Thyroid And Parathyroid

Minor Major Injury Illness

Nurse Treatment Service

Objectives

• Introduction.

• Describe the definition, etiology, clinical manifestations , management, and nursing care for client with:

Hyperthyroidism.Hypothyroidism.Hyperparathyroidism.Hypoparathyroidism.

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Hyperthyroidism• Introduction:

• Thyroid hormone thyroxin (T4) and triode thyroxine (T3) more active form, regulate energy metabolism, and growth and development.

• Hyperthyroidism

• It is continuous, increased synthesis and discharge 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.

2. Toxic multinodular goiter (Plummer's disease) common in iodine deficient area.

3. Toxic adenoma

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Hyperthyroidism- Aetiology Cont. 4. Thyroiditis: Is an inflammatory process in the

thyroid by bacterial or fungal infection,

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

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 common 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 effort.

Musculoskeletal:• Fatigue, muscle weakness, dependent oedemas,

osteoporosis.

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Hyperthyroidism- Clinical Manifestation

Gastrointestinal:

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

Integumentary:

• Warm, smooth, moist skin; thin fragile 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; change of mood, restlessness, personality changes, depression, fatigue, apathy, lack of ability to concentrate, stupor, coma.

Reproductive:• Menstrual irregularities; amenorrhoea; libido

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

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Hyperthyroidism- management• Three classes of medications:

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

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

• It is administered orally in one dose, 80-90 g.

• 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 Applying artificial tears to relieve and moisten

conjunctival membrane. Using light bed covering and change it. Salt restriction and elevate client’s head to

reduce pre- orbital oedema. 10

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. 12

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, therapy for hyperthyroidism, thyrotoxic drugs, maldevelopment, radiation for head. 13

Hypothyroidism-Aetiology Cont. Loss of trophic stimulation

Pituitary or hypothalamus dysfunction.

• Various 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).

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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.15

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 slow movement.17

Hypothyroidism- Clinical Manifestations• Integumentary: dry, cold skin; fragile nails;

vulgar hair, poor turgor of mucosa; oedema; puffy face, decreased sweating; pallor.

• Nervous: Apathy; exhaustion; 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.

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Hypothyroidism- Management

• Low-caloric diet to promote weight gain.

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

• 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. 20

Hypothyroidism- Nursing Management

• Promote activity to the level of client tolerance (monitor cardiovascular response, BP, pulse, respiration before, during, after activities.

• Promote normal bowel elimination.

• Treat hypothermia.

• Facilitates intake of a nutritional diet 21

HyperparathyroidismDefinition

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

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

excretion in kidney.Regulates calcium absorption in intestine 22

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 encourage 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.25

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 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.30

Hyperparathyroidism- Ng. Management

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

• Increased ambulation of client.

• Maintain fluid intake at prescribed level.

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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 itchiness 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)

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Hypoparathyroidism Clinical Manifestation

Neuromuscular manifestation• Tetany with positive Chrostek’s sign , spasms of

wrist, fingers, forearm, feet and toes.• Fatigue, weakness, difficulty in walking.• Convulsions (spasm of total body).• Laryngeal stridor and dyspnea.• Headache, painful oedema, gait change.

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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.

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Hypoparathyroidism Clinical Manifestation

Eye manifestation• Eye changes, cataracts, and loss of sight.

Dental manifestation• Enamel 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.

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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- 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 make worse symptoms of hypocalcaemia.

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Hypoparathyroidism- Ng. Management

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

Signs of hypercalcemia: thirst, polyuria, exhaustion, 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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