Академический Документы
Профессиональный Документы
Культура Документы
Carbohydrate metabolism-stimulates CHO metabolism by increasing glucose uptake, glycolysis, gluconeogenesis, GI absorption of CHO, increased insulin release Fat metabolism-increases fat metabolism resulting weight loss Cardiovascular-vasodilatation of body tissues results in increased blood flow to tissues, increased cardiac output, increased heart rate, increased B.P.
Affects the glucose level, affects the fat metabolism
3
Respiratory effects-with increased BMR, increased need for oxygen and formation of carbon dioxide resulting in increased respiratory rate and depth G.I.-increased appetite, food absorption, digestive juice production, G.I. motility C.N.S.- speeds mental processes, increases activity level, increases muscle tone Calcitonin-modifies Ca++ metabolism resulting in decreased Ca++ level
4
HYPERTHYROIDISM
Most common form is Graves disease, others are toxic nodular goiter (nodules secrete T3, T4), thyroiditis (Hashimotos disease), thyroid cancer, pituitary disorders Incidence- 2% of women aged 30-50 ,and only 0.2% of men; 75% of all cases of hyperthyroidism are Graves disease
HYPERTHYROIDISM
Etiology of Graves= primarily an autoimmune disorder, some feeling there are genetic and environmental factors. Auto-antibodies attach to TSH receptors within thyroid and stimulate release of T3, T4, laboratory value will show an increase in TSAb
Hyperthyroidism
Assessments= 1.inspection/palpation of the thyroid gland=goiter: auscultation of gland=bruits 2. opthalmopathy=changes in eye appearance=exopthalamus, eyelid retraction, infrequent blinking 3. vital signs=> heart rate, palpitaitons, >BP, > temperature, dyspnea
7
Hyperthyroidism
4. weight loss 5. muscle wasting and weakness 6. fine tremors 7. fatigue 8. facial flushing 9. increased irritability, nervousness 10. insomnia 11. increased appetite
14. fine, straight hair, loose pigment, and hairline recedes 15. breast enlargement 16. GI=> motility causing an > in bowel sounds, nausea/vomiting, cramping, abdominal pain, diarrhea 17.gynecological oligomenorrhea/ amenorrhea, < fertility, < libido, abortion tendency, gynecomastia in men
10
11
Diagnostic Studies
Decreased TSH Elevated FT4=Free thyroxine T3,T4 levels=T3=tri-iodothyronine, T4=thyroxine Radioactive iodine uptake test = (RAIU)=used to identify Graves from other thyroid disorders;Graves=35%-95% uptake Thyroiditis=< 20%
12
13
Medications
Antithyroid Medications=inhibit production of thyroid hormones, blocks peripheral conversion of T4 to T3 ie. Propythiouracil=PTU; Methimazole+Tapazole Iodine=preparation ofr thyroidectomy or treatment for thyrotoxic crisis as large dose inhibits T3,T4 and blocks release into circulation; < vascularity of gland and makes surgery safer
14
Medications
Saturated solution of Potassium iodidide=(SSKI), Lugols solution Beta-adrenergic blockers=to relieve cardiac symptoms, ie. Propranolol (Inderal); Atenolol(Tenormin)
15
Surgical Management
Subtotal thyroidectomy is preferred with 90% of the tissue removed. If too much removed results in hypothyroidism in the post-operative period Advantage=removes hormones quickly Endoscopic thyroidectomy=minimal invasion with a nodule <3mm and no cancer; less scar, less pain, and return to ADLs quicker
16
Surgical Preparation
Need to achieve a euthyroid state preoperatively; Monitor for thyrotoxicosis=Thyroid storm=due to infection, trauma, surgery; s/s=severe tachycardia, heart failure, shock, temperature of 105.3. restlessness, can end in delirium and coma Teach to take antithyroid drugs preoperatively and beta adrenergic blocking agents
17
Thyroidectomy
Preoperative teaching/care=1. calm, quiet environment, cool room 2. Restrict visitors, use communication to allay anxiety 3. Teach coughing and deep breathing 4. Teach exercise of the legs 5. Teach support of the head when lifting or turning in bed 6. Teach IV will be present/talking difficult
18
Thyroidectomy: Nutrition
High caloric diet 4000-5000kcal/day to satisfy hunger and prevent breakdown 6 full meals a day to compensate for >metabolism High protein, CHO, minerals, vitamins No caffeine
19
Oxygen administration and suction PRN Tracheostomy tray at the bedside Check for laryngeal nerve damage=check voice quality Monitor respiratory=obstruction can be due to swelling of the neck tissues d/t hemorrhage or edema formation: will see frequent swallowing, irregular breathing patterns, choking Check for laryngeal stridor d/t tetany
20
22
Home Care
Monitor thyroid hormone balanceas some become hypothyroid after surgery. Dr. will not give thyroid hormone immediately post op to allow the thyroid tissue to hypertrophy and release T3/T4: follow up with the doctor is required to check hormone levels
23
Nursing Diagnosis
Activity intolerance r/t fatigue, exhaustion, and heat intolerance secondary hyper-metabolism AEB c/0 weakness, hyperactivity, short attention span, memory lapses, dyspnea, tachycardia, irritability Risk for injury(corneal ulceration r/t < blinking, or inability to close eyes secondary to exophthalamos
24
25
26
Hypothyroidism/Myxedema
Etiology-one of most common disorders in the U.S.; 8% of women and 2% of men over age 50; results from < thyroid hormone Primary=destruction of thyroid tissue or defective hormone synthesis Secondary=pituitary disease r/t < TSH; hypothalamic dysfunction r/t < TRH Iodine deficiency, radiation therapy, surgery, thyroiditis
27
1. Monitor for fatigue 2. Assess if lethargic 3. Identify if personality and mental changes have occurred, psychoses 4. Impaired memory 5. Assess for slowed speech 6. Assess for somolence 7. Monitor for < cardiac output and slowed pulse rate
28
8. Assess for S.O.B. with exertion 9. Monitor for anemia 10. Assess for bruising 11. GI motility is slowed=check for constipation 12. Identify cold intolerance 13. Assess for hair loss, hair being dry and coarse 14. Assess for dry, coarse skin 15. Assess for brittle nails
29
16. Assess for hoarseness, thick tongue, slow speech 17. check for muscle weakness 18. Assess for swelling 19. Monitor for history of weight gain 20 Myxedema (if longstanding ) characterized by pufiness, periorbital edema, mask like or blank expression 21. Check for menorrhagia, infertility
30
31
32
HYPOTHYROIDISM MANAGEMENT
Treat with Levothyroxine (Synthroid, Levothroid)=start with 0.05 mg. P.O. daily; and maintenance dose adjusted to the patients response and lab results; caution with elderly, will start with lower dose ie. 0.0125-0.025 mg/day d/t risk of increased myocardial demands resulting in risk of angina / arrhythmias; s/s begin to reverse in 2-3 days post Rx
33
HYPOTHYROIDISM MANAGEMENT
Teach to report chest pain, palpitations, increased heart rate Monitor cardiac enzymes If no side effects, dose then elevated at 1 to 4 week intervals Inform replacement needed for life Low calorie diet to reduce weight Upon admission, warm environment
34
HYPOTHYROIDISM MANAGEMENT
Skin care=lotions, check breakdown Constipation=increase exercise, fiber, stool softener, avoid enemas d/t cardiac effect of vagal stimulation
35
Can occur with infection, cold, trauma, drugs ie. Narcotics, Tranquilizers, Barbiturates S/S=decreased temperature, decreased BP, decreased respirations Requires acute care (ICU)=mechanical ventilation may be needed, IV thyroid replacement hormone with EKG monitoring, hypertonic saline till Na+ at 130 mEq./L, check of core temperature needed
36
37
Ineffective breathing pattern r/t depressed ventilation Disturbed thought processes r/t depressed metabolism and altered cardiovascular and respiratory status Imbalanced nutrition: more than body requirements r/t hypometabolism AEB weight gain Hypothermia r/t cold intolerance AEB c/o of feeling cold and shivering
38
Constipation r/t GI motility AEB irregular, hard stools Activity intolerance r/t fatigue and depressed cognitive process Disturbed thought processes r/t depressed metabolism and altered cardiovascular and respiratory status Deficient knowledge about the therapeutic regimen for lifelong thyroid replacement therapy See, chart 42-3, pp. 1455-1458.
39
40
Hyperparathyroidism
Incidence=older adults and 2-4 times more common in women Types 1. Primary=hyperplasia or adenoma (80% of cases) in one or more glands 2. Secondary=compensatory response by the parathyroid glands to chronic <Ca ( ie. vitamin D deficiency, malabsorption, chronic renal failure, > Ph) 3. Tertiary=hyperplasia of glands and loss of response to serum Ca levels ie. renal failure, kidney transplant following long dialysis treatment
41
Hyperparathyroidism
Symptoms are related to the effects on the musculoskeletal, renal, and GI systems Musculoskeletal=Bone pain (back, joints, shins), pathologic fractures, muscle weakness of lower extremities, muscle atrophy Renal effects=renal calculi, polyuria, polydipsia GI=loss of appetite, abdominal pain, peptic ulcers, pancreatitis, nausea, constipation
42
Hyperparathyroidism
Hyperparathyroidism
Diagnosis=6 month history of S/S Lab work=check of serum levels of PTH, Ca, Phosphorus, bicarbonate, Cl ; urine for >Ca, >Ph, double antibody parathyroid hormone test X-rays and scans, MRI
44
Hyperparathyroidism
Surgical Treatment=parathyroidectomy, partial or complete (endoscopically now) Criteria=serum Ca>12mg/dl(3.0mmol/L), Hypercalciuria=(400mg/day) Decreased bone density Overt symptoms (neuromuscular effects, renal stones) Very high Calcium=Emergency and treat with IV Na Phosphate, IV K Phosphate Re-implantation of parathyroid tissue to forearm or sternocleidomastoid muscle
45
Hyperparthyroidism
Nonsurgical treatment=annual exam, check of PTH, Ca, Ph, alkaline phosphatase levels, x-rays, urine for Ca Avoidance of immobility Dietary measures= fluid intake of 2000ml./ day ;cranberry juice to lower urinary pH; low calcium intake; avoid large doses of vitamins A and D, antacids containing calcium, and calcium supplements; take 8-10 gm of Na d/t urinary loss with fluid losses from > urine output ;prune juice, stool softeners for constipation
46
Hyperparthyroidism
Other medications=Phosphorus supplements= Pamidronate (Aredia) Alendronate (Fosamax); estrogen or progesterone; diuretics ie. Lasix ( no thiazide diuretics as < excretion of urinary Ca+ +); calcitonin; mithramycin; glucocorticoids
47
Hyperparathyroidism
Nursing care=Postop same for thyroidectomy, special consideration to tetany d/t sudden drop in Ca level, if severe give IV Calcium gluconate Strict I&O Monitor Ca, Ph, K, Mg levels
48
Hyperparathyroidism
Mobility=exercise needed for bones Dietary referral Monitor for S/S of >Ca and <Ca (Hypercalcemic Crisis, serum Ca level > 15mg/dl can occur, see p.1472)
49
Hypoparathyroidism
Results from abnormally low PTH levels, resistance to PTH d/t genetic defects, from consistently low MG++ levels, chronic renal failure, massive blood transfusions, but most commonly d/t damage or removal of the parathyroid glands during thyroidectomy (1st 24-48 hrs. post surgery) Risk for tetany(serum Ca++5mg-6mg/ dl)
50
Hypoparathyroidism
Laboratory findings= decreased serum Ca ++ and increased serum Ph++, < serum Mg++ level, <serum albumin level, <PTH level
51
Hypoparathyroidism
Musculoskeletal=muscle spasms, facial grimacing, carpopedal spasms, tetany, extreme cases convulsions Integumentary=brittle nails, hair loss, dry scaly skin GI=abdominal cramps (pain), malabsorption
52
Hypoparathyroidism
Cardiovascular=arrhythmias CNS=paresthesias (lips (circumoral), hands, feet), mood disorders (irritability, depression, anxiety), hyperactive reflexes, psychosis, >ICP
53
Hypoparathyroidism/Treatment
1. Increasing calcium levels=(norm is 910.0 mg/dl) Use IV calcium gluconate or IV calcium chloride to reduce tetany 2. Will add sedative (Pentobarbitol) if neuromuscular irritabiitu/seizure activity continue 3. PTH administration can be used but allergic reaction is high
54
Hypoparathyroidism
Chronic therapy=Oral calcium preparations=Calcium salts= carbonate (BioCal, Calsam, Caltrate, OsCal, Tums, etc.) ; calcium chloride; calcium citrate (Citrical); calcium glubionate, calcium gluceptate, calcium gluconate (Calcinate), calcium lactate
55
Hypoparathyroidism
Administration of oral Calcium salts 1gm/day for patient <40 and 2gms/day >40 1. Administer 1-1.5 hours after meals and at bedtime
56
Hypoparathyroidism
3. Do not take with food or milk and if possible do not take within 1-2 hrs. of other medications
57
Hypoparathyroidism
Adequate vitamin D intake= dihydrotachysterol (Hytakerol);1,25-dihydroxycholecalciferol (calcitrol); Ergocalciferol(Calciferol)=>diet/>sun Consideration of hormone replacement for women Aluminum hydroxide gel or aluminum carbonate (Gelucil, Amphojel) given after meals to bind phospate and promote elimination through the intestine
58
Hypoparathyroidism
Rebreathing through a paper bag to lower blood pH which raises Ca level Nutrition=Foods high in Calcium= molasses, canned sardines, salmon, rhubarb, broccoli, collard greens, soy flour, (spinach avoided d/t formation of insoluble Ca++ substances ; Milk products also contain Ph++ and require restriction)
59
Hypoparathyroidism
Monitor Ca++ level three to four times per year Teach S/S of >Ca++ and <Ca++(See Chart 42-9, p. 1474)
60
Hypoparathyroidism
Nursing Diagnosis 1. Risk for Injury 2. Decreased cardiac output 3. Disturbed thought processes 4. Risk for ineffective breathing pattern
61