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Assessment and Management of Patients with Endocrine Disorders. Dr Ibraheem Bashayreh. Location of the major endocrine glands. Definition of Hormones. Chemical messengers of the body Act on specific target cells Regulated by negative feedback Too much hormone, then hormone release reduced
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Dr Ibraheem Bashayreh
serve as neurotransmitters for sympathetic system
Glucagon—stimulates glycogenolysis and glyconeogenesis
Somatostatin—decreases intestinal absorption of glucose
Dr Ibraheem Bashayreh, RN, PhD
2-composed of 2 encapsulated lobes, one on either side of the trachea, connected by a thin isthmus.
3-The thyroid extending from the level of the fifth cervical vertebra down to the first thoracic. The gland varies from an H to a U shape,overlying the second to fourth tracheal rings.
4-The pyramidal lobe is a narrow projection of thyroid tissue extending upward from the isthmus and lying on the surface of the thyroid cartilage.Thyroid Anatomy
5-The thyroid is enveloped by a thin, fibrous, nonstripping capsule that sends septa into the gland substance to produce an irregular, incomplete lobulation. No true lobulation exists.
6-The weight of the thyroid of the normal nongoitrous adult is: 10-20 g depending on body size and iodine supply.
7-The width and length of the isthmus average; 20 mm,
and its thickness is ;2-6 mm.
8-The lateral lobes from superior to inferior poles usually measure 4 cm. and their thickness is 20-39 mm.
*The superior belly of the omohyoid
*The anterior border of the sternocleidomastoid
*The larynx & the trachea.
*The pharynx & the oesophagus.
*Associated with these structures are the cricothyroid muscle & its nerve supply, the external laryngeal nerve.
*In the groove between the esophagus and the trachea is the recurrent laryngeal nerve.
The carotid sheath with: The common carotid artery, the internal jugular vein, and the vagus nerve.
Relations of the Isthmus
The anterior jugular veins
Fascia & skin.
The second, third, & fourth rings of the trachea.
1-The superior thyroid vein:
ascends along the superior thyroid
artery and becomes a tributary of the
internal jugular vein.
2- The middle thyroid vein:
follows a direct course laterally to the
internal jugular vein.
3- The inferior thyroid veins :
follow different paths on each side. The
right passes anterior to the innominate
artery to the right brachiocephalic vein or
anterior to the trachea to the left
brachiocephalic vein. On the left side,
drainage is to the left brachiocephalic vein.
Occasionally, both inferior veins form a
common trunk called the thyroid ima vein,
which empties into the left brachiocephalic
The thyroid follicles secretes tri-iodothyronine(T3)and thyroxin(T4)synthesis involves combination of iodine with tyrosine group to form mono and di-iodotyrosine which are coupled to form T3 andT4.
The hormones are stored in follicles bound to thyrogobulin .
When hormones released in the blood they are bound to plasma proteins and small amount remain free in the plasma .
The metabolic effect of thyroid hormones are due to free (unbound)T3 and T4.
90%of secreted hormones is T4 but T3is the active hormone so, T4is converted to T3 peripherally.
Synthesis and libration of T3 and T4 is controlled by thyroid stimulating hormone(TSH)secreted by anterior pituitary gland.
TSH release is in turn controlled by thyrotropin releasing hormone (TRH)from hypothalamus .
Circulating T3and T4 exert –ve feedback mechanism on hypothalamus and anterior pituitary gland .
So, in hyperthyroidism where hormone level in blood is high ,TSH production is suppressed and vice versa.
Hypothyroidism is the disease state in humans and animals caused by insufficient
production of thyroid hormone by the thyroid gland.
4. Weight gain.
5. Memory and mental impairment and decreased
7. Menstrual irregularities and loss of libido.
8. Coarseness or loss of hair.
9. Dry skin and cold intolerance.
10. Irregular or heavy menses.
15. Reflex delay.
16. Bradycardia, elevated diastolic BP.
19. Decreased serum T4,T3 levels.
LIFELONG THYROID HORMONE REPLACEMENT
levothyroxine sodium (Synthroid, T4, Eltroxin)
IMPORTANT: start at low does, to avoid hypertension, heart failure and MI
Teach about S&S of hyperthyroidism with replacement therapy
Rare serious complication of untreated hypothyroidism
Decreased metabolism causes the heart muscle to become flabby
Leads to decreased cardiac output
Leads to decreased perfusion to brain and other vital organs
Leads to tissue and organ failure
LIFE THREATENING EMERGENCY WITH HIGH MORTALITY RATE
With low metabolism metabolites build up inside the cells which increases mucous and water leading to cellular edema
Edema changes client’s appearance
Nonpitting edema appears everywhere especially around the eyes, hands, feet, between shoulder blades
Tongue thickens, edema forms in larynx, voice husky
Replace fluids with IV.
Give levothyroxine sodium IV
Give glucose IV
Check temp, BP hourly
Monitor changes LOC hourly
Aspiration precautions, keep warm
Hyperthyroidism is a condition caused by the effects of too much thyroid hormone on
tissues of the body. Although there are several different causes of hyperthyroidism, most
of the symptoms that patients experience are the same regardless of the cause.
2. Palpitations, elevated systolic BP.
3. Weight changes.
4. Menstrual irregularities and decreased libido.
5. Increased serum T4, T3.
6. Exophthalmos (bulging eyes)
9. Muscle weakness.
10. Heat intolerance.
Thyroiditis is an inflammation (not an infection) of the thyroid gland. Several types of thyroiditis exist .
1-Hashimoto's Thyroiditis. Hashimoto's Thyroiditis (also called autoimmune or chronic lymphocytic thyroiditis) is the most common type of thyroiditis.
Fatigue-Depression-Modest weight gain--Cold intolerance-Excessive sleepiness-Dry, coarse
hair-Constipation-Dry skin-Muscle cramps-Increased cholesterol levels-Decreased
concentration-Vague aches and pains-Swelling of the legs
2-De Quervain's Thyroiditis. (also called subacute or granulomatous thyroiditis). The thyroid gland generally swells rapidly and is very painful and tender.]
Patients will experience a hyperthyroid period as the cellular lining of colloid spaces fails,
allowing abundant colloid into the circulation, with neck pain and fever. Patients typically
then become hypothyroid as the pituitary reduces TSH production and the inappropriately
released colloid is depleted before resolving to euthyroid. The symptoms are those of
hyperthyroidism and hypothyroidism. In addition, patients may suffer from painful
dysphagia. There are multi-nucleated giant cells on histology.Thyroid antibodies can be
present in some cases.There is decreased uptake on isotope scan.
3-Silent Thyroiditis. Silent Thyroiditis is the third and least common type of thyroiditis..
Silent thyroiditis features a small goiter without tenderness and, like the other
types of resolving thyroiditis, tends to have a phase of hyperthyroidism followed
by a phase of hypothyroidism then a return to euthyroidism. The time span of each
phase is not concrete, but the hypo- phase usually lasts 2-3 months.
breathlesness & orthopnoea.
Enlargement of thyroid gland.
Simple (non-toxic) goitre.
simple hyperplastic goitre (colloid goiter)
Cause: -physiological in pregnancy, puberty
Appearance: Large, smooth firm, non-tendern goitre
Effect: euythyroid & pressure effect.
Cause: presence of areas of hyperplasia & areas of hypoplasia in gland.
Appearance: Large, irregular, nodular goiter
Effect: euythyroid & pressure effect.
Cause: Autoimmune disease characterizeby presence of antibodies stimulate TSH receptors in gland.
Appearance: Diffuce, nodular, hyperemic gland.
Toxic Multinodular goiter (plummer’s disease)
Cause: Toxic effect of MNG
Appearance: Large, irregular, nodular goiter.
-malignant: papillary, follicular, anaplastic, medullary and lymphoma
Cause: -complication of MNG.
Appearance: Enlarged goiter associated with lymphadenopathy
Effect: -pressure effect.
Cause: Fibrosis of thyroid
Appearance: Enlarged stony hard thyroid
Effect: Pressure effect
De quervain’s thyroiditis
Cause: Viral infection
Appearance: Diffuse, firm, tender swelling
Effect: Mild hyperthyroidism
Cause: Autoantibody against thyroid gland.
Appearance: Diffuse, enlarged, non-tender goitre
-serum T3, T4.
-serum LATS: (Long Acting Thyroid Stimulator)
in grave’s disease
in hashimoto’s disease.
increase cholesterol level in hypothyroidism
TSH in Graves disease
Radioactive Thyroid Scan
Ultrasonography: used to determine goiter or nodules
EKG: note tachycardia
-chest and neck x-ray:
Show descend of thyroid gland to thorax and mediastanal shifting in retrosternal goitre.
By i.v injection of I131. Then, use gama rays to show hot and cold nodules.
Show thyroid size and if there is compression to trachea
-bronchoscopy: show compression and infiltration of trachea by tumer
-fine needle aspiration biopsy.
Thioamides: blocks thyroid hormone production; takes time
Need to control cardiac manifestations (tachycardia, palpitations, diaphoresis, anxiety) until hormone production reduced: use Beta-adrenergic blocking drugs: propranolol (Inderal, Detensol)
SSKI (saturated solution of potassium iodide)
Potassium iodide tablets, solution, and syrup
decreases blood flow through the thyroid gland
This reduces the production and release of thyroid hormone
Takes about 2 wks for improvement
Leads to hypothyroidism
ACTION: inhibits thyroid hormone release
NOT USED OFTEN BECAUSE OF SIDE EFFECTS: depressions, diabetes insipidus, tremors, N&V
RADIOACTIVE IODINE THERAPY:
Receives RAI in form of oral iodine
Takes 6-8 Weeks for symptomatic relief
Additional drug therapy used during this type of treatment
Not used on pregnant women
Why use surgery?
Used to remove large goiter causing tracheal or esophageal compression
Used for pts who do not have good response to antithyroid drugs
TWO TYPES OF SURGERIES:
Total thyroidectomy (must take lifelong thyroid hormone replacement)
Patient should become euthyroid before surgery to
prevent thyroid crisis.
Assessmment vocal cord condition
Hi protein, hi CHO diet for days/weeks before surgery
Antithyroid drugs to suppress function of the thyroid
Iodine prep (Lugols or K iodide solution) to decrease size and vascularity of gland to minimize risk of hemorrhage, reduces risk of thyroid storm during surgery
Tachycardia, BP, dysrhythmias must be controlled preop
Teach support neck when C&DB
Support neck when moving reduces strain on suture line
Expect hoarseness for few days (endotracheal tube)
C&DB: cough & deep breathing
VS, I&O, IV
Avoid tension on sutures
Pain meds, analgesic lozengers
Humidified oxygen, suction
First fluids: cold/ice, tolerated best, then soft diet
Limited talking , hoarseness common
Assess for voice changes: injury to the recurrent laryngeal nerve
CHECK FOR HEMORRHAGE 1st 24 hrs:
Look behind neck and sides of neck
Check for c/o pressure or fullness at incision site
REPORT TO MD
CHECK FOR RESPIRATORY DISTRESS
Laryngeal stridor (harsh hi pitched resp sounds)
Result of edema of glottis, hematoma,or tetany
Trach set/airway/ O2, suction
CALL MD for extreme hoarseness
Recurrent laryngeal nerve damage.
Superior laryngeal nerve damage
Hypertrofic scaring (keloid)