or gain, mental function, or emotional state. It also important to ask about fatigue, which could appear in both hypo- and hyperthyroidism.
Review of systems Assess changes in menstrual cycle, sexual function, hydration (thirst, changes in urine output, tissue turgor, moisture of mucous membranes), bowel elimination pattern, and tolerance of heat and cold.
Physical examination Pay close attention to facial expression, alertness, vital signs (they reflect metabolic rate); inspect and palpate skin for moisture, temp., and texture; note hair texture, observe for exophthalmos or a goiter, and note a tremor in the hands if present.
Serum T3 and T4 test preparation and postprocedure care Preparation- Tell patient blood will be drawn, nonfasting, some meds may be held. Post- assess for oozing and apply dressing to the site.
Serum thyroid-stimulating hormone (TSH) preparation and postprocedure care Preparation- tell the patient blood will be drawn. Post- assess for oozing and apply dressing at the site.
Thyroid-releasing hormone (TRH) stimulation test preparation and postprocedure care Preparation- tell the patient a drug will be given IV and then several blood samples will be drawn. Post- assess site for oozing and apply bandage to the site.
Radioactive iodine (RAI) uptake test preparation and postprocedure care Preparation- tell the patient the procedure is painless, ask if pregnant (contraindicated), and inform the patient the dose is small and will not harm others. Post- For 24 hrs after test: tell the patient to wash their hands thoroughly after voiding; if caregiver discards urine, the gloves should be worn; the used gloves should be washed, removed and then the bare hands should be washed thoroughly. Pregnant women should avoid contact with patient for 24 hrs.
Thyroid scan preparation and postprocedure care Preparation- tell the patient 131I is used, then will be given the isotope in liquid form and will return to radiology 24 hrs later for the scan. With 123I, scan is done 3-6 hrs. Patient will have to lie on their back for 20 min during the scan. Tell the patient, one week before the test they should not consume products with iodine. Post- same as RAI test.
Thyroid ultrasonography preparation and postprocedure care Preparation- tell the patient the procedure is painless and noninvasive, an instrument is moved over the neck and uses sound waves to create an image of the gland. Post- N/A
Fine-needle aspiration biopsy preparation and postprocedure care Preparation- tell patient the same as ultrasonography and that the physician will use a small needle to remove a tissue sample. Post- assess for bleeding (swelling in the biopsy area), bleeding at the puncture site, and increasing pulse.
s/s of mild hyperthyroidism Weight loss and nervousness
s/s of severe hyperthyroidism Restlessness, irritability, sleep disturbances, emotional lability, personality changes, hair loss, fatigue, weight loss, intolerance to heat, excessive perspiration, changes in menstrual and elimination patterns, warm & moist velvety skin, tremors in the hands, swelling of the neck, exophthalmos, tearing, light sensitivity, decreased visual acuity and swelling around the orbit of the eye.
Thyroid storm or crisis (thyrotoxicosis) Excessive stimulation caused by elevated thyroid hormone levels that produce dangerous tachycardia and hyperthermia.
Medical diagnosis for hyperthyroidism Decreased TSH and elevated serum T4. Graves disease- measurement of thyroid-stimulating antibodies and results of a RAI uptake test.
Methods of treatment for hyperthyroidism 1. drug therapy, 2. surgery, 3. radiation, and 4. beta-adrenergic blocker agents may be given to relieve some of the cardio-vascular symptoms.
Drug therapy for hyperthyroidism Antithyroid drugs that block the synthesis, release, or activity of thyroid hormones.
Thyroid Hormone Replacement Drugs Nursing Interventions Older patients are more at risk for toxicity. Low doses of one or more preparations are given initially. The dosage is increased gradually and the patient is maintained on just one preparation. Hypothyroid patients are usually on lifelong therapy. Monitor and teach patient to monitor the pulse and BP of older patients. Hold the dose and contact doctor if the patient's pulse is >100 bpm. Thyroid replacements interact with other drugs that affect the metabolic rate.
Thionamide Agents (methimazole [Tapazole], propylthiouracil [PTU]) Nursing Interventions Not recommended during pregnancy. Monitor for bleeding due to decreased platelets and prothrombin. Signs of liver toxicity are jaundice and abd pain. S/s of agranulocytosis are fever, sore throat and malaise. S/s for hypothyroidism are weight gain and fatigue. Tell the patient to contact the physician if they experience any of these s/s. Take safety precautions if the patient is drowsy. Instruct patient to take drug as prescribed and keep follow up appts.
Iodide Agents (Lugol's solution and saturated solution of potassium iodide [SSKI]) Nursing Interventions Dilute liquids in water, fruit juice, or milk. Have patient use straw to avoid the unpleasant taste and tooth-staining potential SE. Monitor the patient for excess iodine (fever, rash, oral lesions, metallic taste, diarrhea, parotitis and hypothyroidism). Give SSKI after meals.
Radioactive iodine (RAI): sodium iodide 131I and 123I Nursing Interventions Diagnostic doses usually do not require radiation precautions except with urine for 24 hrs after the test. Therapeutic doses require isolation. Monitor the patient for s/s of hypothyropidism (fatigue and weight gain).
Nursing Interventions for "Decreased Cardiac Output" Monitor pulse and BP. Give beta-adrenergic blockers as ordered. S/s of HF are tachycardia, tachypnea, dyspnea, confusion and edema. Older patients are more at risk for HF and need closer monitoring. Immediately report any s/s of HF to physician. Medical treatment of HF usually includes oxygen, IV fluids, sedatives and cardiac drugs.
Nursing Interventions for "Disturbed Sleep Patterns" Encourage the patient to arrange periods of rest throughout the day and to avoid caffeine. Encourage bedtime rituals to prepare for sleep. If the patient is hospitalized, provide a restful environment, offer a soothing back rub, and give sedatives as ordered. Explain to visitors the reason the patient may be irritable or restless to help coping. Teach patient to recognize stressful triggers and how to avoid them.
Nursing Interventions for "Hyperthermia" Offer light clothing. Adjust room temp to comfort level, patient may need a private room so the another patient may not get too cold. If the patient has excessive perspiration, frequent bathing and clothing changes may help.
Nursing Interventions for "Imbalanced Nutrition: Less than body requirements" Weigh daily. Provide or recommend a high caloric diet, vitamins and minerals. Some patients may need up to 4000 to 5000 calories a day. Additional fluids is also recommended due to excessive water loss.
Nursing Interventions for "Risk for Injury" If the patient has exophthalmos it is important to protect the eyes. Keep the eyeballs moist with lubricated eye pads or artificial tears. It may be necessary to tape the eyelids shut. Raise the head of the bed at night and limit salt intake may be helpful. The patient may also be self conscious, suggesting wearing sunglasses may help and also reassure the patient that usually after the hyperthyroidism is treated the condition will go away.
Nursing Interventions for "Disturbed Sensory Perception" Again if the patient has exophthalmos they also may experience symptoms such as double vision, periorbital edema, tearing, photosensitivity, and a feeling of sand in the eye. Elevate the head of the bed, reduce bright lighting, and advise use of sunglasses. Methylcellulose eye drops and diuretics may be ordered to reduce inflammation and swelling. If inflammation is severe a regimen of prednisone may be ordered for 2-4 wks. After acute inflammation, surgery may be needed to restore coverage of the eye.
Nursing Interventions for "Diarrhea" Give antidiarrheal meds as ordered and monitor the effect. Give thorough perianal cleansing after each stool to reduce risk of skin breakdown.
Nursing Care for a patient having a thyroidectomy preoperative Ask the patient if they understand what the surgery is for and what to expect. Decrease any anxiety. Tell the patient to expect a dressing on the front of the neck. Teach patient not to strain the neck when rising. Teach patient how to rise without straining. Ask patient to demonstrate. Teach patient to deep breathe and ask patient to demonstrate.
Nursing Care for a patient having a thyroidectomy postoperative Rare but sometimes seen complications are airway obstruction, recurrent laryngeal nerve damage, hemorrhage, and tetany. Assess and document respiratory status, LOC, wound drainage or bleeding, voice quality, comfort, and neuromuscular irritability (sign of hypocalcemia, which may indicate damage to the parathyroids).
Interventions for "Ineffective Airway Clearance" postoperative Turning and deep breathing help, but coughing is not recommended due to the strain on the suture line. Assess and document the rate and ease of respirations. Before the patient returns from surgery, prepare the following in the room: suction equipment, a laryngoscope, endotracheal tube, O2, and an emergency tracheotomy tray. Elevate the head of the bed to decrease edema. Use pillows to prop and support the head to avoid stress on the suture line. Assess quality of voice.
S/s of airway obstruction Restlessness, increasing pulse and respiratory rate, and dyspnea.
S/s of laryngeal nerve damage Hoarseness (more severe than the usual of patients returning from general anesthesia) and inability to speak.
S/s of damaged or removed parathyroid glands Tetany, tingle sensation in the face, fingers and toes, painful cramps, laryngospasms, dyspnea, cardiac dysrhythmias, and seizures.
Nursing Interventions for "Decreased Cardiac Output" postoperative Check dressing for bleeding and not just the front but also the back of the neck and upper back. Monitor vitals closely first day postop due to risk of thyroid storm.
Patient Teaching after thyroidectomy If thyroid is completely removed, inform patient they will need lifelong treatment. If only part was removed tell patient they will feel tired for awhile bu the remaining part should increase hormone release to adequate levels with time. The scar usually heals well and is barely noticeable. Take meds exactly as prescribed. Tell patient to inform physician if they experience nervousness or palpitations.
Examples of foods that are goitrogen agents Soybeans, turnips, and rutabagas.
Primary hypothyroidism Atrophy of the thyroid gland, thyroiditis, treatment of hyperthyroidism, dietary iodine deficiency, high intake of goitrogens, and defects in thyroid hormone synthesis.
Secondary hypothyroidism If caused by pituitary or hypothalamic disorders.
S/s of hypothyroidism Gradual. Metabolic rate slows, weight gain, lethargy, forgetfulness, irritability, headaches, constipation, menstrual disorders, numbness and tingling in the arms and legs, intolerance to cold, bradycardia, dyspnea, swelling of the lips and eyelids, dry, thick skin, bruising, thin, coarse hair, and hoarseness.
Medical diagnosis of hypothyroidism If free T4 is low and TSH levels show the physician if it is primary of secondary. A TRH stimulation test may also be ordered.
S/s of myxedema coma Hypothermia, hypotension and hypoventilation.
Treatment for hypothyroidism Treatment is hormone replacement and is lifelong. Patient should be monitored frequently for effectiveness of treatment. An older patient or a patient with heart disease may be started with a low dose and gradually increased due to poor adaptation on increased metabolic rate. If these patients experience chest pain at any time notify the physician.
Nursing Interventions for "Activity Intolerance" Arrange a schedule and allow periods of rest. Sedatives should be avoided. Monitor and document the patient's LOC and respirations.
Nursing Interventions for " Imbalanced Nutrition: More than body requirements" Weekly weights to evaluate the effectiveness of treatment, calorie reduction and balanced diet.
Nursing Interventions for "hypothermia" Provide extra clothing and blankets. Turn up temp in room to patient's comfort (may need private room).
Nursing Interventions for "Constipation" Increase fluids, fiber intake and physical activity. Bulk laxatives may be needed if other measures fail, but must be taken with increased fluids to avoid bowel obstruction. Older patients should increase activity gradually to avoid stress on the heart.
Nursing Interventions for "Risk for Impaired Skin Integrity" Apply lotions and creams for dry and itchy skin. Reduce frequency of bathing.
Nursing Interventions for "Disturbed Thought Processes" Explain to the patient they are due to the hypothyroidism and should improve with treatment and time. The exception is cretinism, which is irreversible. Do not demand too much of the patient. Break teaching sessions down into small intervals.
Nursing Interventions for "Disturbed Body Image" Be accepting of the patient's concerns, encourage good grooming and tell patient treatment will help conditions such as swelling and weight gain.
Health history for parathyroid function Assess mental and emotional state (memory problems, irritability, or personal changes). Ask about musculoskeletal problems (weakness, skeletal pain, backache, muscle twitch or spasms). Ask patient about urinary and bowel function (note polyuria, urinary calculi, or constipation). Document if there is a history of head or neck radiation, renal calculi, or chronic renal failure. List meds including calcium and vitamin D supplements.
Physical examination for parathyroid function Important data includes HR and rhythm, BP, respiratory rate, muscle strength, muscle twitching, hair and skin texture.
Chvostek sign A spasm of the facial muscle when the face is tapped over the facial nerve.
Trousseau sign A carpopedal spasm that occurs when a BP cuff is inflated above the patient's systolic BP and left for 2-3 min.
Diagnostic Tests and Procedures for parathyroid dysfunction Blood and urine tests, skeletal radiographs, and an ECG may also be ordered.
S/s for hyperparathyroidism Poor muscle tone, weakness, bone pain, demineralization, fractures, polyuria, renal calculi, hypertension, dysrhythmias, depressed reflexes, decreased mental function, depression, mood swings, confusion, coma, poor coordination, anorexia, nausea, vomiting, constipation, moist skin, and heat intolerance.
Medical diagnosis for hyperparathyroidism Elevated serum calcium, decreased serum phosphate, elevated PTH, and elevated 24 hour urine calcium. Bone demineralization on radiograph.
Medical Treatment Surgery- removal of tumor if present, removal of one gland or parathyroid tissue transplanted to a muscle in the forearm or neck. Drug treatment can also be used.
Calcium Salts Nursing Interventions Take with food, monitor serum calcium levels and notify physician of s/s of hypercalcemia.
Vitamin D Nursing Interventions Monitor serum calcium levels and notify physician of hypercalcemia.
Pamidronate (Aredia) Nursing Interventions Assess infusion site, do not mix with IV solutions that contain calcium, monitor pulse, BP, fluid intake and urine output.
Etidronate disodium (Didronel) Divide dose through the day to prevent diarrhea, and advise that the metallic taste will go away.
Furosemide (Lasix) Nursing Interventions Monitor I&O, serum calcium and potassium, pulse, BP and blood glucose.
Parathormone Nursing Interventions Available only for parenteral use.
Calcitonin (Calcimar, Cibacalcin) Nursing Interventions Monitor for tachycardia, due to hypocalcemia. Have epinephrine, antihistamines and O2 available. Sensitivity test should be done before administration. Tell patient flushing is temporary. Teach self medication and encourage adequate fluid intake.
Plicamycin (Mithracin) Nursing Interventions Usually just for patients with metastatic parathyroid cancer due to toxic effects. Monitor for bleeding. Avoid injections. Apply pressure to venipuncture sites for 10 min. Assess s/s of infection. Discontinue if extravasation occurs.
Gallium nitrate (Ganite) Nursing Interventions Administer IV with NS, monitor serum electrolytes, BP CBC, and urine output.
Nursing Care for the patient with hyperparathyroidism monitor vitals, urine output, weight, muscle strength, bowel elimination and digestive disturbances.
Nursing Interventions for "Activity Intolerance and Risk for Injury" for the patient with hyperparathyroidism Assess the patient's ability to perform ADLs safely and help where the patient is in need. Assess the environment and make changes as needed. Allow periods of rest. Tell patient weakness and fatigue should improve with treatment.
Patient Teaching for the patient with hyperparathyroidism Take meds as prescribed, eat a balanced diet, notify the physician of bloody urine or pain in the kidney area or groin, and increase fluid intake as ordered by physician.
Possible complications of parathyroidectomy Airway obstruction and hypocalcemia. Nursing care of the two are the same as a thyroidectomy.
S/s of hypoparathyroidism Fatigue, weakness, cramps, twitching, urinary frequency, decreased CO, dysrhythmias, hyperactive reflexes, memory impairment, depression, anxiety, irritability, personality changes, confusion, numbness, tingling of the hands, feet and around the mouth, muscle spasms, abd cramps, brittle nails, dry skin, and cold intolerance.
Medical Diagnosis of hypoparathyroidism S/s, low serum calcium, elevated serum phosphate, low urine calcium, and sometimes low serum magnesium. Chvostek sign and Trousseau sign.
Medical Treatment Acute- sometimes treated with parenteral PTH, IV calcium salts, and other electrolyte imbalances must be treated as well. Chronic- oral calcium salts and a form of vitamin D. Also important to avoid stress and illness which could trigger hypocalcemia.
Nursing Interventions of hypoparathyroidism Administer drugs as ordered, check infusion site (calcium salts leaking into body tissues causes inflammation), watch for s/s of seizures, monitor and document respiratory distress, monitor pulse and BP for dysrhythmias and HF. Report cardiac irregularities, edema, and dyspnea to the physician. Teach patients s/s of calcium imbalances and how to self medicate. Advise to wear medical alert bracelet or medical alert card.
Created by: nursingTSJC2013