Case #1 L.C is a 52-year-old chemistry professor admitted to the hospital with a diagnosis of hyperthyroidism.

The nursing history reveals she has lost 10 pounds in the last 3 months and reports heart palpitations, fatigue, and nervousness. She has exophthalmos. She is currently taking hydrochlorothiazide and following a low sodium diet for hypertension.

Concept Map:
Hyperthyroidism is a metabolic imbalance that results from overproduction of the thyroid hormones triiodothyronine (T3) and thyroxine (T4).

Client LC,female Age: 52 years old Chief Complaint: heart palpitations, fatigue, and nervousness History: has lost 10 pounds in the last 3 months HPN Medications include: hydrochlorothiazide Diet: low sodium diet for hypertension Laboratory Studies:

Risk Factors:
female

Decreased Cardiac Output

Laboratory Studies results

Radioactive iodine (RAI) uptake test: High Serum T4 and T3: Increased Thyroid-stimulating hormone (TSH): Suppressed Thyroglobulin: Increased. Thyroid T3 uptake: high. Protein-bound iodine: Increased. Serum catecholamines: Decreased. Urine creatinine: Increased.

Tremors (+) Shaky hands(+) Hyperkinetic movements -- table drumming, tapping feet, jerky

Fatigue

movements(+) Low bone density Swollen fingertips yellowish, jaundiced cast to the skin; unusually smooth, young-looking skin; hives; lesions or patches of rough skin on the shins;exopthalmos Hair loss bulging or protrusion of the eyes; a stare in the eyes; retraction of upper eyelids; a wide-eyed look; infrequent blinking
Knowledge Deficit

Physical Examination: Tremors Shaky hands Exophthalmos V/S: T 36.6 P 93 R 23 BP:130/100

Impaired Tissue Integrity

Nursing/Medical Interventions

Evaluation/Goals

Diagnostic Studies

Radioactive iodine (RAI) uptake test: High in Graves disease and toxic nodular goiter; low in thyroiditis. Serum T4 and T3: Increased in hyperthyroidism. Normal T4 with elevated T3 indicates thyrotoxicosis. Thyroid-stimulating hormone (TSH): Suppressed (except when etiology is a TSH-secreting pituitary tumor or pituitary resistant to thyroid hormone). Does not respond to thyrotropin-releasing hormone (TRH). Thyroglobulin: Increased. TRH stimulation: Hyperthyroidism is indicated if TSH fails to rise after administration of TRH. Thyroid T3 uptake: Normal to high. Protein-bound iodine: Increased. Serum glucose : Elevated (related to adrenal involvement). Plasma cortisol: Low levels (less adrenal reserve). Alkaline phosphatase and serum calcium: Increased. Liver function tests : Abnormal. Electrolytes: Hyponatremia may reflect adrenal response or dilutional effect in fluid replacement therapy. Hypokalemia occurs because of GI losses and diuresis. Serum catecholamines: Decreased. Urine creatinine: Increased. ECG: Atrial fibrillations; shorter systole time; cardiomegaly, heart enlarged with fibrosis and necrosis (late signs or in elderly with masked hyperthyroidism). Needle or open biopsy: May be done to determine cause of hyperthyroidism, differentiate cysts or tumors, diagnose enlargement of thyroid gland. Thyroid scan: Differentiates between Graves disease and Plummers disease, both of which result in hyperthyroidism.

is Agranulocytosis. Sodium Iodide- lyse thyroid gland cells to bring thyroid glands activity down. Saturated solution of potassium iodide (SSKI)- reserved for severe thyrotoxicosis by blocking synthesis of thyroid hormones to decrease output of T3 & T4. Propanolol- a beta-adrenergic blocker to relieve signs and symptoms of hyperthyroidism e.g. hypertension, tremors, tachycardia, irritability, & other hypersympathetic activities. Thyroidectomy- surgical removal of the thyroid gland. Subtotal thyroidectomy is usually done to patients with hyperthyroidism wherein 5/6 of the total thyroid tissue is removed. Patients need to be evaluated for hypothyroidism, which can develop years after surgery. Nursing management

Provide cool environment. Minimize stress by providing privacy and placing patient in a private room. Teach patient to avoid stimulants such as coffee, sweets, tea, soft drinks, energy bar and cigarette smoking. Watch out for signs of Agranulocytosis (decrease in WBC) such as sudden onset of fever and sore throat when patient has medications such as PTU or Methimazole. Monitor for other unusualities such as allergic reactions to drugs, and others. Patient care post-thyroidectomy

Assessment Assess airway obstruction due to inflammation Assess vital signs- helps detect bleeding or hemorrhage Assess bleeding- look at patients dressing at the back of the neck. Observe if patient always swallows- sign of bleeding Monitor for signs of Hypocalcelmia Monitor voice quality Complications Airway Obstruction Laryngeal Nerve Damage- Normal to have hoarse voice within the first 3 days to weeks. - No improvement of the voice for 6 weeks to 12 months is considered to have

Medical Management

Propylthiouracil (PTU) - block synthesis of thyroid hormones to decrease output of T3 & T4. Methimazole Their lifethreatening adverse effect

permanent damage. (Hermann et al2004). Hemorrhage Hypocalcemia- < 4.5 5 mEq/L or 8.510.5 mg/dL - Signs & symptoms: tetany, paresthesia, bronchospasm, (+) Trosseaus sign,(+) Chvosteks sign, prolonged Q-T interval on cardiac monitor.

At bedside : prepare Tracheostomy set Oxygen Suctioning machine Calcium gluconate

- Eye care for patients with exopthalmos eye shades- for patients with photosensitivity eye drops- helps keep eyeballs moist cover with clean gauzeusually at bedtime to promote sleep raise head of bed- to relieve eye swelling - Question and clarify medication orders for aspirin. Make sure aspirin is avoided as this can increase free thyroid hormones in the system. - Diet should be high in calories and high in protein.

Case #3 M.B is a 45 year-old computer programmer who has developed Cushings syndrome. The nursing assessment reveals an obese man with facial plethora. His blood pressure is elevated and he complains of muscle weakness. He is alert and oriented and has a positive mental outlook.

Concept Map:

Cushing Syndrome from excessive adrenocortical activity.

Client M.B,45 years old Chief Complaint: Muscle weakness Physical Examination: Obese with facial plethora VS: T 36.6 P:75 RR:23 BP: 130/90 alert and oriented and has a positive mental outlook

Factors: obesity, with a Risk central-type

fatty buffalo hump in the neck and supraclavicular areas, a heavy trunk, and relatively thin extremities; skin is thin, fragile, easily traumatized, with ecchymoses and striae. Weakness and lassitude; sleep is disturbed because of altered diurnal secretion of cortisol. Retention of sodium and water, producing hypertension and heart failure. Moon-faced appearance, oiliness of skin and acne. Increased susceptibility to infection; slow healing of minor cuts and bruises. Hyperglycemia or overt diabetes. Changes occur in mood and mental activity; psychosis may develop and distress and depression are common.

Risk for injury related to weakness

Risk for infection

Self-care decits

Nursing/Medical Interventions

related to weakness, fatigue, muscle wasting, and altered sleep patterns

Evaluation/Goals

Assessment and Diagnostic Findings

Overnight dexamethasone suppression test to measure plasma cortisol level (stress, obesity, depression, and medications may falsely elevate results). Laboratory studies (eg, serum sodium, blood glucose, serum potassium, plasma, urinary); 24hour urinary free cortisol level. CT, ultrasound, or MRI scan or ultrasound may localize adrenal tissue and detect adrenal tumors.

Assessment Focus on the effects on the body of high concentrations of adrenal cortex hormones.

Assess patients level of activity and ability to carry out routine and self-care activities. Observe skin for trauma, infection, breakdown, bruising, and edema. Note changes in appearance and patients responses to these changes; family is good source of information about patients emotional status and changes in appearance.

Medical Management Treatment is usually directed at the pituitary gland because most cases are due to pituitary tumors rather than tumors of the adrenal cortex. Surgical removal of the tumor by transsphenoidal hypophysectomy is the treatment of choice (80% success rate).

Assess patients mental function, including mood, response to questions, depression, and awareness of environment. Diagnosis

Radiation of the pituitary gland is successful but takes several months for symptom control. Adrenalectomy is performed in patients with primary adrenal hypertrophy. Post-operatively, temporary replacement therapy with hydrocortisone may be necessary until the adrenal glands begin to respond normally (may be several months). If bilateral adrenalectomy was performed, lifetime replacement of adrenal cortex hormones is necessary. Adrenal enzyme inhibitors (eg, metyrapone, aminoglutethimide, mitotane, ketoconazole) may be used with ectopic ACTH secreting tumors that cannot be totally removed; monitor closely for inadequate adrenal function and side effects.

Potential Complications Addisonian crisis

Adverse effects of adrenocortical activity

Hypertension Congestive Heart Failure Psychosis Electrolyte imbalances (sodium, potassium) Planning and Goals Major goals include decreased risk of injury, decreased risk of infection, increased ability to carry out self-care activities, improved skin integrity, improved body image, improved mental function, and absence of complications. Nursing Interventions Decreasing Risk of Injury Provide a protective environment to prevent falls, fractures, and other injuries to bones and soft tissues.

If Cushing syndrome results from exogenous corticosteroids, taper the drug to the minimum level or use alternate day therapy to treat the underlying disease. Nursing Process

Assist the patient who is weak in ambulating to prevent falls or colliding into furniture. Recommend foods high in protein, calcium, and vitamin D to minimize muscle wasting and osteoporosis; refer to dietitian for assistance.

Decreasing Risk of Infection Avoid unnecessary exposure to people with infections.

result in adrenal insufciency and reappearance of symptoms.

Assess frequently for subtle signs of infections (corticosteroids mask signs of inammation and infection).

Emphasize the need to keep an adequate supply of the corticosteroid to prevent running out or skipping a dose, because this could result in addisonian crisis. Stress the need for dietary modications to ensure adequate calcium intake without increasing risk for hypertension, hyperglycemia, and weight gain. Teach patient and family to monitor blood pressure, blood glucose levels, and weight. Stress the importance of wearing a medical alert bracelet and notifying other health professionals that he or she has Cushing syndrome. Refer for home care as indicated to ensure safe environment with minimal stress and risk for falls and other side effects.

Monitoring and Managing Complications Adrenal hypofunction and addisonian crisis: Monitor for hypotension; rapid, weak pulse; rapid respiratory rate; pallor; and extreme weakness. Note factors that may have led to crisis (eg, stress, trauma, surgery). Administer IV uids and electrolytes and corticosteroids before, during, and after surgery or treatment as indicated.

Monitor for circulatory collapse and shock present in addisonian crisis; treat promptly. Assess uid and electrolyte status by monitoring laboratory values and daily weight. Monitor blood glucose level, and report elevations to physician.

Acute adrenal crisis is a life-threatening condition that occurs when there is not enough cortisol, a hormone produced by the adrenal glands. Teaching Patients Self-Care Present information about Cushing syndrome verbally and in writing to patient and family.

Emphasize importance of regular medical followup, and ensure patient is aware of side and toxic effects of medications. Evaluation Expected Patient Outcomes Has decreased risk of injury

Has decreased risk of infection Increases participation in self-care activities Attains or maintains skin integrity Achieves improved body image Exhibits improved mental functioning Experiences no complications

If indicated, stress to patient and family that stopping corticosteroid use abruptly and without medical supervision can

Complications
Myxedema coma, the most severe form of hypothyroidism, is rare. It may be caused by an infection, illness, exposure to cold, or certain medications in people with untreated hypothyroidism. Signs and symptoms of myxedema coma are:

higher risk for cardiac complications and toxic effects. The medication should not be given if the pulse rate is greater than 100. The treatment is considered to be life-long, requiring ongoing medical assessment of thyroid function. Polypharmacy is a significant concern for the hypothyroid patient. Several classifications of drugs are affected by the addition of thyroid supplements, including beta blockers, oral anticoagulants, bronchodilators, digitalis preparations, tricyclic antidepressants, and cholesterol lowering agents.

Below normal temperature Decreased breathing Low blood pressure Low blood sugar Unresponsiveness

Diagnostic Evaluation

Because significant cardiovascular disease often accompanies hypothyroidism, the patient is at risk for cardiac complications if the metabolic rate is increased too quickly. Therefore, the patient needs to be monitored for cardiovascular compromise (palpitations, chest pain, shortness of breath, rapid heart rate) during early thyroid therapy. The diet for the hypothyroid patient is generally low in calories, high in fiber, and high in protein. As the metabolic rate rises, the caloric content can be increased. The patients intolerance to cold may extend to cold foods,making meal planning more difficult.

Thyroid-stimulating hormone (TSH) assay result is >4.0 mU/L ( normal values: 0.51.5 mU/L). Normal value excludes primary hypothyroidism and a markedly elevated value confirms the diagnosis.

Thyroxine (T4) radioimmunoassay decreased (normal values: 5.012.0 g/dL). Reflects underproduction of thyroid hormones; monitors response to therapy.

Tri-iodothyronine (T3) radioimmunoassay decreased (normal values: 80230 ng/dL). Reflects underproduction of thyroid hormones.

Pharmacologic Highlights

Electrocardiogram (ECG) reveals low voltage, T wave abnormalities.

Treatment consists of replacing the deficient hormone with synthetic thyroid hormone; low doses are initially used, and the dose is increased every 1 to 2 months based on the clinical response and serial laboratory measurements that show normalization of thyroid-stimulating hormone (TSH) levels in primary hypothyroidism. The patient begins to experience clinical benefits in 3 to 5 days, which level off after approximately 4 to 6 weeks. After the dose is stabilized, patients can be monitored with laboratory measurement of TSH annually.

Other Tests: 24-hr radioactive iodine uptake; thyroid autoantibodies; antithyroglobulin

Medical Management
The primary objective is to restore a normal metabolic state by replacing thyroid hormone. Additional treatment in severe hypothyroidism consists of maintaining vital functions, monitoring ABG values, and administering uids cautiously because of the danger of water intoxication.

Most patients are diagnosed and treated on an outpatient basis. The goal of treatment is to return the patient to the euthyroid (normal) state and to prevent complications. The treatment of choice is to provide thyroid hormone supplements to correct hormonal deficiencies.

Levothyroxine sodium a synthetic thyroid hormone replacement is used to returns the patient to the euthyroid (normal) state. Dosage is 1.52.5 mcg/kg PO daily; (use lowest dose possible because overreplacement of thyroid can cause bone loss or cardiovascular complications).

Treatment of the elderly patient is approached more cautiously because of

Response to medications, skin care regimen, nutrition

Nursing Management
Promoting Home and Community-Based Care TEACHING SELF-CARE

Psychosocial response to changes in bodily function, including mental acuity

Oral and written instructions should be provided regarding the following: Desired actions and side effects of medications

Discharge and Home Healthcare Guidelines

Explain all medications, including dosage, potential side effects, and drug interactions.

Correct medication administration Importance of continuing to take the medications as prescribed even after symptoms improve

Instruct the patient to check the pulse at least twice a week and to stop the thyroid supplement and notify the physician if the pulse is greater than 100.

When to seek medical attention Importance of nutrition and diet to promote weight loss and normal bowel patterns

Explain that the healthcare professional should be notified about the condition. Explain that ongoing medical assessment is required to check thyroid function and that the medications may lead to hyperthyroidism despite the patients underlying hypothyroidism.

Importance of periodic follow-up testing Monitor the patients recovery and ability to cope with the recent changes, along with the patients physical and cognitive status and the patients and familys understanding of the instructions provided before hospital discharge.

CONTINUING CARE

Teach the patient about the thyroid gland and hypothyroidism, as well as complications such as heart disease and edema. Teach the patient that new cardiac or hyperthyroidism symptoms need to be reported immediately.

Document and report to the patients primary health care provider subtle signs and symptoms that may indicate either inadequate or excessive thyroid hormone.

Explain that the caloric and fiber requirements vary.

Documentation Guidelines

The patient should report any abnormal weight gain or loss or change in bowel elimination

Physical findings: Cardiovascular status, bowel activity, edema, condition of skin, and activity tolerance

Case #2

ES is a 72-year-old female presenting to your clinic with fatigue that has progressed over the past 3 months. She is normally extremely active in social events in the community. She is a retired math teacher. Edna is a widow and admits to being rather emotionally liable. She also cant tolerate the cold as much anymore, consequently she doesnt get out and teach reading to illiterate adults. About all she can do is get up, have tea, wash the kettle and cup and she has to sit again. She admits to shortness of breath, no chest pain, denies claudication, palpitations, cyanosis, clubbing, thrombosis, has had a bit of ankle edema over the past 2 months.
Concept Map:

Hypothyroidism is a hypothyroid state resulting from a hyposecretion of the thyroid hormones T4 and T3.

Client: ES, 72 years old Physical Examination:

Risk Factors:

shortness of breath, no chest pain, denies claudication, palpitations, cyanosis, clubbing, thrombosis, has had a bit of ankle edema over the past 2 months

Age over 50 years Being female

Lethargy and fatigue Weakness, muscle aches, paresthesias Intolerance to cold Weight gain Dry skin and hair Loss of body hair Bradycardia Constipation Generalized puffiness and edema around the eyes and face. Forgetfulness and loss of memory Menstrual disturbances Cardiac enlargement, tendency to develop congestive heart failure.

Activity Intolerance related to weakness and apathy

Nursing/Medical Interventions

Evaluation/Goals