Thyroid And Parathyroid

Dr. Hanan Said Ali

Minor Major Injury Illness

Nurse Treatment Service

Objectives

• Describe the definition, etiology. Clinical manifestations , management, nursing care for client with:

Hyperthyroidism.Hypothyroidism.Hyperparathyroidism.Hypoparathyroidism.

MINTS 2

Hyperthyroidism• Thyroid hormone thyroxin (T4) and triode

thyroxine (T3) more active form, regulate energy metabolism, and growth and development.

• Hyperthyroidism

• It is sustained, increased synthesis and release of thyroid hormone by the thyroid gland.

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Hyperthyroidism- Aetiology

• The incidence is 4 to 10 times greater in women, and highest frequency is in the 30- 50years age

1.Toxic diffuse goiter (Grave’s disease):

Is an autoimmune disorder(develops antibodies against various antigens within the thyroid gland , by insufficient iodine supply, infection, stress.

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Hyperthyroidism- Aetiology

2. Toxic multinodular goiter(plummer’s disease) common in iodine deficient area.

3. Toxic adenoma

4. Thyroiditis: Is an inflammatory process in the thyroid by bacterial or fungal infection,

5. T3 thyrotoxicism: T3 level elevated but cause is unknown.

MINTS 5

Hyperthyroidism- Aetiology Cont. 6. Hyperthyroidism caused by metastatic

thyroid cancer.

7. Pituitary hyperthyroidism: Rare pituitary adenomas.

8. Iodine induced hyperthyroid over production by administration of supplemental iodine to a person with endemic goiter.

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Hyperthyroidism- Clinical Manifestation

Cardiovascular:• Hypertension; increased rate and force of cardiac

contractions; rapid pulse; increased cardiac output; arrhythmias; palpitations; angina.

Respiratory:• Increased respiratory rate; dyspnoea on mild exertion.

Musculoskeletal:• Fatigue, muscle weakness, dependent oedemas,

osteoporosis.7

Hyperthyroidism- Clinical Manifestation

Gastrointestinal:

• Increased appetite, thirst, weight loss, increased peristalsis, diarrhoea, increased bowel sound, splenomegaly, hepatomegaly.

Integumentary:

• Warm, smooth, moist skin; thin brittle nails, hair loss, palmer erythema; fine silky hair .

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Hyperthyroidism- Clinical Manifestation

Nervous System• Difficulty in focussing eyes. Nervousness; fine

tremor(of fingers and tongue); insomnia; liability of mood, restlessness, personality changes, depression, fatigue, apathy, lack of ability to concentrate, stupor, coma.

Reproductive:• Menstrual irregularities; oligomenorrhea,

amenorrhoea; libido

Others:• Intolerance to heat; Temp., exophthalmoses. 9

Hyperthyroidism- management• Three classes of medications:

1. Ant thyroids of thiomide, which inhibit the synthesis of thyroid hormone.

2. Iodine, which inhibits the release of thyroid hormone Eg- Radioactive iodine.

• It is administered orally in one dose, 80-90 per/g. Of thyroid tissue.

3. Beta- adrenergic blockers, such as Inderal• Surgical Treatment• One lobe (subtotal). Removal gland (total thyroidectomy

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Hyperthyroidism- Ng. management

Placing the client in calm, cool room. Encouraging and assisting with exercise. Restricting visitors who upset the client. Establishing a supportive, trusting

relationship

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Hyperthyroidism- Ng. management

Applying artificial tears to soothe and moisten

conjunctival membrane & wearing dark-colored

glasses.

Using light bed covering and change it.

Salt restriction and elevate client’s head to

reduce pre- orbital oedema.

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Hyperthyroidism- Ng. management

If the client receiving radiation therapy:

• Flush the toilet two or three times after each use.

• Increase intake of fluids to aid excretion.

• Sleep alone for few days and avoid kissing .

• Do not breast feed, delay pregnancy after 6 m.

• RAI should not be used in pregnant women because of the teratogenic effects on foetus

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Hyperthyroidism- Ng. management

As recovery ensure the nurse should:

• Promote adequate rest (back rubs, hot milk)

• Maintain increase activity tolerance

encourage short walk, rest between activity

• Maintain adequate nutrition intake

monitor I&O, weight daily, protein & cal.

• Promote good eye care (dark glass)

• Facilitate improved coping.

• Enhance client knowledge. 14

Hypothyroidism• Definition

Is a metabolic state resulting from a deficiency

of thyroid hormone that may occur at any age Congenital hypothyroidism results in a condition called Cretinism.

• Aetiology

Loss or atrophy of thyroid tissue

Autoimmune thyroiditis, ablative, therapy for hyperthyroidism, thyrotoxic drugs, maldevelopment, radiation for head. 15

Hypothyroidism-Aetiology Cont. Loss of trophic stimulation

Pituitary or hypothalamus dysfunction.

• Miscellaneous alteration• Deficit in hormone biosynthesis, peripheral• resistance to thyroid hormone, iodine deficit

• The most frequent causes 1. Haiter any enlargement of the thyroid gland,

cancer or inflammation (simple goiter), 16

Hypothyroidism-Aetiology Cont.

2. Thyroiditis• Acute thyroiditis : results from infection of

thyroid by pyogenic organisms.

• Subacute nonsuppurative thyroiditis: may follow an upper respiratory infection.

• Chronic thyroiditis.

• Ablative therapy. Total thyroidectomy, radiation therapy of pituitary or

thyroid gland. 17

Hypothyroidism- Clinical Manifestations

• Defective physical development and mental

retardation in infant and children.

Infant Large posterior fontanels, squinting excessive sleeping, thickened skin and lips, enlarged tongue, abdominal distention, vomiting, feeding and respiratory difficulty.

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Hypothyroidism- Clinical Manifestations

• Adult

Cardiovascular: decreased pulse rate, change in

BP, cardiac hypertrophy, weak contractility,

anaemia, CHF, angina and MI.

Respiratory: Dyspnea, decreased breathing capacity.

Gastrointestinal: decreased appetite, nausea, vomiting, weight gain, constipation, abd. distention.

Musculoskeletal : Fatigue; weakness; muscular aches;

and pain; slow movement. 19

Hypothyroidism- Clinical Manifestations

• Integumentary: dry, cold skin; brittle nails; coarse hair, poor turgor of mucosa; oedema; puffy face, decreased, sweating; pallor.

• Nervous: Apathy; lethargy; slowed mental process; hoarseness, slow speech; stupor; coma; anxiety, depression.

• Reproductive: Prolonged menstrual periods or amenorrhoea; decreased libido, infertility.

• Others: increased susceptability to infection, intolerance to cold, decreased hearing. 20

Hypothyroidism- Management• Low-caloric diet to promote weight loss.

• Synthetic oral thyroxine synthroid, levothyroid is the drug of (sodium- levo- thyroxine) of choice.

• Client with compromised cardiac status, a small initial dose (12.5 to 25mg.l)

• If chest pain occur with treatment, ECG and cardiac enzyme tests are performed.

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Hypothyroidism- Nursing Management

• Assessment through history taking.

• If the client has any oedema, coma, mechanical respiratory support necessary &. Cardiac monitoring.

• All medication will be administering IV because unreliable absorption of oral medications due to paralytic ileus.

• The nurse should monitor hypothermia, vital signs, body weight, fluid intake and output.

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Hypothyroidism- Nursing Management• Promote activity to the level of client tolerance

(monitor cardiovascular response, BP, pulse, respiration before, during, after activities.

• Promote positive body image.

• Promote normal bowel elimination.

• Treat hypothermia.

• Facilitates intake of a nutritional diet 23

Hypothyroidism- Nursing Management

• Provide for self- care needs (hygiene, toilet)

• Maintain skin integrity.

• Facilitate safe environment and orientation to environment:

Monitor neurological status every shift. Reorient client frequently. Maintain safe environment. Involve client in decision about care.

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HyperparathyroidismDefinition

• Is a condition involving increased secretion of parathyroid hormone(PTH) make

• FunctionsMaintenance of normal serum calcium.Regulate bone reabsorption of calcium.Regulates phosphate and bicarbonate

excretion in kidney.Regulates calcium absorption in intestine 25

Hyperparathyroidism

Etiology

Hyperparathyroidism is classified to primary, secondary, or tertiary.

• Primary hyperparathyroidism

Is due to an increased secretion of PTH lead to hypocalcaemia and hypophosphatemia. common cause is a benign neoplasm or single adenoma in the parathyroid gland.

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Hyperparathyroidism- Etiology

• Secondary hyperparathyroidism

Appears to be compensatory response to states that induce or cause hypocalcaemia, it associated with vitamin D deficiencies, malabsorption, chronic renal failure.

• Tertiary hyperparathyroidismOccurs when there is hyperplasia of parathyroid glands

and loss of feedback from circulating calcium level in client has had kidney transplant after long dialysis.

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Hyperparathyroidism clinical -Manifestation

• Cardiovascular:

Arrhythmia (shortened in QT interval), hypertension.

• Gastrointestinal:

Vague abdominal pain, anorexia, nausea, vomiting, constipation, pancreatitis, peptic ulcer, weight loss and appetite.

• Integumentary:

Skin necrosis and moist skin.28

Hyperparathyroidism clinical -Manifestation Cont.

• Musculoskeletal:

Skeletal pain, backache, weakness, fatigue, osteoporosis, pathologic fracture, muscle tone

• Neurologic:

Personality disturbance, emotional irritability, memory impairment, psychosis, confusion, coma, incoordinations, abnormalities of gait, headache.

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Hyperparathyroidism clinical -Manifestation Cont.

• Renal:

• Hypercalciuria, kidney stones, urinary tract infection, and polyuria.

• Others:

• Corneal calcification, renal failure, cardiac changes, long bone and rib fractures.

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Hyperparathyroidism- Management

• Plicamycine mithracina and antihypercalcemic agent used for metastatic parathyroid carcinoma and sever bone disease.

• Biophosphonate used to inhibit oestoclostic bone reasbsorption.

• Oral Phosphate used to inhibit calcium absorption effects of vitamin D in intestine.

• Diuretic used to increase the urinary excretion of calcium.

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Hyperparathyroidism- Ng. Management

Parathyroid tumours should be removed:

• Preoperative: Continuing hydration, administration of diuretic,

replacement of electrolytes, and administration of sodium chloride.

• Postoperative:

The same for thyroidectomy

• Complications: Haemorrhage, hypocalcaemia and airway obstruction

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Hyperparathyroidism- Ng. Management

The client respiratory, cardiovascular, neurological and fluid state are monitored:

• Have tracheostomy set and IV calcium available

• Report any signs of haemorrhage, hypocalcaemia, or airway obstruction.

• Assess mental status and motor strength.33

Hyperparathyroidism- Ng. Management

• Assess respiration, elevate head of the bed, deep breathing, coughing and turning 2- 4 h.

• Increased ambulation at client’s tolerance take into account mental status and weakness.

• Maintain fluid intake at prescribed level or enough to achieve:

1000 ml or more if serum calcium level are

normal or 2000 ml or more if they are higher. 34

Hypoparathyroidism Definition

• Inadequate circulatory PTH, is characterized by hypocalcaemia resulting from lack of PTH to maintain serum calcium levels.

• It may be pseudohypoparathyroidism

( idiopathic) or true Hypoparathyroidism

( iatrogenic)

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Hypoparathyroidism- etiology

• ( iatrogenic) Accidental removal of parathyroid or damage to the vascular supply of the glands during neck- surgery.

• Idiopathic due to absence fatty replacement or atrophy of the glands because there is abnormal antibodies directed against parathyroid gland.

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Hypoparathyroidism- etiology Cont.

• Functional Hypoparathyroidism is the result of chronic hypomagnesaemia seen in malabsorption or alcoholism.

• In pseudohypoparathyroidism, the excretion and release of PTH are normal. But there is target tissue resistance to PTH by genetic defect resulting in hypocalcaemia in spite of normal or high PTH.

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Hypoparathyroidism Clinical Manifestation

• Sudden decrease in calcium concentration gives rise to syndrome called tetany.

• Tetany is characterized by tingling of the lips

fingertips, and feet and increased muscle tension leading to stiffness and painful spasms of smooth and skeletal muscles of extremities and face.

• Chrostek’s sign (facial muscle spasm)

• Trousseau’s sign (carpopeda spasm by applying BP Cuff. 38

Hypoparathyroidism Clinical Manifestation

Neuromuscular manifestation• Tetany with positive Chrostek’s and Trousseau’s

sign , spasms of wrist, fingers, forearm, feet and toes.

• Fatigue, weakness, difficulty in walking.• Convulsions (tonic spasm of total body or tonic

clonic activity)• Laryngeal stridor and dyspnea.• Headache, painful oedema, gait change, 39

Hypoparathyroidism Clinical Manifestation

Emotional• Irritability, depression, anxiety, memory

impairment, confusion, personality changes.

Cardiovascular• Decreased contractility of the heart muscle.• cardiac output from CHF.• Prolonged QT and ST intervals.• Resistance to effect of digitalis preparation. 40

Hypoparathyroidism Clinical Manifestation

Eye manifestation• Eye changes, cataracts, papill oedema, loss of sight

Dental manifestation• Enamal defects seen in the tooth crown.• Delayed or absent tooth eruption.• Defective dental root formation.

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Hypoparathyroidism Clinical Manifestation

Integumentary

• Dry skin, hair loss on scalp and body, thin hair, brittle and fragile nails, skin infection.

GIT and Renal

• Abnormal cramps and urinary and fecal incontinence, urinary frequency, malabsorption and steatorrhoea.

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Hypoparathyroidism- Management• Tetany is treated with IV infusion or slow push of

calcium salt ( calcium salts can cause hypotension and cardiac arrest- thin slow push)

• Long- term therapy consists of the administration of vitamin D to increase GIT absorption of calcium.

• Dietary and elemental calcium.

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Hypoparathyroidism- Ng. Management• Assessment for sigs of tetany, airway patency, mental

and emotional status, anxiety, irritability, VS .

• The client have anxiety and ineffective breathing, so he should kept in a room from where the nurse' station can be visible.

• Support the client to prevent hyperventilation because it cause alkalosis and lead to decrease in ionized calcium which exacerbates symptoms of hypocalcaemia.

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Hypoparathyroidism- Ng. Management

• Monitoring signs of: Ineffective treatment: recurrence of tetany.

Signs of hypercalcemia: thirst, polyuria, lethargy, muscle tone, constipation.

Complication: Renal stones ( flank pain i.e. Pain radiating down into groin)

Need for continual follow- up care and dietary changes.

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