ENDOCRINE STUDY GUIDE HEALTH HISTORY Changes in growth and dev Difficulty swallowing Increased/decreased thirst, appetite, urination

Sleep patterns/disturbances Visual changes Altered patterns of hair distribution, hair texture, skin texture, and nails Changes in menstruation and/or libido Changes in memory or ability to concentrate Changes in energy level Recent injuries and medical treatments (esp. those involving the head), and hospitalizations Use of medications, supplements, ETOH, drugs, steroids, smoking Diet, exercise Means of coping Consider genetic predispositions DM, thyroid disorders, obesity, HTN NARROW THE FOCUS: Onset Characteristics Severity Precipitating factors Associated symptoms AGE RELATED CHANGES Pituitary- decreased ACTH, TSH, FSh Thyroid- increased fibrosis, decreased activity Adrenal gland- decreased response to norepinephrine Pancreas- delayed and decreased insulin release and decreased sensitivity to insulin PHYSICAL ASSESSMENT Assess height/weight [BMI] body stature and proportions Measure vital signs Observe distribution of muscle mass and fat distribution- hyper-thin, hypo-overweight Assess condition and pigmentation of skin Assess condition of nails, texture and distribution of hair Inspect eyes for bulging- hyperthyroidism Observe for enlargement of neck and quality of voice Palpate thyroid gland for size and consistency Assess deep tendon reflexes-hyperthyroidism exaggerated response, hypo- minimized response Assess sensory function

HYPOTHYROIDISM

HYPERTHYROIDISM

BASIC INFO

-Most common in women ages 30-60 -Metabolic rate, heat function, and all body functions decrease -If present at birth and untreated cretinism -Myexedema= longterm, untreated cases

CAUSE

CLINICAL MANIFESTATION S

-Autoimmune, Hashimotos most common cause -Atrophy of gland with aging -Therapy for hyperthyroidism -Medications Inderal, Amiodarone, Lithium, anabolic steroids, Dilantin -Iodine deficiency EAT TABLE SALT!! -Radiation -Infiltrative diseases- scleroderma, amyloidosis -Ingestion of large amounts of goitrogenic foods cabbage, spinach, collard greens, Brussels sprouts, broccoli, soy beans, pears, peaches, peanuts, sweet potatoes, strawberries Goiter Fatigue, muscle weakness, muscle sniffness Hair loss, brittle nails Coarse, dry skin Nonpitting edema, periorbital edema Decreased appetite, weight gain Constipation Cold intolerance Irregular period, infertility, decreased libido Hypotension, bradycardia, cardiomegaly Decreases reflexes, hand/foot paresthesias Thick tongue/Slow speech, memory impairment Personality changes, depression, apathy

-Second most prevalent endocrine disorder, more common in women -Increased metabolic rate and SNSs response to stimulation Heart rate, cardiac output and peripheral blood flow increase Oxygen consumption and temp increase carbs, protein and lipid metabolism increase resulting in caloric and nutritional deficiencies -Autoimmune Graves disease. -Thyroiditis -Excessive ingestion of thyroid hormone replacement or iodine -Neoplasms (growths)toxic multinodular goiter -Pituitary adenoma malignant pituitary cancer

COMPLICATION

Myexedema Coma Life threatening, severe stage of hypothyroidism Triggered by acute illness or trauma OR failure to take prescribed meds Normal doses of opiates may cause death Demerol, dilaudid, morphine Clinical manifestations: Unconsciousness Hypothermia, very low temperature Hypoventilation Hyponatremia, hypoglycemia, lactic acidosis Shock and cardiovascular collapse

Goiter Exophthalmos (Graves) Fine, thin hair Fatigue, weakness, muscle wasting Weight loss Nervousness, Insomnia Tachycardia, dysrhythmiasPVCs, afib, palpatitations Increased systolic pressure Diarrhea Heat intolerance Diaphoresis, warm and flushed skin Amenorrhea, decreased libido Fine tremors of hands Photophobia, diplopia, blurred vision Ventricular hypertrophy, heart failure, angina Thyroid Storm Extreme state of hyperthyroidism D/t stressor or manipulation of thyroid during surgery thyroidectomy Critically ill and fatal if untreated S&SHyperpyrexia- fever > 106.7 Tachycardia, systolic hypertension, dysrhythmias Abdominal pain, vomiting, diarrhea, weight loss Respiratory distress Confusion, delirium, coma, seizures TA (thyroglobulin antibody) testGraves Serum TSH decreased Serum T4 increased

Dx FINDINGS

Decreased serum T3 not secreting enough Decreased serum T4 not secreting enough Elevated serum TSH ant pit producing too much

T3RU (T3 resin uptake) decreased Serum cholesterol elevated gaining weight Thyroid scan size and shape of gland Radioactive T3 reuptake test decreased iodine not uptook MEDICAL MGMT

Serum T3 increased Increased RAI uptake Thyroid scan Auscultate a bruit- increased blood flow in gland
Iodine solutions Lugols Solution, SSKI (potassium iodide), sodium iodide Decrease release of TH, reduce vascularity of thyroid and decrease its size; may take 10 15 days to be effective Assess for iodine/shell fish allergies Dilute in full glass of milk or OJ [taste] and administer with straw Increases bleeding tendencies with anticoagulants SSKI blocks uptake of any external radioactive iodine from incidental nuclear accident to prevent thyroid damage Antithyroid drugs methimazole (Tapazole) or propylthiouracil (PTU) Inhibit production of TH May take up to 12 weeks to get desired effects; do not stop abruptly Tapazole crosses placeta NOT during preg Monitor for side effects agranulocytosis, thrombocytopenia, rash, anorexia, hypothyroidism CBC, WBC, plt --reg basis Beta blockers Rapidly control SNS symptoms Assess for bradycardia and heart failure Use with caution in patients with heart failure, COPD, DM RadioIodine Therapy Thyroid gland takes up I131 and destroys thyroid cells Given PO; is tasteless and odorless Takes 6 8 weeks for full results to occur Avoids many side effects of antithyroid drugs but may initially cause thyroiditis and storm Contraindicated in pregnancy and breast feeding May develop hypothyroidism later in life Total Thyroidectomy Surgical removal of thyroid Generally subtotal thyroidectomy is sufficient Performed in special instances Total thyroidectomy performed to treat cancer Antithyroid meds given preop to reduce hormone levels [radioactive] Iodine given to reduce vascularity and size

Levothyroxine (T4)-Levoxyl, Synthroid [mcg] Liothyronine (T3)-Cytomel Liotrix (T3-T4)-Euthyroid, Thyrolar Subtotal thyroidectomy- if goiter causes respiratory difficulties or dysphagia Maintenance of vital functions o Patent airway o Respirations o Cardiovascular status o Fluid, electrolytes, acid-base balance IV thyroid hormones Correction of hypothermia Correction of F&E imbalance, lactic acidosis Treatment of precipitating factors- pneu, DM etc.

of thyroid

NURSING INTERVENTIONS

EDUCATE

Monitor VS, pulse oximetry, ABGs Provide warm environment- NO heat pad or water bottle Avoid application of external heat Advise patient to report chest pain immediately Assess for and avoid constipation Monitor for signs of Lanoxin toxicity if patient on Lanoxin Monitor for signs of increased bleeding if patient on anticoagulants Monitor for increased effects of TH if patient on Dilantin or tricyclic antidepressants Instruct patient on low calorie, low cholesterol, high fiber diet Monitor blood sugars closely risk for DM Avoid sedatives and narcotics Administer thyroid replacement Take meds 1 hour before or 2 hours after meals Calcium supplement is recommended Taking calcium within 4 hours of meds decreases absorption Do not substitute brands of drugs or generics without physician approval no over sea drugs! If diabetic monitor glucose more closely If on anticoagulants report signs and symptoms of bleeding immediately Avoid excessive intake of foods known to inhibit TH Report symptoms of excess hormone to physician S&S of hyperthyroidism

NURSING DX

Decreased CO Constipation Risk for impaired skin integrity

Assess VS, heart and lung sounds, JVD HF from increased SNS stimulation Provide a cool, quiet environment Minimize stress Provide for periods of uninterrupted rest Monitor daily weights Provide for diet high in carbs, proteins, calories, minerals and vitamins with supplemental feedings Avoid stimulants Admin meds Prevent complications including eye injury Teach measures for protecting eyes from injury Use tinted glasses or shields Use artificial tears to moisten Cover or tape eyelids shut at night if lids dont close Elevate HOB 45 degrees to promote decrease in periorbital fluid/edema Promptly report any eye pain or changes in vision Educate about meds and need for long term follow-up No ASA!!!- aspirin displaces thyroid hormone and makes serum levels higher Risk for decreased CO Imbalanced nutrition Disturbed body image and anxiety

PRE-OP THYROIDECTOMY
-Administer antithyroid meds, iodine preparations, beta blockers -Teach patient to support neck when moving about -Teach patient to expect hoarseness postoperatively edema, intubation or from laryngeal spasm [permanent hoarseness or loss of vocal volume is potential danger]

POST-OP THYROIDECTOMY
Monitor VS, I&O Provide comfort measures Elevate HOB to minimize swelling/fluid Monitor for hemorrhage Back of neck, upper shoulders Monitor for respiratory distress/swelling Lose airway Trach tray available at bedside Monitor for tetany (hypocalcemia) IV Ca chloride or Ca gluconate Monitor for thyroid storm Relieve sore throat Encourage voice rest, humidify air, cool mist

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