Specific disorders of the thyroid gland

hypothyroidism

Results from suboptimal levels of the thyroid hormone.

Commonly occurs in patients with previous hyperthyroidism that has been treated with radioiodine or
antithyroid medications and thyroidectomy.

THYROID DEFICIECY- affects all body functions and can be range from mild, subclinical forms to
myxedema.

2 types:

a. Thyroidal hypothyroidism- refers to the dysfunction of the thyroid gland

b. Central hypothyroidism- when the cause of thyroid dysfunction is failure of the pituitary gland
or the hypothalamus or both.

CAUSES:

A. AUTOIMMUNE DSE.

B. ATROPHY OF THE THYROID OR AGING

C. THERAPY OF HYPERTHYROIDISM

D. Medications: LITHIUM, IODINE COMPOUNDS, ANTITHYROID HORMONES

E. Radiation of the neck and head as treatment for cancers and lymphoma

F. Infiltrative dses, of the thyroid gland

G. Iodine deficiency or excess

Clinical manifestations:

a. Fatigue

b. Hair loss, brittle nails and dry skin

c. Numbness and tingling of fingers

d. Husky voice

e. Menstrual disturbances (menorrhagia and amenorrhea)

f. Loss of libido

g. Subnormal temperature

and pulse rate

h. Weight gain w/o food intake

 i. Constipation

Con’t of clinical manifestations:

j. Mental processes may be dull and pt. appears apathetic.

k. Speech may occur slow and deafness may occur

l. ADVANCE hypothyroidism:

- Dementia

- Inadequate ventilation and sleep apnea

- cholesterol, atherosclerosis, CAD

And poor left ventricular function.

MYXEDEMA COMA

- Rare life –threatening condition

- Decompensated state of severe hypothyroidism

- depression

- diminished cognitive status lethargy, and somnolence

- Increasing lethargy may progress to stupor.

- The patient’s respiratory drive is depressed, resulting in alveolar hypoventilation, progressive

carbon dioxide retention, narcosis, and coma.

- cardiovascular collapse and shock, require aggressive and intensive supportive and
hemodynamic therapy if the patient is to survive

MEDICAL MANAGEMENT

A. PHARMACOLOGY

Synthetic levothyroxine (Synthroid or Levothroid)- preferred preparation for treating hypothyroidism

and suppressing nontoxic goiter

Desiccated thyroid- used infrequently today, because it often results in transient elevated serum
concentrations of T3, with occasional symptoms of hyperthyroidism.

Thyroid hormones

-may increase blood glucose levels,

- increase the pharmacologic effects of digitalis glycosides, anticoagulant agents, and

indomethacin (Indocin). -Phenytoin (Dilantin) and tricyclic antidepressant agents may increase
the effects of thyroid hormone.

* Bone loss and osteoporosis may also occur with thyroid therapy.
B. SUPPORTIVE THERAPY

-maintaining vital functions.

-Arterial blood gases.

-monitoring of Oxygen saturation levels.

- Fluids are administered cautiously because of the danger of water intoxication.

- Application of external heat (eg, heating pads) is avoided.

- If myxedema has progressed to myxedema coma, thyroid hormone (usually levothyroxine

[Synthyroid]) is administered intravenously until consciousness is restored

HYPERTHYROIDISM
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.

- may appear after an emotional shock, stress, or an infection, but the exact significance of these
relationships is not understood.

- causes of hyperthyroidism include thyroiditis and excessive ingestion of thyroid hormone.

CLINICAL MANIFESTATION

 NERVOUSNESS

 emotionally hyperexcitable, irritable, and apprehensive

 they cannot sit quietly;

 they suffer from palpitations and their pulse is abnormally rapid at rest as well as on exertion.

 tolerate heat poorly and perspire unusually freely.

 The skin is flushed continuously, with a characteristic salmon color, and is likely to be warm,
soft, and moist.

 patients may report dry skin and diffuse pruritus.

 A fine tremor of the hands may be observed.

 exophthalmos (bulging eyes)

 increased appetite and dietary intake,

 progressive weight loss,

  abnormal muscular fatigability and weakness (difficulty in climbing stairs and rising from a
chair),

 amenorrhea,

 changes in bowel function.

 sinus tachycardia dysrhythmias, increased pulse pressure, and palpitations.

ASSESSMENT AND DIAGNOSTICS

-The thyroid gland invariably is enlarged to some extent.

-It is soft and may pulsate; a thrill often can be palpated, and a bruit is heard over the thyroid arteries

-a decrease in serum TSH, increased free T4, and an increase in radioactive iodine uptake.

MEDICAL MANAGEMENT

-Use of radioactive iodine is the most common form of treatment for Graves’ disease.

- Beta-adrenergic blocking agents (eg, propranolol [Inderal]) are used as adjunctive therapy for
symptomatic relief, particularly in transient thyroiditis

- Surgical removal of most of the thyroid gland is a nonpharmacologic alternative.

PHARMACOLOGICAL THERAPY

1. use of irradiation by administration of the radioisotope iodine 131 (131I) for destructive effects
on the thyroid gland

2. antithyroid medications that interfere with the synthesis of thyroid hormones and other agents
that control manifestations of hyperthyroidism

RADIOACTIVE IODINE THERAPY

-goal : to destroy the overactive thyroid cells

- the radioactive isotope of iodine is concentrated in the thyroid gland, where it destroys thyroid
cells without jeopardizing other radiosensitive tissues.

- The patient is instructed about what to expect with this tasteless, colorless radioiodine, which
may be administered by the radiologist

thyroid storm - life-threatening condition manifested by cardiac dysrhythmias, fever, and neurologic
impairment . Propranolol (Inderal) is useful in controlling these symptoms.

After treatment with radioactive iodine, the patient is monitored closely until the euthyroid state is
reached. In 3 to 4 weeks, symptoms of hyperthyroidism subside. Close follow-up is required to evaluate
thyroid function, because the incidence of hypothyroidism after this form of treatment is very high.

Radioactive iodine has been used to treat toxic adenomas, multinodular goiter, and most varieties of
thyrotoxicosis (rarely with permanent success).
It is preferred for treating patients beyond the childbearing years who have diffuse toxic goiter.

Radioactive iodine is contraindicated during pregnancy (because it crosses the placenta) and while
breast-feeding (because it is secreted in breast milk) to prevent hypothyroidism in the fetus

ANTITHYROID MEDICATIONS

- objective :to inhibit one or more stages in thyroid hormone synthesis or hormone release.

- block the utilization of iodine.

- This prevents the synthesis of thyroid hormone.

- propylthiouracil (PTU) or methimazole (Tapazole) - used until the patient is euthyroid (ie,
neither hyperthyroid nor hypothyroid).

- block extrathyroidal conversion of T4 to T3

Patients taking antithyroid medications are instructed not to use decongestants for nasal stuffiness,
because these agents are poorly tolerated.

PTU is the treatment of choice during pregnancy.

Another goal of therapy is to reduce the amount of thyroid tissue, with resulting decreased thyroid
hormone production.

-Surgery is reserved for special circumstances-for example, in pregnant women who are allergic to
antithyroid medications, in patients with large goiters, or in patients who are unable to take antithyroid
agents.

-Surgery for treatment of hyperthyroidism is performed soon after the thyroid function has returned
to normal (4 to 6 weeks)

-surgical removal of about five sixths of the thyroid tissue (subtotal thyroidectomy) reliably results in a
prolonged remission in most patients with exophthalmic goiter.

Its use today is reserved for patients with obstructive symptoms, for pregnant women in the second
trimester, and for patients with a need for rapid normalization of thyroid function.

PTU is administered until signs of hyperthyroidism have disappeared. A beta-adrenergic blocking agent
(eg, propranolol) may be used to reduce the heart rate and other signs and symptoms of
hyperthyroidism

Long-term use of antithyroid medications is not generally recommended for elderly patients.

THYROIDITIS
-inflammation of the thyroid gland, can be acute, subacute, or chronic

3 TYPES:

A. Acute thyroiditis -rare disorder caused by infection of the thyroid gland. Staphylococcus aureus
and other staphylococci are the most common causes
 - causes anterior neck pain and swelling, fever, dysphagia, and dysphonia.

- Examination may reveal warmth, erythema (redness), and tenderness of the thyroid gland.

- Treatment : antimicrobial agents and fluid replacement. Surgical incision and drainage may be
needed if an abscess is present

B. Subacute thyroiditis - may be subacute granulomatous thyroiditis (de Quervain’s thyroiditis) or

painless thyroiditis (silent thyroiditis or subacute lymphocytic thyroiditis).

-affects women between the ages of 40 and 50 years

- Signs and symptoms: myalgias, pharyngitis, low-grade fever, and fatigue.

- The thyroid enlarges symmetrically and may be painful. The overlying skin is often reddened and
warm

- Irritability, nervousness, insomnia, and weight loss

-Treatment is directed toward control of the inflammation

- Acetylsalicylic acid (aspirin) is avoided if symptoms of hyperthyroidism occur.

- Beta-blocking agents may be used to control symptoms of hyperthyroidism.

C. Chronic thyroiditis-occurs most frequently in women between the ages of 30 and 50 years, has been
termed Hashimoto’s disease

-not accompanied by pain, pressure symptoms, or fever, and thyroid activity usually is normal or low
rather than increased

-If untreated, the disease runs a slow, progressive course, leading eventually to hypothyroidism

-objective : to reduce the size of the thyroid gland and prevent hypothyroidism.

-Thyroid hormone therapy is prescribed to reduce thyroid activity and the production of thyroglobulin

- If hypothyroid symptoms are present, thyroid hormone therapy is prescribed.

- Surgery may be required if pressure symptoms persist.

THYROID CANCER
Cancer of the thyroid is much less prevalent than other forms of cancer; however, it accounts for 90%
of endocrine malignancies

External radiation of the head, neck, or chest in infancy and childhood increases the risk of thyroid
carcinoma

ASSESSMENT AND DIAGNOSTICS

-Lesions that are single, hard, and fixed on palpation or associated with cervical lymphadenopathy

-Thyroid function tests may be helpful in evaluating thyroid nodules and masses
Needle biopsy -Used as an outpatient procedure to make a diagnosis of thyroid cancer, to differentiate
cancerous thyroid nodules from noncancerous nodules, and to stage the cancer if detected.

ultrasound,

MRI,

CT,

thyroid scans,

radioactive iodine uptake studies, and thyroid suppression tests

MEDICAL MANAGEMENT:

- treatment of choice :surgical removal.

- Modified neck dissection or more extensive radical neck dissection if there is lymph node
involvement.

- After surgery, ablation procedures are carried out with radioactive

- After surgery, thyroid hormone is administered in suppressive doses to lower the levels of TSH
to a euthyroid state

The patient who receives external sources of radiation therapy is at risk for mucositis, dryness of the
mouth, dysphagia, redness of the skin, anorexia, and fatigue

Postoperatively, the patient is instructed to take exogenous thyroid hormone to prevent

hypothyroidism.

Total-body scans are performed 2 to 4 months after surgery to detect residual thyroid tissue or
metastatic disease

A repeat scan is performed 1 year after the initial surgery. If measurements are stable, a final scan is
obtained in 3 to 5 years

Free T4, TSH, and serum calcium and phosphorus levels are monitored

NURSING MANAGEMENT

- Important preoperative goals are to gain the patient’s confidence and reduce anxiety

-Quiet and relaxing forms of recreation or occupational therapy may be helpful.

- Providing Preoperative Care

1. instructs the patient about the importance of eating a diet high in carbohydrates and proteins. A high
daily caloric intake is necessary

2. Remind PT. to avoid tea, coffee, cola, and other stimulants

3. informs the patient about the purpose of preoperative tests, if they are to be performed, and explains
what preoperative preparations to expect
4. Preoperative teaching includes demonstrating to the patient how to support the neck with the hands
after surgery to prevent stress on the incision.

-Providing Postoperative Care

1. The nurse periodically assesses the surgical dressings and reinforces them if necessary.

2. monitoring the pulse and blood pressure for any indication of internal bleeding, it is important
to be alert for complaints of a sensation of pressure or fullness at the incision site.

3. a tracheostomy set is kept at the bedside at all times

4. intensity of pain is assessed, and analgesic agents are administered as prescribed for pain.

5. anticipate apprehension in the patient and inform the patient that oxygen will assist breathing.

6.When moving and turning the patient, the nurse carefully supports the patient’s head and avoids
tension on the sutures.

7 .The most comfortable position is the semi-Fowler’s position, with the head elevated and supported
by pillows.

8. IV fluids are administered during the immediate postoperative period. Water may be given by mouth
as soon as nausea subside

9. The patient is advised to talk as little as possible to reduce edema to the vocal cords

10. A high-calorie diet may be prescribed to promote weight gain.

11. Monitoring and Managing Potential Complications such as Hemorrhage, hematoma formation,
edema of the glottis, and injury to the recurrent laryngeal nerve

TETANY- blood calcium level falls, hyperirritability of the nerves occurs, with spasms of the hands and
feet and muscle twitching.

Tetany is usually treated with IV calcium gluconate