Nursing management of patients with Thyroid Crisis Hypertensive

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Nursing management of patients with Thyroid Crisis, Hypertensive Crisis, Adrenal Crisis. Presented by: Reviewed

Nursing management of patients with Thyroid Crisis, Hypertensive Crisis, Adrenal Crisis. Presented by: Reviewed by: Mr. Santhosh Thomas Prof. Shashkumar Lecturer, HOD, MSN Department, YNC YNC

Learning objectives. The students will be able to: Define thyroid crisis. Narrate Risk factors

Learning objectives. The students will be able to: Define thyroid crisis. Narrate Risk factors of thyroid crisis. Explain the Pathophysiology of thyroid crisis. Enumerate the clinical manifestations of thyroid crisis. • Explain the diagnosis and management of thyroid crisis. • • •

Introduction. • Thyroid crisis or thyroid storm life threatening manifestations of thyroid hyperactivity. •

Introduction. • Thyroid crisis or thyroid storm life threatening manifestations of thyroid hyperactivity. • Hyperthyroidism , thyrotoxicosis ↑ thyroid hormone levels in blood. • Graves’ disease, toxic multinodular goiter the most common cause -> 1 – 2 % thyroid storm. • With treatment 20% mortality rate.

Thyroid Storm/ Thyrotoxicosis. • Thyrotoxicosis; also known as thyroid storm, is caused by hyperthyroidism

Thyroid Storm/ Thyrotoxicosis. • Thyrotoxicosis; also known as thyroid storm, is caused by hyperthyroidism but has more excessive concentration of thyroid hormones due to overstimulation of the thyroid gland. This is caused by stress that occurs more often after a subtotal thyroidectomy. This is a life-threatening situation that requires urgent medical response.

Risk factors Of Thyroid Storm Medical • Infection/sepsis • Cerebral vascular accident • Myocardial

Risk factors Of Thyroid Storm Medical • Infection/sepsis • Cerebral vascular accident • Myocardial infarction • Congestive heart failure • Pulmonary embolism • Visceral infarction • Emotional stress • Acute manic crisis

Risk factors Of Thyroid Storm Metastatic • follicular thyroid carcinoma • h. CG-mediated thyrotoxicosis

Risk factors Of Thyroid Storm Metastatic • follicular thyroid carcinoma • h. CG-mediated thyrotoxicosis • Hydatidiform mole • Metastatic choriocarcinoma • Hyperemesis gravidarum TSH-producing pituitary tumors Struma ovarii

Risk factors Of Thyroid Storm Trauma Thyroid surgery Non thyroid surgery Blunt and penetrating

Risk factors Of Thyroid Storm Trauma Thyroid surgery Non thyroid surgery Blunt and penetrating trauma to the thyroid gland • Vigorous palpation of the thyroid gland • Burns • •

 • Endocrine ü Hypoglycemia ü Diabetic ketoacidosis ü Hyprosmolar nonketotic coma.

• Endocrine ü Hypoglycemia ü Diabetic ketoacidosis ü Hyprosmolar nonketotic coma.

 • • • Drug-Related Iodine-131 therapy Premature withdrawal of antithyroid therapy Ingestion of

• • • Drug-Related Iodine-131 therapy Premature withdrawal of antithyroid therapy Ingestion of thyroid hormone Iodinated contrast agents Amiodarone therapy Iodine ingestion Anesthesia induction Miscellaneous drugs (chemotherapy, pseudoephedrine, organophosphates, aspirin)

 • • Pregnancy-Related Toxemia of pregnancy Hyperemesis gravidarum Parturition and the immediate postpartum

• • Pregnancy-Related Toxemia of pregnancy Hyperemesis gravidarum Parturition and the immediate postpartum period

PATHOPHYSIOLOGY • • • ↑ catecholamine-binding site ↑ response to adrenergic stimuli ↑ free

PATHOPHYSIOLOGY • • • ↑ catecholamine-binding site ↑ response to adrenergic stimuli ↑ free T 4 , T 3 Stress precipitating thyroid storm Not sudden release of hormones.

Assessment of the thyroid gland. • Inspection and palpation- Instruct patient to extend neck

Assessment of the thyroid gland. • Inspection and palpation- Instruct patient to extend neck slightly and swallow. -thyroid tissue should rise normally with swallowing. -palpate to note size, shape, symmetry, & tenderness.

Diagnostic Strategies • Elevated thyroxine (T 4) level- > 58. 5 to 150 nmol/L

Diagnostic Strategies • Elevated thyroxine (T 4) level- > 58. 5 to 150 nmol/L • Elevated triiodothyronine (T 3) level- > 1. 15 to 3. 10 nmol/L • High Radioactive Iodine Uptake (RAIU) through thyroid scanning. • Elevated thyroid-stimulating hormone (TSH or thyrotropin) level using serum immunoassay • Elevated free thyroxine (FT 4) level through serum immunoassay. • Negative(benign) or positive(malignant) result after aspiration biopsy

 MANAGEMENT.

MANAGEMENT.

Surgical Management. • Thyroidectomy– Surgical removal of the thyroid gland. Subtotal thyroidectomy is usually

Surgical Management. • Thyroidectomy– Surgical removal of the thyroid gland. Subtotal thyroidectomy is usually done to patients with hyperthyroidism wherein 5/6 of the total thyroid tissue is removed. Patients need to be evaluated for hypothyroidism, which can develop years after surgery.

Nursing Assessment • Assess cardiovascular status; extra heart sounds, complaints of orthopnea or dyspnea

Nursing Assessment • Assess cardiovascular status; extra heart sounds, complaints of orthopnea or dyspnea on exertion. • Assess hydration status because dehydration can further decrease circulating volume and compromise cardiac output. • Assess for pressure ulcer development secondary to hypoperfusion.

Nursing Diagnosis. • Risk for Decreased Cardiac Output related to Uncontrolled hyperthyroidism, hypermetabolic state

Nursing Diagnosis. • Risk for Decreased Cardiac Output related to Uncontrolled hyperthyroidism, hypermetabolic state • Fatigue related to Hypermetabolic state with increased energy requirements • Risk for Disturbed Thought Process related to Physiological changes: increased CNS stimulation/accelerated mental activity. • Risk for Imbalanced Nutrition: Less Than Body Requirements related to Increased metabolism (increased appetite/intake with loss of weight)

Nursing Interventions. • Administer dextrose-containing intravenous fluids as ordered to correct fluid and glucose

Nursing Interventions. • Administer dextrose-containing intravenous fluids as ordered to correct fluid and glucose deficits. • Carefully assess the patient for heart failure or pulmonary edema. • Dopamine may be used to support blood pressure. • Provide supplemental oxygen as ordered to help meet increased metabolic demands. • Once the patient is hemodynamically stable, provide pulmonary hygiene to reduce pulmonary complications. • If the patient is in heart failure, typical pharmacologic agents for treatment of heart failure may also be indicated. • Reduce oxygen demands by decreasing anxiety, reduce fever, decrease pain, and limit visitors if necessary. • Anticipate aggressive treatment of precipitating factor. • Institute pressure ulcer strategies.

Learning objectives. The students will be able to: Define Hypertensive crisis. Narrate causes of

Learning objectives. The students will be able to: Define Hypertensive crisis. Narrate causes of Hypertensive crisis. Explain the Pathophysiology of Hypertensive crisis. Enumerate the clinical manifestations of Hypertensive crisis. • Explain the diagnosis and management of Hypertensive crisis. • • •

Hypertensive Crisis • Severe, abrupt elevation in BP • The rate of in BP

Hypertensive Crisis • Severe, abrupt elevation in BP • The rate of in BP is more important than the absolute value • Most common in patients with a history of HTN who have failed to comply with medications or who have been under-medicated

Pathophysiology • The pathophysiology of hypertensive crises is not completely understood. With mild-tomoderate elevations

Pathophysiology • The pathophysiology of hypertensive crises is not completely understood. With mild-tomoderate elevations in blood pressure, arterial and arteriolar vasoconstriction initially maintains tissue perfusion while preventing increased pressure from being transmitted to more distal vessels.

 • With severe elevations in blood pressure (i. e. , >180/110 mm Hg),

• With severe elevations in blood pressure (i. e. , >180/110 mm Hg), this autoregulation fails, and increased pressure in capillaries leads to endothelial damage of the vascular wall, causing fibrinoid necrosis and perivascular edema. Fibrinoid necrosis obliterates the vascular lumen, resulting in organ damage.

Hypertensive Crisis Clinical Manifestations - Hypertensive encephalopathy ( seizures, confusion, coma) - Renal insufficiency

Hypertensive Crisis Clinical Manifestations - Hypertensive encephalopathy ( seizures, confusion, coma) - Renal insufficiency - Heart failure - Pulmonary edema

Organ damage associated with hypertensive emergency : • • Changes in mental status, such

Organ damage associated with hypertensive emergency : • • Changes in mental status, such as confusion Bleeding into the brain (stroke) Heart failure Chest pain(unstable angina) Fluid in the lungs (pulmonary edema) Heart attack Aneurysm (aortic dissection) Eclampsia (occurs during pregnancy)

Diagnostic Assessment • Review BUN and creatinine to evaluate the effect of BP on

Diagnostic Assessment • Review BUN and creatinine to evaluate the effect of BP on kidneys. BUN>20 mg/d. L and creatinine >1. 5 mg/d. L suggest renal impairment. • Review serial chest radiography for pulmonary congestion. • Review serial 12 -lead ECGs for patterns of injury, ischemia, and infarction

Patient Assessment • Assess the patient for laboratories indicated.

Patient Assessment • Assess the patient for laboratories indicated.

Nursing diagnosis • Risk for decreased Cardiac Output related to Increased vascular resistance, vasoconstriction.

Nursing diagnosis • Risk for decreased Cardiac Output related to Increased vascular resistance, vasoconstriction. • Ineffective tissue perfusion related to compromised blood flow secondary to severe hypertension resulting in end-organ damage. • Activity intolerance related to Generalized weakness • Nutrition: imbalanced, more than body requirements related to excessive intake in relation to metabolic need.

Monitoring of patient. • Monitor arterial BP continuously and note sudden increases or decrease

Monitoring of patient. • Monitor arterial BP continuously and note sudden increases or decrease in readings. A precipitous drop in BP can cause reflex ischemia to the heart, brain, kidneys, and/or GI tract. Note trends in mean arterial pressure and the patient’s response to therapy. • Monitor hourly urine output and note any presence of blood in the urine. • Continuously monitor the ECG fir dysrhythmias or ST segment and T-wave changes associated with ischemia or injury.

Nursing Interventions. • Provide oxygen at 2 to 4 liters/min to maintain or improve

Nursing Interventions. • Provide oxygen at 2 to 4 liters/min to maintain or improve oxygenation. • Minimize oxygen demand by maintaining the patient at bed rest. • Help the patient decrease anxiety, and keep the patient NPO or provide a liquid diet in the acute phase. • Administer nitrates as ordered to reduce preload and afterload. • Administer ? -blockers as ordered. Labetalol may be given as 20 to 80 mg bolus every 10 to 15 minutes to rapidly lower the blood pressure. • Prepare the patient and family for surgical intervention to correct the underlying cause, if this is indicated.

Hypertensive Crisis Nursing and Collaborative Management Hospitalization - IV drug therapy - Monitor cardiac

Hypertensive Crisis Nursing and Collaborative Management Hospitalization - IV drug therapy - Monitor cardiac and renal function - Neurologic checks - Determine cause - Education to avoid future crises

Learning objectives. The students will be able to: Define adrenal crisis. Narrate causes of

Learning objectives. The students will be able to: Define adrenal crisis. Narrate causes of adrenal crisis. Explain the Pathophysiology of adrenal crisis. Enumerate the clinical manifestations of adrenal crisis. • Explain the diagnosis and management of adrenal crisis. • • •

Adrenal crisis. • Adrenal crisis (also known as Addisonian crisis and acute adrenal insufficiency)

Adrenal crisis. • Adrenal crisis (also known as Addisonian crisis and acute adrenal insufficiency) is a medical emergency and potentially lifethreatening situation requiring immediate emergency treatment. It is a constellation of symptoms that indicate severe adrenal insufficiency caused by insufficient levels of the hormone cortisol.

Pathophysiology. • Glucocorticoids are produced in the adrenal cortex under the regulation of the

Pathophysiology. • Glucocorticoids are produced in the adrenal cortex under the regulation of the hypothalamic–pituitary–adrenal (HPA) axis. • Cortisol has many important metabolic and endocrine functions that are essential for human survival, particularly during stress. Surgery, anaesthesia, trauma, and severe illnesses result in elevated plasma ACTH and cortisol levels. Cortisol is required for the metabolism of carbohydrates, lipids and proteins, and for the maintenance of vascular tone and endothelial integrity. It also potentiates the vasoconstrictor actions of catecholamines and has anti-inflammatory effects on the immune system. • Aldosterone is synthesised in the adrenal cortex under the control of the renin–angiotensin system. It regulates sodium and potassium balance and intravascular volume.

Pathophysiology( cont. . . ) • Primary adrenal insufficiency / Addison’s -is due to

Pathophysiology( cont. . . ) • Primary adrenal insufficiency / Addison’s -is due to intrinsic adrenal gland dysfunction and results in decreased cortisol and aldosterone production. Approximately 90% of the gland must be destroyed for clinical adrenal insufficiency to develop. The commonest cause in developed countries is autoimmune adrenalitis. Other causes include infection (e. g. tuberculosis, HIV), drugs, adrenal haemorrhage, sarcoidosis, metastases, and congenital adrenal hyperplasia.

Pathophysiology(cont. . . ) • Secondary adrenal insufficiency -is due to hypothalamic-pituitary dysfunction causing

Pathophysiology(cont. . . ) • Secondary adrenal insufficiency -is due to hypothalamic-pituitary dysfunction causing inadequate ACTH production. This results in cortisol deficiency only. This may be caused by withdrawal of prolonged steroid therapy, pituitary disease or pituitary injury such as trauma, tumour, irradiation or surgery.

Diagnosis. • ACTH (cosyntropin) stimulation test • Cortisol level (to assess the level of

Diagnosis. • ACTH (cosyntropin) stimulation test • Cortisol level (to assess the level of glucocorticoids) • Fasting blood sugar • Serum potassium (to assess the level of mineralocorticoids) • Serum sodium

Recapitulation. • What is adrenal crisis, Explain. • What is hypertensive crisis , Explain.

Recapitulation. • What is adrenal crisis, Explain. • What is hypertensive crisis , Explain. • What is thyroid crisis, Explain.

Refrences. • Brewer M. Five keys to successful nursing management. Philadelphia: Williams & Wilkins,

Refrences. • Brewer M. Five keys to successful nursing management. Philadelphia: Williams & Wilkins, 2003. • Lee RI, Jone LW. The fundamentals of good medical care. Chicago: University of Chicago Press, 1983.