Nursing Management of Clients with

Nursing Management of Clients

with
Tyroid disorders

1
Past Medical History
Hormone replacement therapy
Surgeries, chemotherapy, radiation
Family history: diabetes mellitus,
diabetes insipidus, goiter, obesity,
Addisons disease, infertility
Sexual history: changes,
characteristics, menstruation,
menopause
Physical Assessment
General appearance
Vital signs, height, weight
Integumentary
Skin color, temperature, texture, moisture
Bruising, lesions, wound healing
Hair and nail texture, hair growth
Physical Assessment
Face
Shape, symmetry
Eyes, visual acuity
Neck
Palpating the thyroid gland from behind the client. (Source: Lester V. Bergman/Corbis)

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Physical Assessment
Extremities
Hand and feet size
Trunk
Muscle strength, deep tendon reflexes
Sensation to hot and cold, vibration
Extremity edema

Thorax
Lung and heart sounds
Abnormal Findings
Ask the client:
Energy level
Fatigue
Maintenance of ADL
Sensitivity to heat or cold
Weight level
Bowel habits
Level of appetite
Urination, thirst, salt craving
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Abnormal Findings
(continued)
Ask the client:
Cardiovascular status: blood pressure, heart
rate, palpitations
Vision: changes, tearing, eye edema
Neurologic: numbness/tingling lips or
extremities, nervousness, hand tremors,
mood changes, memory changes, sleep
patterns
Integumentary: hair changes, skin changes,
nails, bruising, wound healing
 Diagnostic Tests
GH: fasting, well rested, not physically
stressed
T3/T4, TSH: no specific preparation
Serum calcium/phosphate: fasting may or may
not be required
Cortisol/aldosterone level
24 urine collection to measure the level of
catacholamines (epinephrine, norepinephrine,
dopamine).

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Thyroid Disorders
Cretinism
Hypothyroidism
Hyperthyroidism
Thyroiditis
Goiter
Thyroid cancer
 TREATMENT

LIFELONG THYROID HORMONE

REPLACEMENT

levothyroxine sodium (Synthroid, T4,

Eltroxin)
IMPORTANT: start at low does, to avoid
hypertension, heart failure and MI
Teach about S&S of hyperthyroidism with
replacement therapy
 MYXEDEMA DEVELOPS

Rare serious complication of untreated

hypothyroidism
Decreased metabolism causes the heart muscle
to become flabby
Leads to decreased cardiac output
Leads to decreased perfusion to brain and other
vital organs
Leads to tissue and organ failure
 LIFE THREATENING
EMERGENCY WITH HIGH
MORTALITY RATE
Edema changes clients appearance
Nonpitting edema appears everywhere
especially around the eyes, hands,
feet, between shoulder blades
Tongue thickens, edema forms in
larynx, voice husky

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PROBLEMS WITH MYXEDEMA
Coma
Respiratory failure
Hypotension
Hyponatremia
Hypothermia
hypoglycemia
TREATMENT OF MYEXEDEMA
Patent airway
Replace fluids with IV.
Give levothyroxine sodium IV
Give glucose IV
Give corticosteroids
Check temp, BP hourly
Monitor changes LOC hourly
Aspiration precautions, keep warm
 Hyperthyroidism
Clinical Manifestations (thyrotoxicosis):
1. Heat intolerance.
2. Palpitations, tachycardia, elevated systolic BP.
3. Increased appetite but with weight loss.
4. Menstrual irregularities and decreased libido.
5. Increased serum T4, T3.
6. Exophthalmos (bulging eyes)
7. Perspiration, skin moist and flushed ; however,
elders skin may be dry and pruritic
8. Insomnia.
9. Fatigue and muscle weakness
10. Nervousness, irritability, cant sit quietly.
11. Diarrhea.
 Medical Management of
Hyperthyroidism
Radioactive 131I therapy
Medications
Propylthiouracil and methimazole
Sodium or potassium iodine solutions
Dexamethasone
Beta-blockers
Surgery; subtotal thyroidectomy
Relapse of disorder is common
Disease or treatment may result in
hypothyroidism
Thyroiditis
Inflammation of the thyroid gland.
Can be acute, subacute, or chronic
(Hashimoto's Disease)
Each type of thyroiditis is characterized
by inflammation, fibrosis, or lymphocytic
infiltration of the thyroid gland.
Characterized by autoimmune damage to
the thyroid.
May cause thyrotoxicosis, thyroidism,
Thyroid Cancer
Much less prevalent than other forms of cancer;
however, it accounts for 90% of endocrine
malignancies.
Diagnosis: thyroid hormone, biobsy
Management
The treatment of choice surgical removal. Total or
near-total thyroidectomy is performed if possible.
Modified neck dissection or more extensive radical
neck dissection is performed if there is lymph node
involvement.
After surgery, radioactive iodine.
Thyroid hormone supplement to replace the
hormone.
Thyroidectomy
Treatment of choice for thyroid cancer
Preoperative goals include the reduction of stress and anxiety
to avoid precipitation of thyroid storm (euothyroid)
Iodine prep (Lugols or K iodide solution) to decrease size and
vascularity of gland to minimize risk of hemorrhage, reduces
risk of thyroid storm during surgery
Preoperative teaching includes dietary guidance to meet
patient metabolic needs and avoidance of caffeinated
beverages and other stimulants, explanation of tests and
procedures, and demonstration of support of head to be used
postoperatively
Postoperative Care
Monitor dressing for potential bleeding and
hematoma formation; check posterior dressing
Monitor respirations; potential airway impairment
Assess pain and provide pain relief measures
Semi-Fowlers position, support head
Assess voice but discourage talking
Potential hypocalcaemia related to injury or removal
of parathyroid glands; monitor for hypocalcaemia
POST-OP THYROIDECTOMY NURSING
CARE
1. VS, I&O, IV
2. Semifowlers
3. Support head
4. Avoid tension on sutures
5. Pain meds, analgesic lozengers
6. Humidified oxygen, suction
7. First fluids: cold/ice, tolerated best, then soft diet
8. Limited talking , hoarseness common
9. Assess for voice changes: injury to the recurrent
laryngeal nerve
POSTOP THYROIDECTOMY NURSING
CARE
CHECK FOR
HEMORRHAGE 1st 24 hrs:
Look behind neck and sides
of neck
Check for c/o pressure or
fullness at incision site
Check drain
REPORT TO MD
CHECK FOR
RESPIRATORY DISTRESS
every 30-60 min
Laryngeal stridor (harsh hi
pitched resp sounds)
Result of edema of glottis,
hematoma,or tetany
Tracheostomy set/airway/ O2,
suction
CALL MD for extreme
hoarseness
 Complication of operation:

Hemorrhage
Laryngeal nerve damage.
Hypoparathyrodism
Hypothyroidism
Sepsis
Postoperative infection
 Hyperparathyroidism
Primary hyperparathyroidism is 24 X more frequent in
women.
Manifestations include elevated serum calcium, bone
decalcification, renal calculi, apathy, fatigue, muscle weakness,
nausea, vomiting, constipation, hypertension, cardiac
dysrhythmias, psychological manifestations
Treatment
Parathyroidectomy
Hydration therapy
Encourage mobility reduce calcium excretion
Diet: encourage fluid, avoid excess or restricted
calcium
Question
Is the following statement True or
False?

The patient in acute hypercalcemic crisis

requires close monitoring for life-
threatening complications and prompt
treatment to reduce serum calcium
levels.

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 Hypoparathryoidism
Deficiency of parathormone usually due to
surgery
Results in hypocalcaemia and
hyperphosphatemia
Manifestations include tetany, numbness and
tingling in extremities, stiffness of hands and
feet, bronchospasm, laryngeal spasm,
carpopedal spasm, anxiety, irritability,
depression, delirium, ECG changes
Trousseaus sign and Chvosteks sign
Management of
Hypoparathyroidism
Increase serum calcium level to 910 mg/dL
Calcium gluconate IV
May also use sedatives such as pentobarbital to
decrease neuromuscular irritability
Parathormone may be administered; potential
allergic reactions
Environment free of noise, drafts, bright lights,
sudden movement
Diet high in calcium and low in phosphorus
Vitamin D
Aluminum hydroxide is administered after meals to
bind with phosphate and promote its excretion
through the gastrointestinal tract.
Adrenal Crisis
Nursing Management
Medical Management
Immediate Assess fluid balance
Reverse shock
Monitor VS closely
Restore blood circulation
Good skin assessment
Antibiotics if infection
Limit activity
Identify cause
Provide quiet, non-
Supplement glucocorticoids
stressful environment
during stressful procedures
or significant illness
 Nursing Process: The Care of the Patient
with Adrenocortical Insufficiency
Assessment
Level of stress; note any illness or stressors that may
precipitate problems
Fluid and electrolyte status
VS and postural blood pressures
Note signs and symptoms related to adrenocortical
insufficiency such as weight changes, muscle weakness, and
fatigue
Medications
Monitor for signs and symptoms of Addisonian crisis
Nursing Process: The Care of the Patient
with Adrenocortical Insufficiency
Diagnoses
Risk for fluid volume deficit
Activity intolerance and fatigue
Knowledge deficit
Interventions
Risk for fluid deficit; monitor for signs and symptoms of fluid
volume deficit, encourage fluids and foods, select foods high
in sodium, administer hormone replacement as prescribed
Activity intolerance; avoid stress and activity until stable,
perform all activities for patient when in crisis, maintain a
quiet nonstressful environment, measures to reduce anxiety
Teaching
(See Chart 42-10)
 Cushings Syndrome
Due to excessive
adrenocortical
activity or
corticosteroid
medications
Women between
the ages of 20
and 40 years are
five times more
likely than men
to develop
Cushing's
syndrome.
Cushings Syndrome/Manifestations
Hyperglycemia which may develop into
diabetes, weight gain, central type obesity with
buffalo hump, heavy trunk and thin
extremities, fragile thin skin, ecchymosis,
striae, weakness, lassitude, sleep disturbances,
osteoporosis, muscle wasting, hypertension,
moon-face, acne, increased susceptibility to
infection, slow healing, virilization in women,
loss of libido, mood changes, increased serum
sodium, decreased serum potassium

Diagnosis: Dexamethasone suppression test,

Na+ glucose, K+, metabolic alkalosis
Cushings Syndrome
Nursing Managment
Medical Management
Pituitary tumor Prevent injury
Surgical removal Increased protein, calcium
radiation and vitamin D in diet
Adrenalectomy Medical asepsis
Adrenal enzyme Monitor blood glucose
inhibitors Moderate activity with rest
Attempt to reduce or periods
taper corticosteroid Provide restful environment
dose
Collaborative Problems/Potential
Complications
Addisonian crisis
Adverse effects of adrenocortical activity
Nursing Process: The Care of the Patient
with Cushings Syndrome

Planning: Goals may include

1. Decreased risk of injury,
2. Decreased risk of infection,
3. Increased ability to carry out self-care
activities,
4. Improved skin integrity,
5. Improved body image,
6. Improved mental function, and
7. Absence of complications
 Interventions
Decrease risk of injury; establish a
protective environment; assist as needed;
encourage diet high in protein, calcium, and
vitamin D.
Decrease risk of infection; avoid exposure to
infections, assess patient carefully as
corticosteroids mask signs of infection.
Plan and space rest and activity.
Meticulous skin care and frequent, careful
skin assessment.
Explanation to the patient and family about
causes of emotional instability.
Patient teaching.
 Diabetes Insipidus
A disorder of the posterior lobe of the pituitary
gland that is characterized by a deficiency of
ADH (vasopressin). Excessive thirst
(polydipsia) and large volumes of dilute urine.
It may occur secondary to head trauma, brain
tumor, or surgical ablation or irradiation of the
pituitary gland, infections of the central
nervous system or with tumors
Another cause of diabetes insipidus is failure
of the renal tubules to respond to ADH

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Medical Management

The objectives of therapy are

1. to replace ADH (which is usually a long-term
therapeutic program),
2. to ensure adequate fluid replacement, and
3. to identify and correct the underlying
intracranial pathology.