THYROID DISORDERS

 Many terms describe normal and abnormal states of thyroid function.

 Euthyroidism means that the thyroid gland functioning normally.
 Like other endocrine disorders, the two primary disorders are related
to increase secretion (hyperthyroidism) and decrease secretion
(hypothyroidism) of the glands hormones.

A. GOITER
- Enlargement of the thyroid gland.
- It generally results from a lack iodine, inflammation, or benign or
malignant tumors.
- Enlargement may also appear in hyperthyroidism especially in
Graves’ disease, in which the client typically has exophthalmos.

Etiology and Risk Factors:

The two major forms of simple goiter are endemic and sporadic.
- Endemic goiter is caused principally by nutritional iodine deficiency. It
typically occurs in fall and winter months. It is twice prevalent in women as it
is in men.
- Sporadic goiter is not restricted to any geographical area.

Major causes include the ff:

 Genetic defects resulting in faulty iodine metabolism.
 Ingestion of large amount if nutritional goitrogens (goiter producing
agents that inhibit thyroxine{T4} production) such as cabbage, soy
beans or spinach
  Ingestion of medicinal goitrogens such as glucocorticoids, dopamine, or
lithium.

Goiters are described in a variety of ways, including the following:

 Toxic goiter
- A goiter that is associated with hyperthyroidism described as toxic goiter.
- Examples of toxic goiters include diffuse toxic goiter (Graves disease), toxic
multinodular goiter, and toxic adenoma (Plummer disease).

 Nontoxic goiter
- A goiter without hyperthyroidism or hypothyroidism is described as
nontoxic goiter.
- It may be diffuse or multinodular, but a diffuse goiter often evolves into a
nodular goiter.
- Examination of the thyroid may not reveal small or posterior nodules.
- Examples of nontoxic goiters include chronic lymphocytic thyroiditis
(Hashimoto’s disease), goiter identified in early Graves’ disease, endemic
goiter, sporadic goiter, congenital goiter, and physiologic goiter that occur
during puberty.

Signs and Symptoms:

 A visible swelling at the base of your neck that may be particularly
obvious when you shave or put on makeup.
 A tight feeling in your throat
 Coughing
 Hoarseness
 Difficulty swallowing
 Difficulty breathing

Treatment:
 Antithyroid drugs (such as propylthiouracil and methimazole)
 Levothyroxine – the levorotatory isomer of thyroxine that is
administered in the form of its sodium salt

Surgical Management:
 Thyroidectomy - Thyroidectomy is the surgical incision of thyroid
gland tissue.

Pathophysiology:
 If there is lack of sufficient dietary iodine or if production of TH is
suppressed, the thyroid enlarges in an to attempt to compensate for
hormonal insufficiency.
 Goiter is essentially an adaptation to a deficiency of TH, but also occur
in response to decrease pituitary secretion of thyroid stimulating
hormone
Difference between Hypothyroidism and Hyperthyroidism:
B. HYPOTHYROIDISM
 - Deficiency of TH resulting in slowed body metabolism decreased
heat production, and decreased oxygen consumption by the tissues.
- Under activity of the thyroid gland may result from primary thyroid
dysfunction, or may be secondary to anterior pituitary dysfunction.

Etiology and Risk Factors:

 Primary Hypothyroidism
 Also known as Hashimoto’s disease.
 TH levels are low and TSH levels are elevated, indicating that the
pituitary is attempting to stimulate the secretion of thyroid hormones
but the thyroid is NOT responding.
 This is the most common form of primary-autoimmune hypothyroidism.

 Secondary Hypothyroidism
 Develops when there is insufficient stimulation of a normal thyroid
gland, resulting in decreased TSH levels.
 Malfunction of the pituitary or hypothalamus or by peripheral
resistance to TH.

 Tertiary Hypothyroidism
 Develops if the hypothalamus cannot produce thyroid-releasing
hormone(TRH) and subsequently does not stimulate the pituitary to
secrete TSH.
 It may be due to a tumor or other destructive lesion in the
hypothalamic region.

 Subclinical Hypothyroidism
 Is defined as hypothyroidism that is diagnosed with an elevated TSH
level but a normal to a low-normal T4 level.

Pathophysiology:
 Inadequate section of thyroid hormone leads to a general slowing all
physical and mental processes.
 There is a general depression of most cellular enzyme systems and
oxidative processes.
 The metabolic activities of all cells of the body decreases, reducing
oxygen consumption, decreasing oxidation of nutrients for energy and
producing less body heat.
 The signs and symptoms of the disorder range from vague, nonspecific
complains that make diagnosis difficult to severe symptoms that may
be life- threatening if unrecognized and untreated.
Clinical Manifestation:
 Manifestation of hypothyroidism depends on whether it is mild, severe
(myxedema), or complicated (myxedemacoma).

 Mild hypothyroidism (most common form) may be asymptomatic or

may experience vague manifestation that is escape detection such as :
*cold *dry skin
*lethargy *forgetfullness

 Myxedema (severe hypothyroidism)

- May develop in clients with undiagnosed or undertreated hypothyroidism
that experience stress such as infection, drug use, respiratory failure, heart
failure and trauma.
- It is characterized by a dry, waxy type of swelling with abnormal deposits of
mucin in the skin and other tissues.
- The edema is non-pitting and is common in the pretibial and facial areas.
- Also have hypercholesterolemia, hyperlipidemia, and proteinemia.

 Myxedema Coma (complicated)

- Most severe complication of hypothyroidism
- An extremely rare condition with a mortality rate of nearly 100%.
- Emergency state is characterized by a drastic decrease in metabolic rate,
hypoventilation leading to respiratory acidosis, hypothermia, and
hypotension.
- Complicating condition include hyponatremia, hypercalcemia secondary to
adrenal insufficiency, hypoglycemia, and water intoxication.

Nursing Diagnosis:
 Potential alteration in cardiac output related to decreased metabolic
rate, decrease cardiac conduction, elevated cholesterol levels,
aterosclerosis, and coronary artery disease
 Activity intolerance related to lethargy and fatigue, depress
neuromuscular status
 Alteration in fluid and nutritional status related to decreased
metabolic, poor appetite, and depress gastrointestinal function

Treatment:
 Thyroid medicine levothyroxine sodium (such as Synthroid, Levoxyl, or
Levothroid)
 If you have severe hypothyroidism by the time you are diagnosed, you
will need immediate treatment.
 Severe, untreated hypothyroidism can cause myxedema coma, a rare,
life-threatening condition. If you have trouble breathing, a ventilator
may be used.
  You will also be monitored for heart problems, including heart attack,
and treated if necessary.

Nursing Management:
 Assessment
- Monitor for the physical manifestations of myxedema such as periorbital
and facial edema, a blank facial expression, thick tongue, and generalized
slowing of all muscle movement.
- Vital signs are also affected and must be monitored closely.
- The client is hypothermic.
- Depressed respiration precipitate respiratory acidosis.
- Alteration in heart rate and blood pressure follow.

C. HYPERTHYROIDISM
- Hyperthyroidism (excessive secretion of TH) is a highly preventable
endocrine disorder.
- It is a disorder that predominantly affect women (in a female-to-
male ratio of 4:1), especially women between ages 20 and 40 years.

Etiology and Risk Factors:

 Hyperthyroidism may be due to over-functioning of the entire gland or,
less commonly to single or multiple functioning adenomas of thyroid
cancer.
 The most common form of hyperthyroidism is Graves’ Disease (toxic,
diffuse goiter), which has three principal hallmarks: hyperthyroidism,
thyroid gland enlargement (goiter), and exophthalmos (abnormal
protrusion of the eyes).

Graves’ disease - an autoimmune disorder mediated by an

immunoglobulin G (IgG) antibody that binds to and activates TSH receptors
on the surface of the thyroid cells
Clinical Manifestation:
 Nervousness, emotional hyperexcitability, irritability, apprehension
 Difficulty in sitting quietly
 Rapid pulse, at rest as well as on exertion (ranges between 90-160);
palpitation.
 Low heat tolerance; profused perspiration; flushed skin
 Fine tremor of hands; change in bowel habits- constipation or diarrhea
 Increased appetite and progressive weight loss
 Muscle fatigability and weakness; amenorrhea
 Atrial fibrillation possible (cardiac decompensation common in elderly
patients)
 Bulging eyes (exophthalmos) –produces a startled expression
 Course may be mild; characterized and exacerbations
 It may progress to emaciation, extreme nervousness , delirium,
disorientation, thyroid storm or crisis, and death.
 Thyroid storm or crisis, and extreme form of hyperthyroidism, is
characterized by hyperpyrexia, diarrhea, dehydration, tachycardia,
arrhythmias, extreme irritation, delirium, coma, shock, and death if not
adequately treated.
 Thyroid storm may be precipitated by stress (surgery, infection, etc.)
or inadequate preparation for surgery for a patient with known
hyperthyroidism.

Nursing Management:
 Assessment
  By obtaining a complete history and asking questions concerning
weight, appetite, activity, heat and tolerance, and bowel activity, you
can assess for the presence of typical manifestations of
hyperthyroidism.
 Also ask about mood alterations.

Hyperthyroidism: Diagnosis
 Diagnosis
 Imbalanced nutrition: less than body requirements.
 Outcome
 Achieves adequate fluid, electrolyte, and nutritional intake.

 Diagnosis
 Potential impaired skin integrity related to extreme diaphoresis,
pyrexia, excessive restlessness, movement and tremor, and rapid
weight loss.
 Outcome
 Demonstrates skin integrity- skin is dry, cool and intact without
reddened, excoriated or infected areas.

 Diagnosis
 Altered thought processes related to insomnia, decreased attention
span, and irritability.
 Outcome
 Demonstrates improved thought processes:
a. maintains concentration, follows conversation and responds
appropriately
b. verbalizes concerns and fears about illness, treatment, and
possible surgery.
c. interacts with family members and visitors.

 Diagnosis
 Apprehension and anxiety related to concerned about upcoming
surgery
 Outcome
 Uses medication as prescribed and relaxation techniques to promote
sleep and relaxation.
 D. THYROIDITIS
 Inflammation of thyroid gland

 Appears in three basic forms, which are:

 Acute suppurative thyroiditis
- Painful thyroiditis associated with non-viral infection)

 Subacute thyroiditis
- either granulomatous or lymphocytic)

 Chronic thyroiditis
- Hashimoto’s thyroiditis and autoimmune thyroiditis, chronic)

 Acute Suppurative Thyroiditis

- Acute suppurative thyrroiditis is an uncommon inflammatory
disease usually caused by bacterial invasion in the form of the
thyroid gland.
- Streptococcus pyogenes
- Staphylococcus aureus
- Pneumococcus pneumoniae
- It affects mostly women between 20 and 40 yrs old.

Pathophysiology:
 Is a state of acute infection and inflammation, usually one lobe of the
thyroid is more affected than the other Follicular destruction, cell
infiltration, and colloid depletion occur. Microabscesses form.

 Subacute Granulomatous Thyroiditis

- Self-initiating inflammatory condition no etiologic agent has been
identified although the condition may be viral in origin and
commonly follows a respiratory tract infection.
- Autoimmune abnormalities have been described. They are also
appears to be a genetic predisposition to the development.

Pathophysiology:
 Sub-acute thyroiditis has three phases:
 Phase 1- the condition begins with a three to four week viral illness
fever, malaise precede the sudden onset of a tender goiter. The
thyroid gland may become 2 to 3 times its normal size. Mild
hyperthyroidism may be present because of sudden release of thyroid
hormones into the circulation. As a result of the inflammation and
destruction of the thyroid gland.
  Phase 2- mild hypothyroidism develops because of incomplete
recovery f the injured gland and exhaustion of stored thyroid
hormones, relapse may occur. Hypothyroidism is rarely permanent.
 Phase 3- the recovery phase be begin 2 to 4 months after onset.

 Chronic Thyroiditis
- Is the most common form of thyroiditis. It is more prevalent in
women than in men and usually occurs between 20 and 50 years of
age.
- Is a long term of inflammatory disorder
- Caused by autoimmune destruction of the thyroid gland, genetic
predisposition is also placed a rule in its causation.

Pathophysiology:
 Hashimoto’s disease is manifested by an enlarge thyroid gland that
may produce hypothyroid manifestation if the gland is destroyed by
the autoimmune system. Euthyroid state may prevail if the gland is not
destroyed.

Manifestation:
 Acute suppurative thyroiditis
- Anterior neck pain with possible radiation to the ear or mandible
affected site
- Fever
- Diaphoresis
• Subacute granulomatous thyroiditis
- Usually painful
• Subacute lymphocytic thyroiditis
- painless goiter , goiter is firm , diffuse , mildly enlarge
 Chronic thyroiditis
- Painless, asymmetrical enlargement of the gland
- Immune antibodies are usually positive

Diagnostic Testing:
1. 24 hr. Radioactive Iodine (RAI) uptake
2. Thyroid scan
3. Resin T3 uptake determination
4. Thyroid needle biopsy
5. T3 and T4 usually become subnormal has the disease progresses

Treatment and Nursing Management:

 The patient should be on thyroid medications to maintain a normal
level of circulating thyroid hormone, this is done to suppress
production of thyrotropin to prevent enlargement of the thyroid and to
maintain euthyroid state.
  Propranolol is often prescribed to control symptoms of thyrotoxicosis if
they occur.
 Firm nodular thyroid enlargement may at times be associated with
tracheal compression, cough, hoarseness, resection of the isthmus can
produce relief of symptoms
 The patient is followed closely to detect and treat hypothyroidism and
myxedema.

E. THYROID CANCER

Incidence:
- Women are three times more likely to develop thyroid cancer than men.
- Its incidence peaks during 60s, but it may arise from infancy to old age.
- Mortality is lowest in the young if the cancer is well differentiated.

Types of Thyroid Cancer:

 Papillary and well-differentiated adenocarcinoma (most
common)
a. Growth is slow, and spread is confined to lymph nodes that surround
thyroid area.
b. Cure rate is excellent after removal of involved areas.

 Follicular (rapidly growing, widely metastasizing type)

a. Occurs predominantly in middle-age and elderly persons.
b. Brief encouraging response may occur with x-ray irradiation.
c. Progression of disease is rapid; high mortality rate.
  Parafollicular-medullary thyroid carcinoma (MTC)
a. Rare, inheritable type of thyroid malignancy, which can be detected
early by a radioimmunnoassay for the hormone, calcitonin.
b. Screening of familial MTC suspects is done by measuring circulating
plasma calcitonin levels.

Etiology and Risk Factors:

 Benign adenomas are usually not dangerous, although they
occasionally grow large enough to cause respiratory problems by
pressing against the trachea.
 Malignant transformation sometimes occurs, and the benign modules
become cancerous.
 Other risk factors include:
- genetic predisposition
- a family history of thyroid cancer
- a history of radiation therapy 10 to 20 years following cancer
treatment elsewhere in the body
 NCM-103
(MTWF)
7:00-11:00

Group 4:
LICAROS, LEONARD RAY
GOBUI, ALBERT HANSEL
NAVAJA, PAUL
LUZARES, GENUS B.
MARINAY, RHETT
HERAMIZ, ANJANETTE