endocrine and metabolic disorders
TRANSCRIPT
ENDOCRINE AND METABOLIC DISORDERSMetabolic hyperthyroidism
“IT IS WHEN CONVERGENCE MEETS DEMAND AND THE CRAVING FOR LEARNING IS VERY BADLY NEEDED”
JOY JOHN DIEGO JACQIE JEFF JAYSON DOMINGO BENJO VENESSE ALVIN MARK LOUIE
HYPERTHYROIDISM
Description: Also called Grave’s disease, Basedow’s
disease, thyrotoxicosis or exophtalmos goiter.
A metabolic imbalance resulting from excessive thyroid hormone production; Grave’s disease is the most common form.
ETIOLOGY AND INCIDENCE:
1. Autoimmune dysfunction2. Genetic factors3. Other possible causes: thyroid tumors pituitary tumors Hypothalmic malignancies stress or infection exposure to iodine Incidence is greatest between ages 30 and
40 and is higher in women than in men
HOW IS HYPERTHYROIDISM DIAGNOSED?
If not diagnosed shortly after birth, hyperthyroidism in the newborn can be fatal. In addition to a complete medical history and physical examination, diagnostic procedures for hyperthyroidism may include measurement of thyroid hormone in the bloodstream.
Diagnosis is based on history, physical examination, and thyroid function tests. Serum TSH is the best test, because TSH is suppressed in hyperthyroid patients except when the etiology is a TSH-secreting pituitary adenoma or pituitary resistance to thyroid hormone. Free T4 is increased. However, T4 can be falsely normal in true hyperthyroidism in patients with a severe systemic illness (similar to the falsely low levels that occur in euthyroid sick syndrome) and in T3 toxicosis. If free T4 is normal and TSH is low in a patient with subtle symptoms and signs of hyperthyroidism, then serum T3 should be measured to detect T3 toxicosis; an elevated level confirms that diagnosis.
POSSIBLE LAB FINDINGS
Increased T4 and T3 levelsNon- detectable TSHThyroid Ultrasonography shows an enlarged thyroid gland
A thyroid scan indicates an increased uptake of radioactive iodine (RAI; 131I and 123I)
OTHER TESTS: MEDIA FILE 1: IODINE 123 NUCLEAR SCINTIGRAPHY: IODINE 123 SCANS OF A NORMAL THYROID GLAND (A) AND COMMON HYPERTHYROID CONDITIONS WITH ELEVATED RADIOIODINE
UPTAKE, INCLUDING GRAVES DISEASE (B), TOXIC MULTINODULAR GOITER (C), AND TOXIC ADENOMA (D).
ANATOMY AND PHYSIOLOGY
WHY DOES SPONGEBOB HAVE CLAUSTROPHOBIA?
Because he is afraid of the Santa Claus!
PATHOPHYSIOLOGY
SIGNS AND SYMPTOMS
CLINICAL MANIFESTATIONS Nervousness, irritability, hyperactivity, emotional lability, and
decreased attention span. Weakness, easy fatigability, exercise intolerance Heat intolerance Increased appetite, loses weight Insomnia, interrupted sleep Diarrhea, frequent stools Irregular or scant menses, decreased libido Warm, sweaty, flushed skin with velvety- smooth texture,
elevated body temperature Tremor, hyperkinesias, hyperreflexia Exopthalmos, retracted eye lids, staring gaze Hair loss (silky hair) Goiter Bruits over thyroid gland Tachycardia, moderate hypertension
POSSIBLE NURSING DIAGNOSIS
Activity intoleranceHyperthermiaHigh risk for injuryAltered Nutrition: Less than Body requirements
COMPLICATIONS
Graves ophthalmopathyGraves ophthalmopathy is more common
in women than in men. Dermopathy
. The skin changes usually include a nonpitting erythematous edema of the anterior shins.
Thyrotoxicosis/Thyroid stormHemorrhageHypocalcemia
PREVENTION
The frequency and severity of symptoms of thyrotoxicosis vary from person to person.
Radiation exposure Recording a careful family history of
autoimmune disease, thyroid disease, and emigration from iodine-deficient areas is important.
Review a complete list of medications.
HEALTH TEACHINGSMEDICATIONS:
Iodine: Potassium Iodide (Lugol’s Solution) saturated K iodide
Propylthiouracil and methimazole: Tapazole
β-Blockers: Propranolol (Inderal)Radioactive sodium iodine (131I, radioiodine): Radioiodine
TREATMENT
Subtotal thyroidectomy (partial removal of the thyroid gland)
Total thyroidectomy (removal of the thyroid gland) Treatment of infiltrative dermopathy and
ophthalmopathy: In infiltrative dermopathy (in Graves' disease), topical corticosteroids sometimes relieve the pruritus. Dermopathy usually remits spontaneously after months or years. Ophthalmopathy should be treated jointly by the endocrinologist and ophthalmologist and may require corticosteroids, orbital radiation, and surgery.
DIET
No special diet must be followed by patients with thyroid disease.
Notably, excess amounts of iodide found in some expectorants, x-ray contrast dyes, seaweed tablets, and health food supplements should be avoided because the iodide interferes with or complicates the management of both antithyroid and radioactive iodine therapies.
ACTIVITY
Often, in otherwise healthy patients with hyperthyroidism, exercise tolerance is not affected significantly. For these people, no reduction in physical activity is necessary. For elderly patients or for those with cardiopulmonary comorbidities, a decrease in activity is prudent until hyperthyroidism is medically controlled.
Often with severe thyrotoxicosis, systolic and diastolic cardiac dysfunction manifested by dyspnea upon exertion exists.
NURSING MANAGEMENT
The Nurse monitors Heart rate and Blood pressure
He or she records the client’s sleep pattern and daily weights
The nurse promotes rest and helps the client avoid excess physical stimulation.
Increased caloric intake can compensate for increased metabolism.
The nurse informs the client that effects of anti-thyroid therapy usually are not apparent until the thyroid gland has secreted the excess thyroid hormone into the blood stream. This process may take several weeks or more.
NURSING CARE PLANSASSESSMENT NURSING
DXANALYSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
SUBJECTIVE: “Ang takaw kopo pero
ang payat-payat ko pa rin”
OBJECTIVE: Underweight Loss of weight with
adequate food intake Poor muscle tone (+) diarrhea Hyperactive bowel
sounds noted
Nutrition imbalanced, less than body requirement r/t inability to ingest adequate nutrient AMB hypermetabolic rate
Metabolic imbalance
Excessive thyroid hormone
Increased metabolic rate
HypermetabolismLose of weight
STO: After 8 hours of nursing intervention the patient will verbalize understanding of causative factor.LTO:After 2 weeks of quality nursing care the patient will: Display
normalization of laboratory values and be free of signs of malnutrition
Demonstrate behaviors, lifestyle changes to regain and maintain appropriate weight
Assess weight, age, body built, strength, activity/rest level
Review indicated laboratory data (eg. Serum albumin)
Assist in developing individualized regimen
Provide diet modifications as indicated, for example increase caloric intake
Weigh weekly and as necessary and document result
Develop stress reduction program
Administer pharmaceutical agent like antidiarrheals
Emphasize importance of well-balanced, nutritions intake
Provide/ reinforce client teaching regarding pre-op & post-op dietary needs when surgery is planned.
Provides comparative baseline data
To check for changes in the lab result
To correct/control underlying causative factors
To/can compensate for increased metabolism
To monitor effectiveness of treatment/ effort/ dietary plan
To decrease instance of hypermetabolism
To prevent dehydration due to frequent BM
Provide info regarding individual nutritional needs & ways to meet these needs within financial constraints
To promote wellness
STO:Goals met as evidence by patient discuss/ recited about illness condition and know necessary modification and regimen.LTO:Goal partially met as evidence by the patient is under/ still in the plan of care
ASSESSMENT NURSINGDX
ANALYSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
SUBJECTIVE:“Mainit po ang aking pakiramdam ko” as verbalized by the patient
OBJECTIVE: Increased in body
temperature Flushed skin Warm to tough Increase RR Tachycardia
Hyperthermia r/t increasing metabolic rate secondary to hyperthyroidism
Metabolic imbalance
Inc. thyroid hormone
Inc. metabolic rate
Inc. heat production
hyperthermia
STO:After 8 hours of quality nursing intervention the patient will: Decrease body
temperature w/n the range of normal eg. From 38.2- 37.7 degrees C
LTO:After 2 days of nursing intervention the patient will: Maintain core
temperature w/n normal range
Monitor V/S Promote surface
cooling by means of loosen clothing
Remote tepid sponge bath
Administer medication as indicated such as
Beta blockersAntipyretics
Maintain bedrest Administer
replacement fluids and electrolytes
Provide high-calorie diet
Discuss importance of adequate fluid intake
Review specific cause such as specific cause such as underlying disease
Process such as thyroid storm
To provide comparative baseline data
Reduce body temp. by radiation and conduction
Heat loss by evaporative and conduction
To treat underlying cause for thyroid storm
To reduce body temperature
To reduce metabolic demands
To support circulating volume and tissue perfusion
To meet meet increased metabolic demands
To prevent dehydration
Indicates need for prompt intervention
STO:Goal is met as evidenced by patient know the causative of the hyperthermia. Body
decreases and reach within Normal range
LTO:Goal is met as manifested by patient temperature stay in normal
DRUG STUDY DRUG NAME INDICATION ACTION CONTRAINDICATION SIDE
EFFECTSROUTE
AND DOSAGE
NURSING IMPLICATION
GENERIC:methimazole
BRANDNAME:tapazole
Hyperthyroidism and prior to surgery or radiotherapy of the thyroid; may be used cautiously to treat hyperthyroidism in pregnancy
Thioamide with actions and use similarto those of propyl –thiouracil but 10 times as potent-actions are less consistent, but effects appear more promptly than with propyl thiouracil. Inhibits of synthesis of thyroid hormones as the drug accumulates in the thyroid gland. Does not affect existing T3 or T4 levels.
Pregnancy (category D), lactation
GI: Hepatotoxicity(rare)Endocrine: HypothyroidismHematologic: ThrombocytopeniaMuscoskeletal: ArthralgiaCNS: Peripheral neuropathy,vertigoSkin: Rash, alopeciaUrogenital: Nephrotic Syndrome
Route: per orem
Onset: 30-40 minutes
Peak: 1hour
Duration: 2-4 hours
Lab test: Periodic blood work, since agranulocytosis is a rare, but possible adverse effect
Closely monitor PT and INR in patients
on oral anti-coagulants. An anti-coagulant activity
may be potentiated. Be aware that skin
rash or swelling of cervical lymp nodes may indicates need to discontinue drug
and change to another anti- thyroid
agent. Consult physician.
Notify physician promptly if the
following symptoms appear, bruising,
unexplained bleeding, sore throat, fever,
jaundice Do not breast feed
while using this drug.
DRUG NAME INDICATION ACTION CONTRAINDICATION SIDE EFFECTS ROUTE AND DOSAGE
NURSING IMPLICATION
GENERIC:Propranolol HydrochlorideBRANDNAME:Inderal
Management of cardiac arrhythmias, myocardial infarction, tachyarrhythmias associated with digitalis intoxicosis, hypertropic subaortic stenosis, angina pectoris due to coronary atherosclerosis, hereditary, essential tremor.
Non selective beta-blocker of both cardiac and bronchial adrenoreceptors which competes with epinephrine and norepinephrine for available beta-receptor sites. In higher doses, exerts direct quinidine-like effect, which depresses cardiac function including contractility and arrhythmias.
Greater than first degree heart block; CHF, right ventricular failure secondary to pulmonary hypertension; cardiogenic shock
Body as a whole: fever; pharyngitis; respiratory distress, weight gain, LE-like reaction, cold extremities, leg fatigue, Urogenital: Impotence or decreased libidoSkin: Erythematous, psoriasis- like eruptions;pruritus, dry skin. AlopeciaCNS: drug- induced psychosis, sleep disturbances, depression, confusion,agitation, vertigo, syncope, weakness, drowsiness, insomniaMetabolic: Hypoglycemia, hyperglycemia hypocalcemiaRespiratory: dyspnea, laryngospasm, brochospasm.
Route: Per oremintravenous
Onset:15-20 min
Peak:3-4 hours
Duration:6-8 hours
>obtain careful medical history to rule out allergies>monitor apical pulse, RR,BP>Evaluate adequate control or dosage interval for hypertension >LAB Test: obtain periodic hematologic, kidney, liver and cardiac functions when propranolol is given for prolonged period>monitor I and O ratio and daily weighing>be aware that propranolol suppresses clinical signs of hypoglycemia>do not discontinue abruptly; can precipitate withdrawal syndrome>make position changes slowly and avoid prolonged standing> do not breast feed while taking this drug without consulting physician
UPDATES!
FREQUENCY
United States Graves disease is the most common form of hyperthyroidism.
Approximately 60-80% of cases of thyrotoxicosis are due to Graves disease. The annual incidence of the disease is 0.5 cases per 1000 persons during a 20-year period, with the peak occurrence in people aged 20-40 years. Toxic multinodular goiter (15-20% of thyrotoxicosis) occurs more frequently in regions of iodine deficiency. Most persons in the United States receive sufficient iodine, and the incidence of toxic multinodular goiter is less than the incidence in areas of the world with iodine deficiency. Toxic adenoma is the cause of 3-5% of cases of thyrotoxicosis.
International The incidences of Graves disease and toxic multinodular goiter
change with iodine intake. Compared to regions of the world with less iodine intake, the United States has more cases of Graves disease and fewer cases of toxic multinodular goiters.
Race Autoimmune thyroid disease occurs with the same
frequency in Caucasians, Hispanics, and Asians, and it occurs less frequently in the black population.
Sex All thyroid diseases occur more frequently in women
than in men. Graves autoimmune disease occurs in a male-to-female ratio of 1:5-10. Toxic multinodular goiter and toxic adenomas occur more frequently in women than in men, with a ratio of 1:2-4.
Age Autoimmune thyroid diseases have a peak incidence in
people aged 20-40 years. Toxic multinodular goiters occur in patients who usually have a long history of nontoxic goiter and, therefore, usually present when they are older than 50 years. Patients with toxic adenomas present at a younger age than patients with toxic multinodular goiter.
OTHER UPDATES:Seasonal Health News
Fatigued or Full Throttle: Is Your Thyroid to Blame?By Debra BruceReviewed by: Brunilda Nazario
Feeling all revved up, even at bedtime? Or maybe your throttle's on idle with symptoms of depression , fatigue, and weight gain. In both cases, the root cause may be your thyroid.
The thyroid -- a butterfly-shaped gland in the front of your neck -- makes hormones that control the way your body uses energy. Your thyroid controls your metabolism, which is how your body turns food into energy, and also affects your heart, muscles, bones, and cholesterol.
While thyroid disorders can range from a small, harmless goiter (enlarged gland) to life-threatening cancer, the most common thyroid problems involve an abnormal production of thyroid hormones. Too much of these vital body chemicals results in a condition known as hyperthyroidism. Too little hormone production leads to hypothyroidism.
Although the effects of thyroid problems are unpleasant or uncomfortable, most thyroid conditions can be managed well if properly diagnosed and treated.
What is an overactive thyroid? Hyperthyroidism happens when the thyroid becomes overactive and produces too much of
its hormones. Hyperthyroidism affects women five timesto 10 times more often than men, and is most common in people younger than 40. People with hyperthyroidism have problems that reflect overactivity of the organs of the body, resulting in symptoms such as sweating, feeling hot, rapid heartbeats, weight loss, and sometimes eye problems.
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