Ch_50_Hypothyroid

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Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

Focus on Hypothyroidism

(Relates to Chapter 50,

Nursing Management: Endocrine Problems,in the textbook)




Hypothyroidism

One of the most common medical

disorders in the United States

Affects 10% of women and 3% of men over 65 years of age




Etiology and Pathophysiology

Results from insufficient circulating

thyroid hormone

Result of a variety of abnormalities




Etiology and Pathophysiology (Contd)

Can be primary or secondary Primary

Related to destruction of thyroid tissue ordefective hormone synthesis

Secondary Related to pituitary disease with TSH

secretion or hypothalamic dysfunction





May be transient, related to

thyroiditis, or from discontinuing

thyroid hormone therapy





Iodine deficiency Most common cause worldwide and

most prevalent in iodine-deficientareas

In places where iodine intake is

adequate, the primary cause is

atrophy of the gland





Atrophy is the end result of

Hashimotos thyroiditis and Graves

disease These autoimmune diseases destroy

the thyroid gland





May also develop because of

treatment for hyperthyroidism

Amiodarone and lithium canproduce hypothyroidism





Cretinism is caused by thyroid

hormone deficiencies during fetal or

neonatal life All infants are screened at birth for

thyroid function




Clinical Manifestations

Vary depending on Severity

Duration Age of onset

Systemic effects characterized by

slowing of body processes




Clinical Manifestations (Contd)

Ranges from no symptoms to classic

symptoms, and physical changes

easily detected on examination





Onset of symptoms may occur over

months to years

Unless occurs after thyroidectomy,thyroid ablation, treatment with

antithyroid drugs





Cardiovascular system Cardiac output

Cardiac contractility





Respiratory system Low exercise tolerance

Shortness of breath on exertion





Neurologic system Fatigued and lethargic

Personality and mood changes Impaired memory, slowed speech,

decreased initiative, and somnolence





Gastrointestinal system Motility

Achlorhydria common Constipation





Integumentary system Cold intolerance

Hair loss Dry/coarse skin

Brittle nails

Hoarseness

Muscle weakness and swelling Weight gain





Integumentary system (contd) Muscle weakness and swelling

Weight gain Reproductive system

Menorrhagia





Those with severe, longstanding

hypothyroidism may display

myxedema Accumulation of hydrophilic

mucopolysaccharides in the dermisand other tissues

Causes puffiness, periorbital edema,

masklike effect




Common Features of Myxedema

Fig. 50-9




Complications

Mental sluggishness

Drowsiness

Lethargy progressing gradually orsuddenly to impairment of

consciousness or coma




Complications (Contd)

Myxedema coma Medical emergency

Can be precipitated by infection,drugs, cold, or trauma

Characterized by subnormal

temperature, hypotension, and

hypoventilation




Complications (Contd)

Myxedema coma (contd)Vital functions must be supported

IVthyroid hormone replacementadministered




Diagnostic Studies

History and physical examination

Laboratory tests

Serum TSH Determines cause of hypothyroidism

Free T4 Serum T3

Serum T4




Diagnostic Studies (Contd)

Laboratory tests (contd)Other abnormal findings are

cholesterol and triglycerides,anemia, and creatine kinase




Diagnostic Studies (Contd)

TRH stimulation test in TSH after TRH injection suggests

hypothalamic dysfunction No change after TRH injection

suggests anterior pituitary dysfunction




Collaborative Care

Restoration of euthyroid state as

safely and rapidly as possible

Low-calorie diet




Collaborative Care (Contd)

Drug therapy Levothyroxine (Synthroid)

Must take regularly Monitor for angina and cardiac

dysrhythmias

Monitor thyroid hormone levels and

adjust (as needed) Patient/family teaching




Nursing Management

Nursing Assessment

Health history Weight gain Mental changes Fatigue Slowed/slurred speech Cold intolerance Skin changes




Nursing Management

Nursing Assessment (Contd)

Health history (contd) Constipation

Dyspnea Recent introduction of iodine

medications




Nursing Management

Nursing Assessment (Contd)

Physical examination Bradycardia

Distended abdomen Dry, thick, cold skin

Thick, brittle nails

Paresthesias

Muscular aches and pains




Nursing Management

Nursing Diagnoses

Imbalanced nutrition: More than

body requirements

Activity intolerance

Disturbed thought processes




Nursing Management

Pl anning

Experience relief of symptoms

Maintain a euthyroid state

Maintain a positive self-image

Comply with lifelong thyroid

replacement therapy




Nursing Management

Nursing Impl ementation

Health Promotion No consensus for thyroid function

screening

High-risk populations screened forsubclinical thyroid disease Family history of thyroid disease, history

of neck radiation, women over 50 years of age, and postpartum




Nursing Management

Nursing Impl ementation (Contd)

Acute Intervention Most individuals do not require acute

nursing care Managed on outpatient basis




Nursing Management


Acute Intervention (contd) Individuals with myxedema coma

require acute nursing care Mechanical respiratory support Cardiac monitoring IV thyroid hormone replacement

If hyponatremic, hypertonic saline may beadministered Monitor core temperature




Nursing Management


Acute Intervention (contd) Individuals with myxedema coma

(contd) Vitals Weight I&O

Visible edema

Cardiovascular response to hormone Energy level Mental alertness




Nursing Management


Ambulatory and Home Care Explain nature of thyroid hormone

deficiency and self-care practices to

prevent complications Patient and family must understand

replacement therapy and that it is lifelong




Nursing Management


Ambulatory and Home Care (contd) Teach measures to prevent skin

breakdown

Emphasize need for warmenvironment

Caution patient to avoid sedatives or

use lowest dose possible




Nursing Management


Ambulatory and Home Care (contd) Discuss measures to minimize

constipation Avoid enemas because of vagal

stimulation in cardiac patient




Nursing Management


Ambulatory and Home Care (contd) Teach patient to notify physician

immediately if signs of overdose

appear Orthopnea, dyspnea, rapid pulse,

palpitations, nervousness, insomnia




Nursing Management


Ambulatory and Home Care (contd) Patient with diabetes should test

capillary blood glucose at least daily as

return to euthyroid state frequently

insulin requirements




Nursing Management


Ambulatory and Home Care (contd) Thyroid preparations potentiate the

effects of some common drug groups Teach patient toxic signs and symptoms

of these drugs Anticoagulants Digitalis compounds




Nursing Management


Ambulatory and Home Care (contd) Provide handouts for patients and

family members with verbal

instructions




Nursing Management

Ev al uation

Expected outcomes Have relief from symptoms

Maintain euthyroid state as evidenced

by normal thyroid hormone and TSHlevels

Adhere to lifelong therapy




Case Study




Case Study

38-year-old female enters a

community outpatient clinic

She is complaining of overwhelming

fatigue that is not relieved by rest




Case Study (Contd)

She is attending graduate school

and is very sedentary

She is so exhausted she has

difficulty waking for classes and

trouble concentrating whenstudying




Case Study (Contd)

Her face is puffy and her skin is dry

and pale

She is dressed inappropriately for

warm weather




Case Study (Contd)

She also complains of generalized

body aches and pains with frequent

muscle cramps and constipation




Case Study (Contd)

Vital signs BP 142/84 mm Hg

Heart rate 52 beats/min

Respiratory rate 12 breaths/min

Temperature 96.8° F




Discussion Questions

1. What are some possible causes of

her symptoms?




Discussion Questions (Contd)

2. No obvious irregularities are found

in her cardiopulmonary

assessment. Her TSH levels comeback 20.9 IU/L. She is diagnosed

with hypothyroidism. What can

you tell her about the treatmentand follow-up?



Discussion Questions (Contd)

3.What teaching will you need to do

with her before she leaves the

clinic?

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