Hyposecretion of thyroid hormones T3 & T4

Characterized by decreased rate of body metabolism

• Lethargy & Fatigue, weakness, muscle aches, paresthesias (tingling)
• Intolerance to cold
• Weight gain
• Dry skin & hair/loss of body hair
• Bradycardia
• Constipation
• Generalized puffiness/edema around eyes & face (myxedema)
• Forgetfulness and loss of memory
• Menstrual disturbances
• Cardiac enlargement/tendency to develop CHF
• Goiter may or may not be present

• VS, including HR & Rhythm
• Administer thyroid replacement (levothyroxine sodium-Synthroid- most common)
• Patient teaching on S/S of hypo & hyper regarding over or underreplacement of the hormone therapy
• Diet teaching for low calorie, cholesterol, & saturated fat intake, fiber/increased fluid if constipated
• Provide warm environment
• Avoid sedatives/opiod analgesics r/t an increased sensitivity to these types of medications
• Monitor for OD of thyroid medications characterized by manifestations of HYPERthyroidism and to report these findings IMMEDIATELY

Rare but serious disorder resulting from persistently low thyroid producion

Can be precipitated by acute illness, rapid withdrawal of thyroid meds, anesthesia/surgery, hypothermia, or use of sedatives and opiod analgesics

• Hypotension
• Bradycardia
• Hypothermia
• Hyponatremia
• Hypoglycemia
• Generlized edema
• Respiratory failure
• Coma

• Maintain patent airway
• Place on aspiration precautions
• Administer IV fluids (normal or hypertonic saline), thyroid meds IV, glucose IV, & corticosteroids as prescribed
• Assess temperature hourly
• Monitor BP frequently
• Keep client warm
• Monitor for mental status changes
• Monitor electrolyte & glucose levels

Common Medications

Administered for Hypothyroidism

• Levothyroxine sodium (Synthroid, Levothroid, Levoxyl, Thyro-Tabs, Unithroid)
• Liothyronine sodium (Cytomel, Triostat)
• Thyroid (Armour Thyroid, Bio-Throid, Nature-Thyroid, Thyroid USP, Westhroid)

Control the metabolic rate of tissues and accelerate heat production and oxygen consumption

Used to replace deficit in conditions such as hypothyroidism and myxedema

Thyroid Hormones

Interactions

ENHANCE action of: oral anticoagulants, sympathomimetics, and antidepressants

DECREASE action of: insulin, oral hypoglycemics, and digitalis preparations

DECREASED ACTION OF THYROID MEDS if taken with: phenytoin (Dilantin) and carbamazepine (Tegretol)

Thyroid Medication

Side Effects

• Nausea/decreased appetite
• Abdminal cramps/diarrhea
• Weight loss
• Nervousness/tremors
• Insomnia
• Sweating/Heat intolerance
• Tachycardia, dysrhythmias, palpitations, chest pain
• HTN
• Headache

Levothyroxine sodium

(Synthroid)

Also includes previous general info on thyroid medications

  Adverse Effects: Thyroid storm, cardiac arrest, menstrual irregularities, fever, alopecia

  Contraindications: Adrenal insufficiency, recent MI, thyrotoxicosis, hypersensitivity to beef, alcohol intolerance

  Precautions: Pregnancy A, breastfeeding, geriatric, angina pectoris, HTN, ischemia, cardiac disease, diabetes

  Interactions: Cholestyramine, colestipol, ferrous sulfate decrease absorption of levothyroxine, Estrogen decreases thyroid hormone effect, SSRI decrease levothyroxine effects

  Herbs: Agar, bugleweed, carnitine, kelpware, soy, spirulina decrease thyroid hormone effect

  Labs: Increased-CPK, LDH, AST, PBI, Blood Glucose; Decreased-thyroid function tests

Liothyronine sodium

(Cytomel)

Also includes previous general info on thyroid medications

  Adverse Reactions: Thyroid storm, cardiac arrest

  Contraindications: Adrenal Insufficiency, MI, thyrotoxicosis

Precautions, Interactions, Herb, & Lab same as levothyroxine sodium

Thyroid Hormones

Interventions

• Assess history of current medications
• Monitor VS & weight
• Monitor T₃, T₄, and TSH levels
• Patient teaching to take med at same time every morning on empty stomach & to monitor pulse rate
• Avoid foods such as strawberries, peaches, pears, cabbage, turnips, spinach, kale, brussels sprouts, cauliflower, radishes, and peas
• Avoid OTC meds
• Wear Medic Alert bracelet
• REPORT SIGNS OF TOXICITY IMMEDIATELY

Hypothyroidism

Lab Values

• Blood levels of T3 & T4: Decreased
• Blood levels of TSH: Increased-primary hypothyroidism, Decreased-secondary hypothyroidism but may also indicate hyperthyroidism

Hypothyroidism

Diagnostic Tests

• Radioactive Iodine Isotope Uptake: Measures absorption of iodine by thyroid to determine gland function; PO or IV; Scan of gland performed within 2-4hrs and then in 24hrs; > indicates hyperthyroidism, < indicates hypothyroidism
• Contraindicated in Pregnancy and if allergic to iodine
• NPO +/- 8hrs prior to procedure
• Toileting precautions for 24hrs/hand washing/flush twice; radioactive material secreted in urine

Results from hypersecretion of thyroid hormones T3 & T4

Characterized by increased rate of body metabolism

Common cause is Grave's disease aka toxic diffuse goiter

Clinical manifestations are referred to as thyrotoxicosis

Hyperthyroidism caused by Graves disease

Assessment

• Enlarged thyroid gland (goiter)
• Palpitations, cardiac dysrhythmias, tachycardia, atrial fibrillation
• Protruding eyeballs (exophthalmos)
• HTN
• Heat intolerance
• Diaphoresis
• Weight loss
• Diarrhea
• Smooth, soft skin & hair
• Nervousness and fine tremors of the hands
• Personality changes such as irritability, agitation, and mood swings

Hyperthyroidism

Interventions

• Provide adequate rest
• Administer sedatives as prescribed
• Provide cool/quiet environment
• Obtain daily weight
• Provide high calorie diet
• Avoid administration of stimulants
• Administer antithyroid meds such as propylthiouracil(PTU) as ordered
• Administer Propanalol (Inderal) for tachycardia as ordered
• Prepare client for radioactive iodine therapy as ordered
• Prepare client for thyroidectomy if ordered

Hyperthyroidism

Thyroid Storm

Acute life threatening condition occuring in clients with uncontrollable hyperthyroidism

Can be caused manipulation of thyroid gland during sx and the release of thyroid hormone into the blood stream; can also occur from severe infection and stress

Thyroid Storm

Assessment

• Elevated temperature
• Tachycardia
• Systolic HTN
• N/V & diarrhea
• Agitation, tremors, anxiety, irritability, restless, confusion, & seizures which all increase as condition progresses
• Delirium and coma

Thyroid Storm

Interventions

• Maintain patent airway/adequate ventilation
• Administer antithyroid meds/sodium iodine solution, propanolol & glucocorticoids as prescribed
• Monitor VS and continually monitor for cardiac dysrhythmias
• Administer nonsaliclate antipyretics as prescribed (salicylates increase free thyroid levels)
• Use cooling blanket to decrease temperature as prescribed

Hyperthyroidism

Thyroidectomy

Removal of thyroid gland

Performed when persistent hyperthyroidism exists

Thyroidectomy

Preoperative Interventions

• Obtain VS/weight
• Assess electrolyte levels/hyperglycemia
• Teach coughing & deep breathing eercises/how to support neck in postoperative period when moving/coughing
• Administer antithyroid meds/sodium iodine solution, propanolol, and glycocorticoids as prescribed to prevent thyroid storm

Thyroidectomy

Postoperative Interventions

• Monitor for respiratory distress
• Maintain in Semi Fowlers position & monitor sx site for edema and bleeding (check dressing anteriorly and at back of neck)
• Have trach set, O₂, and suction at bedside
• Limit client talking, assess level of hoarsness
• Monitor for laryngeal nerve damage AEB respiratory obstruction, dysphonia, high pitched voice, stridor, dysphagia, and restlessness
• Monitor for signs of hypocalcemia/tetany-can be caused by trauma to parathyroid gland
• Prepare to administer calcium gluconate as prescribed for tetany
• Monitor for thyroid storm

Hyperthyroidism

 Antithyroid Medications

Inhibit the synthesis of thyroid hormone

Used for hyperthyroidism or Graves disease

Antithyroid Medications

Side Effects

• N/V, diarrhea
• Drowsiness, HA, fever
• Hypersensitivity with rash
• Agranulocytosis w/leukopenia and thrombocytopenia
• Alopecia & hyperpigmentation
• Toxicity: Hypothyroidism
• Iodism: Characterized by vomitting, abd pain, metallic or brassy taste in mouth, rash, sore gums & salivery glands

Antithyroid Medications

Interventions

• Monitor VS, weight, pulse rate
• Monitor T3/T4 & TSH hormone levels
• Patient teaching to take with meals to avoid GI upset
• Know side effects and when to report to HCP and also know signs of hypothyroidism
• Instruct on importance of compliance with meds and abrupt discontinuation can result in thyroid storm
• Instruct to monitor for signs of thyroid storm-frever, flushed skin, confusion, behavioral changes, tachycardia, dysrhythmias, & signs of heart failure
• Monitor for signs of iodism and consult HCP before consuming anything with iodine
• Teach to avoid acetylsalicylic acid (aspirin) and meds containing iodine
• Report fever or sore throat if taking PTU-Propylthiouracil

Hyperthyroidism

Common Antithyroid Meds

• Methimazole (Tapazole)
• Propylthiouracil (PTU)
• Strong iodine solution (Lugols Solution)
• Potassium iodide
• Iodide I 131 (Iodotope)

Hyperthyroidism

Radioactive Iodine

Administered to destroy Thyroid Cells

Condition caused by hyposecretion of parathyroid hormone by parathyroid gland; can occur following throidectomy

ASSESSMENT: Hypocalcemia, hyperphosphatemia, numbness, tingling in face, Cramps in muscles, abd, or extremities, +trousseau's or chvosteks sign, overt tetany (bronchospasm, laryngospasm, carpopedal spasm, dysphagia, photophobia, cardiac dysrhythmias, seizures), hypotention, anxiety, irritability, depression

INTERVENTIONS: Monitor VS, signs of hypocalcemia/tetany, initiate seizure precaution, place trach, O₂, suction @ bedside, Prepare to admin Ca⁺⁺ gluconate IV for hypocalcemia, Provide high calcium, low phosphorous diet, calcium supplements & Vit D as prescribed, phosphate binders to promote excretion of phosphate through GI tract, wear medic alert bracelet

Hypoparathyroidism

Medication Treatment

Calcium and Vitamin D Supplements r/t the low serum calcium levels

Hypoparathyroidism

Ca⁺⁺ & Vit D Supplements

• Calcium acetate (PhosLo)
• Calcium carbonate(Rolaids, Tums, others)
• Calcium chloride
• Calcium citrate (Citracal)
• Calcium glubionate (Calcionate, calciquid)
• Calcium gluconate
• Calcium lactate (Cal-lac)
• Tribasic calcium phosphate (Posture)
•              VITAMIN D
• Cholecalciferol (Vitamin D₃)
• Ergocalciferol (Vitamin D₂)

Hyperparathyroidism

Assessment

Stones & Bones, Abd Groans with Psychic Overtones

(Renal Calculi, Constipation, Depression)

• Hypercalemia/Hypophosphatemia
• Fatigue/muscle weakness, skeletal pain & tenderness
• Bone deformities resulting in pathological fractures
• Anorexia, N/V, epigastric pain, weight loss, constipation, HTN, cardiac dysrhythmias
• Renal Stones

Hyperparathyroidism

Interventions

• Monitor VS (especially BP), cardiac dysrhythmias, I&O, S/S of renal stones
• Monitor for skeletal pain/move client slowly & carefully
• Encourage fluid intake
• Administer furosemide to lower calcium levels, normal saline IV to maintain hydration, phosphates to interfere with calcium resorption, calcitonin to decrease skeletal calcium release & increase renal excretion of calcium (all as prescribed)
• Monitor calcium & phosphorus levels
• Prepare client for parathyroidectomy as ordered
• Notify HCP IMMEDIATELY if precipitous drop in calcium level occurs & assess for s/s of hypocalcemia (tingling/numbness in face & extremities

Parathyroidectomy

Preoperative Interventions

• Monitor electrolytes, calcium, phosphate, & magnesium levels
• Ensure calcium levels are decreased to near normal values
• Inform client that talking may be painful for first day or two after surgery
• Pt teaching regarding moving & positioning to avoid incisional pain

Parathyroidectomy

Postoperative Interventions

• Monitor for respiratory distress, airway equipment @ bedside
• Monitor VS
• Place client in semi fowlers position
• Assess neck dressing for bleeding
• Monitor for hypocalcemic crisis AEB tingling/twitching in extremities and face
• Assess for +trousseau's and chvosteks signs
• Monitor for changes in voice pattern & hoarsness/ laryngeal nerve damage
• Instruct client in administration of calcium & Vit D as prescribed

Hyperparathyroidism

Medications

Hyperparathryroidism results in high serum calcium levels and bone deminieralization

Medication is used to lower serum calcium levels

Hyperparathyroidism

Common Medications

•   USED TO TREAT HYPERCALCEMIA
• Cinaclcet hydrochloride (Sensipar)
• Doxercalciferol (Hectorol)
• Gallium nitrate (Ganite)
• Paricalcitol (Zemplar)
•   BIPHOSPHONATES & CALCIUM REGULATORS
• Alendronate sodium (Fosamax)
• Calcitonin salmon (Calcimar, Cibacalcin, Fortical)
• Etidronate disodium (Didronel)
• Ibandronate (Boniva)
• Pamidronate disodium (Aredia)
• Risedronate sodium (Actonel)
• Tiludronate disodium (Skelid)
• Zoledronate (Reclast)
• Zoledronate (Zometa)

Hyperparathyroidism

Medication Interventions

• Monitor electrolyte & calcium levels
• Assess for renal calculi
• Instruct client of S/S of hyper & hypocalcemia
• Instruct client to check OTC med labels for possibility of calcium content
• Instruct client using antihypercalcemic agents to avoid foods rich in calcium (green leafy vegetables, dairy products, shellfish, & soy)

Hypercalcemia Medication

Ibandronate (Boniva)

• Bone resorption inhibitor, electrolyte modifier
•   ADVERSE EFFECTS
• Fever, insomnia, dizziness, HA, HTN, Ocular pain/inflammation, uveitis, constipation, N/V, diarrhea, dyspepsia, rash, hypomagnesemia, hypophosphatemia, hypocalcemia, bone pain, myalgia
•   CONTRAINDICATIONS
• Achalasia, esophaeal stricture, hypocalcemia, intraarterial administration, renal failure, Vit D deficiency, hypersensitivity to bisphosphonates
•   PRECAUTIONS
• Pregnancy C, breastfeeding, children, geriatric, anemia, chemo, coagulopathy, dental disease, diabetes, dysphagia, GI/renal disease, GERD, HTN, infection, multiple myeloma, phosphate hypersensitivity
•  INTERACTIONS
• Decreased medication effect with calcium, vit D
• Possible increased neurotoxicity med effect with cyclosporine, tacrolimus
• Digoxin: hypomagnesemia, hypokalemia
• Possible increased neurotoxicity with aminoglycosides, NSAIDs, radiopaque contrast
• Increased hypocalcemia with loop diuretics