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Signs and Symptoms
- HEAT INTOLERANCE
- tachycardia
- full bounding pulse
- tachydysthythmias (A-fib)
- > stroke volume
- > CO and blood flow
- Dyspnea
- Tachypnea
- > appetite and thirst
- Weight loss
- Hyperactive bowel sounds
- > peristaltic activity (N/V/D)
- Splenomegaly
- Hepatomegaly
- Muscle weakness & fatigue
- Muscle wasting
- dependent edema
- osteoporosis
- Difficulty concentrating
- Tremors
- Nervousness
- Restlessness
- Emotional lability
- Insomnia
- Depression/Fatigue
- Hyperreflexia
- Stupor
- Profuse perspiration
- >basal temperature
- Rapid speech
- Goiter
- Exopthalamus
- Menstrual irregularities/ammenorrhea
- <libido
- gynecomastia in men
- impotence
- < fertility
- Hair loss (patchy)
- fine-silky hair
- warm smooth moist skin
- thin brittle nails
- clubbing of fingers or thyroid acropachy
- palmer erythema
- diaphoresis
- bitilago
- pretibial myxedema
- elelid retraction
- lid Lag (stare)
- >tearing
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Complications
- Grave's Disease
- Thyrotoxicosis
- Thyrotoxic Crisis (Thyroid Storm)
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Grave's Disease
- Autoimmune disorder
- Diffuse thyroid enlargement
- Excessive TSH secretion
- 75% of cases of hyperthyroidism
- Most common in Women 20-40 yo
- Too much T3 & T4 production
- Remission & Exacerbation with or without tx
- May progress to destruction of Thyroid tissue i.e. causing HYPOthyroidism
- Both Hyperthyroidism & Thyrotoxicosis found
- S/S
Directly related to hyperthyroidism - Goiter possible
- Exophthalmus
- Bruit possible
- A-Fib in older adults
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Thyrotoxicosis
- Physiological effects or clinical syndrome of hyper metabolism resulting fron excess circulating levels of T3, T4 or both
- Causes: Stress, Infection, Surgery or trauma, MI, CVA, texemia in preg., DKA
- Complication: Thyrotoxic Crisis (Thyroid Storm)
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Thyrotoxic Crisis/Thyroid Storm
Signs/Symptoms
- SEVERE tachycardia (230-280)
- SEVERE Hyperthermia (up to 105.3)Restlessness
- Heart failure
- Shock
- Agitation
- Seizures
- Abd pain with N/V
- Dehydration
- Delirium
- Coma
- Severy HTN
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Thyrotoxic Storm
Treatment
Centers on reducing circulating thyroid hormone levels and reducing clinical minifestations.
We want to block adverse effexcts and stop oversecretion.
Antithyroid drugs (PTU) - Beta blocker (Inderol, Tenormin)
- Iodine
- Radio active Iodine
- Surgical therapy
- Manage respiratory distress
- Fever reduction
- Fluid replacement
- Eliminate stressors
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Drug Therapy for Hyperthyroidism
- Antithyroid drugs
- Beta blockers
- Iodine
- Radioactive Iodine (RAI)
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First Line Antithyroid Drugs
- Propylrthioeruacil (PTU)
- Methimazole (Tapazole)
- Must continue for 6-16 months
- NOT curative
- High rate of NONcompliance
- High rate of reoccurrence when drugs d/c
-
Propylthiouracil
(PTU)
- Lowers hormone levels quickly
- Must be taken TID
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Methimazole
(Tapazole)
Administered qd
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Indications for Antithyroid Drugs
- Grave's in young pt
- Hyperthyroidism during pregnancy
- May be admin to achieve euthroid state prior to surgery or radiation therapy
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Beta-Adrenergic Blockers
- Propranolol (Inderal)
- Atenolol (Tenormin)
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Propranolol
(Inderal)
- Rapidly provides symptomatic relief
- Usually admin with other antithyroid meds
- SE: arrhythmias; bradycardia; chf; pulmonary edema; fatigue; weakness; erictile dysfunction
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Atenolol
(Tenormin)
- Preferred for pt with asthma or heart disease
- SE: Bradycardia; chf; pulmonary edema' fatigue; weakness; erectile dysfunction
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Iodine Therapy
(SSKI, Lugols)
- Decreases vascularity of thyroid gland
- Used with other antithyroid drugs to prep for thyroidectomy or tx of thyrotoxic crisis
- Lg dose rapidly inhibits synthesis of T3 & T4
- blocks te release of these hormones into circulation
- Max effects seen within 1-2 wks
- NOT effective in controlling hyperthyroidism long term
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Nursing Interventions for Iodine Therapy
- Sip through straw
- Mix with juice or water d/t GI irritatation
- Assess for Toxicity: swelling of mucus membranes & buccal mucosa; excessive salivation; N/V; Skin reactions
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Radioactive Iodine Therapy
(RAI)
- Tx choice for NON pregnant adults
- Pt is NOT radioactive
- Destroys thyroid tissue resulting in limited thyroid hormone secretion
- Delayed response: may not see results for 2-3 months
- Treat with antithyroid drgs & beta blocker until effects become apparent (3 mo)
- Necessitates need for life long thyroid hormone replacement!Usually effecxtive but with high incidence of post tx hypothyroidism.
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Surgical treatments
- Thyroidectomy
- Subtotal thyroidectomy
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Thyroidectomy
- Used for:
- pt unresponsive to antithyroid therapy
- Barg goiters causing tracheal compression
- possible malignancy
- not good candidate for RAI
- Advantages:
- Rapid reduction in T3 & T4 levels than RAI alone
-
Endoscopic Thyroidectomy
- Indications:
- Minimally invasive
- Appropriate for pt with sm nodules (<3cm)
- No evidence of malignancy
- Advantages:
- Less scaring
- Less pain
- Faster return to normal activity
-
Subtotal Thyroidectomy
- Preferred surg. proceedure
- Remove 90% of thyroid tissue
- Too much tissue removal results in hypothyroidism
- Complication:
- parathyroid gland removed or damaged-this leads to hypocalcemia and tetany. Can cause laryngeal stridor and need trach tube.
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Preop Care For Subtotal Thyroidectomy
Euthyroid state by admin Iodine, Antithyroid med, beta blocker
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Preop Teaching for Thyroidectomy/subthyroid
- Deep breathing/cough/leg exercises
- post op positioninbg & turning
- Practice neck ROM exercises
- Inform talking may be difficult for short time post op
- expect hoarseness d/t edema
- Avoid caffeine
- scar will fade over time
- High calorie diet (4000-5000 Kcal/day); 6 sm meal/day; high protein, carb mineral & vitamin snacks
- AVOID spicy & high fiber foods
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Post op care
- O2
- suction equipment
- trach tube
- ***If tetany r/t parathyoid damage and hypocalcemia: IV calcium gluconate or IV gluceptate
- Assess q2h for 24hr
- hemorrhage
- trach compression (irregular breathing)
- Neck swelling
- frequent swallowing
- sensations of fullness @ incisiuon line
- choking
- Blood on anterior or posterior dressing
- support in semi-fowlers position
- support head with pillows
- avoid flexion of neck & any tension on suture lines
- monitor & assess VS per protocol
- Check for tetany (tingling around mth, toes, fingers; muscular twitching) for @ least 72 hrs
- Pain/admin meds to control
- Ambulate within hrs of surg
- fluids asatolerated
- soft diet day after surgery
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