THYROID

DISORERS
ENDEMIC
GOITER
The most common type of goiter, once
encountered chiefly in geographic regions
where the natural supply of iodine is deficient.
• Caused by an iodine deficiency; intake of large quantities of
goitrogenic substances (excessive amounts of iodine or
lithium, which is used in treating bipolar disorders).
• Such goiters usually cause no symptoms, except for the
swelling in the neck, which may result tracheal
compression when excessive.
• Many goiters of this type recede after the iodine imbalance
is corrected.
Medical Treatment

Supplementary iodine, such as SSKI to suppress the pituitary’s thyroid-

stimulating activity.

2. Ensure a preoperative euthyroid state through treatment with antithyroid

medications and iodide to duce the size and vascularity of the goiter before
surgery to minimize postoperative complications.

3. Provide children in iodine-poor regions with iodine compounds to prevent

simple or endemic goiter. The introduction of iodized salt has been the single
most effective means of preventing goiter in at-risk populations.
Nodular Goiter

Some thyroid glands are nodular because of areas of hyperplasia (overgrowth). No

symptoms may arise as a result of this condition, but not uncommonly these nodules
slowly increase in size, with some descending into the thorax, where they cause local
pressure symptoms. Some nodules become malignant, and some are associated with a
hyperthyroid state. Therefore, the patient with many thyroid nodules may eventually require
surgery.

-
Thyroid Cancer

- Cancer of the thyroid is much less prevalent than other forms of cancer; however, it
accounts for 90% of endocrine malignancies.
- With one-fourth of the cases occurring in men and three-fourths in women.
- External radiation of the head, neck, or chest in infancy and childhood increases the risk
of thyroid carcinoma. The incidence of thyroid cancer appears to increase 5 to 40 years
after irradiation. Consequently, people who underwent radiation treatment or were
otherwise exposed to radiation as children should consult a physician, and request an
isotope thyroid scan as part of the evaluation.
Assessment & Diagnostic Findings

1. Lesions that are single, hard, and fixed on palpation or associated with cervical
lymphadenopathy suggest malignancy.

2. Thyroid function tests

3. Needle biopsy of the thyroid gland - used as an outpatient procedure to make a diagnosis of
thyroid cancer, to differentiate cancerous thyroid nodules from noncancerous nodules, and to
stage thncer if detected.

4. Additional diagnostic studies: Ultrasound, MRI, CT, Thyroid scans, Radioactive iodine uptake
studies, and Thyroid suppression tests.
Surgical
Management

- Total or Near-total Thyroidectomy

- The treatment of choice for

thyroid carcinoma is surgical removal.

- Efforts are made to spare

parathyroid tissue to reduce the risk of
postoperative hypocalcemia and tetany.
Diagnostic Tests for Thyroid
Problems
1. Thyroid-stimulating hormone (TSH): Normal 0.4 to 4.0 mU/L
- Best screening test for thyroid function; used for monitoring thyroid hormone replacement
2. Serum Free T4: Normal: 0.9 to 1.7 ng/dL
- Active fraction and most commonly used to confirm an abnormal TSH; direct measurement of
unbound Thyroxine;
- the procedure of choice for monitoring changes in T4 secretion during treatment of hyperthyroidism
3. Serum T3: Normal: 70 to 220 ng/dL
- More accurate indicator of hyperthyroidism
4. Serum T4: Normal range: 4.5 to 11.5 ug/dL
5. T3 Resin Uptake Test: Normal: 25%-35%

- Useful in the evaluation of thyroid hormone levels in patients who have received diagnostic or
therapeutic doses of iodine.

6. Thyroid Antibodies

- Are positive in chronic autoimmune thyroid disease (90%), Hashimoto’s thyroiditis (100%),
Graves’ disease (80%)
7. Radioactive Iodine Uptake
- Measures the rate of iodine uptake by the thyroid gland. The patient is administered a tracer dose of iodine 123
(123I) or another radionuclide, and a count is made over the thyroid gland with a scintillation counter, which
detects and counts the gamma rays released from the breakdown of 123I in the thyroid.
8. Fine-Needle Aspiration Biopsy
- Accurate method of detecting malignancy.
9. Thyroid Scan, Radioscan, or Scintiscan
- Are helpful in determining the location, size, shape, and anatomic function of the thyroid gland, particularly when
thyroid tissue is substernal or large. Identifying areas of increased function (“hot” areas) or decreased function
- (“cold” areas) can assist in diagnosis.
 HYPERTHYROIDISM HYPOTHYROIDISM
• Excessive secretion of thyroid A deficiency in thyroid hormones
hormones. It is the second most Types
prevalent endocrine disorder, after 1. Primary Hypothyroidism
diabetes mellitus. 2. Secondary/Pituitary
Hypothyroidism
• Graves’ disease: the most 3. 3. Tertiary/Hypothalamic
common type of hyperthyroidism Hypothyroidism
4. 4. Cretinism

Definition
 RISK FACTORS/CAUSES

HYPERTHYROIDISM HYPOTHYROIDISM
Women; Stress; Infection; Inflammation after Women; between 40 and 70 years;
irradiation of Autoimmune disease
the thyroid; Destruction of thyroid tissue by (Hashimoto’s thyroiditis, post-Graves’
tumor; disease); Atrophy of
Excessive administration of thyroid hormone thyroid gland with aging; Therapy for
for treatment hyperthyroidism;
of hypothyroidism Thyroidectomy; Medications: Lithium, Iodine
compounds,
Antithyroid medications; Radiation to head
and neck;
Infiltrative diseases of the thyroid
(amyloidosis,
scleroderma, lymphoma); Iodine deficiency
and iodine
excess
CLINICAL MANIFESTATIONS
HYPERTHYROIDISM HYPOTHYROIDISM
Thyrotoxicosis: Nervousness; Emotionally Extreme fatigue; Hair loss, brittle nails, and dry skin are
hyperexcitable; common; Numbness and tingling of the finger; Husky
Irritable; Apprehensive; Cannot sit quietly; Palpitations; and
Increased temperature, pulse, and blood pressure hoarseness of voice; Menorrhagia or Amenorrhea; Loss
(heart of
failure/atrial fibrillation); Heat intolerance; Flushed libido: Decreased temperature, pulse rate, and blood
warm pressure; Weight gain; Anorexia: Expressionless and
skin; Dry skin and diffuse pruritus; Fine tremor of the masklike face; Cold intolerance; Apathetic; Speech is
hands; slow;
May exhibit exophthalmos (bulging eyes: irreversible); Tongue enlarges; Hands and feet increase in size;
Increased appetite; Weight loss; Abnormal muscular Deafness may occur; Constipation.
fatigability and weakness; Amenorrhea; Osteoporosis Severe case:
and fracture; Diarrhea; Increased perspiration Dementia; Inadequate ventilation and sleep apnea;
Pleural effusion; Pericardial effusion; Respiratory
muscle
weakness; Hypercholesterolemia; Atherosclerosis,
Coronary artery disease, Hypothermic; Abnormally
sensitive to sedatives, opioids, and anesthetic agents
Patient with
Hyperthyroidism
Patient with
Hypothyroidism
COMPLICATIONS

HYPERTHYROIDISM HYPOTHYROIDISM
Thyroid Storm Myxedema Coma
A life-threatening condition manifested by Is a rare life-threatening condition; a
cardiac decompensated
dysrhythmias, tachycardia, fever, and state of severe hypothyroidism in which the
neurologic patient is
impairment hypothermic, with depressed respiration, and
unconscious.
Occurs most often among elderly women,
precipitated by
cold.
ASSESSMENT AND DIAGNOSTIC
FINDINGS
HYPERTHYROIDISM HYPOTHYROIDISM
Thyroid gland invariably is enlarged, soft and 1. TSH: increased
may pulsate a thrill often can be palpated, and 2. Free T4: decreased
a bruit is heard over the 3. T3: decreased
thyroid arteries. 4. T4: decreased
1. TSH: decreased 5. T3 Resin Uptake Test: decreased
2. Free T4: increased 6. Thyroid Antibodies: Are positive in chronic
3. T3: increased autoimmune thyroid disease (90%),
4. T4: increased Hashimoto’s thyroiditis (100%), Graves’
5. T3 Resin Uptake Test: increased disease (80%)
6. Thyroid Antibodies: Are positive in chronic 7. Radioactive Iodine Uptake: low uptake
autoimmune thyroid disease (90%),
Hashimoto’s thyroiditis (100%), Graves’
disease (80%)
7. Radioactive Iodine Uptake: high uptake
Medical Management Objectives

HYPERTHYROIDISM HYPOTHYROIDISM
Objective: to reduce thyroid hyperactivity, Medical Management
relieve symptoms Objective: to restore a normal metabolic state
and preventing complications. by replacing
The missing hormone.
 HYPERTHYROIDISM HYPOTHYROIDISM
MEDICAL 1. Radioactive iodine therapy (131I)
- used to treat toxic adenomas,
1. Synthetic levothyroxine (Synthroid
or Levothroid)
MANAGEMENT multinodular goiter,
thyrotoxicosis, patients beyond the
The nurse must be alert for signs of
angina,
childbearing especially during the early phase of
years who have diffuse toxic goiter treatment; it
- to destroy the overactive thyroid must be reported and treated at to
cells avoid myocardial
- tasteless, colorless radioiodine infarction.
- 95% of patients are cured by one
dose
- symptoms subside in 3 to 4 weeks
- monitor for signs of hypothyroidism

Contraindicated: during pregnancy

and breast-
feeding; pregnancy should be
postponed for at

least 6 months after treatment.

A major advantage: less side effects
than antithyroid
medications.
 HYPERTHYROIDISM HYPOTHYROIDISM

3. Propylthiouracil (PTU) or Methimazole (Tapazole) Severe/Myxedema:

- blocks conversion of T3 and T4
- watch for fever, rash, urticaria, agranulocytosis and
2. IV fluids with caution
thrombocytopenia 3. ABG analysis
- stop medication if with pharyngitis and fever or mouth 4. Oxygen saturation determination
ulcers 5. Avoid heating pads
- PTU: drug of choice during pregnancy
4. Adjunctive Therapy 6. Coma: Levothyroxine [Synthyroid])
A. Iodine or iodide compounds intravenously
- decrease the release of thyroid hormones from the
thyroid gland and reduce the vascularity and size of
the thyroid (in preparation for surgery)
- are more palatable in milk or fruit juice and are
administered through a straw to prevent staining of
the teeth
- observe for the development of goiter
- cough medications, expectorants, bronchodilators,
and salt substitutes may contain iodide and should
be avoided
Compounds: Potassium iodide (KI), Lugol’s
solution, and Saturated solution of potassium iodide
(SSKI)
B. Beta-adrenergic blocking agents
Propranolol is used to control nervousness,
tachycardia, tremor, anxiety, and heat intolerance
Thyroid storm

- 5. Electrocardiographic (ECG) monitoring

- 6. ABG analysis

- 7. Pulse oximetry

- 8. Oxygen administration

- 9. IV fluids

- 10. Antipyretic

- 11. Cooling blanket

- 12. Patent airway

Surgical Management for
Hyperthyroidism
- Performed soon after the thyroid function has returned to normal (4 to 6 weeks).
Administration of PTU, Iodine solutions, and Beta-blockers before surgery is needed.

- Thyroidectomy
- needs thyroid hormone and calcium replacement after surgery
- hormone levels should be monitored every 6 weeks

- Complications: Hypothyroidism; Hypocalcemia; Hypoparathyroidism