Endocrine Topics II

Hyperthyroidism
Thyroid Storm
Thyroidectomy
Thyroid medical treatments
Hypothyroidism
Hypercortisolism/ Cushing's/
Steroid use
Adrenal insufficiency/ Adrenal
crisis
Case Study 1
Mrs. Taylor is a 32 year old thin,
anxious woman brought in by her
even more concerned husband. She
is diaphoretic, tremulous, moves
continuously in bed, is having
difficulty breathing and complaining
of feeling warm. She tells us “her
heart is pounding.” Over the past 2
weeks, she has been unable to sleep,
she has lost 7 lbs, and her heart has
been “pounding” at times, even at
rest. She said she had been told “she
might have a thyroid problem”

What are you concerned about? What

should you anticipate and assess?
-HR “pounding”
- Labs: Thyroid T3 and T4, TSH
- Blood Pressure: anticipate a
high systolic and decreased
diastolic
- Temperature
- EKG- check if she has
dysrhythmias
- look at thyroid/ hesitant to
palpate because can cause
more spilling of thyroid
hormone
- assess her skin and hair:
silky hair; moist, warm skin
- ask about wt. Loss
- look for exopthalmos
- r/o cardiac problems with
asking questions about the
chest pain and if any of those
point towards MI then get
enzymes CK-MB
- get blood glucose and
anticipate hyperglycemia
because hyperthyroidism
increases glucose intolerance
- r/o sepsis with WBC
anticipate normal
- get electrolytes: Na low
normal, K high normal
Case Study

Admission lab/vital signs

-Na 141 -BP 160/48
-K 4.2 - P 152
irregular
-BUN 8 - R 28
slightly labored
-Creatinine 0.7 - T 39c
-Glucose 156
- Hct 34.7
- Hgb 12.3
- T3 260 (70-205)
- T4 20 (4-12)
- TSH <2 (normal)
- WBC normal
- generally doesn't have signs of hyperglycemia because the body is using it up in hyperthyroidism
- irregular HR should check perfusion, LOC, skin signs
- specifically looking for atrial tachycardia or supraventricular tachycardia
- If cardiac perfusion is inadequate have to deal with the cardiac issues before the hyperthyroidism
- If atrial tachycardia with inadequate perfusion will give adenosine to pause heart, reboot, and
decrease HR
- if has adequate cardiac perfusion then tx. goes towards hyperthyroidism
- If have TSH normal with elevated T3 T4 is acute exacerbation of a chronic condition so worried about
thyroid crisis

Thyroid Crisis: excessive hyperthyroidism leading to cardiac decompensation

– how impending the crisis is is indicated by the temp (will increase quickly)
– want to bind T3 and T4 to solve all the other system problems
– in crisis the mortality is 25% even with treatments
– increase in catecholamines causing tacy dysrhythmias and decreased perfusion
– hyperthermia big red flag and temp will keep rising
– hyperglycemic with high BMR (basal metabolic rate)
– because the thyroid is so vascular if there is a tumor will try to reduce the size of the thyroid and
tumor before surgery

Chronic Hyperthyroidism
– greying of hair
– splitting of nails (onycholosis)
– moody, irritable (not getting enough sleep and high BMR)
– hard for them to accomplish anything
– loss of weight
– worn out
– sweating a lot
– hyperglycemia
– menstrual problems
– increased libido

Case Study

Admitting medication orders

– IV D5NS at 125ml per hour

– Methimazole (Tapazole) 60mg po/NG
– Propylthiouracil (PTU) 300 mg po/Ng
– Sodium Iodide 0.5 g IV
– Propanolol (Inderol) 1mg IV
– SoluCortef 100mg IV
– Consider Lorazepam (Ativan) 1-2 mg IV
– Acetaminophen 125 mg po/pr if T> 38c

Treatment
– HOB up
– O2 (get order for)
– Put in IV for fluids D5NS (maintenance fluid, D5 for high BMR, and IV access)
– Propanolol to get HR down
– *Sodium Iodide attracts thyroid hormone into thyroid and decrease vascularization of the
thyroid gland to decrease size
– SoluCortef: improves survival rate. Blocks conversion T4 to T3, blocks degradation of cortisol
– Could give some ativan to decrease anxiety
– *Tapazole and *PTU po: supresses hormones, blocks production of T3 and T4, release of T3
and T4, PTU also blocks conversion of T4 to T3
– Acetaminophen po prn for temp
– Later: nutritional needs, rest, anxiety, home care, decrease stimulation, change linens due to
diaphoresis
*Blocks Thyroid hormones

Mrs. Taylor is a candidate for medical management of her hyperthyroid condition with radioactive
iodine treatment (RAI) or Mrs. Taylor can opt for surgery.

– her diagnosis is autoimmune disease

– oral radioactive iodine on an outpatient basis
– will destroy gland because iodine is only present in the thyroid
– excreted slowly in the urine
– takes 8weeks to 6months till thyroid is destroyed to stabilize
– over 90% who have RAI become hypothyroid which is easier to treat

She decides to have surgery.

Preparation for Surgery

– keep her stabilized
– needs to know risks: bleeding, thyroid crisis, laryngeal nerve damage causing vocal damage
– reassurance
– call post op if: SOB, numbness or tingling, fullness or tightness in throat, stridor (sounds when
she breathes)
– Post OP: collar bone incision, bulky dressing, J/P drain, HOB up
– teach her how to move with a splint support (support neck when turn, cough, and deep breathe)
– suction at bedside
– going to try and remove 4/5 of gland and preserve 1/5 and the parathyroid glands (responsible
for calcium production)

Case Study

Mrs. Taylor returns to the floor from the PACU:

Drowsy but alert and oriented when aroused, airway patent, R= 22 unlabored, shallow, O2 Sat 93%
with humidified O2 via mask, dressing dry and intact, IV normal saline infusing, JP drain intact
BP 124/74 P 96 irreg.
Concerned about:
– #1 assess airway and breathing by listening to lung sounds anticipate clear. Encourage deep
breath. Probably just post op drowsiness.
– low O2 sat
– irregular pulse (assess perfusion)
– assess pain (could cause her to have shallow breaths)
– Check urine output to assess perfusion
– check the dressing and bleeding on sides and posteriorly
– check JP drainage is slowly filling with serosanguinous fluid not fast with red blood
– measure neck circumference
– assess swallowing and secretions
– need to have airway (emergency trach kit) at bedside. Can't get endotracheal tube in with all the
edema
– usually trach kit is on crash cart and the trach tube is at the bedside
– assess voice quality probably hoarse in the first 24 hours and put on voice rest. Quality of voice
will resume in 24 hours.

Hypocalcemia
Tetany: due to hypcalcemia
Trousseau's sign: BP cuff hand flexion
Chvostek's sign: tap near eye and they twitch
– Ask if there is any numbness or tingling
– Administer Ca Gluconate
– probably removed parathyroids during surgery

Case Study

Mrs. Taylor will be discharged today. Her husband is questioning her readiness to go home. “We both
lost our jobs, we have no place to go, you have to keep us here!”
The nurse needs to get the patient ready for her discharge today and comlete the discharge teaching.

Discharge
– get social services and discharge planners to help with placement
– gauze dressing
– teach how to care for sx. Site and signs of infection
– signs of hypocalcemia and who to call
– hypothyroid
– on levothyroxine
– prednisone 60mg because had autoimmune disease
– so signs of cushing's from prednisone
– has atrial fibrillation so she is sent home on digoxin
– know what hypothyroid looks like

Hypothyroidism
– general edema
– tired
– loss of feeling
– fatigue, apathy
– skin dry

Cushing's Syndrome: from steroid use

– moon face (rounder) with bright eyes (diff. from hypothyroidism)
– buffalo hump
– mood swings
– think paper like skin
– hyperglycemia
– decreased wound healing

Case Study

Mrs. Taylor was discharged from the ED with instructions to decrease the Prednisone by one pill a day.
She is to continue the same Levothyroxine dose. She was also given a prescription to being taking
0.125mg Digoxin each day beginning tomorrow.

2 days later, Mrs. Taylor is rushed to the ED. She is unable to sit upright unassisted. She is pale, cool,
and diaphoretic.
BP 80/30 P110 R22
Na 128
K 5.5
Glucose 68

If stopped Prednisone (Addisonian crisis)

-hypoglycemia, hyponatremia, hypotensive
If stopped Levothyroxine (Myxedematous coma)
– hypothermic
– lethargy
– decreased LOC
– wt. gain
– hypglycemic
– decreased BP and brady P
– decreased R

So she's in an Addisonian crisis because she abruptly stopped her Prednisone

Addisonian Crisis 4 H's

Hypotension/Hypvolemia
Hyponatremia
Hyperkalemia
Hypoglycemia

Treatment
– D5NS
– Give some prednisone like med (solucortef)
– Get rid of potassium because hyperkalemia is worse than hypokalemia because they will die
from asystole. Give insulin to drive potassium into cells. But don't want to cause hypglycemia so give
glucose 1:1 with insulin
– Give kexalate to bind potassium in the long term.