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1、.,1,Thyroid Disorders,.,2,Word List,Thyroid disorders 甲状腺病症Isthmus 峡部Thyroxine 甲状腺素Triiodothyronine 三碘甲状腺氨酸Parathyroid glands 甲状旁腺Calcitonin 降钙素,.,3,Recurrent laryngeal nerve 喉返神经Hyperthyroidism 甲亢Hypothyroidism 甲减Goitre 甲状腺肿Exophthalmos 突眼症Tremor 震颤TSH 促甲状腺激素,.,4,Thyroidectomy 甲状腺切除术Thyroid crisis
2、甲状腺危象A tracheostomy set 气管切开包Tetamy 手足抽搐,Thyroid Gland,It is a part of the endocrine (内分泌) system, plays a major role in regulating the bodys metabolism.,.,6,Section 1,Anatomy/physiology of thyroid,.,7,PlaceBlood supplyNerves supplyFunctions,Anatomy/physiology of thyroid,.,8,Located in the lower nec
3、k anterior to the trachea. Two lateral lobes connected by an isthmus（峡部）Butterfly- shaped organ 5cm long , 3cm wide ，30g The parathyroid glands（甲状旁腺） lying on the dorsal side（背面） of the thyroid gland.,.,9,Rich , from the superior and inferior thyroid artery.Artery: The arterial branches provide bloo
4、d supply to other structures in the area. The interior thyroid artery provides branches to the pharynx, trachea and esophagus . Vein: 1) The superior thyroid vein 2) The middle thyroid vein 3) The inferior thyroid vein,.,10,The nerves supplying the thyroid originate from vagus (迷走神经）, innervate the
5、epithelial cells （上皮细胞） of the follicles（滤泡） of the thyroid gland. One must be aware of the bilateral existence of a recurrent laryngeal nerve （喉返神经） during dissection.,.,11,Produces, synthesizes , stores , and secretes Two Hormones Called Thyroxine (T4)Thyronine (T3)Regulates Metabolism so Your Cel
6、ls Function ProperlyAffects Every Cell in the Body, necessary for normal growth and development,.,12,Common disorder: A deficiency of iodine Other disorder : Autoimmune thyroid diseaseClassification: Hyperthyroidism(甲亢）, hypothyroidism（甲减）, tumours , cancer or goitre（甲状腺肿）.,.,13,When the Thyroid Doe
7、snt Work,Hyperthyroidism Too Much Thyroid Hormone Metabolism Speeds Up,Hypothyroidism Too Little Thyroid Hormone Metabolism Slows Down,.,14,Hyperthyroidism(甲状腺功能亢进）,.,15,Definition,Hyperthyroidism is an imbalance of metabolism caused by overproduction of thyroid hormone.,.,16,Cause: Increased secret
8、ion of thyroid hormone. Females : males = 4 : 1 , it tends to affect males more severely . Incidence : 20 40 years old group .,.,17,Clinical Manifestation,GoiterExophthalmos (突眼征）Increased metabolic rateIncreased function of sympathetic nerve (交感神经）Cardiovascular alteration,.,18,The thyroid can be p
9、alpated for asymmetry (不对称） and size. It may enlarge 3-4 times to its normal size. It is called goitre.,Hyperthyroidism,.,20,.,21,As a result of increased thyroid hormone production, the client has an increased metabolic rate. Weight loss despite increased appetite , fatigue , poor tolerance to heat
10、 , and profuse perspiration, menstrual irregularities .,.,22,Nervous, restlessness, irritability, difficulty concentrating , emotional liability, mood swings, personality changes.Fine tremors of the fingers and tongue, shaky handwriting , clumsiness, trouble in climbing stairs, or dyspnea possibly a
11、t rest.,.,23,The skin is warm and moist , characteristic salmon colour ( 鲜肉色） .The hair is fine and soft with premature grey and increased hair loss . The nails appear fragile with distal nail separation from the nail bed .,.,24,Tachycardia : 160 bpm and down to 80 bpm during sleep. Pulse pressure i
12、s widened. There can be muscular weakness and atrophy (萎缩）, paralysis（瘫痪）.,.,25,Diagnostic Tests,TSH（促甲状腺激素）T3 , T4Radioactive iodine uptake（131）Thyroid scanMensuration of basic metabolism rate (BMR),.,26,TSH (ThyroidStimulating Hormone) normal TSH reflect a euthyroid (甲状腺机能正常的） state. Hyperthyroidi
13、sm : TSH is low or absent . In mild forms of hyperthyroidism : slightly abnormal .,Thyroid scan Scan are helpful in determining location , size, shape, and anatomic function of the thyroid gland.,.,28,Mensuration of Basic Metabolism Rate ( BMR ),Conditions : Early in the morning , empty stomach , at
14、 the time of rest Basic Metabolism Rate = ( Pulse rate + Pulse pressure) - 111,.,29,Grade,Normal: 10% Slightly abnormal: +20% +30% Moderately abnormal: +30% +60%Seriously abnormal: +60%,.,30,Treatment,Antithyroid drugs , radioactive iodine, or thyroidectomy (甲状腺切除术）. Individualized and depends on th
15、e age and general state of health ，the size of the goiter and the ability to obtain follow-up care.,.,31,Partial or complete thyroidectomy may be carried out as primary treatment .The type and extent of the surgery depend on the diagnosis, goal of surgery , and prognosis.,.,32,Surgical Indications,A
16、 very large goiter or a multinodular goiter with relatively low radioactive iodine uptakeMalignant thyroid nodule Psychologically or mentally incompetent patients,.,33,Surgery,A portion of the thyroid gland is removed, but a total thyroidectomy may be performed (expensive, risks).Indications for sub
17、total thyroidectomy : the main advantages are rapid control of the disease and a lower incidence of hypothyroidism than can be achieved with radioiodine treatment.,.,34,Surgery,If a partial thyroidectomy is done , the remaining thyroid tissue should provide adequate amounts of thyroid hormones. If a
18、 complete thyroidectomy is done, the client will require thyroid hormone replacement for a lifetime.,.,35,The neck is extended and a symmetrical, gently curved incision is made 1 to 2 cm above the clavicle（锁骨）.,Closure of the wound is accomplished by the strap muscles in the midline. A small suction
19、 catheter is usually inserted through a stab wound.,.,36,Complications after surgery,Dyspnea , asphyxiaInjury of laryngeal nerveSpasms Thyroid crisis（甲状腺危象）,.,37,HaemorrhageHaematoma(血肿）formation Tracheal collapse（气管塌陷）Tracheal mucous accumulationLaryngeal or local tissue edema,Cause,.,38,Complicati
20、ons after surgery,Respiratory distress and haemorrhage. Difficulty in respiration which is the occurs within after the surgery .,most critical complication,48 hours,.,39,Management,Surgical evacuation is required. The first aid by the bed A. cut off the suture B. opened the wound wide C. removed the
21、 hematoma The trachea is cut , apply oxygen Send to the operation room for further treatment.,.,40,Preventive interventions,A tracheostomy set (气管切开包）is kept at the patients bedside at all times , and the surgeon is summoned at the first indication of respiratory distress.,.,41,Injury of laryngeal n
22、erve,Any voice changes are noted because they might indicate injury to the recurrent laryngeal nerve（喉返神经）, which lies just behind the thyroid next to the trachea. Talk as little as possible. Can be cured spontaneously, or by physical therapy.,.,42,Spasm,The parathyroid glands may be injured or remo
23、ved disturbance of the calcium metabolism of the body blood calcium level falls spasms of the hands and feet and muscular twitching “tetany”,laryngospasm,.,43,Management,TemporaryLimit taking of meat , eggs which are high in phosphorus（磷）Use of the sedative to control the pain Intravenous administra
24、tion of calcium gluconate葡萄糖酸钙,.,44,Thyroid crisis (storm),Reason: insufficient preoperative preparation , a release of large amounts of thyroid hormone , rare Outcome: can lead to cardiac, hepatic or renal failure. Stressful factors: surgery , infection or trauma, pregnancy .,.,45,Time of occurring
25、 : the first 12 hours postoperative. Clinical manifestation: Tachycardia ( 130 bmp)T 39, sometimes 41Exaggerated symptoms of hyperthyroidismDisturbances of a major system,.,46,Gastrointestinal (diarrhea, abdominal pain) Neurologic (psychosis, somnolence, coma) Cardiovascular (edema, chest pain, dysp
26、nea, palpitations),.,47,Fatalness: The client may develop congestive heart failure and die .Preventions: The key is to do the preoperative preparation sufficiently , and perform the surgery until the BMR become normal.,.,48,Medical Management,The physician must be informed immediately . Transfer the
27、 patient to the intensive care for closer monitoring Iodine is administered to decrease the output of thyroid hormone . Take KI solution 3ml orally , or put 10% iodine sodium 5ml into in 10% glucose, and give iv injection to the patient .,.,49,200400mg Hydrocortisone氢化可的松 is prescribed to treat shoc
28、k or adrenal insufficiency .The usage of sedative( luminal鲁米纳 Q6-8h)Reduce body temperature and heart rate and to prevent vascular collapse ( 37 ) . A large amount of glucose are needed .,.,50,Oxygen therapy : Humidified oxygen is administered to improve tissue oxygenation and meet the high metaboli
29、c demands Cardiac problems : arterial fibrillation, and congestive heart failure, sympatholytic agents may be administered, such as propranolol (心得安),.,51,Preoperative care,Perfect preoperative careBaseline informationPharmacologic therapyMental supportNutritionInstruction,.,52,Pharmacologic therapy
30、,It is necessary for surgical treatment, but it can not act as a therapuetic medication.Encourages the patient to take the medications as prescribed . Iodine preparations may have been prescribed 10 to 14 days before surgery to decrease thyroid vascularity and decrease bleeding .,.,53,2 to 5 drops o
31、f potassium iodide solution(复方碘化钾) or Lugols iodine solution (卢戈氏液) are given in conjunction with propylthiouracil (丙基硫尿嘧啶) to decrease the friability and vascularity of the thyroid, it should be applied until the time of operation and the patient became euthyroid .,.,54,Requirement : euthyroid Pati
32、ents mood is steady , the sleep takes a favorable turn, gain weight , pulse rate 90 times /min , Basic Metabolism Rate +20%.情绪稳定、睡眠正常、体重增加、心跳正常、代谢恢复,.,55,Nutrition,Several well-balanced meals of small amount, even up to six meals a day. Highly seasoned foods and stimulants, such as coffee, tea , col
33、a, and alcohol are discouraged. High-calorie, high-protein foods are encouraged.,.,56,Preoperative teaching,How to support the neck with the hands after surgery to prevent stress on the incision.Eye care and protection may become necessary , correct instillation of eye drops or ointment prescribed t
34、o soothe the eyes and protect the exposed cornea.,.,57,Postoperative care,PositionObservationOxygenNutritionMedicationHealth instruction,.,58,Observation,Cardiac and respiratory function are assessed by measuring vital signs and cardiac output, ECG monitor, arterial blood gases. Surgical dressing ar
35、e assessed periodically and reinforced when necessary, especially at the back of the neck for bleeding.,.,59,If there is a drain , approximately of drainage is expected at the 1st day. If there is no drainage, the drain must be checked for,50 ml,links or obstruction,.,60,Laryngeal nerve : The nurse
36、should encourage voice test for 48 hours postoperatively with voice checks every 2 to 4 hours to make certain there is no laryngeal nerve damage.,.,61,Nutrition,Intravenous fluids are administered during the immediate postoperative period; water may be given by mouth as soon as nausea subsides. Cold
37、 fluids and ice may be taken better than hot fluids. No difficulty in swallowing , soft diet .,.,62,Medications,KI (potassium iodine)should be taken 3 times a day, 16 drops each time, reduce 1 drop day by day, until the condition being steady. Sedative are administered as prescribed for pain .,.,63,Health instruction,Knowledgeable about the signs and symptoms of complications that may occur.,iodine,
