DYSFUNCTION

1) Thyroiditis >inflammation of the thyroid gland >inflammation, fibrosis, or lymphocytic infiltration of the thyroid gland. 1.1) ACUTE THYROIDITIS

ETIOLOGY

SIGNS AND SYMPTOMS

NURSING/MEDICAL MANAGEMENT

infection of the thyroid gland by bacteria, fungi, mycobacteria, or parasites. Staphylococcus aureus and other staphylococci are the most common causes.

1.2) SUBACUTE THYROIDITIS Subacute thyroiditis may be subacute granulomatous thyroiditis (deQuervains thyroiditis) or painless thyroiditis (silent thyroiditis or subacute lymphocytic thyroiditis): often occurs in the postpartum period and is thought to be an autoimmune process.

caused by a viral infection. The condition often occurs after a viral infection of the upper respiratory tract, such as mumps and influenza.

anterior neck pain and swelling, fever, dysphagia, and dysphonia. Pharyngitis or pharyngeal pain is often present. warmth, erythema (redness), and tenderness of the thyroid gland painful swelling in the anterior neck that lasts 1 to 2 months and then disappears spontaneously without residual effect thyroid enlarges symmetrically overlying skin is often reddened and warm. Swallowing may be difficult and uncomfortable. Irritability, nervousness, insomnia, and weight lossmanifestations of hyperthyroidismare common, and many patients experience chills and fever as well.

antimicrobial agents and fluid replacement. Surgical incision and drainage(if an abscess is present)

aims to control the inflammation >(NSAIDs) are used to relieve neck pain. >Acetylsalicylic acid (aspirin) is avoided >Beta-blocking agents (eg, propranolol [Inderal]) may be used to control symptoms of hyperthyroidism. Antithyroid agents, which block the synthesis of T 3 and T4, are not effective > in severe cases, oral corticosteroids may be prescribed to reduce swelling and relieve pain; > may necessitate thyroid hormone therapy. >Treatment is directed at symptoms, and yearly follow-up is recommended

1.3) CHRONIC THYROIDITIS (HASHIMOTOS DISEASE)

caused by a reaction of the immune system against the thyroid gland. related to

usually not accompanied by pain, pressure symptoms, or fever, and thyroid activity is usually normal

objective of treatment is to reduce the size of the thyroid gland and prevent hypothyroidism. Thyroid

diagnosis is based on the histologic appearance of the inflamed gland

other endocrine (hormonal) disorders caused by the immune system. Hashimoto's disease can occur with adrenal insufficiency and type 1 diabetes. In these cases, the condition is called type 2 polyglandular autoimmune syndrome (PGA II).

or low rather than increased. the disease runs a slow, progressive course, leading eventually to hypothyroidism

hormone therapy is prescribed to reduce thyroid activity and the production of thyroglobulin. thyroid hormone therapy is prescribed. Surgery may be required

2) THYROID TUMORS
Classifications: 1) benign or malignant 2) the presence or absence of associated thyrotoxicosis 3) diffuse or irregular quality of the glandular enlargement. If the enlargement is sufficient to cause a visible swelling in the neck, the tumor is referred to as a goiter.

2.1) ENDEMIC (IODINE-DEFICIENT) GOITER (simple

or colloid goiter.) most common type of goiter,

1)encountered chiefly in geographic regions where the natural supply of iodine is deficient(If the mean iodine intake is less than 40 fg/day, the thyroid gland hypertrophies.) 2)may be caused by an intake of large quantities of goitrogenic substances (excessive amounts

usually cause no symptoms swelling in the neck, which may result in tracheal compression when excessive.

>Supplementary iodine, such as SSKI, is prescribed to suppress the pituitarys thyroid-stimulating activity. >When surgery is recommended, the risk for postoperative complications is minimized by ensuring a preoperative euthyroid state by treatment with antithyroid medications and iodide to reduce the size and vascularity of the goiter. > Providing children in iodine-poor regions with iodine compounds

of iodine or lithium, which is used in treating bipolar disorders) 3)recede after iodine imbalance is corrected.

> The World Health Organization recommends that salt be iodized to a concentration of 1 part in 100,000, which is adequate for the prevention of endemic goiter > The introduction of iodized salt has been the single most effective means of preventing goiter in at-risk populations.

DYSFUNCTI ON

ETIOLOGY
1)results from an excessive output of thyroid hormones caused by abnormal stimulation of the thyroid gland by circulating immunoglobulin s. 2)may appear after an emotional shock, stress, or an infection, 3) thyroiditis and excessive ingestion of thyroid hormone.

SIGNS AND SYMPTOMS

exhibit a characteristic group of signs and symptoms (sometimes referred to as thyrotoxicosis) nervousness. emotionally hyperexcitable, irritable, and apprehensive; cannot sit quietly; palpitations; rapid pulse at rest as well as on exertion. They tolerate heat poorly and perspire unusually freely. The skin is flushed continuously, with a characteristic salmon color, and is likely to be warm, soft, and moist. Elderly patients, however, may report dry skin and diffuse pruritus. A fine tremor of the hands may be observed. Patients may exhibit exophthalmos (bulging eyes), which produces a startled facial expression. increased appetite and dietary intake, progressive weight loss,

3) HYPERTHY ROIDISM
second most prevalent endocrine disorder, after diabetes mellitus.

DIAGNOSTIC TEST > thyroid gland

invariably is enlarged to some extent. It is soft and may pulsate; a thrill often can be palpated, and a bruit is heard over the thyroid arteries > an increase in serum T4 and an increased 123I or 125I uptake by the thyroid in excess of 50%. > Measurement of TSH is indicated in elderly patients with unexplained physical or mental deterioration

NURSING MANAGEMENT > The patient is observed

for signs of thyroid storm; propranolol is useful in controlling these symptoms. > the importance of periodic follow-up is emphasized because medication sensitization, fever, rash, urticaria, or even agranulocytosis and may develop. > With any sign of infection, especially pharyngitis and fever or the occurrence of mouth ulcers, the patient is advised to stop the medication, notify the physician immediately.

MEDICAL MANAGEMENT
> directed toward reducing thyroid hyperactivity to relieve symptoms and remove the cause of important complications. > Two forms of pharmacotherapy are available for treating hyperthyroidism and controlling excessive thyroid activity: (1) use of irradiation by administration of the radioisotope 123I or 131I to destroy the overactive thyroid cells contraindicated in pregnancy and in nursing mothers because radioiodine crosses the placenta and is secreted in breast milk. A major advantage of treatment with radioactive iodine is

Graves disease,
the most common type of hyperthyroidis m

3.1) Recurrent Hyperthyroi dism >etiology:

No treatment

> instructed not to use decongestants for nasal stuffiness because they are

for thyrotoxicosis is without side effects

> patients
who had very severe disease, discontinuatio n of antithyroid medications before therapy is complete, a long history of dysfunction, ocular and cardiac symptoms, large goiter, and relapse after previous treatmen

abnormal muscular fatigability and weakness,amenorrhea, and changes in bowel function. The pulse rate ranges constantly between 90 and 160 beats/min; blood pressure is elevated; atrial fibrillation may occur; and cardiac decompensation in the form of heart failure is common, especially in elderly patients. Osteoporosis and fracture Cardiac effects may include sinus tachycardia or dysrhythmias, increased pulse pressure, and palpitations Myocardial hypertrophy and heart failure may occur if the hyperthyroidism is severe and untreated. the untreated person becoming emaciated, intensely nervous, delirious, and even disoriented; eventually, the heart fails. Symptoms of hyperthyroidism may occur with the release of excessive amounts of thyroid hormone as a result of inflammation after irradiation of the thyroid or destruction of thyroid tissue by tumor. Such symptoms may also occur with excessive administration of thyroid hormone for treatment of hypothyroidism. Long-standing use of thyroid

poorly tolerated. > Antithyroid medications are contraindicated in late pregnancy because they may produce goiter and cretinism in the fetus. > elderly patients are more likely to develop granulocytopenia. > Solutions of iodine and iodide compounds are more palatable in milk or fruit juice and are administered through a straw to prevent staining of the teeth. > monitor for symptoms of iodism include swelling of the buccal mucosa, excessive salivation, coryza, and skin eruptions. > The nurse periodically assesses and monitors the patients cardiac status, including heart rate, blood pressure, heart sounds, and peripheral pulses. > Foods and fluids are selected to replace fluid lost through diarrhea and diaphoresis.( highly seasoned foods and

that it avoids many of the side effects associated with antithyroid medications. The use of radioactive iodine is generally recommended for treatment of thyrotoxicosis in elderly patients unless an enlarged thyroid gland is pressing on the airway. (2) antithyroid medications that interfere with the synthesis of thyroid hormones and other agents that control manifestations of hyperthyroidism. to reduce the amount of thyroid tissue, with resulting decreased thyroid hormone production > propylthiouracil (Propacil, PTU) or methimazole (Tapazole): These medications block extrathyroidal conversion of T4 to T3. Surgical removal of most of the thyroid gland is a nonpharmacologic alternative.

hormone in the absence of close monitoring may be a cause of symptoms of hyperthyroidism. Gerontologic considerations: Elderly patients commonly present with vague and nonspecific signs and symptoms, making disorders hard to detect. Symptoms such as tachycardia, fatigue, mental confusion, weight loss, change in bowel habits,

stimulants such as coffee, tea, cola, and alcohol are discouraged. High-calorie, high-protein foods are encouraged) > need reassurance that these symptoms are expected to disappear with treatment > The nurse encourages relaxing activities if they do not overstimulate the patient. >improving self esteem: If changes in appearance are very disturbing to the patient, mirrors may be covered or removed >exopthalmus: eye care and protection may become necessary: patient may need instructions about instillation of eye drops or ointment prescribed to soothe the eyes and protect the exposed cornea. > MAINTAINING NORMAL BODY TEMPERATURE: The nurse maintains the environment at a cool, comfortable temperature and changes

> Thyroid hormone is occasionally administered with antithyroid medications to put the thyroid gland at rest > Thyroid hormone is available as thyroglobulin (Proloid) and levothyroxine sodium (Synthroid) > Liothyronine sodium (Cytomel) has a more rapid onset, and its action is of short duration. > Compounds such as potassium iodide (KI), Lugols solution, and saturated solution of potassium iodide (SSKI) may be used in combination with antithyroid agents or beta-adrenergic blockers to prepare the patient with hyperthyroidism for surgery. These agents reduce the activity of the thyroid hormone and the vascularity of the thyroid gland, making the surgical procedure safer. > Beta-adrenergic blocking agents are important in

bedding and clothing as needed. Cool baths and cool or cold fluids may provide relief. > MONITORING AND MANAGING POTENTIAL COMPLICATIONS Cardiac and respiratory function are assessed by measuring vital signs and cardiac output, ECG monitoring, arterial blood gases, and pulse oximetry. Oxygen is administered to prevent hypoxia, to improve tissue oxygenation, Teaching Patients Self-Care how and when to take prescribed medication, and provides instruction about the essential role of the medication in the broader therapeutic plan. This information is repeated as the time of surgery approaches(bec. Of decreased attention span r/t hyperexcitability) Continuing Care importance of adhering to the therapeutic

controlling the sympathetic nervous system effects of hyperthyroidism. For example, propranolol (Inderal) is used to control nervousness, tachycardia, tremor, anxiety, and heat intolerance. >subtotal thyroidectomy: reserved for large goiters, presence of obstructive symptoms, pregnant women, or when there is a need for rapid normalization of thyroid function

regimen and the recommended follow-up monitoring. avoid stressful situations that may precipitate thyroid storm.