A&P Flashback
• Butterfly-shaped gland at base of neck, below Adams apple
• One of several glands that make up endocrine system
• Weighs less than an ounce
• Produce hormones –triiodothyronine (T-3) & thyroxine (T-4) – these hormones maintain rate at which body uses fats and carbohydrates, control body temperature, influence heart rate protein production regulation
• Hormones produced coordinate several body activities from digestion to metabolism to reproduction.
• Rate at which they are released is controlled by pituitary gland.

What is Hashimoto’s Disease
• Autoimmune disorder in which immune system creates antibodies that damages the thyroid gland causing inflammation of the thyroid gland leading to gradual destruction leading to inadequate production of the thyroid hormones the body needs (hypothyroidism)
• Polyglandular autoimmune syndrome (PGA I) – Hashimoto’s w/ hypoparathyroidism, adrenal insufficiency, and fungal infections of mouth and nails
• Polyglandular autoimmune syndrome (PGA II)- Hashimoto’s w/ adrenal insufficiency and type I diabetes

Clinical Manifestations
Depends on severity of hormone deficiency – are those of an underactive thyroid gland (hypothyroidism)
• NONE
• Intolerance to cold
• Weight gain-occurring infrequently & rarely more than 10-20 lbs, mostly fluid
• Fatigue
• Constipation
• Enlarged neck or presence of goiter
• Pale, dry skin
• Hair loss
• Heavy and irregular menses
• Difficulty concentrating or thinking
• Pain and stiffness in joints, swelling in knees or small joints in hands & feet
• Muscle aches, tenderness, and stiffness-especially in shoulders & hips
Hashimoto’s Disease
WHAT YOU NEED TO KNOW

Signs & Symptoms – con’t
• Facial swelling/moon face
• Hoarse voice
• Elevated blood cholesterol level
• Muscle weakness, especially in lower extremities

Causes
• Cause is unknown
• May be linked to a virus or bacterium

Risk Factors
Other factors that may increase risk
• Heredity – individuals with a family hx of thyroid disease
• Sex – can occur in anyone, but most common in women
• Age – most common in women between 30-50 years of age

Screening & Diagnosis
• Initial assessment – questions about weight gain, mental changes, fatigue, slowed and slurred speech, cold intolerance, bradycardia, constipation, and dyspnea, distended abdomen, thick, brittle nails, paresthesias, muscle aches and pains, skin changes such as increased dryness or thickening. Assess for presence of enlarged thyroid gland (goiter)
• Thyroid antibody test (via blood test) – test will show the presence of antithyroid peroxidase antibody, antithyroglobulin antibody
• Hormone test (TSH, T-3, T-4) via blood test– Free T-4 level will be low, serum TSH level will be high, T-3 level will be low or normal.
• Fine needle aspiration (needle biopsy) – will show lymphocytes and macrophages
• Radioactive uptake scan – radioactive substance administered usually by mouth -will show diffuse uptake in an enlarged thyroid gland
• Ultrasound – will show enlarged thyroid gland

Complications
• Goiter – enlarged thyroid glands caused by constant stimulation of thyroid to release more hormones
• Heart problems – high levels of low-density lipoprotein (LDL) cholesterol – “bad” cholesterol are usually present in those with underactive thyroid gland, which increases their risk for heart disease. Hashimoto’s can also lead to an enlarged heart.
• Mental health issues – may occur early on in disease and progress. Hashimoto’s can also cause decreased libido in men and women and cause slowed mental functioning.
• Myxedema – life-threatening – develops due to chronic hypothyroidism as a result of untreated Hashimoto’s. Assess for s/s of cold intolerance, drowsiness, profound lethargy and unconsciousness. Sedatives, infection, stress on the body may trigger.
• Birth defects – babies born to women with untreated Hashimoto’s have increased risk for birth defects such as cleft palate and problems with the heart, brain and kidneys

Hashimoto’s Disease
WHAT YOU NEED TO KNOW

Prevention
• No known preventative measure
• Awareness of risk factors - such as family hx of Hashimoto’s – early awareness may allow for prompt diagnosis & treatment

Treatment
• Synthetic hormones – Levothroid, Levoxyl, Synthroid - identical to thyroxine produced in the thyroid gland – restores adequate hormone levels, returning body to its normal functioning. May reverse weight gain and gradually lower cholesterol levels elevated by disease. Side effects include cardiovascular collapse, arrhythmias, tachycardia, weight loss, insomnia, irritability, nervousness
• Natural extracts – Armour Thyroid - derived from glands of pigs contains levothyroxine and triiodothyronine. Concerns – T-4 & T-3 amounts in animals are not the same as in humans, exact amount in each batch of natural extract may vary leading to varying amounts of hormones in patients blood
• Dosage determined by level of T-3 & T-4 being produced & hearts response to medication therapy. Overtreatment of levothyroxine may cause arrhythmias and accelerate bone loss
• Surgery – to remove large goiters

Nursing Care
• Careful assessment of patient - questions about weight gain, mental changes, fatigue, slowed and slurred speech, cold intolerance, bradycardia, constipation, and dyspnea, thick, brittle nails, paresthesias, muscle aches and pains, skin changes such as increased dryness or thickening. Assess for presence of enlarged thyroid gland (goiter)
• Usually outpatient - unless complications develop
• Monitor vital signs, weight, I&O, assess for edema
• Cardiac assessment – cardiovascular response to hormone determines medication regimen
• Monitor energy level & mental alertness
• Explain nature of thyroid hormone deficiency – especially important to emphasize need for lifelong replacement.
• Emphasize need for warm environment – due to decreased tolerance for cold
• Discuss measures to minimize constipation – such as increased fiber intake in diet, use of stool softeners, gradual increase in activity and exercise. Avoid the use of enemas due to possible vagal stimulation.
• Instruct patient on diagnostic procedure requirements – patient may need to be NPO prior to diagnostic test, assess for iodine & shellfish allergies for any test that may utilize radioactive substances
• Teach patient about side effects of medications & s/s to report – signs of thyroid preparation overdose include orthopnea, dyspnea, rapid pulse, palpitations, nervousness, insomnia
• Teach patient about effects of using thyroid preparations with certain drugs – increase effects of anticoagulants, antidepressants and digitalis compounds.
• Teach patient about drugs that may affect absorption of thyroid preparations – iron supplements, Questran (used to lower cholesterol), aluminum hydroxide (found in some antacids), Kayexalate (used to prevent high blood potassium levels), Sucralfate (ulcer medication) and Calcium supplements.
• Teach patient to avoid the use of sedatives – Myxedema, a complication of untreated Hashimoto’s, may be triggered by sedatives.

REFERENCE PAGE

Hashimoto’s Thyroiditis. Montefiore Medical Center, 1-2. Retrieved March, 2 2007, from the World Wide Web: http://www.montefiore.org/healthlibrary/adult/endocrine/hashim.htm Hurd, Robert. MD. (May 12, 2006) “Medical Encyclopedia: Chronic thyroiditis (Hashimoto’s Disease)” Medline Plus, 1-3, Retrieved March 2, 2007, from the World Wide Web: www.nlm.nih.gov/medlineplus/print/ency/article/00371.htm

Kelly, Robert B. MD., M.S. (Sep 2002) “ Hashimoto’s Disease: What It Is and How It’s Treated” Familydoctor.org, 1-2. Retrieved March 2, 2007, from the World Wide Web: http://familydoctor.org/548.xml

Shomon, Mary. (July 27, 2007) “Hashimoto’s vs. Hypothyroidism: What’s the Difference?” About: Thyroid Disease, 1-2. Retrieved March, 2 2007, from the World Wide Web: http://www.thyroid.about.com/cs/hypothyroidism/a/hashivshyp.htm