THYROID DISORDERS

(Hyperthyroidism and Hypothyroidism)

Presented by Group 1
Arietta, Alline Jannica
Genuino, Johan
Jalijali, Sean Michael
Lerias, Manuel III
Ordonez, Louie
Ricaplaza, Clarence
Roxas, Carmina A.
 THE THYROID GLAND
• located at the base of the throat, just inferior to the Adam’s
apple

• it is fairly large gland consisting of two lobes joined by a

central mass, or isthmus

• it makes two hormones, one called thyroid hormone, the

other called calcitonin.

• it is composed of hollow structures called follicles, which

store a sticky colloidal material. Thyroid hormone is
derived from this colloid.
 thyroid hormones
often referred to as the body’s major metabolic hormone, is actually two active
iodine-containing hormones such as:

•THYROXINE or T4 - major hormone secreted by the thyroid follicles.

•TRIIODOTHYRONINE or T3 - formed at the target tissues by conversion of

thyroxine to triidothyronine.

these two hormones are very much alike. Each is constructed from two tyrosine
amino acids linked together, but thyroxine has for bound iodine atoms, whereas
triiodothyronine has three (thus T4, and T3, respectively)
 functions of thyroid hormones
• Primary function is to control cellular metabolic activity.

T4, a relatively weak hormone, maintains body metabolism in a steady state.

T3, is about five (5) times as potent as T4 and has a more rapid metabolic action.

• influence cell replication and are important in brain development.

• necessary for normal growth

 synthesis of thyroid hormone
IODINE - essential to the thyroid gland for synthesis of its
hormones.

The thyroid gland is extremely efficient at taking 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.
regulation of thyroid hormone
• CALCITONIN, OR THYROCALCITONIN - the second
important hormone product of the thyroid gland.

It is secreted in response to high plasma levels of calcium, and

it reduces the plasma level of calcium by increasing its
deposition in bone.

Whereas thyroxine is made and stored in follicles before it is

released to the blood, calcitonin is made by the so-called C
(parafollicular) cells found in the connective tissue between
the follicles.
 laboratory and diagnostic studies
• SERUM THYROID-STIMULATING HORMONE - it is the best screening test of thyroid
function in outpatients because of its high sensitivity. Normal value: 10-26 µg/dL

• SERUM FREE T4 - test most commonly used to confirm an abnormal TSH result. It is direct
measurement of free (unbound) thyroxine, the only metabolically active fraction of T4. It is the
procedure of choice for monitoring the changes in T4 secretion during treatment of
hyperthyroidism. Normal value: 0.9 - 1.7 ng/dL

• SERUM T3 AND T4 - includes protein-bound and free hormone levels that occur in response to
TSH secretion. Normal value: T3 70 to 220 ng/dL; T4 4.5 to 11.5 µg/dL

• T3 Resin Uptake Test - is an indirect measurement of unsaturated TBD. Its purpose is to

determine the amount of thyroid hormone bound to TBG and the number of available binding
sites. This provide an index of the amount of thyroid hormone already present in the circulation.
Normal T3 uptake value is 25% to 35%, which indicates that about one-third of the available
sites of TBG are occupied by thyroid hormone.

• THYROID ANTIBODIES - Autoimmune thyroid diseases include both hypothyroid and

hyperthyroid conditions. Results of testing by immunoassay techniques for antithyroid
antibodies are positive in chronic autoimmune thyroid disease (90%), Hashimoto’s thyroiditis
(100%), Grave’s disease (80%) and other organ -specific autoimmune diseases such as lupus
 laboratory and diagnostic studies
• RADIOACTIVE IODINE UPTAKE - measures the rate of
iodine uptake by the thyroid gland.

• FINE-NEEDLE ASPIRATION BIOPSY - It is often the

initial test for evaluation of thyroid masses

• THYROID SCAN, RADIO SCAN, OR SCINTISCAN -

helpful in determining the location, size, shape and anatomic
function of the thyroid gland, particularly when the thyroid
tissue is substernal or large

• SERUM THYROGLOBULIN - it is used to detect

persistence of thyroid carcinoma.
 hypERthyroidism
THYROTOXICOSIS - clinical syndrome that results when
tissues are exposed to high levels of circulating thyroid
hormone.

• In most instances, thyrotoxicosis is due to hypersensitivity of

the thyroid gland, or hyperthyroidism.

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.
 pathophysiology
MODIFIABLE FACTORS
NON-MODIFIABLE FACTORS 1. EXCESSIVE INGESTION OF THYROID
1. GRAVES DISEASE (characterized by HORMONE (medications such as amiodarone)
exophthalmos and toxic goiter - enlargement of the 2. INFLAMMATION OF THE THYROID GLAND
thyroid gland) (THYROIDITIS)

EXCESSIVE PRODUCTION OF THYROID HORMONES

EXAGGERATED TARGET TISSUE RESPONSE

INCREASED METABOLIC RATE

AND OXYGEN CONSUMPTION
• weight loss despite a large
appetite
INCREASED CNS ACTIVITY
• tachycardia
• palpitations • rapid speech
• shortness of breath • emotional instability
• increased activity • fine muscle tremor
• excessive sweating, heat • nervousness and irritability
intolerance
•hyperventilation
 THYROID STORM
• (thyrotoxic crisis) is a form of severe hyperthyroidism, usually of
abrupt onset. Untreated, it is almost always fatal.

Manifestations:

• High fever (hyperpyrexia) above 38.5oC

• Extreme tachycardia (more than 130bpm)
• Exaggerated symptoms of hyperthyroidism
• Altered neurologic or mental state, which frequently appears as
delirium psychosis, somnolence, or coma
 management
• A hypothermia mattress or blanket, ice packs, a cool environment, hydrocortisone,
and acetaminophen.

• Humidified oxygen is administered to improve tissue oxygenation and meet the

high metabolic demands.

• IV fluids containing dextrose are administered to replace liver glycogen stores that
have been decreased in the hyperthyroid patient.

• PTU or methimazole is administered to impede formation of thyroid hormone and

block conversion of T4 to T3, the more active form of thyroid hormone.

• Hydrocortisione is prescribed to treat shock or adrenal insufficiency.

• Iodine is administered to decrease output of T4 from the thyroid gland. For cardiac
problems such as atrial fibrillation, dysrhythmias, and heart failure, sympatholytic
agents may be administered. Propanolol, combined with digitalis, has been effective
in reducing severe cardiac symptoms.
 medical management
PHARMACOLOGIC THERAPY

•Irradiation by administration of the

radioisotope 123I or 131I for destructive
effects on the thyroid gland.

•Antithyroid medications that interfere with the

synthesis of thyroid hormones.
 RADIOACTIVE IODINE THERPY

•To destroy the overacting thyroid cells.

•Most common treatment in elderly patients.
•Over a period of several weeks, thyroid cells exposed
to the radioactive iodine are destroyed,resulting in
reduction of the hyperthyroid state and inevitably
hypothyroidism.
•About 95% of patient are cured by one dose of
radioactive iodine.
•Use of an ablative dose of radioactive iodine initially
causes an acute release of thyroid hormones from the
thyroid gland and may cause an increase of symptoms.
•Observed for signs of thyroid storm.
 ANTITHYROID MEDICATIONS

•Inhibit one or more stages in thyroid hormone

synthesis or hormone release.

•Reduce the amount of thyroid tissue,with resulting

decreased thyroid hormone production.

•Antithyroid agents block the utilization of iodine by

interfering with the iodination of thyrosine and the
coupling of iodothyrosines in the synthesis of thyroid
hormones .
•Most commonly use medications:
-Propylthiouracil(Propacil,PTU)
-Methimazole(Tapazole)
-block extrathyroidal conversion of T4 to T3
-may take several weeks for relief of symptoms
-SE: fever,rash,urticaria, or even agranulocytosis and
thrombocytopenia

•Instruct the patient to avoid nasal decongestants.

 ADJUNCTIVE THERAPY

•Iodine or iodide compounds

-decrease the release of thyroid hormones from the
thyroid gland and reduce the vascularity and size of the
thyroid.

-Solution of iodine compounds are more palatable in

milk or fruit juice and are administered through a straw to
prevent staining of teeth.

-Reduce the metabolic rate more rapidly than antithyroid

medications, but their action does not last as long.
•Beta-adrenergic blocking agents
-controls the sympathetic nervous system effects of
hyperthyroidism.

Example: propranolol - is used to control

nervousness,tachycardia,tremor,anxiety,and heat
intolerance.

-Intake is continued until the FT4 is within the normal

range and the TSH level approaches normal.
 surgical management

• SUBTOTAL THYROIDECTOMY - surgical removal of

about five sixths of the thyroid tissue. It reliably results in a
prolonged remission in most patients with exophthalmic
goiter.
 hypothyroidism
• Hypothyroid state is one in which thyroid hormone secretion is inadequate to
maintain normal levels of target tissue stimulation. The result is a generalized
fall in the metabolic rate.

• Primary or Thyroidal Hypothyroidism - refers to the dysfunction of the

thyroid gland itself.

• Central Hypothyroidism - refers to the failure of the pituitary gland, the

hypothalamus or both.

• Pituitary or secondary hypothyroidism - if the cause is entirely a pituitary

disorder.

• Hypothalamic or tertiary hypothyroidism - if its is attributable to a disorder of

the hypothalamus resulting in inadequate secretion of TSH because of
decreased stimulation by TRH
 PATHOPHYSIOLOGY
NON-MODIFIABLE FACTORS
NON-MODIFIABLE FACTORS
1. Iodine deficiency and iodine excess, medications
1. Autoimmune disease such as post grave’s disease
such as lithium, iodine compounds, and antithyroid
and hashimoto’s disease
medications
2. atrophy of thyroid gland with aging, infiltrative
2. therapy for hyperthyroidism such as radioactive
diseases of the thyroid such as amyloidosis,
iodine and thyroidectomy, radiation to head and neck
scleroderma and lymphoma
for treatment of head and neck cancers and lymphoma

Decreased production of T4

increase in the secretion of TSH by the pituitary gland

stimulates hypertrophy and hyperplasia of the thyroid gland and thyroid T4-
5'-deiodinase
the thyroid activity
release more T3

stimulates hypertrophy and hyperplasia of the thyroid gland and thyroid T4-
systemic effects occur
5'-deiodinase activity

stimulates hypertrophy and hyperplasia of the thyroid gland and thyroid T4-
5'-deiodinase activity

Derangement in metabolic processes Direct effects by myxedematous infiltration

Signs and symptomsEarly Poor muscle tone (
muscle hypotonia) Fatigue Cold intolerance, incre
ased sensitivity to cold Constipation Depression
Muscle cramps and joint pain Goiter Thin, brittle
fingernails Coarse hair Paleness Decreased sweating
Dry, itchy skin Weight gain and water retention[4][5]
[6] Bradycardia (low heart rate – fewer than sixty beats
per minute)Late Slow speech and a hoarse, breaking
voice – deepening of the voice can also be notic
ed, caused by Reinke's Edema. Dry puffy skin,
especially on the face Thinning of the outer third o
f the eyebrows (sign of Hertoghe) Abnormal menstrual
cycles Low basal body temperature
(1)myxedematous changes in the heart decreased contractility,
cardiac enlargement, pericardial effusion, decreased pulse, and
decreased cardiac output(2)GI tractachlorhydria and decreased
intestinal transit with gastric stasis(3)Delayed puberty,
anovulation, menstrual irregularities, and infertility(4)change
in metabolic clearanceincreased levels of total cholesterol and
low-density lipoprotein (LDL) cholesterol and a possible change
in high-density lipoprotein (HDL) cholesterol (5)increase in
insulin resistance
 myxedematous coma
• life-threatening, end-stage expression of hypothyroidism.

• it is characterized by coma, hypothermia, cardiovascular,

collapse, hypoventilation, and severe metabolic disorders
that include hyponatremia, hypoglycemia, and lactic
acidosis.
 medical management
Objective: to restore a normal metabolic state by replacing the missing hormone.

PHARMACOLOGIC:

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

hypothyroidism and suppresing nontoxic goiters. It is used to replace or supplement hormone
production from and underactive thyroid.

IV levothyroxine - maybe used in myxedema coma

NURSING RESPONSIBILITY:

•monitor for myocardial ischemia or infarction, which can occur in response to therapy.

•nurse must be alert for signs of angina, especially during the early phase of treatment
manifestations of hypothyroid and hyperthyroid
states (comparison)
LEVEL OF ORGANIZATION HYPOTHYROIDISM HYPERTHYROIDISM
Basal Metabolic rate Decreased Increased
Sensitivity to cathecolamines Decreased Increased
General features Myxedematous features Exolphthalmos (in Graves disease)
Deep voice Lid lag
Impaired growth (child) Accelerated growth (child)
Blood Cholesterol levels Increased Decreased
General Behavior Mental retardation (infant) Restlessness, irritability, anxiety
Mental and physical sluggishness Hyperkinesis
Somnolence Wakefulness
Cardiovascular Function Decreased cardiac output Increased cardiac output
Bradycardia Tachycardia and palpitations
Gastrointestinal Function Constipation Diarrhea
Decreased appetite Increased appetite
Respiratory Function Hypoventilation Dyspnea
Muscle and Tone Reflexes Decreased Increased, with tremor and twitching
Temperature Tolerance Cold Intolerance Heat intolerance
Skin and Hair Decreased sweating Increased sweating
Coarse and dry skin and hair Thin and silky skin and hair
Weight Gain Loss