Where is the thyroid located?

What is it responsible for?

What are the three hormones the thyroid hormones produces?

anterior portion of the neck

responsible for all metabolism in the body

T3, T4, calcitonin

responds to high circulating calcium levels in the blood

inhibits calcium resporption (loss of substance) from bone, increases calcium storage in bone, and increases renal excretion of calcium and phosphorus

What percentage of thyroid hormone is T3 and T4?

Which is more potent?

T4 - 90%

T3 - 10%

T3 is more potent

Negative feedback look

decreasing circulating levels of thyroid hormone ---> excretion of TSH ---> release of thyroid hormone

MEasures fraction of T3 that exists in a free state unbound to protein

hypo: decreased

hyper: increased

Measures thyroxine in blood that is not bound to protein

Hypo: decreased

Hyper: increased

Measures rate of I 131 uptake by thyroid gland

Hypo: decreased accumulation

Hyper: increased accumulation

What does the thyroid scan do?

What might a cold or hot spot indicate?

scintillation detector localizes radioactive iodine in the area being scanned

cold spot: possible cancer

hot spot: increased function

What does the TSH stimulation test do?

What does indicates hypofunction?

What indicates hyperfunction?

differentiates primary from secondary hypothyroidism

hypo: elevated TSH with primary hypothyrdoidism

hyper: decreased TSH

increased capillary fragility

decreased rate and force of contraction

varied changes in BP

cardiac hypertrophy

distant heart sounds

anemia

tendency to develop heart failure, angina, myocardial infarction

dyspnea

decreased breathing capacity

decreased appetite

n/v

weight gain

constipation

distended abdomen

enlarged, scaly tongue

dry, thick, inelastic, cold skin

thick, brittle nails

dry, sparse, coarse hair

poor turgor of mucosa

generalized interstitial edema

puffy face

decreased sweating

pallor

fatigue, muscle weakenss

muscular aches, pains

slow movements

arthralgia

apathy, lethargy

forgetfulness

slowed mental processes

hoarsenes

slow, slurred speech

prolanged relaxation of deep tenden reflexes

stupor, coma

paresthesias

anxiety, depression

polyneuropathy

prolonged menstrual peroids or amenorrhea

decreased libido

infertility

increased susceptibility to infection

increased sensitivity to opoids, barbiturates, anesthesia

intolerance to cold

decreased hearing

sleepiness

goiter

surgery/removal of thyroid

I 131 treatment

antithyroid drugs

Hashimoto's disease (autoimmune)

swallowing

bowel movement

lethargy

intolerance to cold

trouble breathing

confusion

mental changes

VS

speech

palpate thyroid

reflexes

nails

abdominal distension

Labs

emotional needs

symptom relief

prevent chilling

avoid medicating with sedatives/hypnotics

fiber/fluids/stool softeners

encourage gradually increased exercise

assess level of consciousness and reorient

be alert for signs of CAD -- hypercholesterolemia and atherosclerosis

teach need for compliance with meds

assess for hypoventilation

monitor temperature

external heating devices are contraindicated (vasodilation can lead to vascular collapse)

What are the symptoms of myxedema coma?

Who is it more likely to affect?

change in mental status

coma

respiratory failure

hypotension

hypoatremia

hypothermia

hypoglycemia

can lead to shock, organ failure and death

more likely to affect women, elderly, and those with coexisiting medical problems

accumulation of hydrophilic muco-polysaccharides in the dermis and other tissues

leads to "face" of hypothyroidism: puffiness, peri-orbital edema, mask like effect

What is the hormone replacement therapy of choice for hypothyroidism?

How quickly will pt see a reduction in symptoms?

How is the correct dosage obtained?

synthyroid

3-12 weeks

dosage starts low, then gradually increased until correct dose is found; dependent on TSH levels and physical response to medication (regular lab follow up is neede)

corrects thyroid imbalance

restores metabolic function

weight loss

tremors

insomnia

nervousness

orthopnea

dyspnea

palpitations

rapid pulse

on empty stomach

2-4 hours apart from Calcium

decrease constipation with high fiber, high fluid diet and use of laxatives or stool softners

low cholesterol intake

low caloric intake

how saturated fat intake

increase fluid to 2-3 L/ day

systolic hypertension

increased rate and force of contractions

bounding rapid pulse

increased cardiac output

cardiac hypertrophy

systolic murmurs

dysrhythmias

palpitations

atrial fib

angina

increased respiratory rate

dyspnea on mild exertion

increased appetite, thirst

weight loss

increased peristalsis

diarrhea, frequent defecation

increased bowel sounds

splenomegaly

hepatomegaly

warm, smooth, moist skin

thin, brittle nails detached from nail bed

hair loss

clubbing of fingers

palmar erythema

fine silky hair

premature graying

diaphoresis

vitiligo

pretibial myxedema

fatigue

muscle weakness

proximal muscle wasting

dependent edema

osteoporosis

difficulty in focusing eyes

nervousness

fine tremors

insomnia

labilty of mood, delirium

restlessness

personality changes

exhaustion

hyperreflexia of tendon reflexes

depress, fatigue, apathy (especially older adult)

lack of ability to concentrate

stupor, coma

menstrual irregularities

amenorrhea

decreased libido

impotence in men

gynecomastia in men

decreased fertility

interolence to heat

increased sensitivity to stimulant drugs

elevated basal temp

lid lag, star

eyelid retraction

exophthalmos

goiter

rapid speech

more woman than men

highest frequency in people 20-40 years

autoimmune disease where patient develops antibodies to TSH receptor, causing increased release of thyroid hormones

excerbations/remission with or with treatment, eventually tissue is destroyed causing hypothyroidism

What percentage of cases of hyperthyroidism are caused by Grave's disease?

What percentage of people with hyperthyroidism have goiters?

75%

95%

apical pulse, BP, temp

skin temp

heart murmurs, arrhythmias, decompensation

increased bowel sounds

tremors, rapid speech, rapid body movements

ask about recent infections

stress

previous goiter

injury

trauma

herbal medications

travel to foreign contries

immigration from iodine deficient area

maintain calm manner

protech from stress and fatigue

encourage pleasant environment

change linens and provide cool room

keep diarrhea under control

dietary modifications

What do antithyroid drugs do?

When is improvement seen?

How long does therapy last?

inhibits synthesis of thyroid hormones

1-2 weeks

6-15 months to allow for spontaneous remission

used with antithyroid drugs to prepare pt for thyroidectom or for treatment of thyrotoxic crisis

iodine in lg doses inhibits synthesis of T3 and T4 and blocks release of hormones into circulation

decreases vascularity of thyroid gland, making surgery safer and easier

treatment of choice for nonpregnant adults

damages or destroys thyroid tissue, thus limiting thyroid hormone secretion

usually effective, high incidence of posttreatment hypothyroidism

unresponsive to antithyroid treatment

very large goiter causing tracheal compression

possible malignancy

minimally invasive procedure

appropriate for pts with small nodules w/ no evidence of malignancy

advatages include less scarring and pain and faster return to normal activity

cough and DB

semi Fowler's

assess VS and pain

observe for complaints of fullness (could indicated breathing issue)

cold liquids

advise to talk as little as possible

observe for voice changes

assess dressing anteriorly and posteriorly

keep trach tray and O2 and suction equipment by bedside

hemorrhage

resp distress

hypocalcemia

tetany

Chvosteks' and Trousseau's sign

calcium gluconate

hypothyroidism

What is Chovstek's sign?

What is Trousseau's sign?

stimulation of facial nerve

adduction of hand w/ blood pressure cuff

high caloric (4-5000 kcal)

small meals

increased protein, calories, and carbs

prevents muscle breakdown

increase fluids

avoid gaseous foods, high fiber, and caffeine

vitamin and mineral supplement

small, paired, and highly vascularized glands located on the upper portion of each kidney

each gland consists of two parts, the medulla, and the cortex

catecholamines:

epinephrine

norepinephrine

dopamine

(normally neurotransmitters, but hormones when released from medulla)

sugar -- glucocorticoids

salt -- mineralcorticoids

sex -- androgens

cortisol

increases sugar metabolism and decreases immune response

supportive in stress response, released in times of physical and emotional stress

aldostreone

regulated by angiotensin and serum potassium levels

maintains ECF

promotes Na and H20 water reabsorption

allows secretion of K+

Cushing's -- ACTH levels low to immeasurable

primarly adrenal insufficency -- ACTH level are elevated

What is Addison's disease?

When do symptoms usually appear?

What hormones are affected?

adrenal hypofunction

usually not until 90% of adrenal cortex is destroyed

one, two, or three hormones can be affected

(glucocortocoids, mineralcortocoids, androgens)

weight loss

bronzed or smokey hyperpigmentation

hypotension

muscoskeletal fatigability

fluids and elecrtolytes -- hypoatremia, hypovolemia, dehydration, hyperkalemia

hypoglycemia

postural hypotension

GI anorexia, nausea, vomiting

fluid and electrolyte -- sodium loss, decreased volume of extracellular fluid, hyperkalemia, salt craving

weakeness

decreased heart rate

decreased axillary and pubic hair

decreased libido

sexual changes

decrease in muscle size and tone

life threatening emergency

triggers:  psychological stress, sudden decrease in exogenous of corticosteroids

hypotension

electrolyte imbalance

shock

treatment: hydrocortisone

1) VS and fluid volume deficit and electrolyte imbalance (q 30min - 4 hours for 1st 24 hours

depending on pt stability)

2) daily weights

3) education about diligent corticosteroid administration for rest of life

4) complete assistance with daily hygeine

5) monitor glucose, have pt recognize signs of hypoglycemia

6) promote good nutrition - high protein, calcium, and K but low in fat and simple carbs

7) fall risk

anti inflammatory actions

immunosuppression

maintenance of normal BP, increases Na and H20 retention

carbohydrate and protein metabolosim

hypokalemia

predisposition to peptic ulcer disease

skeletal muscle atrophy/weakeness

mood and behavior changes

predisposition to DM

fat from extremities is redistributed to face and trunk

hypocalcemia

delayed healing

susceptibility to infection

supression of pituitary ACTH

increased blood pressure

protein depletion decreasing bone formation, density, and strength, which predispose to fractures

- as non replacement therapy, should be taken once daily or once every other day

- taken early in the morning

- pt should be aware of the danger of stopping abruptly

- 3+ months of drug therapy may cause osteoporosis, therefore pt may need increased Ca intake, Vit D supplementation and low impact exercises

-- eat diet high in protein, calcium and potassium but low in fat and simple CHO

-- adequate rest and sleep, avoid caffeine

-- maintain exercise program

-- recognize edema

-- restrict sodium intake

-- monitor glucose levels

-- notify health care provider if expereincing heartburn or epigastric pain not relieved by antacids

-- see eye specialist yearly

-- stand up slowly

-- proper lighting to prevent accidents

-- maintain good hygiene

-- avoid persons with colds or contagious disease

-- inform all health care providers of long term therapy

-- may need increased corticosteroids in times of physical or emotional stress

-- NEVER abruptly stop the corticosteroids bc this could lead to addisonian crisis and possible death

iatrogenic administration of exogenous corticosteroids

pituitary hypersecretion of ACTH

Cushing's: truncal obesity

Addison's: weight loss

experience relief of symptoms

have no serious complications

maintain positive self image

actively participate in therapeutic plan

VS

daily weights

glucose

possible infection

S/S thromboemboletic phenomena (sudden chest pain, dyspnea or tachypnea)

change in appearance such as

-- ccentripetal obesity

-- multiple bruises

-- hirsutism

-- gynecomastia

What is the goal of drug therapy for adrenal hyperfunction?

When is it used?

inhibit of arenal function

when surgery is contraindicated or in addition to surgery

suppressed cortisol production

alters peripheral metabolsim of cortisol

decreased plasma and urine corticosteroid levels

essentially results in medical adrenalectomy

used to inhibit cortisol synthesis

side effects include anorexia, nausea, and vomiting, GI bleeding, vertigo, skin rashes, and diplopia

may be necessary if patient is not a good candidate for surgery or surgical outcomes not optimal

always watch for collatoral damage, and do a good neuro assessment

if underlying cause is pituitary adenoma, pituitary tumor is surgically removed

adrenalectomy is indicated for Cushing syndrome caused by adrenal tumors or hyperplasia

laproscopic adrenalectomy is used unless there is a suspicion or knowledge of malignant adrenal tumor