Download Hyperthyroid

Hyperthyroid
Situation:
Charlene Poole is a 38 yo female admitted to the med/surg unit for complaints of chest pain and palpitations with
a RBS of 165mg/dl . NKDA FULL CODE
Background:
PMH: Paroxysmal supraventricular tachycardia PSVT, Rheumatoid Arthritis
SH: Divorced 2 mo ago and has no children
Home meds: Medication for RA, (salycilate base)
Subjective Assessment
I have felt very nervous lately.
I have had some trouble sleeping I just toss and turn so I am tired all the time
No I am not thirsty but I am very hungry all the time and I am eating tons of food but I am losing weight because
my pants are getting very baggy.
I came to the hospital because my chest really hurt and it felt like my heart was going to jump out of my chest.
I have been having trouble with seeing double lately.
Objective Assessment
Height 5 ft 6 weight 110 lbs BP 168/56 (112 pulse pressure) P120, R 24 T 100.1F
H-T assessment: WNL except: Thin, exophthalmos, enlarged area anterior neck soft non tender to palpation. Very
anxious and has trouble paying attention and I having fine hand tremors. DTR’s 4+
Collaborative assessment
Review orders: Ask why? Correlate to the symptoms
12 lead EKG
Remote telemetry
Ck-MB serial Troponin
CMP
CBC with differential
Thyroid panel
Blood glucose monitoring before meals and at bedtime
Results:
12 lead Sinus tachycardia (put strip on Prezi) no ischemia or infarct noted
Cardiac enzymes negative
Thyroid Panel
Value
T3
T4
Hyperthyroid
Increased
Increased
Hypothyroid
Decreased
Decreased
TSH
CMP & CBC normal
decreased
increased
Doctor orders Thyroid scan
Discuss the test and the associated nursing implications for this test:
Evaluates the position, size, and functioning of the thyroid gland.
Radioactive iodine (RAI [123I]) is given by mouth, and the uptake of iodine by the thyroid gland (radioactive iodine
uptake [RAIU]) is measured.
The half-life of 123I is short, and radiation precautions are not needed.
Pregnancy should be ruled out before the scan is performed.
The normal thyroid gland has an uptake of 5% to 35% of the given dose at 24 hours. RAIU is increased in
hyperthyroidism.
Assess whether the patient has undergone procedures or has taken drugs that might affect the results of the scan.
Procedures that use iodine-containing dye (e.g., renography) should not be performed for at least 4 weeks before a
thyroid scan is done.
Any drug that contains iodine should be discontinued for 1 week before the scan .
Nursing Implications:
Explain procedures to the patient.
Check for iodine allergy.
Be sure patient understands that radioactive iodine taken orally is harmless.
No special preparation is required.
Patient should not have supplemental iodine for several weeks before the test.
Thyroid medications interfere with uptake test results.
Charlene is diagnosed with hyperthyroidism.
Hyperthyroid disease? Discuss the pathophysiology of this condition
Discuss causes:
Graves disease: 75% of the cases of hyperthyroidism.
Graves’ Disease: autoimmune disease of unknown etiology: marked by diffuse thyroid enlargement and excessive
thyroid hormone secretion.
Precipitating factors such as insufficient iodine supply, infection, and stressful life events may interact with genetic
factors.
The patient develops antibodies to the TSH receptor.
These antibodies attach to the receptors and stimulate the thyroid gland to release T3, T4, or both causing the
clinical manifestations associated with thyrotoxicosis.
The disease is characterized by remissions and exacerbations with or without treatment.
It may progress to destruction of the thyroid tissue, causing hypothyroidism.
Example: Barbara Bush
Hyperthyroidism occurs in women more than men, with the highest frequency in persons 20 to 40 years old.
Precipitating factors such as insufficient iodine supply, infection, and stressful life events may interact with genetic
factors.
In the United States, where most people use iodized salt, goiter is more often due to the overproduction or
underproduction of thyroid hormones or to nodules that develop in the gland itself.
Dr Orders
Propylthiouracil (PTU) 150 mg every 8 hours orally
Propranolol (Inderal) 20 mg orally 4 times per day
Labs: Liver Profile (AST, ALT, Alk Phos, bilirubin etc Why?
Antithyroid Drugs: 1st line antithyroid drugs:
propylthiouracil (PTU) and methimazole (Tapazole).
Nursing Safety Priority Drug Alert: Both propylthiouracil and methimazole are effective but dangerous drugs.
Propylthiouracil now has a black box warning because it is associated with an incidence of serious liver injury
and liver failure. Methimazole can cause birth defects. The Food and Drug Administration recommends that unless
a patient is pregnant or is allergic to methimazole, propylthiouracil should be avoided. Assess any patient taking
propylthiouracil for manifestations of liver problems (e.g., yellowing of the sclera and skin, dark urine, clay-colored
stools, elevated liver enzymes) (Aschenbrenner, 2009).
Nursing Interventions
Activity intolerance related to fatigue, exhaustion, and heat intolerance secondary to hypermetabolism as evidenced
by complaints of weakness, inability to perform usual activities, short attention span, memory lapses, dyspnea,
tachycardia, irritability
Assess:
 excess physical and emotional fatigue because hyperthyroidism results in protein catabolism, overactivity,
and increased metabolism leading to exhaustion.
 cardiorespiratory response to activity (e.g., tachycardia, other dysrhythmias, dyspnea, diaphoresis, pallor,
blood pressure [BP], and respiratory rate) because tachycardia and BP elevations can indicate excessive
activity.
Treat:
 Assist with regular physical activities (e.g., ambulation, transfers, turning, and personal care) to make
certain patient's daily needs are met. (Lewis 1268)
 Assist the patient to understand energy conservation principles (e.g., the requirement for restricted activity
or bed rest) to avoid fatiguing patient. (Lewis 1268)
 Assist the patient to schedule rest periods. (Lewis 1268)
 Avoid care activities during scheduled rest periods to promote adequate rest periods.
Imbalanced nutrition: less than body requirements r/t hypermetabolism and inadequate food intake as
evidenced by complaints of weight loss; less than optimal body weight
Record intake for nutritional content/calories to evaluate nutritional status.
 Weigh patient at appropriate intervals to evaluate effectiveness of nutritional plan.
 In collaboration with the dietitian, the number of calories and type of nutrients needed to meet nutrition
requirements
 Provide patient with high-protein, high-calorie, nutritious finger foods and drinks that can be readily consumed
because hyperthyroidism increases metabolic rate with resulting need to prevent muscle breakdown and weight
loss.
 Offer snacks (e.g., frequent drinks, fresh fruits/juice) to maintain adequate caloric intake. A high-calorie diet (4000 to
5000 cal/day) may be ordered to satisfy hunger and prevent tissue breakdown.
 Provide appropriate information about nutritional needs and how to meet them to promote self-care.
 Assist the patient in receiving help from appropriate community nutritional programs .
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6 full meals a day and snacks high in protein, carbohydrates, minerals, and vitamins, particularly vitamin
A, thiamine, vitamin B6, and vitamin C.
Protein content should be 1 to 2 g/kg of ideal body weight.
Carbohydrate intake is increased to compensate for increased metabolism.
Carbohydrates provide energy and lessen the use of body-stored protein.
Provide substitutes for caffeine-containing liquids such as coffee, tea, and cola because the stimulating
effects of these fluids increase restlessness and sleep disturbances.
Teach the patient to avoid highly seasoned and high-fiber foods because these foods can further stimulate
the already hyperactive GI tract.
Irritation and dryness..
Nursing interventions to relieve eye discomfort and prevent corneal ulceration
Applying artificial tears to soothe and moisten conjunctival membranes.
Salt restriction may help reduce periorbital edema.
Elevate the patient's head to promote fluid drainage from the periorbital area; the patient should sit upright as
much as possible.
Dark glasses reduce glare and prevent irritation from smoke, air currents, dust, and dirt.
If the eyelids cannot be closed, they should be lightly taped shut for sleep.
To maintain flexibility, teach the patient to exercise the intraocular muscles several times a day by turning the eyes
in the complete range of motion.
Good grooming can be helpful in reducing the loss of self-esteem that can result from an altered body image.
If the exophthalmos is severe, treatment options including corticosteroids, irradiation of retro orbital tissues, orbital
decompression, or corrective lid or muscle surgery may be used.
1. How should the nurse describe the action of the propranolol (Inderal) to Ms Pool?
a. Decreases the size of the thyroid gland
b. Blocks the production of thyroid hormone
c. Reduces symptoms such as palpitations and nervousness
d. Decreases blood flow to the thyroid gland.
Ms. Pool has difficulty swallowing pills and asks for a liquid medication.
The medication prescribed comes in a solution of 10mg/mL. 150/10=15 mL
How many teaspoonfuls will the nurse instruct Ms Pool to take for each dose of 150 mg? 3 teaspoons
9. Which instructions should the nurse include when teaching Ms Pool about the use of PTU?
a. “Call the clinic if the symptoms do not subside within 24 hours.”
b. “You will continue taking this medication the rest of your life.”
c. “Drink this medication with water or fruit juice.”
d. ”Report the onset of a sore throat or fever to the HCP.”
MOA: PTU also blocks peripheral conversion of T4 to T3.
Improvement usually begins 1 to 2 weeks after the start of therapy.
Good results: seen within 4 to 8 weeks.
Therapy: continued for 6 to 15 months to allow for spontaneous remission [occurs in 20% to 40%]
Disadvantages: patient noncompliance and a high rate of recurrence of hyperthyroidism when the drugs are d/c’d
PTU lowers hormone levels more quickly but must be taken three times per day .. pregnancy category D drug.
Lilley Table 31-3
Lifespan considerations include increased sensitivity to the effects of thyroid medications in elderly patients.
Individualization of drug therapy is important with thyroid replacement, because different patients may respond
very differently to the same drug and/or dosage.
Assess:
1. Vital signs and assess for signs and symptoms of thyroid crisis, or what is often called thyroid storm.
2. Cautions and contraindications: interactions with oral anticoagulants (which can cause an increase in
anticoagulation and thus risk for bleeding) and any medications that may lead to bone marrow suppression
4. Monitor complete blood counts to watch for potential problems with leukopenia
5. It is also important to monitor the results of liver function studies during follow-up visits with the prescriber.
TABLE 31-4
ANTITHYROID DRUGS: COMMON ADVERSE EFFECTS
Treat:
1. Antithyroid medications are better tolerated when taken with meals or a snack.
2. Must also be given at the same time every day to maintain consistent blood levels of the drug.
Teach:
1. Dosing the medication with meals to help decrease stomach upset.
2. Report: Any fever, sore throat, mouth ulcers or sores, or skin eruptions, as well as any unusual bleeding or
bruising needs to be reported to the prescriber immediately.
Why? These symptoms may indicate problems of liver and bone marrow toxicity and possible leukopenia.
What is leukopenia?
3. Avoid the use of iodized salt or eating shellfish because of their potential for altering the drug's effectiveness.
4. Be aware of the signs and symptoms of hypothyroidism, including unexplained weight gain, loss of mental and
physical stamina, hair loss, firm edema, and yellow dullness of the skin (indicative of myxedema or a decrease in
metabolic rate).
5. If these occur, patients must report them immediately to the prescriber.
.
6. DO NOT take any over-the-counter medications without first consulting with the prescriber or pharmacist and to
read all drug labels thoroughly.
7. Avoid eating foods high in iodine, such as tofu and other soy products, turnips, seafood, iodized salt, and some
breads. These foods may interfere with the effectiveness of the antithyroid drug .
8. They must never be withdrawn abruptly. Make sure home meds are continued unless contraindicated.
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##After several months of treatment with medication, Ms Pool’s T3 & T4 remain elevated and she is readmitted
with thyroid storm.
Onset of a thyroid storm, a life-threatening event that occurs with uncontrolled hyperthyroidism and is
characterized by high fever and severe hypertension. Immediately report a temperature increase of even one
degree Fahrenheit. If this task is delegated to unlicensed assistive personnel (UAP), instruct them to report the
patient's temperature to you as soon as it has been obtained. If a temperature elevation is reported, immediately
assess the patient's cardiac status. If the patient has a cardiac monitor, check for dysrhythmias.
Chart 66-5 Emergency Care of the Patient During Thyroid Storm
• Maintain a patent airway and adequate ventilation.
• Give antithyroid drugs as prescribed: methimazole (Tapazole), up to 60 mg daily; propylthiouracil (PTU, PropylThyracil ), 300 to 900 mg daily.
• Administer sodium iodide solution, 2 g IV daily as prescribed.
• Give propranolol (Inderal, Detensol ), 1 to 3 mg IV as prescribed. Give slowly over 3 minutes. The patient should
be connected to a cardiac monitor, and a central venous pressure catheter should be in place.
• Give glucocorticoids as prescribed: hydrocortisone, 100 to 500 mg IV daily; prednisone, 4 to 60 mg IV daily; or
dexamethasone, 2 mg IM every 6 hours.
• Monitor continually for cardiac dysrhythmias.
• Monitor vital signs every 30 minutes.
• Provide comfort measures, including a cooling blanket.
• Give non-salicylate antipyretics as prescribed.
• Correct dehydration with normal saline infusions.
• Apply cooling blanket or ice packs to reduce fever.
After being stabilized The HCP offers Ms Pool the option of radioactive iodine (RAI) or surgery.
Treatment of choice for most nonpregnant adults.
(A pregnancy test is done on all women who experience menstrual cycles before initiation of therapy.)
RAI damages or destroys thyroid tissue, thus limiting thyroid hormone secretion.
RAI has a delayed response, and the maximum effect may not be seen for 2 to 3 months .
For this reason, the patient is usually treated with antithyroid drugs and propranolol before and during the first 3 months after
the initiation of RAI until the effects of radiation become apparent.
10. What nursing intervention is appropriate for a client receiving RAI?
a. assess for respiratory stridor
b. assess the client’s voice for hoarsness
c. instruct to avoid hyperextension of the neck
d. encourage the client to drink plenty of fluids.
For Initial Treatment of Severe Hyperthyroidism or Thyrotoxicosis
Iodine and iodine-containing agents: Lugol's solution, Saturated solution of potassium iodide (SSKI),
Dosages vary depending on the agent, how the drug is administered, and the severity of the manifestations
The sudden excess of iodine rapidly inhibits thyroid hormone release and dramatically (but temporarily) resolves the cardiac and
other manifestations of hyperthyroidism. These agents are not recommended for long-term therapy.
Administer these drugs 1 hour after a thionamide has been given.
Initially, the iodine agents can cause an increase in the production of thyroid hormones.
Giving a thionamide first prevents this initial increase in thyroid hormone production.
Check patient for a fever or rash, and ask about a metallic taste, mouth sores, sore throat, or GI distress.
These are manifestations of iodism, a toxic effect of the drugs, and may require that the drug be discontinued.
Chart 66-4
Safety Precautions for the Patient Receiving an Unsealed Radioactive Isotope
• Use a toilet that is not used by others for least 2 weeks after receiving the radioactive iodine.
• Sit to urinate (males and females) to avoid splashing the seat, walls, and floor.
• Flush the toilet three times after each use.
• If urine is spilled on the toilet seat or floor, use paper tissues or towels to clean it up, bag them in sealable plastic bags, and
take them to the hospital's radiation therapy department.
• Men with urinary incontinence should use condom catheters and a drainage bag rather than absorbent gel-filled briefs or pads.
• Women with urinary incontinence should use facial tissue layers in their clothing to catch the urine rather than absorbent gelfilled briefs or pads.
• Using a laxative on the second and third days after receiving the radioactive drug helps you excrete the contaminated stool
faster (this also decreases the exposure of your abdominal organs to radiation).
• Wear only machine-washable clothing, and wash these items separate from others in your household.
• After washing your clothing, run the washing machine for a full cycle on empty before it is used to wash the clothing of others.
• Avoid close contact with pregnant women, infants, and young children for the first week after therapy. Remain at least 3 feet
(about 1 meter) away from these people, and limit your exposure to them to no more than 1 hour daily.
• Some radioactivity will be in your saliva during the first week after therapy. Precautions to avoid exposing others to this
contamination (both household members and trash collectors) include:
•Not sharing toothbrushes or toothpaste tubes
•Using disposable tissues, rather than cloth handkerchiefs, and either flushing used ones down the toilet or keeping them in a
plastic bag and turning them in to the radiation department of the hospital for disposal
•Use disposable utensils, plates, and cups
•Selecting foods that can be eaten completely and do not result in a saliva-coated remnant (Foods to avoid are fruit with a core
that can be contaminated, meat with a bone [e.g., chicken wings or legs, ribs])
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Ms Pool decides that a thyroidectomy is the best choice for her.
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Discuss thyroidectomy:
Surgery: The patient is usually given antithyroid drugs and iodine to produce a euthyroid state and possibly βadrenergic blockers to relieve symptoms preoperatively.
Thyroidectomy : indicated for individuals with
1) a large goiter causing tracheal compression,
2) have been unresponsive to antithyroid therapy, or
3) have thyroid cancer,
4) individual is not a candidate for RAI.
Pre Op Nursing care: If time I will review
Assess: Understanding of surgery, VS, pre op ck list
Treat:
1. To alleviate thyrotoxicosis, iodine treatment or PTU may be used before surgery.
2. Iodine is mixed with water or juice, sipped through a straw, and administered after meals.
3. Assess the patient for signs of iodine toxicity such as swelling of the buccal mucosa and other mucous
membranes, excessive salivation, nausea and vomiting, and skin reactions.
4. If toxicity occurs, iodine administration should be discontinued and the health care provider notified.
Teach:
1. comfort and safety measures.
2. coughing, deep breathing, and leg exercises and instruct the patient on their importance.
3. how to support the head manually while turning in bed, because this maneuver minimizes stress on the suture line
after surgery.
4. Range-of-motion exercises of the neck should be practiced.
5. Routine postoperative care such as IV infusions.
6. Tell the patient that talking is likely to be difficult for a short time after surgery
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After surgery and an hour in PACU Ms Pool returns to the nursing unit. She is drowsy but arousable.
Her VS: T98, P88, R 14, BP 110/72. Her breath sounds are clear bilaterally. Her IV is infusing at 125ml/hr. She
reports incisional pain 4/10. Humidified oxygen titrated to keep O2 sat> 96%
Slide 20 Post op orders;
Levothyroxine 50 mcg orally per day
VS q2h
Trach set at bedside
Lytes in AM
CBC in am
NPO
IV D5W 0.45& NS @ 125mL/hr
After a thyroidectomy do the following:
1.Assess the patient every 2 hours for 24 hours for signs of hemorrhage or tracheal compression such as irregular
breathing, neck swelling, frequent swallowing, sensations of fullness at the incision site, choking, and blood on the
anterior or posterior dressings.
2.Place the patient in a semi-Fowler's position and support the patient's head with pillows, and avoid flexion of the
neck and any tension on the suture lines.
3.Monitor vital signs. Complete the initial assessment by checking for signs of tetany secondary to
hypoparathyroidism (e.g., tingling in toes, fingers, or around the mouth; muscular twitching; apprehension) and by
evaluating difficulty in speaking and hoarseness. Trousseau's sign and Chvostek's sign should be monitored for 72
hours Expect some hoarseness for 3 to 4 days after surgery because of edema.
4.Control postoperative pain by giving medication.
5. If postoperative recovery is uneventful, the patient is ambulated within hours after surgery, is permitted to take
fluid as soon as tolerated, and eats a soft diet the day after surgery.
The appearance of the incision may be highly distressing to the patient.
Reassure the patient that the scar will fade in color and eventually look like a normal neck wrinkle.
A scarf, jewelry, a high collar, or other covering can effectively camouflage the scar.
Iggy:Problems
1.
Hemorrhage is most likely to occur during the first 24 hours after surgery.
Inspect the neck dressing and behind the patient's neck for blood.
A drain may be present, and a moderate amount of serosanguineous drainage is normal. Hemorrhage may be seen as bleeding at the
incision site or as respiratory distress caused by tracheal compression.
2.
Respiratory distress can result from swelling, tetany, or damage to the laryngeal nerve resulting in spasms. Laryngeal stridor (harsh,
high-pitched respiratory sounds) is heard in acute respiratory obstruction. Keep emergency tracheostomy equipment in the patient's
room. Check that oxygen and suctioning equipment are nearby and in working order.
Nursing Safety Priority Critical Rescue
When stridor, dyspnea, or other symptoms of obstruction appear after thyroid surgery, notify the Rapid
Response Team. In some agencies, nurses can remove clips or sutures when medical assistance is not
immediately available and swelling at the surgical site is obstructing the airway.
3.
4.
5.
Hypocalcemia and tetany may occur if the parathyroid glands are removed, damaged or their blood supply is impaired during thyroid
surgery, resulting in decreased parathyroid hormone (PTH) levels.
Ask the patient hourly about tingling around the mouth or of the toes and fingers.
Assess for muscle twitching as a sign of calcium deficiency.
Calcium gluconate or calcium chloride for IV use should be available in an emergency situation. (For information on the later signs of
hypocalcemia, see the discussion of postoperative care on p. 1407 in the Hyperparathyroidism section, and p. 1408 in the Assessment
discussion in the Hypoparathyroidism section. The care of patients with hypocalcemia is also discussed in Chapter 13.)
Laryngeal nerve damage may occur during surgery. This problem results in hoarseness and a weak voice. Assess the patient's voice at
2-hour intervals, and document any changes. Reassure the patient that hoarseness is usually temporary.
Thyrotoxic crisis (also called thyroid storm) is an acute, rare condition in which all hyperthyroid manifestations are heightened.
Although it is considered a life-threatening emergency, death is rare when treatment is initiated early.
Thyrotoxic crisis is thought to result from stressors (e.g., infection, trauma, surgery) in a patient with preexisting hyperthyroidism,
either diagnosed or undiagnosed.
Heart and nerve tissues become more sensitive to sympathetic nervous system activation due to more binding sites for epinephrine and
norepinephrine.
Manifestations include severe tachycardia, heart failure, shock, hyperthermia (up to 105.3° F [40.7° C]), restlessness, agitation,
seizures, abdominal pain, nausea, vomiting, diarrhea, delirium, and coma.
Discuss thyroid hormone replacement:
Levothyroxine (Synthroid) is the drug of choice.
In the young and otherwise healthy patient, the maintenance replacement dose is adjusted according to the patient's
response and laboratory findings.
In the older adult patient and the person with compromised cardiac status, a smaller initial dose is recommended
because the usual dose may increase myocardial oxygen demand.
The increased oxygen demand may cause angina and cardiac dysrhythmias.
Any chest pain experienced by a patient starting thyroid replacement should be reported immediately, and an
electrocardiogram (ECG) and serum cardiac enzyme tests must be performed. (Lewis 1271)
DRUG ALERT—
Levothyroxine (Synthroid)
•Carefully monitor patients with cardiovascular disease.
•Monitor heart rate and report pulse greater than 100 beats/min.
•Promptly report chest pain, weight loss, nervousness, tremors, insomnia. (Lewis 1271)
TABLE 31-2
TABLE 31-3
THYROID DRUGS: COMMON ADVERSE EFFECTS (Lilley 504)
THYROID DRUGS: INTERACTIONS (Lilley 504)
A common medication error is to write the intended dose in milligrams instead of micrograms. If not caught, this error would result in a
thousandfold overdose.
Doses higher than 200 mcg need to be questioned in case this error has occurred. Levothyroxine is available in an intravenous form. The
intravenous dose is generally 50% of the oral dose.
PATIENT-CENTERED CARE: LIFESPAN CONSIDERATIONS FOR THE ELDERLY PATIENT
Thyroid Hormones
•Elderly patients are much more sensitive to thyroid hormone replacement drugs (as they are to most drugs). They are also more likely to
experience adverse reactions to thyroid hormones than are patients in any other age group.
•Elderly patients experience more negative consequences related to drug therapy because their hepatic and renal functioning is decreased.
•Thyroid hormone replacement requirements are approximately 25% lower in patients 60 years of age and older than in younger patients.
Dosage in elderly patients may therefore need to be adjusted or titrated downward.
•Elderly patients must contact the prescriber immediately if they experience palpitations, chest pain, stumbling, falling, depression, incontinence,
sweating, shortness of breath and/or aggravated heart disease, cold intolerance, or weight gain.
•Drug therapy for elderly patients must be initiated with caution and with very individualized dosages. If higher dosages are necessary, increases
must be made with the prescriber's guidance and done gradually. (Lilley 506)
Complication: The day after surgery Ms Pool begins to complain of numbness and tingling in her
arms, and feelings of anxiety and agitation. She tells the nurse her heart I racing and she is short of
breath. Physical assessment reveals VS: 99, P135 and regular, R 30 and moderately labored. BP
94/60. Lungs are clear. Her dressing is dry and intact, she denies dysphagia or choking sensation.
The nurse suspects that she is experiencing hypocalcemia.
15. What assessment technique should the nurse perform to assess for hypocalcemia?
a. Assess for Battle’s sign
b. Elicit a Babinski’s sign
c. Perform a Allen’s test
d. Assess for Chvostecks sign
The additional assessment for hypocalcemia is positive;
16. Which nursing action should be implemented immediately?
a. Set the defibrillator for 200 joules.
b. Place her in the shock position
c. Confirm that a tracheostomy set, suction, and O2 are at the bedside.
Reduce Ms Pool’s IV KVO of 20mL/hr.
d.
SAFETY ALERT
•Although not common, airway obstruction may occur postoperatively.
•Airway obstruction is an emergency situation.
•Oxygen, suction equipment, and a tracheostomy tray should be readily available in the patient's room .
Complications:
1.
2.
3.
Recurrent laryngeal nerve damage leads to vocal cord paralysis. If there is paralysis of both cords, spastic airway
obstruction will occur, requiring an immediate tracheostomy.
Respiration may also become difficult because of excess swelling of the neck tissues, hemorrhage, hematoma
formation, and laryngeal stridor.
Laryngeal stridor (harsh, vibratory sound) may occur during inspiration and expiration as a result of edema of the
laryngeal nerve.
Laryngeal stridor may also be related to tetany, which occurs if the parathyroid glands are removed or damaged
during surgery, leading to hypocalcemia. To treat tetany, IV calcium salts such as calcium gluconate or gluceptate
should be available.
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nurse notifies the HCP immediately regarding her condition.
The HCP orders stat labs (serum Ca, Mg, Phos, and CBC), an ECG, and IV medication be given.
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17. The nurse would expect to administer which medication to treat Ms Pool’s hypocalcemia?
a. Calcium gluconate
Calcitonin
Calcitrol (Rocaltrol)
(Mithracin)
The
b.
c.
d. Picamycin
Discuss the difference in these medications:To treat tetany, IV calcium salts such as calcium gluconate or gluceptate
should be available. Calcium gluconate can be given IV and there is a rapid onset. This will correct the problem faster. Make
sure the IV is patient. Look up in the Davis Drug guide.
Calcitonin, in its drug forms, is derived from salmon (fish) sources. Although it is available in both injectable
form and nasal spray, the nasal spray (Miacalcin) is now more commonly used. (Lilley 554)
Common adverse effects of calcitonin include flushing of the face, nausea, diarrhea, and reduced appetite. (Lilley
553)
Calcium supplements and antacids can interfere with the absorption of the bisphosphonates, and therefore they need
to be spaced 1 to 2 hours apart to avoid this interaction.
Calcium supplements, although often needed by patients with osteoporosis, are also more likely to cause
hypercalcemia in patients receiving calcitonin.
Ambulatory and Home Care: Postoperative Care
The patient and family need to be aware that thyroid hormone balance should be monitored periodically to ensure that normal
function has returned.
Most patients experience a period of relative hypothyroidism soon after surgery because of the substantial reduction in the size of
the thyroid.
However, the remaining tissue usually hypertrophies, recovering the capacity to produce hormones, but this takes time.
The administration of thyroid hormone is avoided because exogenous hormone inhibits pituitary production of TSH and delays
or prevents the restoration of normal gland function and thyroid tissue regeneration.
Caloric intake must be reduced substantially below the amount that was required before surgery to prevent weight gain.
Adequate iodine is necessary to promote thyroid function, but excesses can inhibit the thyroid gland.
Seafood once or twice a week or normal use of iodized salt should provide sufficient intake. Encourage regular exercise to
stimulate the thyroid gland.
Teach the patient to avoid high environmental temperatures because they inhibit thyroid regeneration.
Regular follow-up care is necessary.
The patient should be seen biweekly for a month and then at least semiannually to assess for the development of
hypothyroidism.
If a complete thyroidectomy has been performed, instruct the patient about the need for lifelong thyroid
replacement.
Teach the patient the signs and symptoms of progressive thyroid failure and instruct him or her to seek medical care
if these develop.
Hypothyroidism is relatively easy to manage with oral administration of thyroid replacement .
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Several months later Ms Pool is readmitted with the diagnosis of myxedema because she
ran out of medication 
Nursing Safety Priority Action Alert
Myxedema coma can lead to shock, organ damage, and death. Assess the patient with hypothyroidism at least
every 8 hours for changes that indicate increasing severity, especially changes in mental status, and report these
promptly to the health care provider (Simmons, 2010).
Chart 66-7 Emergency Care of the Patient During Myxedema Coma
• Maintain a patent airway.
• Replace fluids with IV normal or hypertonic saline, as prescribed.
• Give levothyroxine sodium IV as prescribed.
• Give glucose IV as prescribed.
• Give corticosteroids as prescribed.
• Check the patient's temperature hourly.
• Monitor blood pressure hourly.
• Cover the patient with warm blankets.
• Monitor for changes in mental status.
• Turn every 2 hours.
• Institute Aspiration Precautions.
Imbalanced nutrition: more than body requirements r/t calorie intake in excess of metabolic rate as evidenced by
weight gain secondary to hypometabolism.
Assess: Ideal body weight to plan weekly weight loss goals.
Determine, in collaboration with dietitian, number of calories and type of nutrients needed to meet nutrition
requirements.
Monitor recorded intake for nutritional content and calories to evaluate patient's management of nutrition.
Weigh patient at appropriate intervals to monitor progress toward target weight.
Treat:
Assist in developing well-balanced meal plans consistent with level of energy expenditure.
Develop with the individual a method to keep a daily record of intake, exercise sessions, and/or changes in body
weight to promote progress toward final goal.
Teach: ????
Provide appropriate information about nutritional needs and how to meet them so patient will be more agreeable to
dietary restrictions.
Discuss with individual the relationship between food intake, exercise, weight gain, and weight loss to promote
understanding of weight management.
Constipation r/t GI hypomotility as evidenced by irregular, hard stools
•Instruct patient/family on high-fiber diet to increase knowledge of how to increase fecal mass.
Assess: Monitor bowel movements, including frequency, consistency, shape, volume, and color, to plan
appropriate interventions.
Treat: •Suggest use of laxatives/stool softeners to stimulate bowel evacuation.
•Encourage increased fluid intake (e.g., 2-3 L of fluids per day) to maintain soft stool
Teach:
patient/caregivers about timeframe for resolution of constipation because elimination patterns will improve
with treatment of hypothyroidism
Impaired memory r/t hypometabolism AEB: forgetfulness, memory loss, somnolence, and personality changes
Assess:
•Changes in orientation, cognitive and behavioral functioning, and quality of life to determine appropriate
interventions.
Treat: •Inform patient of person, place, and time to decrease confusion.
•Speak to patient in slow, distinct manner with appropriate volume to allow patient to understand.
•Avoid requests that exceed the patient's capacity (e.g., abstract thinking when patient can think only in concrete
terms, decision making beyond preference or capacity) to decrease frustration and loss of self-esteem.
•Use environmental cues (e.g., signs, pictures, clocks, calendars) to maintain orientation to time and day.
Provide a low-stimulation environment for patient in whom disorientation is increased by overstimulation.
Fatigue r/t decreased metabolic rate, anemia, decreased cardiac output, and neurologic changes AEB:
compromised concentration, increase in rest requirements, lack of energy, lethargy, disinterest in surroundings,
and verbalization of an overwhelming lack of energy
Assess:
•physiologic status for deficits resulting in fatigue to determine extent of problem and plan appropriate
interventions.
•for evidence of excess physical and emotional fatigue to evaluate effectiveness of treatment.
•cardiorespiratory response to activity (e.g., pulse rate, cardiac rhythm, respiratory rate) to determine effect of
activities and plan activity increases.
Monitor/record patient's sleep pattern and number of sleep hours as sleep patterns are often altered in fatigue.
Treat:
•Encourage alternate rest and activity periods to prevent fatigue.
Promote bed rest/activity limitation (e.g., increase number of rest periods) to improve patient's tolerance and
comfort level.
•Plan activities for periods when the patient has the most energy to allow maximum participation. Teach activity
organization and time management techniques to prevent fatigue.
Ms Pools symptoms subside and her TSH levels remain WNL, and she remains on a constant dose of thyroid
medication without any further problems.
Outcome: She remains euthyroid and reports feeling like her “old self”.
TABLE 50-7
1266)
COMPARISON OF HYPERTHYROIDISM IN YOUNGER AND OLDER ADULTS (Lewis
Hypothyroid care
Cause hypothyroid: Most cases of hypothyroidism in the United States occur as a result of thyroid surgery and
radioactive iodine (RAI) treatment of hyperthyroidism.
TABLE 66-2 CAUSES OF HYPOTHYROIDISM
Primary Causes: Decreased Thyroid Tissue
•
Surgical removal of the thyroid
•
Radiation-induced thyroid destruction
•
Autoimmune thyroid destruction
Chronic
autoimmune thyroiditis (Hashimoto's thyroiditis) can lead to hypothyroidism which thyroid tissue is replaced by
lymphocytes and fibrous tissue.
It is the most common cause of hypothyroid goiters in the United States.
Silent painless thyroiditis is a form of lymphocytic thyroiditis with a variable onset.
In women, this condition may occur in the postpartum period and usually resolves within 3 to 12 months.
It is believed to be an autoimmune disease and may be early Hashimoto's thyroiditis.
Thyroid hormone levels [T3 & T4] are usually low in chronic Hashimoto's thyroiditis, and the TSH level is high.
• Congenital thyroid agenesis
• Congenital thyroid hypoplasia
•
Congenital thyroid dysgenesis
•
Cancer (thyroidal or metastatic)
Decreased Synthesis of Thyroid Hormone
• Endemic iodine deficiency
• Excessive exposure to iodine
• Drugs:Lithium, Phenylbutazone, Propylthiouracil, Sodium or potassium perchlorate, Aminoglutethimide