Hyperthyroidism

sustained hyperfunctioning of the thyroid gland due to an increase in thyroid

hormones (T3 and T4). Elevated thyroid hormones suppress serum TSH levels.

General manifestations of hyperthyroidism

● Anxiety & insomnia

● Palpitations
Symptoms ● Heat intolerance
● Increased perspiration
● Weight loss without decreased appetite

● Goiter
● Hypertension
● Tremors involving fingers/hands
Physical examination ● Hyperreflexia
● Proximal muscle weakness
● Lid lag
● Atrial fibrillation
 Nutritional measures, including consumption of a diet high in calories (high in protein,
carbohydrates, vitamins, and minerals) to satisfy hunger and prevent weight loss and
tissue wasting.

● Adherence to a high calorie diet (4000-5000 calories per day).

● Consumption of approximately 6 full meals and snacks per day. These should
be packed with protein (1-2 g/kg of ideal body weight), carbohydrates, and be
full of vitamins and minerals.
● Avoidance of high-fiber foods due to the constant hyperstimulation of the
gastrointestinal (GI) tract. High-fiber foods may increase GI symptoms (eg,
diarrhea). However, high-fiber diets are recommended if the client with
hyperthyroidism has constipation.
● Avoidance of stimulating substances (eg, caffeinated drinks: coffee, tea, soft
drinks).
● Avoidance of spicy foods as these can also increase GI stimulation.

Treatment

RAI - radioactive iodine

the primary form of treatment for individuals with hyperthyroidism. destroys or damages
the thyroid (or part of it) but has a delayed response and may take up to 3 months to
have a maximum effect. It is important for the nurse to teach the client about
precautions to prevent exposing others to this radioactive substance.

● Avoid close proximity to pregnant women or children

● Do not breastfeed as RAI may be excreted through breast milk and could harm
the infant
● Do not share utensils with others or use bare hands to handle food that is to be
served to others
● Isolate personal laundry (eg, bed linens, towels, daily clothes) and wash it
separately
● Use a separate toilet from the rest of the family and flush 2-3 times after each
use
● Wash hands frequently and thoroughly, especially after restroom use
● Drink plenty of fluids
● Sleep in a separate bed from others and do not sit near others in an enclosed
area for a prolonged period of time (eg, train or flight travel)

radioactive iodine uptake (RAIU) test. measures the metabolic activity in the thyroid
gland in order to differentiate between the many types of thyroid disorders. For an
accurate measurement, medications affecting the thyroid should be held 7 days prior to
the test date and clients are NPO for 4 hours prior to iodine administration.
Premenopausal women must take a pregnancy test. Dentures, metal, and jewelry
should be removed.

Thyroidectomy
Respiratory distress is a life-threatening complication of thyroid surgery that occurs
when swelling in the surgical area at the base of the neck compresses the
airway. Stridor and/or difficulty breathing in the client who has had thyroid surgery
should be reported immediately to the registered nurse, and a rapid response should be
activated. Suctioning devices, oxygen, and a tracheostomy tray should be available for
rapid surgical intervention

Exophthalmos
a complication of hyperthyroidism (hypermetabolic state due to thyroid hormone
overproduction) from Graves' disease. It is defined as a protrusion of the eyeballs
caused by increased orbital tissue (connective, adipose, muscular) expansion and can
be irreversible. The exposed cornea is at risk for dryness, injury, and infection.
Nursing care for a client with exophthalmos includes:
● Maintaining the head of the bed in a raised position to facilitate fluid drainage
from the periorbital area
● Using artificial tears or other similar products to moisten the eyes to prevent
corneal drying (causes abrasions/ulcers)
● Taping the client’s eyelids shut during sleep if they do not close on their own
● Teaching the client the following:
o Regular visits to the ophthalmologist are necessary to measure eyeball
protrusion and evaluate condition.
o If recommended, anti-thyroid drugs should be taken to prevent further
exacerbation of exophthalmos.
o Smoking cessation is necessary as smoking increases the risk of Graves’
disease and associated eye problems.
o Restrict salt intake to decrease periorbital edema.
o Use dark glasses to decrease glare and prevent external irritants and
infection.
o Perform intraocular muscle exercises (turning the eyes using complete
range of motion) to maintain flexibility.

Hypothyroidism
characterized by thyroid hormone deficit (low T3 and T4). TSH is elevated due to compensatory
increase from pituitary.
Thyroid storm (thyrotoxicosis)
a serious and potentially life-threatening emergency for clients with Graves disease. This
condition occurs when the thyroid gland releases large amounts of thyroid hormone in response
to stress (eg, trauma, surgery, infection, mva).
Characteristic features include: tachycardia, hypertension, cardiac arrhythmias (eg, atrial
fibrillation), and fever up to 104-106 F (40-41 C).
Other findings include severe nausea, vomiting, and the client often feels anxious, tremulous, or
restless. Confusion and psychosis can occur, as can seizures and coma. Rapid treatment is
necessary.

Beta-adrenergic blockers (atenolol, metoprolol, and propranolol) are given to relieve some of the
symptoms of thyrotoxicosis. They block the effects of the sympathetic nervous system and treat
symptoms such as tachycardia, hypertension, irritability, tremors, and nervousness in
hyperthyroidism.

Myxedema coma is a complication associated with progression of symptoms

of hypothyroidism from lethargy and mental sluggishness to a coma
state. hypothermia, bradycardia, hypotension, and depressed mental status. The
highest-priority intervention is respiratory support for the client exhibiting signs of acute
respiratory distress.

Levothyroxine sodium
the first-line treatment for hypothyroidism during pregnancy to maintain adequate
levels of maternal thyroid hormones, which are critical for fetal brain development.
instruct the client to take levothyroxine in the morning on an empty stomach, at least 4
hours before or after taking a prenatal vitamin. Take separate from other medications
Symptoms of hypothyroidism typically begin to improve approximately 3-4 weeks after
initiating levothyroxine. Therapy should not be stopped, even if symptoms resolve.
A client's dose is adjusted based on serum TSH levels to prevent too much or too little
hormone. Treatment is lifelong. Clients must be taught to report signs of excess thyroid
hormone such as heart palpitations/tachycardia, weight loss, and insomnia
Expected response includes improved well-being with elevated mood, higher energy
levels, and a heart rate that is within normal limits. The nurse should consult the health
care provider if the heart rate is >100/min, or if the client reports chest pain,
nervousness, or tremors; this may indicate that the dose is higher than necessary.
Pharmacological therapy manages the symptoms of hypothyroidism, but it takes up to 8
weeks after initiation to see the full therapeutic effect.

Hyperparathyroidism
hypersecretion of parathyroid hormone causing bone breakdown that leads to
hypercalcemia. Clients with hyperparathyroidism exhibit manifestations of
hypercalcemia (eg, constipation, polyuria, muscle weakness, bone pain) and may
subsequently develop pathologic fractures, osteoporosis, and/or kidney stones.

Hyperparathyroidism & hypoparathyroidism

Hyperparathyroidism (↑ PTH) Hypoparathyroidism (↓ PTH)

● ↑ Calcium, ↓ phosphate ● ↓ Calcium, ↑ phosphate

● Osteoporosis ● Tingling, numbness
 ● Nephrolithiasis ● Trousseau & Chvostek signs
● Polydipsia, polyuria ● Muscle spasms
● Constipation ● Seizures
● Bone pain
● Muscle pain

Hypocalcemia (serum calcium <8.6 mg/dL [2.15 mmol/L]) is a potential complication

of parathyroidectomy because the parathyroids regulate calcium levels in the blood.
When one or more parathyroids are removed, it may take some time for others that have
been dormant during hyperparathyroidism (which causes an increase in serum calcium)
to begin regulating serum calcium.

Trousseau's sign may indicate hypocalcemia before other signs and symptoms of
hypocalcemia, such as tetany, occur. Trousseau's sign can be elicited by placing the BP
cuff on the arm, inflating to a pressure > than systolic BP, and holding in place for 3
minutes. This will occlude the brachial artery and induce a spasm of the muscles of
the hand and forearm when hypocalcemia is present.
Chevostek's sign another early indicator of hypocalcemia, should also be assessed. It
may be elicited by tapping the face at the angle of the jaw and observing
for contraction on the same side of the face.

Addison's disease, or chronic adrenal insufficiency

adrenal glands do not produce adequate amounts of steroid hormones
(mineralocorticoids, glucocorticoids, androgens).
Symptoms include weight loss, muscle weakness & fatigue, low blood pressure,
hypoglycemia, and hyperpigmented skin (skin folds, buccal area, palmar crease),
hyperkalemia, vitiligo, weight loss, depression irritability.
Treatment consists of replacement therapy with oral mineralocorticoids and
corticosteroids
A potential life-threatening complication is Addisonian crisis. Signs and symptoms
include hypotension, tachycardia, hyperkalemia, hyponatremia, hypoglycemia, fever,
weakness, and confusion; these should be reported to the PHCP immediately.
Emergency management includes shock management with fluid resuscitation using
0.9% normal saline and 5% dextrose, and administration of high-dose hydrocortisone
replacement IV push.

Diabetes insipidus (DI)

low levels of antidiuretic hormone (ADH)
the kidneys excrete large quantities of very dilute urine (polyuria). This causes
hypernatremia (elevated serum sodium due to deficit of free water) and increased serum
osmolality, which lead to excessive thirst (polydipsia). low specific gravity (<1.003).
Fluid volume deficit can lead to dehydration, hypernatremia, high serum osmolality, and
weight loss.

Desmopressin acetate (DDAVP) is a synthetic form of ADH, which can be administered

intravenously, orally, or via nasal spray. Effectiveness of therapy with desmopressin
would be manifested by decreased urinary output and increased urine specific gravity as
the urine becomes less dilute
Syndrome of inappropriate antidiuretic hormone (SIADH)
potential complication of head injury results in increased ADH. Too much ADH causes
increased total body water, resulting in a low serum osmolality and low serum sodium.
As ADH is secreted and water is retained, urine output is decreased and concentrated,
resulting in a high specific gravity.
SIADH treatment includes fluid restriction, oral salt tablets, and administration of 3%
saline IV and/or vasopressin receptor antagonists eg, conivaptan
Malignant lung tumors are a common cause of syndrome of inappropriate antidiuretic
hormone secretion (SIADH). When serum sodium drops below 120 mEq/L (120
mmol/L), immediate intervention is necessary to prevent severe neurologic dysfunction.

Cushing syndrome
prolonged exposure to excess corticosteroids
Clinical manifestations: weight gain, truncal obesity, moon face, skin atrophy, easy
bruising, purple striae on the abdomen, muscle weakness, hypertension, and
hyperglycemia. Associated androgen excess can result in acne, hirsutism, and
menstrual irregularities.

Clinical features of Cushing syndrome include:

● Skin manifestations such as easy bruising, purple striae, and skin atrophy
(topical preparations), which are a result of collagen loss.
● Fat redistribution resulting in truncal obesity and moon like face; thin
extremities. Fat pads are seen on the neck and supraclavicular areas
● In women, androgens are produced in the adrenal gland. Androgen excess from
adrenal gland stimulation can result in acne, hirsutism, and menstrual
irregularities (oligomenorrhea)
● Mineralocorticoid (aldosterone) excess can result
in hypernatremia, hypokalemia, and hypertension
● Hyperglycemia as a result of excess corticosteroids.
● Untreated clients can develop proximal muscle weakness and bone
loss (steroids catabolic on muscles and bone)

Acromegaly
an uncommon condition caused by growth hormone overproduction leading to
overgrowth of soft tissues of the face, hands, feet, and organs. It is usually due to
pituitary adenoma, and onset in adult clients generally occurs at age 40-45.The nurse
should monitor the client for signs and symptoms of acute complications (eg, heart
failure) and report findings to the health care provider. Additional heart sounds (S3, S4)
require further assessment for cardiac conditions (eg, heart failure).

acute pancreatitis
Supportive care for symptom relief and prevention of complications are the major goals
These strategies include:
1. NPO status - The client is maintained on NPO status as any ingestion of food
will stimulate the excretion of pancreatic enzymes. A nasogastric tube is used to
suction out gastric secretions; this will reduce nausea and lessen stimulation of
the pancreas as these juices will move to the duodenum.
2. Pain management - Intravenous opioids (eg, hydromorphone, fentanyl) are
frequently utilized for pain management. Morphine can also be used; worsening
pancreatitis due to increase in sphincter of Oddi pressure has not been proven in
studies.
3. IV fluids - Aggressive fluid replacement to prevent hypovolemic shock is critical.
Inflammation of the pancreas releases chemical mediators that increase capillary
permeability and cause third spacing (fluid going into empty spaces).

4. maintain positions that flex the trunk and draw the knees up to the abdomen
(semi-Fowler's) to decrease tension on the abdomen. A side-lying position with
the head elevated to 45 degrees will help relieve the pain even better.

Pheochromocytoma is a condition caused by a tumor in the adrenal medulla. This

results in excess release of catecholamines such as epinephrine and norepinephrine,
leading to paroxysmal hypertensive crisis.
Important points to note when caring for these clients include the following:
1. Hypertension is difficult to treat and is often resistant to multiple drugs.
2. The client should avoid activities that can precipitate a hypertensive crisis (eg,
bending, lifting, Valsalva maneuver).
3. Abdominal palpation should be avoided as manipulation of the adrenal gland
and release of catecholamines can precipitate a hypertensive crisis.

GLUCOSE / INSULINE ISSUES

Hypoglycemia
evidenced by low blood glucose <70 mg/dL
acute and potentially serious complication. Signs and symptoms include shakiness,
palpitations, anxiety/arousal, restlessness, diaphoresis, and pallor. neuroglycopenic
symptoms (confusion, seizures, coma) develop.

hypoglycemic reaction
A client who is alert enough to ingest food/liquids orally should be given 15grams of a
simple carbohydrate (eg, 1 tbs syrup or honey, 4 tsp jelly, 4-6 oz orange juice, or 8 oz
low-fat milk). Fingerstick blood glucose should be checked 10-15 minutes after. shows
no improvement, the simple carbohydrate can be readministered orally.
Dextrose (D50 IV push) aministered to hypoglycemic clients who are unable to ingest a
simple oral carbohydrate. These can cause rebound hypoglycemia by stimulating
additional insulin release from the body in response to increased serum glucose levels.

Stress-induced hyperglycemia
can occur in hospitalized clients in relation to surgery, trauma, acute illness, and
infection.
causes complications in the hospitalized client. To minimize complications, the
recommended target glucose range for critically ill clients is 140-180 mg/d. For non-
critically ill clients, <140 mg/dL fasting and <180 mg/d random blood glucose are
recommended.

**Hemoglobin A1C is a diagnostic test used to measure the percentage of glycosylated

hemoglobin in the blood over a period of 2-3 months. A normal hemoglobin A1C is 4%-
6% in clients without diabetes; the goal is to keep the level <7% in clients with diabetes.

Acanthosis nigricans

a skin condition that occurs with obesity and diabetes and appears as velvet-like patches
of darkened, thick skin. These areas typically occur around the back of the neck and in
the groin and armpits.
velvety light brownish to black skin thickening seen in the axillae, neck, or flexures and is
indicative of insulin resistance (diabetic dermopathy). Skin tags (acrochordons) are
commonly present on regions affected by acanthosis nigricans.

Metabolic syndrome (insulin resistance syndrome)

- have an increased risk of diabetes and coronary artery disease.
Features of metabolic syndrome include increased waist circumference, elevated blood
pressure, increased triglycerides, decreased HDL, and increased fasting blood glucose.
The mnemonic is "We Better Think High Glucose" (Waist circumference, Blood
pressure, Triglyceride, HDL, Glucose).
 ● Increased waist circumference: ≥40 in (102 cm) in men, ≥35 in (89 cm) in
women (abdominal obesity)
● Blood pressure: ≥130 mm Hg systolic or ≥85 mm Hg diastolic or drug
treatment for hypertension (HTN)
● Triglyceride level: >150 mg/dL (1.7 mmol/L) or drug treatment for elevated
triglycerides
● High-density lipoprotein (HDL) levels: <40 mg/dL (1.04 mmol/L) in men and <50
mg/dL (1.3 mmol/L) in women or drug treatment for low HDL-C
● Fasting glucose levels: ≥100 mg/dL (5.6 mmol/L) or drug treatment for
elevated blood glucose (hyperglycemia)

Diabetic meal planning

eat foods with a low glycemic index and high fiber content. Saturated fats and sodium
should be restricted.

1. Monitor carbohydrate intake

2. Manage caloric intake if weight loss is desired
3. High-fiber foods (30-35 g of fiber per day), including whole grains, legumes,
fruits, vegetables, and low-fat dairy products
4. Use monounsaturated fats, limit use of saturated fat, and eliminate trans fatty
acids
5. Choose foods with a low glycemic index
6. Consume total cholesterol of <300 mg per day
7. Reduce sodium intake
8. Limit intake of foods containing sucrose
9. Limit intake of alcoholic beverages

Instructions for diabetic foot care include:

1. Wash feet daily with warm water and mild soap; test water temperature with
thermometer beforehand. Gently pat feet dry, particularly between the toes. Use
lanolin to prevent dry and cracked skin, but do not apply between the toes.
2. Inspect for abrasions, cuts, or sores. Have others inspect the feet if eyesight is
poor.
3. To prevent injury, use cotton or lamb's wool to separate overlapping toes. Cut
toenails straight across and use a nail file to file along the curves of the toes.
Avoid going barefoot and wear sturdy leather shoes. Use mild foot powder to
absorb perspiration and wear clean, absorbent socks with seams aligned.
4. Avoid using over-the-counter products (eg, iodine, alcohol, strong adhesives) on
cuts or abrasions.
5. To improve circulation, do not sit with legs crossed or for extended periods, avoid
tight-fitting garments, and perform daily exercise.
6. Report other types of problems such as infections or athlete's foot immediately.

Diabetes Type 2 – Treatment

- Thiazolidinediones (rosiglitazone [Avandia] and pioglitazone [Actos]) are used

to treat type 2 diabetes mellitus. These agents improve insulin sensitivity but
 do not release excess insulin, leading to a low risk for hypoglycemia (similar to
metformin). These drugs can worsen heart failure by causing fluid retention
and increase the risk of bladder cancer. Heart failure or volume overload is a
contraindication to thiazolidinedione use. These medications also increase the
risk of cardiovascular events such as myocardial infarction.

- Sulfonylureas (eg, glyburide) stimulate insulin release via the pancreas and
carry a risk for severe and prolonged hypoglycemia in the geriatric population
due to potential delayed elimination. Avoidance of these drugs is
recommended by the Beers Criteria. Instead, other medications that are at lower
risk for hypoglycemia should be used (eg, metformin). The major adverse effects
of sulfonylurea medications (eg, glyburide, glipizide, glimepiride) are
hypoglycemia and weight gain. Weight gain should be addressed. Clients
taking glyburide should be taught to use sunscreen and protective clothing as
serious sunburns can occur.

- Metformin is an oral antidiabetic medication used to manage hyperglycemia in

clients with type 2 diabetes. Metformin increases the sensitivity of insulin
receptors in cells and reduces glucose production by the liver. These actions
increase the efficacy of insulin present in the body and prevent large rises in
blood glucose after meals. Because metformin does not stimulate insulin
secretion by the pancreas, the risk of hypoglycemia is minimal.

Insulin
Insulin glargine should not be mixed in a single syringe with any other insulin as the
mixture may alter the pharmacodynamics of the drug.

Regular insulin is the only insulin that can be administered via IV push; this is
typically performed only in an acute care facility under close observation by the nurse.

Insulin pump
A client prescribed CSII is taught how to self-manage the insulin pump. Key points
include the importance of checking blood glucose levels at least 4 times a day, how to
administer a bolus dose at mealtime to cover carbohydrate intake, how to administer a
supplemental bolus dose to correct pre- and postprandial hyperglycemia, and the
importance of balancing diet and exercise to avoid excess weight gain.

Diabetics complications

Diabetic ketoacidosis (DKA)

DKA is a life-threatening complication generally due to lack of insulin in type I diabetes
characterized by hyperglycemia (>250 mg/dL) that results in ketosis, a metabolic
acidosis. Glucose cannot be taken out of the bloodstream and used for energy without
insulin. The body begins to break down fat stores into ketones, as it does in a state of
starvation, causing a metabolic acidosis (low pH and low HCO3). The lack of insulin
also results in increased glucose production in the liver, worsening the hyperglycemia.

All clients with DKA experience dehydration due to osmotic diuresis (Hyperglycemia
causes osmotic diuresis). The cardinal signs of dehydration are poor skin turgor, dry
mucosal membranes, tachycardia, orthostatic hypotension, weakness, and lethargy.
Prompt and adequate fluid therapy restores tissue perfusion and suppresses the
elevated levels of stress hormones. The initial hydrating solution is 0.9%
saline infusion. – this is the priority
Insulin therapy should be started after the initial rehydration bolus as serum glucose
levels fall rapidly after volume expansion.
D5W is initiated when serum glucose is <250 mg/d to prevent hypoglycemia.
Hypokalemia often occurs with resolution of acidosis and administration of IV insulin as
insulin shifts potassium from the intravascular space to the intracellular space.
Therefore, potassium is administered even when the client is normokalemic (3.5-5.0
mEq/L to prevent hypokalemia and subsequent life-threatening arrhythmias.

Hyperosmolar hyperglycemic state

Serious complication usually associated with type 2 diabetes
severe hyperglycemia happens more slowly and is often not noted until neurological
manifestations occur. neurological manifestations such as blurry vision, lethargy,
obtundation, and progression to coma. Because some insulin is present, symptoms
associated with ketones and acidosis, such as Kussmaul respirations (hyperventilation)
and abdominal pain, are typically absent