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Ignatavicius: Medical-Surgical Nursing, 6th Edition

Chapter 66: Care of Patients with Proble s of the !h"roid and Parath"roid #lands $e" Points % Print Chapter 66 reviews common disorders of the thyroid and parathyroid glands. Hormones from the thyroid and parathyroid glands affect overall metabolism, electrolyte balance, and excitable membrane activity. &"perth"roidis is excessive thyroid hormone secretion from the thyroid gland, where normal feedback control over thyroid hormone secretion fails. Thyroid hormones affect metabolism in all body organs and systems, thus, excesses produce many different manifestations called thyrotoxicosis. Excessive thyroid hormones cause hypermetabolism and increased sympathetic nervous system activity. The most common cause of hyperthyroidism is Graves disease, also called toxic diffuse goiter. !atients with Graves disease usually have thyrotoxicosis, a goiter or enlargement of the thyroid gland, exophthalmos or abnormal protrusion of the eyes, and pretibial myxedema or dry, waxy swelling of the front surfaces of the lower legs. Graves disease is an autoimmune disorder in which antibodies are made and attach to the thyroid stimulating hormone receptor sites on the thyroid. The patient may report eye problems, a recent unplanned weight loss, an increased appetite, and an increase in the number of bowel movements per day. " hallmark of hyperthyroidism is heat intolerance with diaphoresis even when environmental temperatures are comfortable for others. #bserve the si$e and symmetry of the thyroid gland and palpate the thyroid gland to assess the presence of a mass or general enlargement. %ardiac problems of hyperthyroidism include increased systolic blood pressure, tachycardia, dysrhythmias, and atrial fibrillation, which may be apparent on electrocardiography. The patient with hyperthyroidism often has wide mood swings, irritability, decreased attention span, and manic behavior. Testing for hyperthyroidism includes measurement of triiodothyronine &T'(, thyroxine &T)(, T' resin uptake &T'*+(, and thyroid,stimulating hormone &T-H(. Thyroid scan evaluates the position, si$e, and functioning of the thyroid gland. +ltrasonography can determine si$e and the composition of any masses or nodules. The goals of medical management are to decrease the effect of thyroid hormone on cardiac function and to reduce thyroid hormone secretion. !riorities for nursing care focus on monitoring for complications, reducing stimulation, promoting comfort, and teaching about therapeutic drugs and procedures. .rug therapy with antithyroid drugs is the initial treatment of hyperthyroidism. *adioactive iodine therapy may be used to destroy some of the cells that produce thyroid hormone but is not used in pregnant women. -urgery to remove all or part of the thyroid gland may be needed when a large goiter causes tracheal or esophageal compression or with poor response to drugs. Thyroid surgery can cause hemorrhage, respiratory distress, parathyroid in/ury resulting in hypocalcemia and tetany, damage to laryngeal nerves, and thyroid storm. Thyroid storm or thyroid crisis occurs when the disease is untreated or poorly controlled or is triggered by stressors such as trauma, infection, diabetic ketoacidosis, and pregnancy. This is an extreme state of hyperthyroidism in which manifestations are more severe and life
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threatening and is most common in patients who have Graves disease. The patient at risk for thyroid storm should remain in a cool, dark, and 6uiet environment. The manifestations of h"poth"roidis are the result of decreased metabolism from low levels of thyroid hormones. -ometimes the thyroid cells themselves are damaged and no longer function normally or the individual does not ingest enough iodide and tyrosine. 7yxedema coma is a rare, serious complication of untreated or poorly treated hypothyroidism. .ecreased metabolism causes the heart muscle to become flabby and dilated, resulting in decreased cardiac output and perfusion to the brain and other vital organs. The mortality rate for myxedema coma is extremely high and this condition is considered a life,threatening emergency. #bserve the patient s overall appearance for coarse features, edema around the eyes and face, a blank expression, a thick tongue, and slow movement. %ardiac and respiratory functions are decreased and body temperature is often low. 8eight gain is very common, even when the person is ingesting an appropriate amount of calories for si$e, age, and gender. Triiodothyronine &T'( and thyroxine &T)( serum levels are decreased. The patient with hypothyroidism re6uires lifelong thyroid hormone replacement. The patient with more severe symptoms of hypothyroidism is started on the lowest dose of thyroid hormone replacement, especially with known cardiac problems. !h"roiditis is an inflammation of the thyroid gland. There are three types9 acute or bacterial, subacute or viral, and chronic. %hronic thyroiditis or Hashimoto s disease is the most common type. Hashimoto s disease is an autoimmune disorder that is usually triggered by a bacterial or viral infection. The four distinct types of th"roid cancer are papillary, follicular, medullary, and anaplastic, with the initial manifestation of a single, painless lump or nodule. -urgery is the treatment of choice for papillary, follicular, and medullary carcinomas. " total thyroidectomy is usually performed with a nodal neck dissection if regional lymph nodes are involved. +sually the patient is hypothyroid after treatment for thyroid cancer. :ursing interventions then focus on teaching the patient about hypothyroidism and its management. The parathyroid glands maintain calcium and phosphate balance. 5n h"perparath"roidis , increased levels of parathyroid hormone act directly on the kidney, causing increased kidney reabsorption of calcium and increased phosphate excretion. These processes cause hypercalcemia and hypophosphatemia. "sk about bone fractures, recent weight loss, arthritis, or psychological distress. .etermine whether the patient has received radiation treatment to the head or neck. High levels of !TH cause kidney stones and deposits of calcium in the soft tissue of the kidney. ;one lesions are due to an increased rate of bone destruction and may result in pathologic fractures, bone cysts, and osteoporosis. Gastrointestinal manifestations are common when serum calcium levels are high. -erum !TH, calcium, and phosphate levels and urine cyclic adenosine monophosphate are

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laboratory tests used to detect hyperparathyroidism. .iuretic and hydration therapies are used most often for reducing serum calcium levels in patients who are not candidates for surgery. The priority nursing interventions focus on monitoring and prevention of in/ury. .rug therapy is used when hydration and furosemide cannot reduce hypercalcemia, or if it is necessary to discontinue 5> fluids. #ther drugs, such as oral phosphates and calcium chelators, can help to reduce the manifestations of hyperparathyroidism, especially those related to hypercalcemia. -urgical management of hyperparathyroidism is a parathyroidectomy. 8hen hyperparathyroidism is due to hyperplasia, three glands plus half of the fourth gland are usually removed. 5f all four glands are removed, a small portion of a gland may be implanted in the forearm, where it produces !TH and maintains calcium homeostasis. &"poparath"roidis is a rare endocrine disorder in which parathyroid function is decreased. 8hether the problem is a lack of !TH secretion or an ineffectiveness of !TH on tissues, the result is the same9 hypocalcemia. 5atrogenic hypoparathyroidism, the most common form, is caused by the removal of all parathyroid tissue during total thyroidectomy or by deliberate surgical removal of the parathyroid glands. 5diopathic hypoparathyroidism can occur spontaneously and may be autoimmune. The physical assessment may show excessive or inappropriate muscle contractions that cause finger, hand, and elbow flexion, signaling an impending attack of tetany. .iagnostic tests for hypoparathyroidism include electroencephalography, blood tests, and computed tomography. 7edical management of hypoparathyroidism focuses on correcting hypocalcemia, vitamin . deficiency, and hypomagnesemia. :ursing management includes teaching about the drug regimen and interventions to reduce anxiety. Teach the patient to eat foods high in calcium but low in phosphorus. %ollaborate with the nutritionist to teach patients about diets that are restricted in calcium or phosphate and include the person who prepares the patient s meals. -tress that therapy for hypocalcemia is lifelong.

'E(IE) 7anifestations of heat intolerance, increased bowel movement, weight loss, and tachycardia reflect possible9 ". Hypoparathyroidism ;. Hypothyroidism %. &"perth"roidis .. Hyperparathyroidism

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