THYROID DISRORDERS

THYROIDITIS
Definition
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Inflammation of the thyroid glands

Forms

by bacteria, fungi, mycobacteria, or parasites

Staphylococcus aureus and other staphylococci are the

most common causes.

Infection typically causes anterior neck pain and swelling,
fever, dysphagia, and dysphonia. Pharyngitis or
pharyngeal pain is often present. Examination may reveal

than increased.
If untreated, the disease runs a slow, progressive course,

leading eventually to hypothyroidism.

May lead to respiratory distress and dysphagia because

of painless, asymmetrical enlargement of the gland

Thyroid hormone therapy is prescribed to reduce thyroid

activity and the production of thyroglobulin.

If hypothyroid symptoms are present, thyroid hormone

warmth, erythema (redness), and tenderness of the

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pressure symptoms persist.

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replacement. Surgical incision and drainage may be

without residual effect.

often follows a respiratory infection.
thyroid enlarges symmetrically and may be painful. The

be an autoimmune process.
Symptoms of hyperthyroidism or hypothyroidism are

possible.
Treatment is directed at symptoms

Simple Goiter enlargement of thyroid due to iodine

insufficiency
Endemic Goiter geographic
Sporadic Goiter genetic defect, ingestion of large amounts
of nutritional goitrogens, and ingestion of medical goitrogens

Risk Factors

Endemic Goiter

Cardiovascular: HR + SV= CO ; possible hypertension

the tissues and pronounced personality changes.

Myxedema complication of hypothyroidism characterized by a

Hematologic: anemia

generalized metabolic state

Myxedema Coma life-threatening situation in which all body

Renal: fluid retention

systems are severely compromised by the hypometabolic state

Respiratory: dyspnea, respiratory muscle weakness,

Gastrointestinal: decrease motility, achlorhydria
Musculoskeletal: muscle cramps and weakness, transient pain, slow
movements
Integumentary: dry coarse scaly skin, hair fall and brittle nails,
periorbital edema, thick puffy skin in face and pretibial areas, cold

Incidence

corticosteroids
Subacute lymphocytic
also called painless thyroiditis
often occurs in the postpartum period and is thought to

slowed body metabolism due to decreased oxygen consumption by

of hyperthyroidismare common, and many patients

Tertiary Hypothyroidism
Hypothalamic dysfunction

Clinical Manifestation

nervousness, insomnia, and weight lossmanifestations

adrenergic blocker, antithyroid hormones and

Hypothyroidism deficiency of thyroid hormone resulting in

may be difficult and uncomfortable. Irritability,

Secondary Hypothyroidism
Pituitary dysfunction
Peripheral resistance to thyroid hormone

Definition

overlying skin is often reddened and warm. Swallowing

experience chills and fever as well.

pharmacologic agents used are NSAIDs, aspirin, beta-

HYPOTHYROIDISM

lasts 1 to 2 months and then disappears spontaneously

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Surgery or radioactive therapy for hyperthyroidism

Chronic inflammatory diseases (Hashimotos disease,
amyloidisis, sarcoidisis)

therapy is prescribed. Surgery may be required if

thyroid gland.
treatment includes antimicrobial agents and fluid

needed if an abscess is present.

Subacute granulomatous
presents as a painful swelling in the anterior neck that

play role to its causation

usually not accompanied by pain, pressure symptoms, or

fever, and thyroid activity is usually normal or low rather

Acute suppurative
a rare disorder caused by infection of the thyroid gland
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Chronic (Hashimotos disease)

also called chronic lymphocytic thyroditis
most common form of thyroiditis
has an autoimmune basis and genetic predisposition may

Women > Men (4:1)

30 60 years of age
More than 95% - primary form

intolerance
Endocrine: normal to enlarged thyroid
Neurologic: decrease DTR, fatigue, somnolence, apathy, depression,
slow deliberate speech, impaired short-term memory, lethargy
Reproductive: decrease libido, menorrhagia, irregular menses,

Etiology

anovulation, impotence

Other: Myxedema

Primary Hypothyroidism
Cretinism
Defective hormone synthesis
Iodine deficiency
Antithyroid drugs

MYXEDEMA

Dry, waxy type of swelling with abnormal deposits of mucin in

the skin and other tissues

Edema is nonpitting type and common in facial and pretibial
areas

MYXEDEMA COMA
Drastic decrease in the metabolic rate
Hypoventilation leading to respiratory acidosis
Hypothermia
Hypotension

Laboratory Findings

Do not change brands.

Avoid foods that can inhibit thyroid secretion.

Other Thyroid Hormones include:

LIOTHYRONINE (Cytomel) synthetic T3

LIOTRIX (Euthroid, Thyrolar) mixture of levothyroxine

Serum T4: normal-low

Myxedema Coma.

Administer oxygen
IV fluids
Sodium levothyroxine IV with glucose and corticosteroids

Surgical Management

Thyroidectomy if goiter is very large, not responding to

Serum T3: normal-low

treatment or putting too much pressure on other structures in

Free T4: decreased

the neck

Free T3: (not used)

(Thyroidectomy discussed on Hyperthyroidism)

RAUI: decreased
Hypercholesterorlemia, hyperlipidemia, hyperproteinemia, dilutional
hyponatremia, elevated creatine phosphokinase, aspartate
aminotransferase and LDH

Medical Management:
Hypothyroidism.

Uses: to treat hypothyroidism, myxedema and cretinism

Action: increases levels of T4 and T3 thus increasing metabolic rate

of tissues, oxygen consumption and body growth

S/E: irritability, insomnia, nausea, vomiting, diarrhea, cramps,

tremors, nervousness, headache, weight loss

Adverse Reactions: tachycardia, hypertension, palpitations,

thyroid crisi, cardiovascular collapse, dysrhythmias

Contraindication: thyrotoxicosis, MI, severe renal disease
Caution in: cardiovascular disease, hypertension, angina pectoris
Nursing Considerations:

Monitor VS especially pulse, RR and BP

Encourage client to take drug at the same time each day,

preferably before breakfast. Food will hamper absorption rate.

Instruct client to report signs of hyperthyroidism.

Hyperthyroidism excessive secretion of thyroid hormone

Thyrotoxicosis refers to clinical manifestations that occur

when the body tissues are stimulated by increase thyroid hormone

Graves disease - most common type of hyperthyroidism, results
from an excessive output of thyroid hormones caused by
abnormal

stimulation

of

the

thyroid

gland

by

circulating

immunoglobulins.
Incidence

Women > Men (4:1)

20 40 years of age

Etiology

overfunctioning of entire gland

single or multiple functioning adenomas of thyroid cancer
overtreatment of myxedema with thyroid hormone
thyroiditis
excessive ingestion of thyroid hormone

Nursing Management
NURSING DIAGNOSES:

Altered nutrition: less than body requirements r/t slowed

metabolic rate
Activity intolerance r/t weakness and apathy secondary to

decrease metabolic rate

Constipation r/t decrease peristalsis secondary to slowed

metabolic rate and activity intolerance

High risk for impaired skin integrity r/t edema and dryness

secondary to infiltration of fluid into interstitial spaces

Hypothermia r/t slowed metabolic rate
Social isolation r/t lethargy, weakness, apathy and change in

appearance
High risk for decreased cardiac output r/t sustained

bradycardia, edema and decreased urine output

Knowledge deficit r/t pharmacologic and nutrition care

Thyroid Hormone: replacement therapy for hypothyroidism

Prototype: LEVOTHYROXINE SODIUM (Levothroid, Synthroid)

Definition

sodium and liothyronine sodium in a 4:1 ratio

TRH: increased
TSH: increased

HYPERTHYROIDISM

NURSING INTERVENTIONS:

Careful history taking

Modifying activity
Monitoring physical status
Promoting physical comfort
Providing emotional support
Promote self-care

GRAVES DISEASE
THREE HALLMARKS:
1.
2.
3.

hyperthyroidism
thyroid gland enlargement (goiter)
exophthalmos

Clinical Manifestations
Cardiovascular: HR + SV= CO ; palpitations, rapid bounding
pulse, possible CHF,
Respiratory: respiratory rate and depth, SOB
Renal: fluid retention
Gastrointestinal: increase motility, increase GI secretions
Musculoskeletal: muscle weakness, fatigue, malnutrition, tremors
Integumentary: flushed moist warm skin, fine soft straight hair,
profuse sweating, heat intolerance
Endocrine: usually enlarged thyroid, bruit over thyroid
Neurologic: increase DTR, nervousness, restlessness, anxiety,
increased SNS activity

Reproductive: decrease libido, amenorrhea, irregular menses,

Uses: to treat hyperthyroidism, adjunct therapy before

thyroidectomy
Action: rapidly inhibits thyroid hormone synthesis and release,

Nursing Considerations:

impotence
Other: exophthalmos

Laboratory Findings
TRH: decreased
TSH: decreased

Serum T4: increased

Serum T3: increased
Free T4: High normal-increased

Free T3: increased

RAUI: increased

decrease vascularity of thyroid gland

S/E: nausea, vomiting, hypothyroidism, irregular heartbeat
Adverse Reactions: hypersensitivity, iodine poisoning
Contraindication: hypersensitivity
Caution in: tuberculosis, impaired renal and cardiac function
Nursing Considerations:

Monitor potassium levels.

Advise client to take drug after meals with fruit juice, water or
milk.
Restrict iodine rich foods.
Emphasize the importance of drug compliance.

Beta-adrenergic Blokers
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Prototype: PROPYLTHIOURACIL (PTU)

Uses: to treat hyperthyroidism

Action: inhibits synthesis of thyroid hormone
S/E: nausea, vomiting, diarrhea, loss of taste, dizziness,
drowsiness
Adverse Reactions: agranulocytosis
Contraindication: hypersensitivity
Caution in: bone marrow depression
Nursing Considerations:

Monitor CBC

Advise client to take drug with food.

Instruct client to report signs of hypothyroidism.

Assess for signs of infection.

Emphasize the importance of drug compliance.

Radioiodine Therapy (131I)

Uses: to treat hyperthyroidism

Action: destroys thyroid tissue

S/E: feeling of fullness in neck, metallic tatse, hypothyroidism
Nursing Considerations:

Stop all antithyroid medications one week before 131I

administration.
Give on empty stomach.
Monitor thyroid function closely.
Institute radiation precautions on body secretions 3 days after
ingestion.

METHIMAZOLE (Tapazole) has longer half-life than PTU

Surgical Management

Iodine:

THYROIDECTOMY

Prototype: SATURATED SOLUTION OF POTASSIUM IODIDE or SSKI

(Iostat, Pima, Thyro-block)

The client must be euthyroid.

The client must be adequately rested, at optimal weight and

in good health.
Answer questions, and allow time for the client to verbalize

concerns.
NPO at least 6 hours preop.

Postoperative:

Surgical removal of thyroid either total or partial

Total Thyroidectomy
total removal of thyroid gland

Provide comfort measures: Administer analgesic pain

medications as ordered, and monitor their effectiveness;
place the client in a semi-Fowlers position after recovery from

anesthesia; support head and neck with pillows.

WOF for signs of hemorrhage, respiratory distresss, laryngeal
nerve damage, thyroid storm and tetany.

Adjunctive therapy to control activity of sympathetic nervous

system

Other Thyroid Hormones include:

LUGOLS SOLUTION

Medical Management

Preoperative:

Other Thyroid Hormones include:

Antithyroid Hormone:

Subtotal Thyroidectomy
partial removal of thyroid gland (5/6 of the gland)

Nursing Management
NURSING DIAGNOSIS:

Imbalanced nutrition, less than body requirements, r/t

exaggerated metabolic rate, excessive appetite, and increased

gastrointestinal activity
Ineffective coping related to irritability, hyperexcitability,

apprehension, and emotional instability

Low self-esteem related to changes in appearance, excessive

appetite, and weight loss

Altered body temperature

NURSING INTERVENTIONS:

Provide adequate rest

Provide non stimulating, quiet and cool environment
Provide high calorie diet
Promote safety
Protect eyes, if exophthalmos is present