Question

Med Surge 49

1.Describe the pathophysiology signs and symptoms, complications, and treatment of hyperthyroidism , thyroid cancer, hyperparathyroidsm , and hypoparathyroidism.

2. Assist in the development of nursing care plans for patients with disorders of the thyroid glands.

Answer 1

1.

HYPERTHYROIDISM

pathophysiology

In hyperthyroidism, serum T3 usually increases more than does T4, probably because of increased secretion of T3 as well as conversion of T4 to T3 in peripheral tissues. In some patients, only T3 is elevated (T3 toxicosis).

T3 toxicosis may occur in any of the usual disorders that cause hyperthyroidism, including Graves disease, multinodular goiter, and the autonomously functioning solitary thyroid nodule. If T3 toxicosis is untreated, the patient usually also develops laboratory abnormalities typical of hyperthyroidism (ie, elevated T4 and iodine-123 uptake). The various forms of thyroiditis commonly have a hyperthyroid phase followed by a hypothyroid phase.

signs and symptoms

Whole body: excess sweating, excessive hunger, fatigue, or heat intolerance

Behavioural: hyperactivity, irritability, or restlessness

Heart: abnormal heart rhythm, fast heart rate, or palpitations

Mood: mood swings, nervousness, or panic attack

Eyes: abnormal protrusion of eyes or puffy eyes

Menstrual: irregular menstruation or short and light menstruation

Sleep: difficulty falling asleep or insomnia

Also common: weight loss, diarrhoea, hair loss, muscle weakness, tremor, or warm skin.

complications

• Graves' ophthalmopathy
• Thyroid storm
• Arrhythmia (abnormal heart beat, such as atrial fibrillation)
• Cardiac dilation (increase in the size of the heart cavities, which actually thins the heart muscle) and congestive heart failure
• Sudden cardiac arrest
• Hypertension
• osteoporosis

Treatment

Radioactive iodine:- Taken by mouth, radioactive iodine is absorbed by thyroid gland, where it causes the gland to shrink. Symptoms usually subside within several months. Excess radioactive iodine disappears from the body in weeks to months.This treatment may cause thyroid activity to slow enough to be considered underactive (hypothyroidism), and you may eventually need to take medication every day to replace thyroxine.

Anti-thyroid medications :-These medications gradually reduce symptoms of hyperthyroidism by preventing your thyroid gland from producing excess amounts of hormones. They include methimazole (Tapazole) and propylithiouracil. Symptoms usually begin to improve within several weeks to months, but treatment with anti-thyroid medications typically continues at least a year and often longer.

Beta blockers:- Although these drugs are usually used to treat high blood pressure and don't affect thyroid levels, they can ease symptoms of hyperthyroidism, such as a tremor, rapid heart rate and palpitations. For that reason, doctor may prescribe them to help you feel better until your thyroid levels are closer to normal. These medications generally aren't recommended for people who have asthma, and side effects may include fatigue and sexual dysfunction.

Surgery (thyroidectomy):- In a thyroidectomy, doctor removes most of your thyroid gland. Risks of this surgery include damage to your vocal cords and parathyroid glands — four tiny glands situated on the back of your thyroid gland that help control the level of calcium in your blood.

THYROID CANCER

Pathophysiology

Normally thyroid cancer occurs in the follicular cells.all the etiological factors that affect the normal thyroid follicular cells which leads to follicular cell hyperplasia which leads to follicular adenoma of thyroid that later leads to follicular carcinoma of thyroids and signs and symptoms.

Signs and symptoms

A lump (nodule) that can be felt through the skin on your neck

Changes to your voice, including increasing hoarseness

Difficulty swallowing

Pain in your neck and throat

Swollen lymph nodes in your neck

Complications

Injury to the voice box and hoarseness after thyroid surgery.

Low calcium level from accidental removal of the parathyroid glands during surgery.

Spread of the cancer to the lungs, bones, or other parts of the body.

Treatment

Very small thyroid cancers that have a low risk of spreading in the body might not need treatment right away

Surgery :-

thyroidectomy :-An operation to remove the thyroid gland might involve removing all of the thyroid tissue (total thyroidectomy) or most of the thyroid tissue (near-total thyroidectomy). The surgeon often leaves small rims of thyroid tissue around the parathyroid glands to reduce the risk of damage to the parathyroid glands, which help regulate the calcium levels in your blood.

Removing a portion of the thyroid (thyroid lobectomy):- During a thyroid lobectomy, the surgeon removes half of the thyroid. It might be recommended if you have a slow-growing thyroid cancer in one part of the thyroid and no suspicious nodules in other areas of the thyroid.

Removing lymph nodes in the neck (lymph node dissection):-When removing your thyroid, the surgeon may also remove nearby lymph nodes in the neck. These can be tested for signs of cancer.

Thyroid hormone therapy

After thyroidectomy, the thyroid hormone medication levothyroxine (Levoxyl, Synthroid, others) are given.

This medication has two benefits: It supplies the missing hormone your thyroid would normally produce, and it suppresses the production of thyroid-stimulating hormone (TSH) from your pituitary gland. High TSH levels could conceivably stimulate any remaining cancer cells to grow.

External radiation therapy

Radiation therapy can also be given externally using a machine that aims high-energy beams, such as X-rays and protons, at precise points on your body (external beam radiation therapy).

Radioactive iodine

Radioactive iodine treatment uses large doses of a form of iodine that's radioactive.

Radioactive iodine treatment is often used after thyroidectomy to destroy any remaining healthy thyroid tissue, as well as microscopic areas of thyroid cancer that weren't removed during surgery. Radioactive iodine treatment may also be used to treat thyroid cancer that recurs after treatment or that spreads to other areas of the body.

Radioactive iodine treatment comes as a capsule or liquid that you swallow. The radioactive iodine is taken up primarily by thyroid cells and thyroid cancer cells, so there's a low risk of harming other cells in your body.

Chemotherapy

Chemotherapy is a drug treatment that uses chemicals to kill cancer cells. Chemotherapy is typically given as an infusion through a vein. The chemicals travel throughout the body, killing quickly growing cells, including cancer cells.

Injecting alcohol into cancers

Alcohol ablation involves injecting small thyroid cancers with alcohol using imaging such as ultrasound to ensure precise placement of the injection. This procedure causes thyroid cancers to shrink.

Supportive (palliative) care

Palliative care is specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness.

HYPERPARATHYROIDISM

Pathophysiology

Primary hyperparathyroidism (PHPT) is characterized by hypersecretion of parathyroid hormone (PTH) leading to hypercalcemia and relative hypophosphatemia. PTH acts by binding to cell surface receptors coupled to G proteins. Cyclic AMP is the classic second messenger of PTH action, but substantial evidence indicates that PTH also acts to stimulate formation of the dual second messengers, inositol trisphosphate and diacylglycerol, thereby mobilizing intracellular calcium. The physiologic actions of PTH include (1) an increase in extracellular fluid ionized calcium through direct actions on kidney and bone, the classic target organs for PTH, and (2) a decrease in extracellular fluid phosphate primarily through renal action. The pathophysiologic effects of PTH arise from (1) direct actions of PTH on bone and kidney, and possibly on nonclassic target organs, and (2) indirect effects of altered mineral homeostasis.

signs and symptoms

Osteoporosis

Kidney stones

Excessive urination

Abdominal pain

Tiring easily or weakness

Depression or forgetfulness

Bone and joint pain

Frequent complaints of illness with no apparent cause

Nausea, vomiting or loss of appetite

Complications

Osteoporosis. The loss of calcium often results in weak, brittle bones that fracture easily (osteoporosis).

Kidney stones. Too much calcium in your blood may lead to too much calcium in your urine, which can cause small, hard deposits of calcium and other substances to form in your kidneys. A kidney stone usually causes major pain as it passes through the urinary tract.

Cardiovascular disease. Although the exact cause-and-effect link is unclear, high calcium levels are associated with cardiovascular conditions, such as high blood pressure and certain types of heart disease.

Neonatal hypoparathyroidism. Severe, untreated hyperparathyroidism in pregnant women may cause dangerously low levels of calcium in newborns.

Treatment

Surgery

Surgery is the most common treatment for primary hyperparathyroidism and provides a cure in most cases. surgeon will remove only those glands that are enlarged or have a tumor.

If all four glands are affected, a surgeon will likely remove only three glands and perhaps a portion of the fourth — leaving some functioning parathyroid tissue.

Drugs

Medications to treat hyperparathyroidism include the following:

Calcimimetics:-A calcimimetic is a drug that mimics calcium circulating in the blood. The drug may trick the parathyroid glands into releasing less parathyroid hormone. This drug is sold as cinacalcet (Sensipar).

Hormone replacement therapy:- For women who have gone through menopause and have signs of osteoporosis, hormone replacement therapy may help bones retain calcium. This treatment doesn't address the underlying problems with the parathyroid glands.

Bisphosphonates:- Bisphosphonates also prevent the loss of calcium from bones and may lessen osteoporosis caused by hyperparathyroidism.

HYPOPARATHYROIDISM

pathophysiology

All the etiological factors that leads to decrease in gland function that leads to resistance to PTH action that leads to inadequate PTH secretion and increased absorption of Calcium in GI tract that leads to blood calcium fall to low level that leads to muscular hyper iritability that leads to uncontrolled spasm and hypocalcemic tetany.

signs and symptoms

Tingling or burning in your fingertips, toes and lips

Muscle aches or cramps in your legs, feet, stomach or face

Twitching or spasms of your muscles, particularly around your mouth, but also in your hands, arms and throat

Fatigue or weakness

Painful menstrual periods

Patchy hair loss

Dry, coarse skin

Brittle nails

Depression or anxiety

Complications

reversible complications

Cramplike spasms of hands and fingers that can be prolonged and painful, or muscle pain and twitches or spasms of the muscles of your face, throat or arms. When these spasms occur in your throat, they can interfere with breathing, creating a possible emergency.

Tingling or burning sensations, or a pins and needles feeling, in lips, tongue, fingers and toes.

Seizures.

Malformed teeth, affecting dental enamel and roots, in cases when hypoparathyroidism occurs at an early age when teeth are developing.

Problems with kidney function.

Heart arrhythmias and fainting, even heart failure.

irreversible complications

Stunted growth

Slow mental development in children

Calcium deposits in the brain, which can cause balance problems and seizures

Clouded vision due to cataracts

Treatment

Oral calcium carbonate tablets :-Oral calcium supplements can increase calcium levels in blood. However, at high doses, calcium supplements can cause gastrointestinal side effects, such as constipation, in some people.

Vitamin D :-High doses of vitamin D, generally in the form of calcitriol, can help body absorb calcium and eliminate phosphorus.

Magnesium. If magnesium level is low and if experiencing symptoms of hypoparathyroidism, doctor may recommend that you take a magnesium supplement.

Thiazide diuretics:-If calcium levels remain low even with treatment, thiazide diuretics can help decrease the amount of calcium lost through your urine.

Parathyroid hormone (Natpara). The U.S. Food and Drug Administration has approved this once-daily injection for treatment of low blood calcium due to hypoparathyroidism.

Diet

Rich in calcium:-This includes dairy products, green leafy vegetables, broccoli and foods with added calcium, such as some orange juice and breakfast cereals.

Low in phosphorus:- This means avoiding carbonated soft drinks, which contain phosphorus in the form of phosphoric acid, and limiting meats, hard cheeses and whole grains.

2.

NURSING CARE PLANS FOR THYROID DISODERS

a) Nursing diagnosis:

Imbalanced Nutrition: More Than Body Requirements

May be related to:

Greater intake than metabolic needs.

Possibly evidenced by:

Decreased appetite.

Sedentary activity level.

Weight gain.

Desired outcome:

Client will maintain a stable weight and takes in necessary nutrients.

Interventions:

• Assess the client’s appetite.
• Assess the client’s weight.
• Educate the client and family regarding body weight changes in hypothyroidism.
• Provide a food diary to the client
• Collaborate with a dietician to determine client’s caloric needs.
• Encourage the intake of foods rich in fiber.
• Provide assistance and encouragement as needed during mealtime.
• Encourage the client to eat six small meals throughout the day.

b) Nursing Diagnosis

Risk for Decreased Cardiac Output

Risk factors may include

Uncontrolled hyperthyroidism, hypermetabolic state

Increasing cardiac workload

Changes in venous return and systemic vascular resistance

Alterations in rate, rhythm, conduction

Possibly evidenced by

Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.

Desired Outcomes

Maintain adequate cardiac output for tissue needs as evidenced by stable vital signs, palpable peripheral pulses, good capillary refill, usual mentation, and absence of dysrhythmias.

Nursing Interventions

• Monitor BP lying, sitting, and standing, if able. Note widened pulse pressure.

Rationale: General or orthostatic hypotension may occur as a result of excessive peripheral vasodilation and decreased circulating volume. Widened pulse pressure reflects compensatory increase in stroke volume and decreased systemic vascular resistance (SVR).

• Monitor central venous pressure (CVP), if available.

Rationale: Provides more direct measure of circulating volume and cardiac function.

• Investigate reports of chest pain or angina.

Rationale: May reflect increased myocardial oxygen demands or ischemia.

• Assess pulse and heart rate while patient is sleeping.

Rationale: Provides a more accurate assessment of tachycardia.

• Auscultate heart sounds, note extra heart sounds, development of gallops and systolic murmurs.

Rationale: Prominent S1 and murmurs are associated with forceful cardiac output of hypermetabolic state; development of S3 may warn of impending cardiac failure.

• Monitor ECG, noting rate and rhythm. Document dysrhythmias

Rationale: Tachycardia (greater than normally expected with fever and/or increased circulatory demand) may reflect direct myocardial stimulation by thyroid hormone. Dysrhythmias often occur and may compromise cardiac output.

• Auscultate breath sounds. Note adventitious sounds.

Rationale: Early sign of pulmonary congestion, reflecting developing cardiac failure.

c) Nursing Diagnosis

Fatigue

May be related to

Hypermetabolic state with increased energy requirements

Irritability of central nervous system (CNS); altered body chemistry

Possibly evidenced by

Verbalization of overwhelming lack of energy to maintain usual routine, decreased performance

Emotional lability/irritability; nervousness, tension

Jittery behavior

Impaired ability to concentrate

Desired Outcomes

Verbalize increase in level of energy.

Display improved ability to participate in desired activities.

Nursing Interventions

• Monitor vital signs, noting pulse rate at rest and when active.

Rationale: Pulse is typically elevated and, even at rest, tachycardia (up to 160 beats/min) may be noted.

• Note development of tachypnea, dyspnea, pallor, and cyanosis.

Rationale: O2 demand and consumption are increased in hypermetabolic state, potentiating risk of hypoxia with activity.

• Provide for quiet environment; cool room, decreased sensory stimuli, soothing colors, quiet music.

Rationale: Reduces stimuli that may aggravate agitation, hyperactivity, and insomnia.

• Encourage patient to restrict activity and rest in bed as much as possible.

Rationale: Helps counteract effects of increased metabolism.

• Provide comfort measures: touch therapy or massage, cool showers. Patient with dyspnea will be most comfortable sitting in high Fowler’s position.

Rationale: May decrease nervous energy, promoting relaxation.

• Provide for diversional activities that are calming, e.g., reading, radio, television.

Rationale: Allows for use of nervous energy in a constructive manner and may reduce anxiety.

• Avoid topics that irritate or upset patient. Discuss ways to respond to these feelings.

Rationale: Increased irritability of the CNS may cause patient to be easily excited, agitated, and prone to emotional outbursts.