HYPERTHYROIDISM  Normal: 3.

10%
Risk Factors (Causes)
Hyperplasia
 Increase number of thyroid cells Medications
 Nodules: multinodular
 If malignant: Adenoma – tumor
Autoimmune
 Antibodies attack own thyroid cells
 Common cause: Grave’s Disease
Thyroiditis
 Inflammation of the thyroid gland
Jodbasedow’s Effect
 Excessive intake of hormones T3&T4
Problem:
 Triodothyronine (T3)
 Thyroxine (T4)
 Increase O2 consumption
o Hyperactivity
o Insomnia (sleeplessness)
o Tremors & nervousness
 Regulate the body production
o Heat intolerance
o Hyperthermia – Increase body
temperature
o Diaphoresis - Increase Sweating
o Skin: Warm & Moist
 Increase Metabolism
o Increase Appetite
o Weight loss
o Diarrhea
 Increase Cell Activity
o Increase Vital Signs
o Exophthalmos – bulging of the
eyes
o Amenorrhea – absence of
menstruation
*ALL ARE INCREASED EXCEPT WEIGHT AND
MENSTRUATION*
Diagnostic Tests
Surgical Management
 BLOOD
Thyroidectomy
o TSH – (Normal: 0.5-1.5 mili IU/L)
Pre-Op:
cause: increase; diseased:
decrease
o T3 – (Normal: 80-200 ng/dL)
Post-Op:
increase
o T4 – (Normal: 4-11 mcg/dL)
Increase
 TSH STIMULATION TEST – Failure to
increase
 RADIOACTIVE IODINE UPTAKE TEST –
measures the rate of Thyroid Activity
o Assess allergy to iodine, seafoods, Nursing Management
shellfish
o Administration of Iodine 131(oral)
o Result: More than 10%
 THYROID SCAN
o Result: Enlargement of the Thyroid
 ANTITHYROID DRUG
o Thiomides
 Propylthiouracil (PTU)
 Methimazole (tapazole)
 Action: blocks
T3&T4 production
 Effectiveness:
adequate sleep
- Side Effects: hypothyroidism S/S
- Adverse Effect: Agranulocytosis
 IODIDES - so/n
o Lugol’s solution
o Saturated solution K + iodide (SSKI)
 Action: blocks the release T3, T4
 Other purpose: decrease
vascularity, decrease bleeding
 Usually gven before
Thyroidectomy
 S/E: (lugol’s solution)
 Metallic Taste
 Staining of the Teeth
 Mix with fruit juice to decrease
metallic taste
 Use straw to avoid staining of
the teeth
 BETA BLOCKERS
o Decrease Hypertension
o Propranolol
 RADIOACTIVE IODINE – (radiation)
o Internal radiation: Iodine 131
o Action:
 Destroys overactive thyroid
(Hyperthyroidism)
 Destroys malignant cells
(Thyroid CA)
 VS – baseline
 Drugs: lugol’s solution (Iodine), SSKI
 Position: semi-fowler’s
 Priority: Airway
 Bedside: Tracheotomy Set
 Monitor Complications
o Hemorrhage – Frequent Swallowing
o Hematemesis – Bright red blood
 Assess: Behind the Neck
o Ice collar –
 o Avoid Neck Hyperextension (Don’t Signs and Symptoms
Hangad)  High Temperature – 39-40 degrees
 Tachycardia –VS: HR; risk: dysrhythmia
LARYNGEAL NERVE DAMAGE
o Signs and Symptoms: voice loss Nursing Management
o hoarseness  Airway
Management  PTU: 200mg - DOC
 Assess: let the patient speak  O2
 Rest the voice
 If no damage: hoarseness subsides HYPOTHYROIDISM
AKA: mixed Edema
TETANY Risk Factors
 Cause: Accidental removal of the  Atrophy: decrease size of thyroid cells
Parathyroid Gland o Common cause: Autoimmune –
 Result: Hypocalcemia (<8.5 mg/dL) Hashimoto
 S/S: o Primary hypo – problem: thyroid
o Chvostek’s sign – Tap the cheek =  TSH stimulation
twitching o Secondary HYPO – Problem: Pituitary
o Trousseau’s Sign – BP = Spasm Gland
o Spasm – Bronchus – Constriction  Iatrogenic Cause:
o Spasm – muscles – extremities o Treatment causes the disease
o Spasm – around the mouth Signs ang Symptoms
 Priority: Airway  Decrease in T3 & T4
 Drug of Choice: Calcium Gluconate  Decrease in O2 Consumption
 Vitals: RR o Hypoactivity – slow
o Sleepy
Nursing Management: (Hyperthyroidism) o Slow mental process
 Provide Comfort and Rest o Fatigue – NDx: Activity Intolerance
o Environment: Cool & Quiet  Decrease Body Heat Production
o Room: Private o Cold Intolerance
o Clothing: Light & Loose o Hypothermia – Decrease Body
o Balance activity & rest Temperature
o Promote sleep o Decrease Sweating
 Diet o Skin: Dry
o Calories – 4,000-4,000  Decrease Metabolism
o CHON: increase o Anorexia
o Fiber: decrease o Weight Gain
o No Caffeine o Constipation
 Monitor Complications o Decrease Nutrient Absorption
o Corneal Dryness  Hair: hair loss, receding hairline
 Protect the eyes (coarse hair)
 Artificial Tears  Nails: Brittle
 Anemia
THYROID STORM (THYROID CRISIS)  Decrease Cell Activity
 Severe o Vital signs: Decreased
 Exaggerated o Menorrhagia – Menstruation increase
 Life threatening *ALL ARE DECREASED EXCEPT
Risk Factors WEIGHT AND MENSTRUATION*
 Stress – physical Diagnostic Tests
o Trauma  Blood
o Infection o T3: Decrease
o Pregnancy o T4: Decrease
o Surgery – thyroidectomy, any type of o TSH: Increase (+) hypoT
surgery, dental procedure (tooth  Radioactive Iodine Uptake
extraction)
 o Hypoactive Thyroid Cells - < 3% CUSHING’S DISEASE
 Thyroid Scan Causes:
o Atrophy – Decrease cell size  Tumor – Adenoma
o Primary Cushing: site – Adrenal
Gland
o Secondary Cushing: Site - Pituitary
Medication Gland
Thyroid Hormones – Synthetic Drugs o Tumor secretes ACTH – stimulates
 Levothyroxine (Synthroid) – Replaces T4 adrenal gland to produce GMA
o SE: Increase vital signs  Iatrogenic:
o SE: Hyperthyroidism S/S o Treatment causes the disease
o Before breakfast; assess pulse. Pathophysiology
o LIFETIME G - Glucocorticoids – cortisol – sugar
 Liothyronine (Cytomel) – Replaces T3 M – Mineralocorticoids – Aldosterone –
o SE: Increase vital signs salt
o SE: Hyperthyroidism S/S A – Androgen – Sex Hormone (Male)
o Before breakfast; assess pulse. Increase Glucocorticoids
o LIFETIME  Increase glucose: hyperglycemia
Nursing Management: (Hypothyroidism)  Risk: Infection – Private Room
 Assess & Monitoring  Skin: Thin & fragile – risk: bruising
o VS: HR/Pulse (priority)  Abnormal fat deposits
o If (+) chest pain: notify physician o Moon face
o Weight daily o Truncal obesity
o Drugs: Lifetime o Thin extremities
 Promote Comfort o Buffalo Hump
o Environment: Warm Increase Mineralocorticoids
o Clothing: Thick: Na+: hypernatremia
o Avoid Heating Pads – decrease  H2O retention – (+) edema
sensation/ (+) paresthesia  Hypervolemia
o Dry Skin: Lotion – to moisturize  Increase BP/ HPN
 Diet K+: hypokalemia
o Cholesterol: Increase  Muscle weakness
o Fiber: Increase – Cereal, wheat,  Risk factors: dysrhythmias – Uwave
oats, fruit & vegetables  Bedside: ECG monitor
o Fluids: Increase Increase Androgen
o For constipation: Stool Softener –  Hirsutism
Ducossale (colace)  Acne
 Monitor Complication  Virilization
o Myxedema Coma  Decrease libido
 Severe Hypothyroidism Diagnostic Test
 Cause: 1. Blood
 Stress a. Glucose: increase – hyperglycemia
 Skipping of drugs - b. Cortisol: Increase
noncompliance c.WBC: Decrease – Risk for infection
 Surgery – any dental d. Na+: Increase
 Signs and Symptoms: e. K+: Decrease (3.5-5 meQ/L)
o V/S: decrease – hypo s/s 2. Ultrasound
o Hyperventilation – risk: a. Shows the tumor – Abdominal
acidosis
Medications
Nursing Management:
 Airway  Adrenocortical Steroid Inhibitors
 Blanket – to warm patient o Aminogluthimide (Elipten)
 Correct Hypothermia – warm environment o Metyrapone (Metoperone)
 Drug: Levothyroxine Action: inhibit/stops ACTH production – no
stimulation of adrenal gland
 GOAL: Decrease GMA o Body Hair loss
Surgery: Adrenalectomy – Removal of the o Impotence
Adrenal Gland Medications
 Goal: Reduce/ Decrease GMA 1. Glucocorticoids
 Risk: Bleeding – Hemorrhage – Shock a. Prednisone
 Monitor V/S: Hypotension b. Hydrocortisone
c. Dexamethasone
*Steroids – Lifetime Only for Addisons*
Nursing Management
 Prevent Infection
o Room: Private Nursing Management: (Addison’s)
o Hand washing 1. Monitoring
o Monitor Temperature – check fever a. Vital signs: BP, HR, RR, Temp
o Avoid persons with colds b. F/E: Na+ & K+
o Avoid fresh fruits & flowers c. Weight: assess DHN
d. Infection:
 Diet
i. If taking steroids
o Na+: Decrease Sodium
ii. V/s: fever
 Avoid Canned Foods
iii. Lab: WBC
o K+: Increase Potassium
2. Diet
o Protein: Increase
a. CHO & CHON: increase
 Health Teaching b. Fluids: increase
o Theracom – c.Na+: normal intake – 3g/day or
o AAssurance: resolves w/ treatment increase
o If (+) Surgery – bilateral – lifetime d. Potassium: decrease
treatment 3. Health Teachings
o Avoid Over the counter Medicine a. Reduce stress
Addisonian Crisis
ADDISON’S DISEASE b. if (+) stress: increase – steroids
Risk Factors (Causes) c. drug adherence – compliance –
 Iatrogenic lifetime
o Surgery: Bilateral Adrenalectomy – d. Medic alert Bracelet – to prevent
risk Shock
o Overdose: GMA inhibitors
 Hypoplasia – decrease cell number ADDISONIAN CRISIS
o Congenital Risk Factors (Causes)
 Atrophy – Decrease Cell Size  Stress
Signs and Symptoms (Problems)  Sudden Steroid Discontinuation
 Decrease GMA  Infection (fever, colds, cough, flu)
 Decrease Glucocorticoids  Trauma (accidents, surgery)
o Hypoglycemia Signs and Symptoms (Problems)
o Weight loss  Severe hypotension
o Muscle Weakness  Headache
 Decrease Mineralocorticoids  Abdominal Pain
o Hyponatremia – Hypovolemia  Pallor
o Decrease BP – Dehydration – risk  Shock
for Shock; increase HR; increase Nursing Management
RR  IVF: NSS/ LR (best choice)
o Nursing Diagnosis: Fluid Volume  IV drug: Hydrocortisol
Deficit  Vital signs: Blood pressure
o Hyperkalemia
 anorexia
o ECG Tall T wave
o Hyperpigmentation: Eternal Tan
(Bronze Skin)
 Decrease Androgen
 o Common in pregnant
o Steps:
 NPO – 10-12 hours
 Oral Glucose: (juice)
 Blood Extraction: 2 hours
o Normal: 120-160 mg/dL
 After 1-1 1/2 hours – (-200)
 After 2H - <140 (return to
N)
o Positive: DM - >200 mg/dL after 2H,
Type 1 Type 2 3H, 4H
AKA IDDM NINDM (Non-
(Also (Insulin Dependent Insulin  Glycosylated Hemoglobin (Hb &1C)
known as) Diabetes Mellitus) Dependent o Measures the glucose control for the
Diabetes past 2-4 months
Mellitus)
Age of <30 years old >30 – 35 o Indicator of glucose utilization/
Onset uptake
Juvenile DM Adult - Onset o Result:
DM
Risk
 N: <7% - good control
 Heredity – Genetics  Obesity –
Factors  Autoimmune – increase  Fair: 8-9% - borderline
attacks pancreatic resistance of  DM: >9% - poor management for
cells the binding the past 2-4 months
 Viral – HVI, of insulin of
Coxsackie glucose to (noncompliance)
 Destruction of the the receptors Nursing Management
Pancreas  Heredity –  Diet
 Insulin Output: Genetics
(Race: Blacks) a. Balanced Meal – food pyramid
Decrease or
Absence insulin  Cell i. 55-60% CHO
receptors: ii. 30% Fats
lacking/
damage
iii. 10-15% CHON
 Hyperglycemia - Increase blood b. Do not Skip Meals
glucose c. Increase Fiber
 Glucose: Osmotic Diuretic – d. Sweetener: equal, stevia, Slenda
Polyuria
 Nursing Diagnosis: Fluid Volume
e. No diabetic diet
Deficit  Medications
S/S: a. Insulin: for type 1DM
 3P’s i. A: transports cglucose to the cell
o Polyuria
o Polydipsia ii. Effect: lwo serum glucose (blood)
o Polyphagia iii. Route: subcutaneous (Abdomen)
 Sudden Weight loss iv. Avoid aspiration
 Glucosuria: risk – candidiasis, UTI v. Rotate sites – inch/2.5cm
Increase Blood Viscosity
o Decrease blood flow (decrease distance to prevent lipodystrophy
circulation) vi. Avoid Massage
o Decrease Oxygen vii. Only insulin that can be given IV:
o Poor Wound Healing
Regular Insulin
Complications:
1. Gangrene – ulceration/necrosis viii. Storage (Body) – DON’T freeze –
2. Diabetic Retinopathy – Blurred if frozen, DISCARD
vision ix. Before injection: room temp.
3. Nephropathy – Renal Failure
(Kidney Failure) Cold insulin can cause
4. Neuropathy – Paraesthesia lipodystrophy
(NDx: Altered Sensation) x. Mixing of 2 insulins
5. b. Oral Hypoglycemic Agent (OHA):
Diagnostic Tests: For type 2 DM
 Fasting Blood Sugar i. A. Sulfonylureas “ide”
o N: 70 – 110 mg/dL 1. Glipizide
o Result: >120mg/dL 2. Glybunide
 Oral Glucose Tolerance Test ii. Stimulates insulin production
o Most sensitive
 iii. Decreases the insulin - Cx of type 1 DM
resistance to cell receptors - Out of Control DM: >200-250mg/dL
iv. B. Biguanides – metformin - Causes:
1. Blocks the hepatic o Skipping insulin – non compliance
production of o Stress – release cortisol
glucose o Steroids – worsens DM
2. Side Effects: GIT o Severe Illness/infection: VS – check
S/E Fever
3. Adverse Effects: (-) insulin – increases glucose – dehydration
Acidosis  Increase Fat breakdown
 Product: ketones
o s/s: breath – fruity/acetone
o decrease in LOC
 Exercise
a. Purpose (CommonBoardQuestion)  Ketones: Acidic – pH imbalance:
i. Increase insulin & glucose Metabolic Acidosis
utilization – uptake o pH: decreases
ii. Increase circulation o HCO3: decreases
iii. Decrease blood cholesterol o NV & anorexia
b. Assess – Serum/ blood glucose  Compensatory: breathing – deep,
level rapid
i. Avoid during insulin peak – o Term: Kussmaul’s
regular 2-4hrs DKA Management:
ii. Risk for hypo  IVF – NSS/ NaCl 0.9%
c.Frequency: 3x a week o 500ml
d. Bring snack – simple carbohydrate  Regular Insulin – route: IV (emergency)
 Foot Care o 5-10 units
a. Avoid walking barefoot  Sodium Bicarbonate
b. Inspect the feet: mirror – corns, o To control: metabolic acidosis (Drug
callus of choice)
c.Refer to podiatrist o KCI – IVF w/ infusion pump safe
d. Shoes: well-fitted
o avoid IV push
e. Socks(white): cotton – absorb
2. Hyperglycemic Hyperosmolar Non-ketotic
moisture
Syndrome (HHNS)
f. Use cornstarch – foot powder
 Complication of type 2 DM
g. Cut toenail – straight across
h. Lotion/ lanolin – massage but not  Cause: infection
in between the toes o (+) insulin – but insufficient
 Monitor Phenomena & Complications o No fat breakdown
a. Somogyi Phenomenon o s/s: (-) ketones
i. At bed time: High blood glucose o hyperglycemia – 3p’s
ii. Cause: increased insulin in the o risk: dehydration
body Management:
iii. 2-3AM: hypoglycemia Goal:
iv. Compensatory: rebound  Rehydrate
hyperglycemia a. IVF
Management b. Insulin
- Bedtime snacks 3. Hypoglycemia
- Adjust evening dose: decrease insulin  Blood glucose <60 mg/dL – more fatal
b. Dawn’s Phenomenon  RISK FACTORS:
i. No hypoglycemia o Decrease food – skipping meals
ii. Nocturnal release: GH – 3am o Insulin overdose
iii. 3AM – glucose increase o Excessive Exercise
Management:
o Excessive Alcohol
- Give insulin: bedtime (10-11pm)
MILD MODERATE SEVERE
Complications Glucose 40-60 20-40 <30
1. Diabetic Ketoacidosis Level
 Signs and -Tachycardia -Acute -Unconscious  DONOT: cough/sneeze, strain, Valsalva,
-Irritability -seizure
Symptoms -Restlessness
-Headache bend. Lift
-Blackout -coma
-Excessive  AVOID: brushing teeth (2 weeks) – to
-Hunger -Contusion
-Diaphoresis -Disorientation prevent tension to suture lines
-Shaking
-Tremors
MANAGEMENT: DIAPHRAGMATIC HIATAL HERNIA
 Assess – serum glucose (GERD)
 Reverse Hypoglycemia – ASAP Risk Factors (Causes)
o 10-15grams C – Constipation
 Orange juice O – Obesity & Ascites
 Candy P – Pregnant
 Crackers *Common: increase Intraabdominal Pressure*
 For unconscious: 1st – SQ: Glucagon
blood glucose Cause: Esophageal hiatus (opening) – weakness
 IVF: D5W – (+) glucose Problem: Stomach Herniation / Protrusion
GROWTH HORMONE HYPERSECRETION If fundus only: Paraesophageal Hernia (Rolling)
Risk Factors (Causes) If fundus & cardiac sphincter: Sliding (Mixed)
 Excessive Growth Hormone
 Gigantism – Common: Children Common Complication (Cx): Acid Reflux (GERD)
o Epiphyseal plate: Open Signs and Symptoms
o Bone growth: Longitudinal  Pyrosis – Heartburn
(7 - 8ft)  Hematemesis – vomiting of blood
 Acromegaly – Common: Adult o Appearance: bright red/ coffee-
o Epiphyseal Plate: Closed ground
o Bone growth: Transverse  Dysphagia
Signs and symptoms Diagnostic Test
 Face: Coarse, Rough, Thick
 Barium Swallow – upper GI series
 Jaw: Protruding – Prognathism
 Hand: Enlargement of the Hand/ o Shows herniation (protrusion) –
Increase Ring Size outline
 Feet: Enlarged – Increase Shoe Size  Endoscopy – Visualization: herniation/
 Organomegaly (Including tongue, protrusion
heart) o Anesthesia – local (lidocaine
*Ensure Airway Patency* spray)
 Voice Deepening
o Check: Gag reflex – after
Medications
 Growth Inhibiting Hormone  NPO until (+) Gag reflex
o Octreotide (Sandostatin) Management
 Action: inhibits GH  Nissen Fundoplication
 Route: Subcutaneous (SQ)  Surgery of Choice
 S/E: GIT  Wrapping of Esophagus
 S/S  Vagotomy – Cutting of the Vagus Nerve
o abdominal cramps  Goal: Decrease Hydrochloric Acid
o nausea and vomiting Nursing management:
o Diarrhea  Relieve S/S
Surgery:  Position: Fowlers/Semi-fowler’s
 Hypophysectomy (4-6 blocks) HOB elevated
o Removal: Pituitary Gland (Anterior)  Medication:
o Approach: Transsphenoidal  Antacid, H2 blockers (ranitidine),
Hypophysectomy Proton pump Inhibitors (PPI)
o Incision: Under the upper lip (not visible)
 Eating – no bedtime snacks
o Pressure: nasal pack
 Small Frequent Feeding (SSF)
o Post OP:
o Avoid 3 large meals = 6 small
 HOB elevated – 30 degrees
 To decrease Cranial Pressure
meals
 Assess: CSF o Avoid caffeinated/ alcohol
o Halo sign  NO Cola
o Otorrhea  NO Chocolates
o Rhinorrhea  NO Coffee
 o Diet: High Fiber
 Prevent Increase Intra-Abdominal
Pressure
o No constrictive clothing
o Avoid: Lifting, Bending, Straining
(Valsalva) – softener
 Ducosale – Colace