Hyperthyroidism An incapacity of closing the eyelids

2nd prevalent disorder completely

Causes
1. Severe emotional stress
2. Autoimmune disorder
3. Excessive infection of thyroid hormone
Grave’s Disease
3 Basic concepts
● Increased metabolic rate (T3)
● Increased body heat production (T4)
● Hypocalcemia (Calcitonin)
Signs and symptoms
Subjective
Nervousness, mood swings, palpitations, heat
intolerance, dyspnea, weakness
Strabismus - parang banlag
Skin:
Warm, moist, velvety, increased sweating;
increased melanin pigmentation
Grave’s Dermopathy (Shiny heel)
- Weight loss despite increased appetite
V/S:Increased systolic BP, widened pulse
pressure (N: 20-30mmHg), tachycardia,
peritoneal edema
Goiter: Thyroid gland (Noticeable & palpable)
Gyne: abnormal menstruation
GI: frequent bowel movements
Activity Pattern: fatigue which leads to
depression

Objective Lab studies

● Exophthalmos - Thyroid stimulating hormone test
- Thyroid eye disease - Total thyroxine
- Accumulation of fat pads in the - Free thyroxine and free thyroxine index
eye (bulging eyes) - Free triiodothyronine
- 5x more common for smokers - Calcitonin
● Dalyrimple sign - Thyroid antibodies
- a widened palpebral (eyelid) - Thyroglobulin
opening, or eyelid spasm, seen
in thyrotoxicosis causing Diagnostic Imaging
abnormal wideness of the - Thyroid scan and radioactive iodine
palpebral fissure. uptake
- There’s dryness in the cornea - Ultrasound
- Nursing Intervention:
Eyes Naturale (Eyedrops)
Drop plain NSS on gauze while
pt is sleeping Diagnostics:
● Von Graefe’s sign - Serum T3 & T4 level → ↑
slow, delayed downward movement of - T3 (N: 70-220 ng/dl)
the upper eyelid on downgaze - T4 - 80% bound to TBG (N: 4.5-11.5
● Stellwag’s sign ug/dl)
Thyroid stare - Elevated RAIU
Bilateral - Thyroid - TSH (N: 0.4-1.5 uU/L)
Unilateral - Tumor - FT4 (0.9-1.7 ng/dl)
● Griffith sign
Lid lag of the lower eyelid Management:
● Jellink’s sign Pharmacologic
Hyperpigmentation of the eyelid A. Radioactive Iodine Therapy
● Rosenbach’s sign - Use of irradiation single oral dose is
Tremor of the eyelids administered (radiologist)
● Lagophthalmos
 - Causes acute release of thyroid
hormones
- C.I. for pregnant and lactating mothers
- Delay pregnancy for 6 months after
therapy (6 mons-1 yr)
- Delay contraceptive for 24hrs
- Place patient on isolation for few days
- Check WBC (withhold if <4500)
- NPO
- Emergency med care at bedside
- 131-123 p. o. (alternative of RAIU
because of lesser iodine)
- FT4 - confirmatory test
- Makinang yung thyroid after 2, 6, 24 hrs
- Uses Scintillation camera
- Client is radioactive for 2 weeks
- Use straw as it can stain teeth
(recommend taking it one sip)
- Put client on Euthyroid state
May result in thyroid storm if left
unmanaged before therapy or surgery
- 3-4 weeks before replacement med
- Thyroglobulin & Levothyroxine -
synthetic drugs
Agranulocytosis
- Refrain from using nasal decongestants
for nasal stuffiness
- C.I. late pregnancy
- Occasionally administered w/ thyroid
hormones
- → avoids hypoT
B. Anti-thyroid medications
- Prevents synthesis of thyroid hormones
- STOP medications if w/ s/sx of
infections
1. Methimazole (Tapazole)
● Inhibits thyroid hormone by blocking
oxidation of iodine in thyroid gland
● Lifetime med
● Initial:
15mg/d PO for mild hyperthyroidism
30-40 mg/d for moderat-to-severe’
2. Propylthiouracil (PTU)
- Most commonly used
- Derivative of thiourea that inhibits
organification of iodine by thyroid gland
- Blocking type 1 deiodinase
- Inhibit T3 & T4
- Max 100-300/day
● Initial:
300-400 mg/d PO divided lied: not to
exceed 1200 mg/d
3. Iodine preparations (SSKI, Lugol’s solution)
● Inhibits thyroid hormone
secretion. Contains 5% iodine
and 10% potassium iodide.
Contains 8 mg iodide per drop
● Takes 2-4 weeks before results
are evident
● Common Preoperative drugs.
● Given for those who have
enlarged vasculature in the neck
before surgery
4. Beta blockers
● Propranolol (Inderal), Atenolol
(Tenormin), Metoprolol (Lopressors)
- Do not give Propranolol and
Atenolol for client with asthma
as it promotes
bronchoconstriction
- Metoprolol - cardio-selective
beta blockers
● Surgery
- Subtotal Thyroidectomy
- ⅚ gland removed
- Total thyroidectomy
Pre-Operative Care:
● Promote Euthyroid state
● Assess V/S, weight, electrolyte &
glucose level
● Teach DBE & coughing as well as how
to support neck
● Administer Iodides as ordered
Subtotal Thyroidectomy
● Post-Op Care
- Position: Semi-Fowler’s
- Immobilize head with
pillows/sandbags
- Prevent Hemorrhage
- Monitor V/S amd monitor for
respiratory distress
- Have tracheostomy set, O2 &
suction machine at the bedside
 - Ask if the patient to speak every Thyroid Crisis/Storm
hour ● Acute & life threatening condition in
- Assess for laryngeal nerve uncontrolled hyperthyroidism
damage ● Risk factors:
- Monitor for signs of - Infection, surgery, beginning
hypocalcemia & tetany labor to give birth, taking
- ROM exercises at the neck 3-4 inadequate antithyroid
times a day after discharge medications before
thyroidectomy
WOF Thyroid Storm s/sx:
- Fever, tachycardia, hypotension,
Post-Surgical Complications marked respiratory distress,
1. Transient vocal cord paralysis 3% pulmonary edema, irritability,
2. Prolonged postoperative hypocalcemia apprehension, agitation,
in 3% restlessness, confusion,
3. Permanent hypoparathyroidism in 1% seizures
4. Recurrent hyperthyroidism in 2% Management:
- Maintain quiet calm, cool,
Nursing Intervention private environment until crisis
1. Nutrition is over
- High caloric, high CHON, ↑ OFI - Administer oxygen as needed
- ✓ Daily weight Meds:
2. Improvings self-esteem - PTU or Tapazole
- Changes in appearance, - Sodium iodide IV or Lugal’s
appetite and weight solution orally
- Meticulous care of affected eye - Propranolol
3. Maintain normal temperature - Steroids
- Cool environment, cool baths,
cool fluids Hypothyroidism
- Provide changes in Hyposecretion at the thyroid hormone
beddings/linens characterized by decreased rate of body
4. Managing Potential Complications metabolism.
- WOF s/sx: Thyroid storm, ● Women
Hypothyroidism ● 95% of cases → Primary/Thyroidal
HypoT
- Tracheostomy set with mosquito Central HypoT
forceps at the bedside table (WOF Endemic and Multinodular Goiters
tetany) ● Endemic Goiter
- Assess the client’s voice (WOF Caused by deficiency of Iodine in the
Laryngeal Stridor) Hypocalcemia diet.
Inability of the thyroid to use iodine or
Primary Assessment - Assess the nape of the relative iodine deficiency caused by
client for bleeding increasing body demands for thyroid
hormones.
Ice Collar - to prevent edema and bleeding ● Nontoxic Goiter (simple or colloid
goiter)
An enlarged thyroid
 ● Nodular Goiters Diagnostics:
Contain one or more areas of ● ↑TRH, TSH
hyperplasia ● Normal-low serum T4&T3
● Decreased PAUI
Causes:
- Autoimmune (Hashimoto’s Thyroiditis) Management:
- Surgery ● Goal:
- Radiation therapy Provide appropriate goal and
- Antithyroid drugs management
● Supportive:
3 Basic Concepts Pharmacotherapy
- Decreased metabolic rate
- Decreased body heat production Myxedema Coma
- Hypercalcemia ● Extreme, severe stage of
hypothyroidism in which the client is
Thyroid-related symptoms hypothermic and unconscious
● Decreased Metabolic Activity ● S/Sx:
● Decrease mental processes Hypotension, bradycardia,hypothermia,
● Cholesterol Problems hyponatremia, hypoglycemia,
● Need for vitamins respiratory failure & death
● Loose skin ● Management:
● Dry skin, dry hair - IV thyroid hormones
● Sleeplessness, Depression, Fatigue (Levothyroxine)
● Decreased Libido - Correction of hypothermia
● Inflammation of the tendons & joints - Maintenance of vital functions
● Cold internally - Treat precipitating factors
● Overall weight pain more evenly
distributed Adrenal Glands
● Weak heart ● Medullary Hormones
● Fat & Carbohydrate metabolism altered - Dopamine (catecholamines) promotes
metabolism and use caloric demands for
Assessment: fight & flight
● Subjective Data - increase blood pressure
Weakness, extreme fatigue, lethargy, - Norepinephrine
headache, slow memory, loss of interest - Epinephrine - Dilate thrombus and
in social activity, cold intolerance increase cardiac rate
● Objective Data - Opioid Peptides
- Depressed MMR; intolerance to ● Cortical Hormones
cold - Mineralocorticoids (salt)
- Cardiomegaly, bradycardia, - Glucocorticoids (cortisol)
hypotension, anemia responsible for glucose,
- Menorrhagia, amenorrhea, inflammatory response, and
infertility allergic reactions.
- Dry skin, Brittle hair, coarse hair, - Androgen (Sex hormones)
hair loss
- Slow speech, hoarseness, Circulatory Collapse/schock
thickened tongue Dilated blood vessels
- Weight gain
- Thickened skins
Disorders of the Adrenal Glands 3. CT Scan/MRI
● Adrenal Insufficiency (Addison’s 4. Visual Field
Disease) 5. Hormonal Assay
● Acute Adrenal Crisis (Addisonian Crisis)
● Cushing's Syndrome (Adrenocortical CUSHING’S MNEMONIC
Hyperfunction) C - Central obesity. Cervical fat pads, Collagen
● Hyperaldosteronism fiber weakness. Comedones
U - Urinary free cortisol and glucose increase
Cushing’s Syndrome S - Striae, suppressed immunity
● Dr. Harvey William Cushing H - Hypercortisolism, Hypertension,
● Hypersecretion of adrenal cortex Hyperglycemia, Hirsutism
hormones I - Iatrogenic
● Causes: N - Non-iatrogenic
1. Tumor (adrenal cortex/pituitary) G - Glucose intolerance, Growth retardation
ectopic
● Bronchogenic CA Triad:
2. Prolonged Steroid Therapy Hypernatremia
3. ECTOPIC ACTH syndrome Hyperglycemia
● ATH dependent Hypokalemia
● ACTH independent
Management:
Adrenal-Related Symptoms 1. Surgery
● Weight accumulation around mid section ● Adrenalectomy
● Inability to handle stress ● Hypophysectomy
● Salt Cravings ● Radiation Therapy
● Sleeping difficulties 2. Adrenal Enzyme Inhibitors/Cytotoxic
● Fluid retention (ankles); dehydration agents
● Calcium deposits due to altered pH Anti-fungal - most common
● Low oxygen in tissues 3. Tapering of corticosteroids
● Pain and inflammation
Nursing Management
Laboratory/Diagnostic Procedure Adrenalectomy
1. 24h urinary free cortisol level ● Surgical removal of one more of the
>50-100 mcg a day adrenal gland because of tumors or
2. Midnight Plasma Cortisol overactivity
> 50 nmol/L - Unilateral adrenalectomy
3. Late Night Salivary Cortisol - Bilateral (hormonal replacement
Measurement for lifetime - glucocorticoids)
Diagnostic ranges vary ● Preop
4. Dexamethasone Suppression Test Reduce risk of post op complication
A. Low Dose Dexamethasone A. Prescribed steroid therapy,
Suppression test (LDDST) Given 1 week before surgery
B. Overnight One Dose B. Antihypertensive drugs D/C
Dexamethasone Suppression C. Sedation as ordered
Test to find out cause of Cushings’s D. Monitoring of blood glucose and
Syndrome Insulin therapy
1. CRH stimulation test ● Intraop
2. High Dose Dexamethasone Monitor for hypotension & hemorrhage
Suppression Test (HDDST)
 ● Post Op
1. Promote hormonal balance
2. Observe for hemorrhage and
shock
3. Prevent infection
4. Administer cortisone or
hydrocortisone as prescribed
Taking control of your life with Cushing’s
Syndrome
● Move forward with treatment
recommended by your doctor
● Join a support group for people with
Cushing’s Syndrome
● Take care of your body
● Learn all you can about Cushing’s
Syndrome
● Ask your doctor about how to manage
symptoms
Addison’s Disease
● Dr. Thomas Addison
● Adrenocortical Insufficiency
● Hyposecretion of the adrenal cortex
hormones
● Causes:
Therapeutic use of corticosteroids
TB
Primary Adrenal Insufficiency
90% of Adrenal destroyed - 10%Pituitary
Decrease cortisol and aldosterone
● Primary lack of adrenal hormones
including both cortisol and aldosterone
● Cause:
- Autoimmune
- TB
- Metastatic tumor
- Bilateral Hemorrhage
- Low Cortisol and aldosterone,
high ACTH
- Irregularly shaped blotchy
melanin patches on oral mucosa
- Affects the buccal mucosa near
the commissures first and
spreads posteriorly
Cause:
● Adrenal Dysgenesis
● Impaired Steroidogenesis
- Congenital Adrenal Hyperplasia
- Ketoconazole
- Rifampicin/Phenytoin
● Adrenal Destruction
● Tumors
● Amyloidosis
● Auto-immune disorders
● Cancer
● AIDS related infection
● Adrenalectomy
● Hemorrhage/bleeding into Adrenal
Gland
● Fungal Infections
Secondary Adrenal Insufficiency
● Impaired Hypothalamic-Pituitary-Adrenal
Axis
Cause:
1. Steroid use
2. Hypophysectomy
3. Hypofunction of the Pituitary Gland
Diagnostics
1. Serum Na, Blood glucose, serum K, and
WBC
2. 8 hour Intravenous ACTH test
● ACTH Stimulation test
● CRH Stimulation test
Assessment:
Management
1. Hormone Replacement Therapy
● Cortisone, Florinef
● Steroid
Nursing Management during Steroid
Therapy:
- Gave medication on full stomach
Addisonian Crisis
● Life-threatening condition caused by
acute adrenal insufficiency
● May cause hyponatremia,
hypoglycemia, hyperkalemia, & shock
● S/sx:
- Severe generalized muscle weakness,
severe hypotension, hypovolemia,
shock
Management: Diabetic Emergencies
● IV Glucocorticoids ● Diabetic Ketoacidosis
● Hydrocortisone Na succinate ● Hyperosmolar Hyperglycemic state
(Solu-Cortef) ● Hyperglycemia
● Fludrocortisone
Nursing Management:
Types:
Nursing process for Addison’s Disease
● Risk for deficient fluid Volume Type I
● PC: Hypoglycemia 1. IDDM (Insulin Dependent DM)
● Fatigue - Juvenile - onset
● Risk for injury - Thin
Nursing Process for Cushing’s Syndrome - Prone to KDA
● Excess Fluid Volume
● Risk for Impaired skin integrity Management
● Disturbed Body Image ● Diet
● Activity/Exercise
Diabetes Mellitus ● Insulin (always a component of
Diagnostic Test management of Type I DM)
● FBS Type II
80-120 mg/dl (NPO) - NIDDM (Non-Insulin Dependent DM)
● 2hrs PPBS - Maturity - onset
100 g of carbohydrate in diet - Stable Dm
● Hba1c - Ketosis
4-5.6% - Normal - Onset is 40 years
5.7-6.4% - Borderline - Obese
6.5-higher% - Diabetic - Prone to HHNC
● OGTT/GTT (Oral Glucose
Tolerance Test) Management:
- 150-300 g of CHO/p.o. - Diet
- Series of blood specimen is - Activity/Exercise
collected: - OHA (Oral Hypoglycemic Agent)
- 30 mins - Insulin
- 1॰ - Pregnancy
- 2॰
- 3॰, 4॰, 5॰ as required
(NPO during test)
Lab Studies
● Glycosylated Hemoglobin
● Fasting Blood Glucose Level
● RBS/CBG
● Insulin
● Glucogen
● Serum Ketones
Insulin Nursing Responsibilities:
● Rapid Acting ● Avoid Lipodystrophy
● Intermediate ● 20 mins cooldown of Insulin
● Long Acting ● Do not massage the site of injection
to avoid increase of absorption
● Provide Foot care - Diabetic
Onset Peak Duratio
n Neuropathy
● Observe for side-effects
Rapid 5 mins 30 2-4hrs Localized
Acting mins-1hr - Induration or Redness, swelling,
Lispro lesion at the site, Lipodystrophy
(Humalo
Generalized
g)
- Edema, sudden resolution of
Interme 1-2 hrs 6-8 hrs 18-24hrs hyperglycemia
diate - → Retention of water
Acting Hypoglycemia
Humulin
N./
Somogyi phenomenon
Humulin
(I.) Prolong Insulin therapy →
Lente, Hyperinsulinemia→ Hypoglycemia→ Stress
Monotar response→ Release of Adrenal
d, NPH Hormones→ Rebound Hyperglycemia
Counterregulatory hormones are secreted
Long 3-4hrs 16-20 30-36
Acting hrs hrs
Humulin Dawn's phenomenon
U, → Normoglycemia at night→ release of
Ultralen GH→ Hyperglycemia in AM
e,
Glargine Signs of Hypoglycemia
(Lantus)
Sweating
Premixe 0.5-1hrs 2-12 hrs 16-24hrs Tremor
d Tachycardia
Insulin Palpitations
70% Nervousness
NPH - Hunger
30%
regular
50% Simple Carbohydrate to treat
NPH - Hypoglycemia
50% 3 or 4 commercially prepared glucose tablet
Regular 4-6 ounces of fruit juice or regular soda
6-10 life savers or hard candy
2-3 teaspoons of sugar or honey
Diabetic ketoacidosis
Exercise ● Surgery
Assessment: ● GI upset
3 Ps
Blurred Vision Management
Weakness
● Simple ● Patent AW
Headache
Sugars p.o. ● O2 therapy
Hypotension ● 3-4 oz ● NSS plus
Weak, rapid pulse regular regular
Anorexia, nausea, vomiting & abdominal softdrink insulin/IV
pain ● 8 oz fruit ● D10 W once
Acetone breath juice & CHO
Kussmaul’s respirations ● 5-7 pcs. reaches
Lifesaver’s urine output
Mental Status changes
acndies is adequate
● 3-4 pcs. ● Monitor
Treatment of Diabetic Ketoacidosis Hard blood sugar
● Restore fluid and electrolyte candies ● Patient
imbalance by administering fluids ● 1 tbsp. teaching
● Reverse acidosis by administering Sugar
● 5ml pure
NaHCO3
honey/karo
● Monitor urine ketones syrup
● Restore CHO, CHON, fat ● 10-15
metabolism by administering regular grams CHO
insulin (usually continuous to lose ● D50W
dose IV) 20-50
● Maintain accurate I&O records mo./IV push
● Monitor
● Prevent complications such as
blood sugar
hypokalemia and hypoglycemia ● Patient
teaching
Type II
● Hyperosmolar Nonketotic Coma
Chronic Complications of Diabetes
● Similar to DKA but without
Mellitus
Kussmaul’s respirations and acetone
● Peripheral Neuropathy
breath
● Diabetic Nephropathy
● Diabetic Retinopathy
Hypoglycemia Hyperglycemia ● Vascular Disturbances

(Insulin Shock) (DKA)

Causes

● Omission of ● Infections
Meals ● Over eating
● Overdose of ● Under-dose
Insulin of Insulin
● Strenuous ● Stress