Question

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1. Show three ways how nurses can collaborate with the interprofessional team to coordinate high quality care and promote cellular regulation and optimal nutrition in patients who have thyroid or parathyroid disorders.
2. Show three ways how nurses can teach the patient and caregiver(s) about home safety issues affected by impaired nutrition or Cellular regulation resulting from thyroid or parathyroid problems.
3. Show three ways how nurses can identify community resources for patients requiring assistance with any disorder of the thyroid or parathyroid glands.
4. Show three ways how nurses can implement nursing interventions to decrease the psychosocial impact caused by acute or chronic problems of the thyroid gland or parathyroid glands.
5. Show three ways how nurses can apply knowledge of anatomy, physiology, and pathophysiology to assess patients with impaired thyroid or adrenal parathyroid function affecting nutrition or cellular regulation.
6. Show three ways how nurses can interpret clinical changes and laboratory data to determine the effectiveness of therapy for hyperthyroidism and for hypothyroidism.
7. Show three ways how nurses can prioritize evidence-based nursing care for the patient with thyroid storm.
8. Show three ways how nurses can teach the patient and caregiver(s) about common drugs and other management strategies used for thyroid gland or parathyroid gland problems.
9. Show three ways how nurses can prioritize evidence-based care for the patient with myxedema coma.
10. Rapid intervention in the event of thyroid storm or hypocalcemia is essential on the part of the nurse; describe these interventions in detail for Thyroid storms and Hypocalcemia.

Answer 1

Nursing Interventions

Nursing interventions for a patient with hypothyroidism include the following:

• Promote rest. Space activities to promote rest and exercise as tolerated.
• Protect against coldness. Provide extra layer of clothing or extra blanket.
• Avoid external heat exposure. Discourage and avoid the use of external heat source.
• Mind the temperature. Monitor patient’s body temperature.
• Increase fluid intake. Encourage increased fluid intake within the limits of fluid restriction.
• Provide foods high in fiber.
• Manage respiratory symptoms. Monitor respiratory depth, rate, pattern, pulse oximetry, and ABG.
• Pulmonary exercises. Encourage deep breathing, coughing, and use of incentive spirometry.
• Orient to present surroundings. Orient patient to time, place, date, and events around him or her.

Evaluation

A successful nursing care plan has achieved the following goals:

• Increased participation in activities.
• Increased independence.
• Maintained normal body temperature.
• Return of normal bowel function.
• Improved respiratory status.
• Maintained normal breathing pattern.
• Improved thought processes.

Discharge and Home Care Guidelines

At the completion of the home care instruction, the patient or caregiver will be able to:

• Medication compliance. State that compliance to medical regimen is life-long.
• Cold intolerance. State the need to avoid extreme cold temperature until condition is stable.
• Follow-up visits. State the importance of regular follow-up visits with health care provider.
• Weight reduction. Identify strategies for weight reduction and prevention of constipation such as high-fiber, low-calorie intake and adequate fluid intake.

Documentation Guidelines

The focus of documentation should include:

• Level of activity.
• Vital signs before, during, and after activity.
• Record of core temperature, initially and prn.
• Results of laboratory and diagnostic studies.
• Usual and current bowel pattern, duration of the problem, and individual contributing factors.
• Characteristics of stool.
• Respiratory pattern, breath sounds, and use of accessory muscles.
• Plan of care.
• Teaching plan.
• Response to interventions, teaching, and actions performed.
• Attainment or progress toward desired outcomes.
• Modifications to plan of care.
• Long term needs.

The function of thyroid gland is regulated by a feedback mechanism, which involves the brain. When thyroid hormone levels are significantly low, the hypothalamus in brain produces a hormone known as thyrotropin releasing hormone (TRH), causing the pituitary gland (located at the base of brain) to release thyroid stimulating hormone (TSH). Thus,TSH stimulates the thyroid gland to release more T4. Since the thyroid gland is controlled by pituitary gland and hypothalamus, any disorder of these tissues can affect functioning of thyroid.

The parathyroid glands release a hormone called parathyroid hormone. This hormone helps to control the levels of three minerals in the body: Calcium, Phosphorus and Magnesium. Parathyroid hormone has several effects in the body:

If thyroid storm is suspected, emergency treatment needs to be instituted immediately. Patients may need cardiac monitoring, intubation and mechanical ventilation with supplemental oxygen, and IV fluids. The patient requires antithyroid medications and may receive IV corticosteroids and beta-adrenergic medications.

Nursing Interventions for Hypocalcemia

• Safety (prevent falls because patient is at risk for bone fractures, seizures precautions, and watch for laryngeal spasms)
• Administer IV calcium as ordered (ex: 10% calcium gluconate)….give slowly as ordered (be on cardiac monitor and watch for cardiac dysrhythmias). Assess for infiltration or phlebitis because it can cause tissue sloughing (best to give via a central line). Also, watch if patient is on Digoxin cause this can cause Digoxin toxicity.
• Administer oral calcium with Vitamin D supplements (given after meals or at bedtime with a full glass of water)
• If phosphorus level is high (remember phosphorus and calcium do the opposite) the doctor may order aluminum hydroxide antacids (Tums) to decrease phosphorus level which in turn would increase calcium levels.
• Encourage intake of foods high in calcium:

MyXEDEMA COMA

1. Continuously monitor ECG for dysrhythmias or profound bradycardia that can adversely affect cardiac output.
2. Continuously monitor pulmonary artery pressure, central venous pressure (if available) and blood pressure.
3. Monitor fluid volume status; measure urine output hourly and determine fluid balance every 8 hours.

Patient Assessment

1. Assess cardiovascular status: note quality of peripheral pulses and capillary refill.
2. Observe for increase jugular vein distention and pulsus paradoxus, which may indicate pericardial effusion.

Diagnostic Assessment

1. Review thyroid studies as available.
2. Thyroid stimulating hormone should decline within 24 hours of therapy and should normalize after 7 days of therapy.

Patient Management

1. Administer intravenous fluids as ordered to maintain BP >90 mm Hg; carefully monitor for fluid overload and development of heart failure.
2. Vasopressor agents may be used if hypotension is refractory to volume administration and if thyroid replacement has not had time to act. Carefully monitor the patient for lethal dysrhythmias.

Description

Thyroid deficiency can affect all body functions and can range from mild, subclinical forms to advanced forms.

• Hypothyroidism results from suboptimal levels of thyroid hormone.
• Hypothyroidism also commonly occurs in patients with previous hypothyroidism that has been treated with radioiodine or antithyroid medications or thyroidectomy.
• The term myxedema refers to the accumulation of mucopolysaccharides in subcutaneous and other interstitial tissues.

Classification

The types of hypothyroidism are classified according to their causes:

• Central hypothyroidism. There is a failure of the pituitary gland, the hypothalamus, or both to stimulate production of thyroid hormones.
• Secondary or pituitary hypothyroidism. The cause is entirely a pituitary disorder in secondary hypothyroidism.
• Tertiary or hypothalamic hypothyroidism. This refers to the cause as a disorder of the hypothalamus resulting in inadequate secretion of TSH due to decreased stimulation of TRH.
• The thyroid disorder is already present at birth in cretinism.

Pharmacologic therapy. Synthetic levothyroxine is the preferred preparation for treating hypothyroidism and suppressing nontoxic goiters.

Prevention of cardiac dysfunction. As long as metabolism is subnormal and the tissues require relatively little oxygen, a reduction in the blood supply is tolerated without overt symptoms of coronary artery disease.

Supportive therapy. Oxygen saturation levels should be monitored; fluids should be administered cautiously; application of external heat must be avoided, and oral thyroid hormone therapy should be continued.