THE THYROID GLAND

Description
• a butterfly-shaped organ located in the lower neck, anterior to the trachea
• consists of two lateral lobes connected by an isthmus.
• blood flow to the thyroid is very high (about 5 mL/min per gram of thyroid tissue), approximately five times the blood flow to the liver
• this reflects the high metabolic activity of the thyroid gland
• the thyroid gland produces three hormones: thyroxine (T4), triiodothyronine (T3), and calcitonin
Anatomic and Physiologic Overview
• Thyroid Hormone
− composed of T4 and T3, two separate hormones produced by the thyroid gland
− both are amino acids that contain iodine molecules bound to the amino acid structure
− T4 contains four iodine atoms in each molecule, and T3 contains three
− these are synthesized and stored bound to proteins in the cells of the thyroid gland until needed for release into the bloodstream
o Synthesis of Thyroid Hormone
 iodine is essential to the thyroid gland for synthesis of its hormones
 iodide is ingested in the diet and absorbed into the blood in the GI tract.
 the thyroid takes up iodide from the blood and concentrating it within the cells, where iodide ions are converted to iodine
molecules, which react with tyrosine (an amino acid) to form the thyroid hormones
o Regulation of Thyroid Hormone
 the secretion of T3 and T4 is controlled by TSH (also called thyrotropin) from the anterior pituitary gland
 TSH controls the rate of thyroid hormone release through a negative feedback mechanism
 in turn, the level of thyroid hormone in the blood determines the release of TSH
 if the thyroid hormone concentration in the blood decreases, the release of TSH increases which causes increased output
of T3 and T4
 the term euthyroid refers to thyroid hormone production that is within normal limits
 thyrotropin-releasing hormone (TRH), secreted by the hypothalamus, exerts a modulating influence on the release of TSH
from the pituitary
 environmental factors, such as a decrease in temperature, may lead to increased secretion of TRH, resulting in elevated
secretion of thyroid hormones
o Function of Thyroid Hormone
 primary function of thyroid hormone is to control cellular metabolic activity
 T4, a relatively weak hormone, maintains body metabolism in a steady stat
 T3 is about five times as potent as T4 and has a more rapid metabolic action
  these accelerate metabolic processes by increasing the level of specific enzymes that contribute to oxygen consumption
and altering the responsiveness of tissues to other hormones.
 these influence cell replication and are important in brain development and normal growth because they influence every
major organ system
•Calcitonin
− or thyrocalcitonin, is another important hormone secreted by the thyroid
− secreted in response to high plasma levels of calcium, and it reduces the plasma level of calcium by increasing its deposition in bone
HYPERTHYROIDISM AND GRAVES’ DISEASE

Hyperthyroidism is the second most prevalent endocrine disorder, after diabetes mellitus. Graves’ disease, the most common type of hyperthyroidism,
results from an excessive output of thyroid hormones caused by abnormal stimulation of the thyroid gland by circulating immunoglobulins. It is
an autoimmune disease where the thyroid is overactive, producing an excessive amount of thyroid hormones. This is caused by autoantibodies to the TSH-
receptor that activate that TSH-receptor, thereby stimulating thyroid hormone synthesis and secretion, and thyroid growth. The resulting state of
hyperthyroidism can cause a dramatic constellation of neuropsychological and physical signs and symptoms, which can severely compromise the patients’
ability to maintain jobs and relationships. It affects women eight times more frequently than men, with onset usually between the second and fourth
decades. The disorder may appear after an emotional shock, stress, or infection, but the exact significance of these relationships is not understood. Other
common causes of hyperthyroidism include thyroiditis and excessive ingestion of thyroid hormone.

Etiology and Risk Factors

• Gender – women
• History – past history of thyroid problems, autoimmune disease, or endocrine disease
• Age – between 20 and 40 years of age
• Smoking
• Excessive intake of thyroid hormone
• Exposure to or excess of iodine/iodine drugs
• Certain medical treatments and drugs – interferons and interleukins, immunosuppresants, antiretrovirals, lithium
• Trauma to the thyroid – vigorous manipulation and palpation, surgery, injection, biopsy, neck injuries
• Major emotional stress
• Nutritional or dietary deficiencies
• Bacterial or viral infections

Pathophysiology
Genetic factors (increased expression of MHC Class II/HLA-
DR3; lack of suppressor T cells); Environmental Factors
(smoking, infection, stress)

Activation and multiplication of

CD4+ T cells
 Stimulation of B
lymphocytes

Production of Thyroid Stimulating

Hormone Receptor (TSHR) antibodies
and cytokines

Binding of TSHR antibodies to thyroid TSHR antibodies bind to TSHR in

membrane causing functional changes to fibroblasts
target cell
Production of
Negative feedback
Stimulation of hypersecretion of thyroid inflammatory
mechanism to pituitary
hormones cytokines by T cells
gland

Decreased TSH Hyperthyroidis Goiter Tissue damage and scar tissue

production m formation

Increased sympathetic nervous system Increased deposition of

activity glycosaminoglycans -
Surgery, infection, stress, hyaluronan
Increased heart and pulse rate, trauma, uncontrolled
palpitations, increased blood Cardiovascula hyperthyroidism
r Swelling in muscle and Accumulation in dermis
pressure, atrial fibrillation, heart
connective tissue behind and subcutaneous
eyes tissue
Tachypnea, dyspnea Respiratory Thyroid
storm Compression
Increased intraorbital Fluid and
Accelerated bone pressure occlusion of lymphatic
Musculoskele retention
remodeling, Hyperpyrexia, accelerated vessels
tal
osteoporosis, fractures tachycardia, hypertension, high-output
heart failure, arrhythmias, agitation, Compression of orbital
Increased lipid and Lymphede
Metaboli delirium, seizures, coma contents with traumatic
carbohydrate metabolism, ma
c injury
weight loss, increased appetite,
diarrhea Death Forward protrusion of the Pretibial
Irritability, hyperreflexia, globe myxedema
hyperexcitability, fatigability,
insomnia,
 Neurolog
ic
Ophthalmopathy – proptosis,
Nervousness, emotional lability, Psychologi exophthalmos, diplopia, limitation of
anxiety, restlessness, hyperactivity cal eye movement, photophobia,
periorbital edema, impaired and loss
Poor heat tolerance, profuse of vision
diaphoresis, flushed warm skin, salmon Integumenta
colored skin, dry skin, diffuse pruritus, ry
thin and fine hair, brittle nails
Clinical Manifestations
• Nervousness
• Emotional hyperexicitability, irritability, apprehension and restlessness (hand tremor at rest)
• Hyperactive reflexes
• Insomnia
• Poor heat tolerance and profuse diaphoresis
• Flushed warm, soft, and moist skin with characteristic salmon color
• Dry skin and diffuse pruritus
• Thin and fine hair
• Brittle nails
• Exophthalmos
• Dry eyes; excessive lacrimation
• Photophobia
• Dyslogia
• Dalrymple’s sign (thyroid stare)
• Von Graefe’s sign (lid lag)
• Goiter
• Increased appetite and dietary intake
• Progressive weight loss
• Amenorrhea and changes in bowel function; diarrhea
• Palpitations and abnormally rapid pulses at rest as well as on exertion (constantly between 90 and 160 bpm)
• Elevated systolic blood pressure, temperature, and respiration; increased pulse pressure; shortness of breath
• Atrial fibrillation; cardiac decompensation in the form of heart failure
• Sinus tachycardia or dysrhythmias
• Myocardial hypertrophy and heart failure
• Abnormal muscular fatigability and weakness
 • Osteoporosis and fracture
• Loss of libido

Assessment and Diagnostic Findings

Physical Examination
• Inspection: Enlarged thyroid gland
• Palpation: Soft thyroid and may be with pulsations and thrills
• Auscultation: Bruit heard over thyroid arteries
Laboratory Tests
• Serum TSH
− Single best screening test of thyroid function because of its high sensitivity (NV: 0.2-5.4 U/mL)
− Suppressed
• Serum Free T4
− Confirms abnormal TSH; not affected by variations in protein binding (NV: 0.8-27 ng/dL)
− Increased
• Serum T3 and T4
− Includes protein-bound and free hormone levels that occur in response to TSH secretion (T3 NV: 70-220 ng/dL; T4 NV: 4.5-11.5 µg/dL)
− High
• Radioactive Iodine Uptake
− Measures the rate of iodine uptake by the thyroid gland to determine thyroid function (NV: 5-35% in 24 hours)
− High
• Thyroid Stimulating Immunoglobulin (TSI)
− Helps diagnose autoimmune thyroid disease and to separate it from other forms of thyroiditis
− Present

Medical Management
Radioactive iodine therapy (131i, 123i)
• Prescribed mainly for middle-aged and older clients
• Economical, simple to administer, can be prescribed on an outpatient basis
• Dissolved in water and administered orally
• Manifestations of hyperthyroidism subside 6 to 12 weeks after administration
• Concurrent treatment with beta-adrenergic blockers may be desirable because of the delay of therapeutic effects
Antithyroid medications
• Recommended for clients younger than 18 years of age and for pregnant women
• Major medications:
 − Propylthiouracil (ptu) – impairs thyroid hormone synthesis
− Methimazone – blocks the action of thyroid hormone in the body
Adjunctive therapy
• Adrenergic blocking agents
− Given as an adjunct to control the activity of the sympathetic nervous system
− Propanolol and reserpine
• Iodine preparations
− Potassium iodide, lugol’s solution, saturated solution of potassium iodide
− Act temporarily to prevent release of thyroid hormone into the circulation by increasing the amount of thyroid hormone stored in the
gland
Surgical management – thyroidectomy
• Subtotal and total thyroidectomy
• Indications: a large goiter, suspicious nodules or cancer
• Preoperative treatment with antithyroid drugs (e.g. Lugol’s solution) to render the patient euthyroid
• Postoperative complications:
− Transient vocal cord paralysis
− Prolonged postoperative hypocalcemia
− Permanent hypoparathyroidism
− Recurrent hyperthyroidism
Nursing Management
Improving nutritional status
• Several well-balanced meals of small size (6 meals a day)
• Foods and fluids to replace fluid lost through diarrhea and diaphoresis
• Discourage highly seasoned foods and stimulants such as coffee, tea, cola, and alcohol
• High-calorie and high-protein foods are encouraged (4000-5000 calories)
• Quiet atmosphere during mealtime to aid digestion
• Recording of weight and dietary intake
Enhancing coping measures
• Take time to explain the disease process
• Reassure that the emotional reactions being experienced are a result of the disorder
• Minimize environmental stimuli
• Minimize stressful experience
• Maintain quiet and uncluttered environment
 Improving self-esteem
• Convey understanding problems and promote use of effective coping strategies
• Remove or cover mirrors
• Eye care and protection – instillation of eye drops or ointment
• Discourage smoking
• Arrange for patient to eat alone if embarrassed by the need to eat large meals
Maintaining normal body temperature
• Maintain the environment at a cool, comfortable temperature
• Change bedding and clothing as needed
• Cool baths and cool or cold fluids for relief
Monitoring and managing potential complications
• Monitor for signs and symptoms that may be indicative of thyroid storm
• Constant monitoring of vital signs and cardiac output, electrocardiographic monitoring, arterial blood gases, and pulse oximetry
• Administration of oxygen to prevent hypoxia, to improve tissue oxygenation and meet the high metabolic demands
• IV fluids may be necessary to maintain blood glucose levels and replace lost fluids
• Antithyroid and adjunctive medications
Promoting home and community-based care
• Teach patients self-care regarding medications, postoperative management, avoidance of stress and signs and symptoms of complications

Nursing Care Plan

KEY ISSUE
Altered Nutrition: Less than body
requirements related to accelerated metabolic
rate resulting in weight loss and decreased energy
levels.
Scientific Basis:
Clients with Grave’s disease are usually extremely
hungry because of the increased metabolism.
Black, Joyce M., Jane Hokanson Hawks, and
Annabelle M. Keene (2002). Medical Surgical
Nursing: Clinical Management for Positive
Outcomes (6th ed). Philadelphia: W.B. Saunders
Company. p 1103.
Many of the manifestations of hyperthyroidism are
INTERVENTIONS EVALUATION
1. Weigh the patient daily. Desired Outcome
R: To establish patient’s baseline data. Continued The patient’s weight loss will end, as evidenced by
weight loss in the face of adequate caloric intake an ability to consume sufficient calories to return
may indicate failure of antithyroid therapy. to ideal body weight.
2. Monitor daily food intake.
R: Establishes baseline data as basis for nutritional
interventions.
3. Encourage patient to eat and increase number
of meals and snacks, using high-calorie foods that
are easily digested.
R: Aids in keeping caloric intake high enough to
keep up with rapid expenditure of calories caused
by hypermetabolic state.
4. Avoid foods that increase peristalsis such as
tea, coffee, fibrous and highly seasoned foods that
cause diarrhea
related to the increase in oxygen consumption and
use of metabolic fuels associated with the
hypermetabolic state, as well as to the increase in
sympathetic nervous system activity. With the
hypermetabolic state, there are frequent
complaints of nervousness, irritability, and
fatigability. Weight loss is common, despite a large
appetite.
R: Increased motility of the GI tract may result in
diarrhea and impair absorption of needed
nutrients.
5. Consult with the dietician to provide diet high in
calories, protein, carbohydrates and vitamins.
R: May need assistance to ensure adequate intake
of nutrients, identify appropriate supplements.

Porth, Carol Mattson (2006). Essentials of

Pathophysiology: Concepts of Altered Health
States (2nd ed). Philadelphia: Lippincott Williams &
Wilkins. p 550.