Thyroid CrisisPresented by

BSN4-N/ group 54

Submitted To:

Mr. Angel Ramos RN,Man

Contents:

• Hyperthyroidism

• Hypothyroidism

• Thyroiditis

• Thyroid cancer

Anatomy of the thyroid gland

Hyperthyroidism

• Is the term for overactive tissue within the thyroid gland causing an overproduction of thyroid hormones (thyroxin or "T4" or triiodothyronine or "T3").

• Thyroid hormone functions as a controller of the pace of all of the processes in the body. This pace is called metabolism. If there is too much thyroid hormone, every function of the body tends to speed up.

Etiology The major causes in humans are:

• Graves disease

• Toxic thyroid adenoma

• Toxic multinodule goiter

• High blood levels of thyroid hormones (hyperthyroxinemia)

• Thyroiditis

• Amiodarone, an anti-arrhythmic drug is structurally similar to thyroxine and may cause either under- or overactivity of the thyroid.

• Post partum thyroiditis

Sign and Symptoms• Palpitations• Heat intolerance• Nervousness• Insomnia• Breathlessness• Increased bowel movements• Light or absent menstrual periods• Fatigue• Fast heart rate• Trembling hands• Weight loss• Muscle weakness• Warm moist skin• Hair loss• Staring gaze

Pathophysiology

• In hyperthyroidism, serum T3 usually increases more than does T4, probably because of increased secretion of T3 as well as conversion of T4 to T3 in peripheral tissues. In some patients, only T3 is elevated (T3 toxicosis).

• T3 toxicosis may occur in any of the usual disorders that produce hyperthyroidism, including Graves' disease, multinodular goiter, and the autonomously functioning solitary thyroid nodule.

• If T3 toxicosis is untreated, the patient usually also develops laboratory abnormalities typical of hyperthyroidism (ex. elevated T4 uptake). The various forms of thyroiditis commonly have a hyperthyroid phase followed by a hypothyroid phase.

Physical AssessmentPhysical finding Differential Diagnosis Special Features

Single Nodule    Multiple Nodules    Diffuse Goiter     Tenderness

Autonomously functioning adenoma or edematous nodule   Hyperplasia secondary to unilobar agenesis, multi nodular goiter, hashimotos thyroiditis Graves Diseases, thyroid lymphoma    Subacute thyroiditis, infracted adenoma

Opposite lobe not palpable, rubbery firm , tenderness suggest hemorrhage or infarction. Opposite lobe not palpable , firm lobes or irregular surface may be misinterpreted as multiple nodules Bruit or thrill, pyramidal nodule, irregular surface rubbery or firm, occasionally tender, fibrous variant may be hard Unilateral or bilateral,tenderness often severe, discrete nodule with tenderness

Diagnostic Exam

Thyroid Test• Serum thyroid stimulating hormone- ability to detect minute changes

TSH make it possible to distinguish subclinical thyroid disease.

• Thyroid Antibodies- testing by immunoassay techniques for anti thyroid antibodies.

• Radioactive iodine uptake- test measures the rate of iodine uptake by the thyroid gland.

• Fine needle aspiration biopsy- to sample the thyroid tissue, safe and accurate.

Diagnostic Exam

• Thyroid scan- scintallation detector or gamma camera moves back and forth to the area.

• Serum thyroglobulin- Tg can be measured reliably in the serum by radioimmunoassay.

Nursing diagnosis• Nursing Diagnosis : Risk for imbalanced body temperature

Goal: Maintenance of normal body temperature

Intervention: Promotes extra layer of clothing

Discourage use of external heat source

Monitor pt’s temperature

Protect from exposure to cold and drafts

 • Nursing Diagnosis: Constipation related to depressed GI function

Goal: Return of normal bowel function

Intervention: Encouraged increase fluid intake

Provide food high in fiber

Monitor bowel function

 • Nursing Diagnosis: Ineffective breathing pattern r/t depressed ventilation

Goal: Improved respiratory status and maintenance of normal breathing pattern

Intervention: Monitor respiratory rate, depth, pattern, pulse oximeter

Encouraged deep breathing, coughing

Administer medication as ordered

Maintain patent airway through suction and ventilator support•  

Management

Management

• Surgical management

Surgical Removal of the Gland or Nodule

surgery is not used as frequently as the other treatments for this disease. The biggest reason for this is that the most common forms of hyperthyroidism are a result of overproduction from the entire gland (Graves' disease)

NURSING ASSESSMENT AND INTERVENTIONS

Preoperative Nursing Care

• The nurse should conduct a thorough nursing assessment on the patient. This assessment consists of detailed data describing both physical and psychosocial aspects of the patient. Essential information should include the patient's cardiac and respiratory status, muscle strength, emotional state, elimination pattern, skin condition, weight history, and voice quality.

• Whatever the concern, the nurse should discuss these feelings with the patient preoperatively and provide appropriate interventions to help reduce stress.

• Preoperatively, the nurse should carefully assess the condition of the patient's skin, as well as the voice quality. Patients diagnosed with a hyperthyroid state may have thin, textured skin and edema of the lower extremities. Such problems may place these patients at risk for injury intraoperatively and for problems with wound healing and infection postoperatively.

• Preoperative assessment of voice quality is essential postoperatively in detecting early evidence of nerve injury, such as hoarseness.

• Preoperatively, the nurse should document any enlargement noted in the patient's neck, and/or complaints made by the patient concerning difficulty swallowing or breathing.

• Patient must be admitted few months before the procedure.• Patient should be placed in a quiet room or comfortable room.• Limit the number of visitors.

Postoperative Nursing Care• The postoperative phase begins when the patient arrives in the postanesthesia care

unit. The nurse must be alert to postanesthetic priorities, carefully monitoring the patient's cardiopulmonary status, neurological status, comfort level, surgical wound condition, and metabolic state.

• The nurse should monitor the patient's level of consciousness, vital signs, EKG, and pulse oximetry.

• The nurse should assess the patient's pain level and provide individualized management as ordered.

• The nurse should continually assess and document the patient's airway patency, oxygen saturation levels, and respiratory status.

• Bleeding should be carefully noted, both on the patient's dressing and from the surgical drains.

• The nurse should document the presence of drains, the amount and consistency of drainage, and the functioning status of the equipment.

• The nurse should monitor the patient's dressing for changes in drainage and tightness.

• The nurse should also note the presence of neck swelling (edema) around the edge of the neck dressing.

• The nurse should also observe the thyroidectomy patient for evidence of metabolic disturbances, such as thyroid storm and hypocalcemia. Thyroid storm, described above, usually occurs intraoperatively or up to 18 hours postoperatively.

• The nurse should assess the patient for any numbness or tingling around the lips or hands.

• The nurse should evaluate the patient's voice quality and swallowing postoperatively. Any change in voice or problems with aspiration should be reported to the physician and documented.

Hypothyroidism

• Hypothyroidism is the disease state in humans and in vertebrates caused by insufficient production of thyroid hormones by the thyroid gland. 

• Cretinism is a form of hypothyroidism found in infants.

Signs and symptoms

Signs and symptoms

Late

• Slow speech and a hoarse, breaking voice – deepening of the voice can also be noticed, caused by Reinke's Edema.

• Dry puffy skin, especially on the face

• Thinning of the outer third of the eyebrows (sign of Hertoghe)

• Abnormal menstrual cycles

• Low basal body temperature

 

Signs and symptoms

Pathophysiology

On average, the normal thyroid releases about 100 mcg of thyroxine (T4) daily and only small amounts of triiodothyronine (T3). Levothyroxine (either natural or synthetic T4), a prohormone, is converted to liothyronine (natural or synthetic T3), the active hormone in the peripheral tissues. Decreased production of T4 causes an increase in secretion of TSH by the pituitary. TSH causes the thyroid to release more T3 by stimulating thyroid T4-5'-deiodinase activity and stimulates hyperplasia and hypertrophy of the thyroid. Decreasing levels of T4 and increasing thyroid production of T3 leads to preservation of T3 levels and lowering of T4 levels early in the disease.

Complication

Myxedema • a rare serious complication of untreated or poorly

treated hypothyroidism

• The decreased metabolism causes the heart muscle to become flabby and the chamber size to increase

• The result is decreased cardiac output and decreased perfusionto the brain and other vital organs

Myxedema

• Untreated myxedema coma leads to shock, organdamage and death

• The mortality rate or myedema coma is extremely high and this condition is considered as life threatening emergency

Myedema photo

Diagnostic Test

• Free triiodothyronine (fT3)

• Free levothyroxine (fT4)

• Total T3

• Total T4

Diagnostic exam

• 24-Hour urine-free T3

• Antithyroid antibodies — for evidence of autoimmune diseases that may be damaging the thyroid gland

• Serum cholesterol — which may be elevated in hypothyroidism

• Prolactin — as a widely available test of pituitary function

• Testing for anemia, including ferritin

• Basal body temperature

Nursing diagnosis

• Decreased cardiac output related toaltered heartrate and rhythmas a result of decreased myocardial metabolism

• Ineffective breathing pattern related to decreased energy, obesitty, and fatigue

• Disturbed thought process related to impaired brain metabolism and edema

Management

Use of Thyroid Hormones : • T4 Only

This treatment involves supplementation of levothyroxine alone, in a synthetic form. It is currently the standard treatment in mainstream medicine.

• T4 and T3 in Combination

This treatment protocol involves administering both synthetic L-T4

and L-T3 simultaneously in combination.

• Desiccated Thyroid Extract

Desiccated thyroid extract is an animal based thyroid extract, most commonly from a porcine source. It is also a combination therapy, containing natural forms of L-T4 and L-T3

Thyroiditis

Thyroid cancer

Etiology

• High-dose irradiation to the head and neck.

• Patients with Hodgkin lymphoma treated with mantle field irradiation have an increased risk of developing thyroid cancer, although hypothyroidism is more likely

Risk Factors

• Exposure to high levels of radiation. Examples of high levels of radiation include those that come from radiation treatment to the head and neck and from fallout from nuclear accidents or weapons testing.

• Personal or family history of goiter. Goiter is a noncancerous enlargement of the thyroid.

• Certain inherited genetic syndromes. Genetic syndromes that increase the risk of thyroid cancer include familial medullary thyroid cancer, multiple endocrine neoplasia and familial adenomatous polyposis

Clinical manifestation

• first sign is an enlarged lymph node

• nodule in the thyroid region of the neck

• pain in the anterior region of the neck and changes in voice

Pathophysiology

• The pathophysiology of thyroid cancer is not completely defined. Alterations of several molecular factors have been associated with thyroid malignancy. These include proliferative factors such as growth hormones and oncogenes, and apoptotic and cell-cycle inhibitory factors such as tumor suppressors.

• Physiological behavior depends upon tumor type. Thyroid cancer is thought to reflect a continuum from well differentiated to anaplastic, characterized by early and late genetic events. Up to one third of patients with differentiated thyroid cancer experience tumour de-differentiation, accompanied by increased tumor grade and loss of thyroid-specific functions such as iodine accumulation

• Papillary carcinoma tends to spread to local lymph nodes, whereas follicular and Hurtle cells more often spread haematogenously. Anaplastic thyroid cancer is a rare, aggressive, undifferentiated carcinoma with a high propensity for local invasion and metastatic spread. Nodal spread is common with thyroid lymphomas.

Diagnostic exam• Physical exam—The doctor will feel the neck, thyroid, voice box, and lymph nodes in

the neck for unusual growths (nodules) or swelling.

• Blood tests—The doctor may test for abnormal levels (too low or too high) of thyroid-stimulating hormone (TSH) in the blood. TSH is made by the pituitary gland in the brain. It stimulates the release of thyroid hormone. TSH also controls how fast thyroid follicular cells grow.

If medullary thyroid cancer is suspected, the doctor may check for abnormally high levels of calcium in the blood. The doctor also may order blood tests to detect an altered RET gene or to look for a high level of calcitonin.

• Ultrasonography—The ultrasound device uses sound waves that people cannot hear. The waves bounce off the thyroid, and a computer uses the echoes to create a picture called a sonogram. From the picture, the doctor can see how many nodules are present, how big they are, and whether they are solid or filled with fluid.

• Radionuclide scanning—The doctor may order a nuclear medicine scan that uses a very small amount of radioactive material to make thyroid nodules show up on a picture. Nodules that absorb less radioactive material than the surrounding thyroid tissue are called cold nodules. Cold nodules may be benign or malignant. Hot nodules take up more radioactive material than surrounding thyroid tissue and are usually benign.

• Biopsy—The removal of tissue to look for cancer cells is called a biopsy. A biopsy can show cancer, tissue changes that may lead to cancer, and other conditions. A biopsy is the only sure way to know whether a nodule is cancerous.

Nursing diagnosis

• Ineffective airway clearance related to swelling and obstruction.

• Impaired swallowing related to presence of tumor.

• Imbalanced nutrition: Less than body requirements related to dysphagia

• Impaired verbal communication related to presence of tumor.

Nursing intervention• Observe the patient’s neck, noting any mass or enlargement.

• Palpate the thyroid gland for size, shape, configuration, consistency, tenderness, and presence of any nodules.

• Describe the number of nodules present and whether the nodule is smooth or irregular, soft or hard, or fixed to underlying tissue.

• Assess the patient’s ability to cope with the sudden illness and the diagnosis of cancer.

• Determine what a diagnosis of cancer means to the patient. Consider the type of cancer (and the speed of cancer growth) when assessing the patient’s and family’s response to the disease.

• Maintain aspiration precautions.

• Provide supportive care, such as nutritional supplements and analgesic administration for pain as needed.

• Encourage the patient to voice his concerns, and offer reassurance.

Management

Pharmacological management

• Armour thyroid (thyroid desiccated)• Adriamycin (doxorubicin)• Nexavar (sorafenib)• Thyrogen (thyrotropin alpa)• Iodotope (sodium iodide-i-131)

Pre operative

• Explain to the patient that thyroidectomy will remove diseased thyroid tissue or, if necessary, the entire gland. Tell him that he’ll have an incision in his neck; that he’ll have a dressing, and possibly, a drain in place after surgery; and that he may experience some hoarseness and a sore throat from intubation and anesthesia. Reassure him that he’ll receive analgesics to relieve his discomfort.

• If thyroidectomy is being performed to treat hyperthyroidism, ensure that the patient has followed his preoperative drug regimen, which will render the gland euthyroid to prevent thyroid storm during surgery. He probably will have received either propylthiouracil or methimazole, usually starting 4 to 6 weeks before surgery. Expect him to be receiving iodine as well for 10 to 14 days before surgery to reduce the gland’s vascularity and thus prevent excess bleeding. He may also be receiving propranolol to block adrenergic effects. Notify the physician immediately if the patient has failed to follow his medication regimen.

Surgical management

Thyroidectomy

Pre operative

• Collect samples for serum thyroid hormone determinations to check for euthyroidism. If necessary, arrange for an electrocardiogram to evaluate cardiac status.

• Ensure that the patient or a legally authorized representative has signed an informed consent form.

Post operative• To prevent complications after the thyroidectomy, careful monitoring for airway

obstruction and stridor is essential.

• A tracheostomy tray should be kept near the patient at all times during the immediate recovery period

• monitor for signs of thyrotoxicosis (tachycardia, diaphoresis, increased blood pressure, anxiety) and hypocalcemia (tingling of the fingers and toes, carpopedal spasms, and convulsions).

• The surgical dressing and incision also need to be assessed for excessive drainage or bleeding during the postoperative period.

• Monitor the patient’s ability to speak with each measurement of vital signs. • Assess the patient’s voice tone and quality, and compare it with the

preoperative voice

Post operative • Keep the patient in high Fowler’s position to promote venous return from the head

and neck and to decrease oozing into the incision. Check for laryngeal nerve damage by asking the patient to speak as soon as he awakens from anesthesia.

• Watch for signs of respiratory distress. Tracheal collapse, tracheal mucus

• accumulation, laryngeal edema, and vocal cord paralysis can all cause respiratory obstruction, with sudden stridor and restlessness. Keep a tracheotomy tray at the patient’s bedside for 24 hours after surgery, and be prepared to assist with emergency tracheotomy, if necessary.

• Assess for signs of hemorrhage, which may cause shock, tracheal compression, and respiratory distress. Check the patient’s dressing and palpate the back of his neck, where drainage tends to flow. Expect about 50 ml of drainage in the first 24 hours; if you find no drainage, check for drain kinking or the need to reestablish suction. Expect only scant drainage after 24 hours.

Post operative• Assess for hypocalcemia, which may occur when the parathyroid glands are

damaged. Test for Chvostek’s and Trousseau’s signs, indicators of neuromuscular irritability from hypocalcemia. Keep calcium gluconate available for emergency I.V. administration.

• Be alert for signs of thyroid storm, a rare but serious complication.

• As ordered, administer a mild analgesic to relieve a sore neck or throat. Reassure the patient that his discomfort should resolve within a few days.

• If the patient doesn’t have a drain in place, prepare him for discharge the day following surgery as indicated. However, if a drain is in place, the physician will usually remove it, along with half of the surgical clips, on the second day after surgery; the remaining clips, the following day, before discharge.

 

 

Submitted by:

Adarne , Allana Franchesta V.

Bay , Erwin

De guzman , Kim Eduard

Flores, Cathleen

Galicia, Jomar

Godinez, Margaret Ludean

Laurel, Sarah Jane

Magpantay, Jessa Rose

Mejares, Veronica Jane

Ranin, Rosalyn

San Mateo,Marlon

Talaga, Kiefer