Nursiswati, M.Kep.,Sp.

KMB Titis Kurniawan, MNS

Outline
Anatomy & physiology Thyroid Gland Thyroid Hormone Regulation

Hyperthyroid Patophysiology (etiology, clinical manifestation, complication, & Nursing problem) Diagnostic test NCP
Hypothyroid Patophysiology (etiology, clinical manifestation, complication, & Nursing problem) Diagnostic test NCP Case Review

Anatomy of Thyroid Gland

Single, bi-lobed gland in the anterior neck, shape of

butterfly Largest of all endocrine gland (weight = 25 30g) Regulation; low level of thyroid TRH (thyrotropin releasing hormone) pituitary gland release TSH (thyroid-stimulating hormone) anterior pituitary gland release thyroid (T3 and T4) Hormone produced: Thyroxine (T4) & tri-iodothyronin (T3) dependent on iodine & BMR responsible for cell metabolism (oxidasi & termogenesis), growth & development Calcitonin regulating blood calcium level

Isthmus

Negative feedback

T3 & T4 Blood <<

TRH

TSH

T3 & T4 Blood >>

Thyroid Regulation

Hyperthyroidism
Excess thyroid hormone production 2nd most common endocrine disorder, after

diabetes mellitus. Women; 8 x more often (age = 30 50 years) Etiology: Graves disease, toxic multinodular goiter, thyroiditis, adenoma thyroid gland, & excess iodine/thyroid intake Graves disease; autoimmune disorder (Ig stimuli TSH), most cause of hyperthyroid Risk factors: pregnancy, trauma, stress, amiodarone therapy, and age (Tierney et al., 2001)

Clinical Manifestations
Thyrotoxicosis; Loss weight, >> appetite Rapid pulse/Palpitation atrial fibrilation/decompensatio cordis Blood pressure (systolic) M>> Warm & moist skin Heat intolerance, fatigue Hand/tongue tremor Nervousness, irritable Hyperactive Exopthalmus/bulging eye Amenorhea Osteoporosis/fracture

Thyroiditis

Graves Disease Autoimmune

Goiter

Adenoma

Patofisiologi
Enlargment thyroid gland

Substance like TSH

TSH >> >> T3 & T4 Thyrotoxicosis >> metabolism
Prot & Fat <<

Change body image

Symphatis >> heat >> sweat Tremors

Fibroblas & folikel mata

Cardiovascular System

Change Jar. Obital & otot mata

Loss body weight

Nutrition problem

Palpitaion
DeComp/ Atrial Fibrilation

Exophthalmus

Iritation Risk of Injury

Diagnostic Test
Test
TSH test

Nature of test
Laboratory Blood test

Normal Range
Adults: 2-12 microinternational unit/ml

Use in Diagnosis
Differentiate primary & secondary hypothyroid. Primary THS >>, secondary TSH << (absent) even with low level of T3 & T4
Help differentiate primary & secondary hypothyroid. Primary diseases unable to increase thyroid hormone Confirm the presence of primary hyperthyroidism. Little or no increase in TSH is seen doe to suppression effect of excess circulation of TH. Excessive increase of TSH early hypothyroid

Nx Implication
Prepare patient for blood test, fasting is not required, may be affected by recent radioisotop for other diagnostic
Prepare patient for blood test & fasting is not required

TSH stimulation test

Laboratory Blood test

Evidence increase thyroid function with administration of TSH

TRH test

IV bolus of TRH

Quick rise in TSH level within 30 minutes after bolus

Prepare patient for blood test & fasting is not required. Explain the procedures & monitoring the site of drug insertion

Diagnostic Test
Test
Thyroxine (T4) screen

Nature of test
Laboratory Blood test

Normal Range
Adults: 4 -11 mcg/dl

Use in Diagnosis
Identify T4 blood level . Increase T4 (Hyperthyroidism), low level of T4 (hypothyroid)

Nx Implication
Preparation, result may be affected iodine contrast scans, medications (estrogen, oral contraception, seizure medication, opiates, & antithyroid drug Explain the procedure

Tyroxine index (free T4 index) Triiodothyro nine radioimmun oassay Iodine uptake scan

Laboratory Blood test

Identify T4 or T3 blood level . Increase level (Hyperthyroidism), low level (hypothyroid) Accurately measure thyroid function. When level less than normal hypothyroid Measure how much iodine is taken by thyroid gland Hypothyroid takes up little iodine Hyperthyroid takes up a lot of iodine

Laboratory Blood test

Fasting is not required. May be affected by pregnancy, recent radioisotope administration. NPO, usually done in conjunction with thyroid lab studies

Patient takes oral dose of radioactive iodine on an empty stomach (Iodine uptake by thyroid gland)

Diagnostic Test
Test
Thyroid scan

Nature of test
A radioactive substance is given to enhance visualization of the gland. Ultrasound

Normal Range
Reveal normal size, shape, position, & function

Use in Diagnosis
Differentiate thyroid nodule, Graves disease from Plummers disease

Nx Implication
Contraindicated for pregnancy & allergies to iodine

Thyroid ultrasound

Reveal normal size, shape & position of gland

Differentiate cystic from solid thyroid nodules. Can be used to aid in placement of needle for biopsy. Differentiate malignant or benigna

Explain the procedures

Needle biopsy

Biopsy

Medical Management
Treatment ; directed to reduce thyroid hyperactivity to

relieve symptoms & remove the cause of complications. Depends on the cause of the hyperthyroidism and may require a combination of therapeutic approaches. Antithyroid drugs; inhibit production of active thyroid hormone, initial & long term treatment
PTU (Propilthiouracil); 3 divided doses Methimazole; one daily dose, rapid improvement in T3

& T4 serum & better patients compliance

Radioactive iodine; destrys all/part thyroid gland

reduce excessive thyroid hormone Subtotal thyroidectomy; most of thyroid gland removed reduce thyroid hormone production

Medical Management
Medication PTU Action Slowing TH production. Given several months & may cause temporary/longterm remission of hyperthyroidism Inhibits synthesis of TH Side Effects Allergic (rash, hives, fever, joint pain), << WBC, sore throat, infection, impaired liver function, loss off appetite, abdominal pain Caution in patients with liver diseases, bone marrow disorder, allergy history, & congenital anomalies Diarrhea, vomiting, nausea, abdominal pain, skin rash, GI bleeding (adverse reaction) Decrease HR, myocardial oxygen consumption, & lowering blood pressure No serious complications reported Nx Care Instruct patient to have regular follow up, monitor WBC, liver function, report side effects symptoms

Methimazole (Tapazole, carbimazole)

Instruct patient to aware the side effect symptoms. Avoid giving when the (anti cancer drug, lithium, iodine-containing drug, sulfonamide, interferon) are given Advise patient to drink all solution, use straw to prevent discoloration of teeth, not to withdraw and report iodism (abdominal symptoms) CI for asthma, sinus bradycardia/hearth block,. Advise patient not to discontinue abruptly Advise patient to have TH level monitored regularly, take thyroid replacement on empty stomach, dont change the hormones brands without follow up monitoring

Iodide or iodide products Propanolol (Indrenal) Radioactive iodine (I-123)

Inhibits synthesis of TH & decrease size 7 vascularity of thyroid. Effective for short term treatment (7-14 days) Beta-adrenergic blocking agents. Decrease the effect of hyperthyroidism Destroys thyroid tissue with maximum benefit apparent in 3-6 months.

Recurrent Hyperthyroidism
No treatment for thyrotoxicosis without side

effects, and all three treatments (radioactive iodine therapy, antithyroid medications, and surgery) share the same complications: relapse or recurrent hyperthyroidism and permanent hypothyroidism.
The rate of relapse increases in patients who

had very severe disease, a long history of dysfunction, ocular and cardiac symptoms, large goiter, and relapse after previous treatment.

Nursing Management
Nursing diagnoses:
Imbalanced nutrition, less than body requirements, related to

exaggerated metabolic rate, excessive appetite, and increased gastrointestinal activity Anxiety, restlessness, hand tremor, insomnia secondary to hypermetabolism Ineffective coping related to irritability, hyperexcitability, apprehension, and emotional instability Body image (change/disruption) related to changes in physical appearances (weight loss, exophthalmus, thyroid enlargement) Risk for injury (eye) secondary to exophthalmus & inability to close eyelids properly Risk for decrease cardiac output related to hypermetabolic state

Nursing Interventions
Improving nutritional status; Diet consultation Nutritional supplements Information supports (effect of hypo/hyperthyroid on body weight); Administer antithyroid as prescribed Monitor patients body weight Enhancing coping; Restful environment Social support Information supports (effect of hypo/hyperthyroid); Administer antithyroid as prescribed

Nursing Interventions
Risk for injury Encourage patients to flush eyes with warm water at interval while awake Use artificial tears Cover eye while sleeping Decrease Cardiac output Monitor vital signs frequently Administer antythyroid & cardiac medication as prescribed Maintain restful & calm environment Assess toleration of physical activity Monitoring and managing potential complications Promoting home and community-based care
Teaching patients self-care

Hypothyroidism
Results from suboptimal levels of thyroid

hormone.
Thyroid deficiency can affect all body

functions range from mild, subclinical forms to an advanced form (myxedema).

The most common cause of hypothyroidism

in adults is autoimmune thyroiditis (Hashimotos disease)

Pathophysiology
More than 95% hypothyroidism primary or

thyroidal hypothyroidism dysfunction of the thyroid gland. Central hypothyroidism thyroid dysfunction caused by failure of the pituitary gland, the hypothalamus, or both decreased stimulation of TRH << TH Pituitary or secondary hypothyroidism pituitary disorder Hypothalamic or tertiary hypothyroidism hypothalamus disorder Cretinism thyroid deficiency present at birth (the mother may also suffer from thyroid deficiency).

Pathophysiology
Myxedema the accumulation of mucopolysaccharides in subcutaneous and other

interstitial tissues.
Myxedema occurs in long-standing hypothyroidism, the term is used appropriately only to describe the

extreme symptoms of severe hypothyroidism.

Clinical Manifestations
Early symptoms nonspecific, but extreme fatigue

makes it difficult for the person to complete a full days work or participate in usual activities.

Integuments: Reports of hair loss, brittle nails, and dry

skin are common, and numbness and tingling of the fingers may occur.
complain of hoarseness.

The voice may become husky, and the patient may Menstrual disturbances; menorrhagia or amenorrhea

occur, in addition to loss of libido.

NURSING DIAGNOSES
Risk for imbalanced body temperature;

hypothermia secondary to metabolic dysfunction Activity intolerance and fatigue secondary to hypometabolic state with decrease cardiac output Constipation secondary to lethargy, activity intolerance, & hypometabolic state Risk for impaired skin integrity secondary to TH deficiency

Life Threatening Complications

Myxedema coma
Life threatening Occurs when precipitating event trauma, infection, sedation compromises the hypothyroid patients (older adults with long-standing primary thyroid diseases) Weight gain, extreme fatigue, bradycardia, lethargy, mental dullness, memory impairment, cold intolerance Very low body temperature (32,8 35C), skin cold & dry, seizure, severe bradycardia, delayed deep tendon reflexes, non pitting edema (face and around eyes), enlarged tongue, loss of consiousness, mood disturbance, & psychosis Low TSH (if pituitary is involved) & very high TSH (thyroid gland is affected tissue), low serum FT4, hyponatremia, hypoglycemia, hyperlipidemia, respiratory acidosis, ECG; prolong QT intervals, pleural/pericardial effusions, presence antithyroid antibodies Vital signs, level of consciousness Hormone replacement therapy

Thyroid Storm
Occurs when there is failure of the compensatory metabolic, thermoregulatory, & cardiovascular system in hyperthyroid patients Significant unexplained weight loss, warm, moist skin, heat intolerance, cardiac palpitation, tachycardia, tachypneu, & dyspneu on exertion Tachycardia (> 14x/mnt), atrial fibrilation, arrhytmias, increase stroke volume, synptoms of high output hearth failure with pulmonary edema. Very high body temperature > 40 C, restlessness, agitation, abdominal pain, nausea, vomiting, coma, emotional lability, exophthalmus, goiter, coma Low level TSH, high serum FT4, elevated liver function test, elevated alkaline phosphatase

Early symptoms

Signs & synptoms

Laboratory values

Assessment Treatment

Body temperature, blood glucose level Antithyroid drugs, surgery

Nursing Interventions
Risk for imbalanced body temperature
Goal: Maintenance of normal body temperature 1. Provide extra layer of clothing or extra blanket. 2. Avoid and discourage use of external heat source (eg, heating pads, electric or warming blankets). 3. Monitor patients body temperature and report decreases from patients baseline value.

Nursing Interventions
Activity intolerance and fatigue secondary to hypometabolic state with decrease cardiac output

Goal: Increased participation in activities

Assess patient ability/activities tolerance level Include patients in the low impact ativities Helps patients conducting ADL Include families during intervention Instruct patient on administration of hormone replacement 6. Avoid sadatives
1. 2. 3. 4. 5.

Nursing Intervention
Nursing Dx: Constipation secondary to lethargy, activity intolerance, & hypometabolic state Goal: Return of normal bowel function 1. Encourage increased fluid intake within limits of fluid restriction. 2. Provide foods high in fiber. 3. Instruct patient about foods with high water content. 4. Monitor bowel function. 5. Encourage increased mobility within patients exercise tolerance. 6. Encourage patient to use laxatives and enemas sparingly.

Nursing Intervention
Nursing Dx:Risk for impaired skin integrity secondary to TH deficiency Goal: improve skin condition (intact, soft, moist, no itching/breaking) 1. Avoid use of soap, astringents, or alcohol 2. Liberally apply emollient skin lotion 3. Cut patients nails properly 4. Monitor skin integrity 5. Consider air mattress if needed 6. Administer replacing hormone therapy as prescribed