1、Word ListvThyroid disorders 甲状腺病症vIsthmus 峡部vThyroxine 甲状腺素vTriiodothyronine 三碘甲状腺氨酸vParathyroid glands 甲状旁腺vCalcitonin 降钙素vRecurrent laryngeal nerve 喉返神经vHyperthyroidism 甲亢vHypothyroidism 甲减vGoitre 甲状腺肿vExophthalmos 突眼症vTremor 震颤vTSH 促甲状腺激素vThyroidectomy 甲状腺切除术vThyroid crisis 甲状腺危象vA tracheostomy s
2、et 气管切开包vTetamy 手足抽搐Thyroid GlandIt is a part of the endocrine(内分泌内分泌)system,plays a major role in regulating the bodys metabolism.Section 1Anatomy/physiology of thyroidPlaceBlood supplyNerves supplyFunctionsAnatomy/physiology of thyroid vLocated in the lower neck anterior to the trachea.Two lateral
3、 lobes connected by an isthmus（峡部）（峡部）vButterfly-shaped organv 5cm long ,3cm wide，30gv The parathyroid glands（甲状旁腺）（甲状旁腺）lying on the dorsal side（背面）（背面）of the thyroid gland.vRich,from the superior and inferior thyroid artery.vArtery:vThe arterial branches provide blood supply to other structures in
4、 the area.The interior thyroid artery provides branches to the pharynx,trachea and esophagus.vVein:1)The superior thyroid vein 2)The middle thyroid vein 3)The inferior thyroid vein vThe nerves supplying the thyroid originate from vagus(迷走神经）迷走神经）,innervate the epithelial cells（上皮细胞）（上皮细胞）of the foll
5、icles（滤（滤泡）泡）of the thyroid gland.vOne must be aware of the bilateral existence of a recurrent laryngeal nerve（喉（喉返神经）返神经）during dissection.vProduces,synthesizes,stores,and secretes Two Hormones Called Thyroxine(T4)Thyronine(T3)vRegulates Metabolism so Your Cells Function ProperlyvAffects Every Cell
6、 in the Body,necessary for normal growth and developmentvCommon disorder:A deficiency of iodine vOther disorder:Autoimmune thyroid diseasevClassification:Hyperthyroidism(甲亢）甲亢）,hypothyroidism（甲减）（甲减）,tumours,cancer or goitre（甲状腺肿）（甲状腺肿）.When the Thyroid Doesnt WorkHyperthyroidism Too Much Thyroid Ho
7、rmone Metabolism Speeds UpHypothyroidism Too Little Thyroid Hormone Metabolism Slows DownHyperthyroidism(甲状腺功能亢进）甲状腺功能亢进）Definition Hyperthyroidism is an imbalance of metabolism caused by overproduction of thyroid hormone.vCause:Increased secretion of thyroid hormone.vFemales:males=4:1,it tends to a
8、ffect males more severely.vIncidence:20 40 years old group.Clinical ManifestationGoiterExophthalmos (突眼征）突眼征）Increased metabolic rateIncreased function of sympathetic nerve(交感神经）交感神经）Cardiovascular alteration v The thyroid can be palpated for asymmetry(不对称）不对称）and size.v It may enlarge 3-4 times to
9、its normal size.It is called goitre.HyperthyroidismvAs a result of increased thyroid hormone production,the client has an increased metabolic rate.vWeight loss despite increased appetite,fatigue,poor tolerance to heat,and profuse perspiration,menstrual irregularities.vNervous,restlessness,irritabili
10、ty,difficulty concentrating,emotional liability,mood swings,personality changes.vFine tremors of the fingers and tongue,shaky handwriting,clumsiness,trouble in climbing stairs,or dyspnea possibly at rest.vThe skin is warm and moist,characteristic salmon colour(鲜肉色）鲜肉色）.vThe hair is fine and soft wit
11、h premature grey and increased hair loss.vThe nails appear fragile with distal nail separation from the nail bed.v Tachycardia:160 bpm and down to 80 bpm during sleep.v Pulse pressure is widened.vThere can be muscular weakness and atrophy(萎缩）萎缩）,paralysis（瘫痪）（瘫痪）.Diagnostic TestsTSH（促甲状腺激素）（促甲状腺激素）T
12、3,T4Radioactive iodine uptake（131131）Thyroid scanMensuration of basic metabolism rate(BMR)vTSH(ThyroidStimulating Hormone)normal TSH reflect a euthyroid(甲状腺机能正甲状腺机能正常的）常的）state.v Hyperthyroidism:TSH is low or absent.v In mild forms of hyperthyroidism:slightly abnormal.Thyroid scan Scan are helpful i
13、n determining location,size,shape,and anatomic function of the thyroid gland.Mensuration of Basic Metabolism Rate (BMR)vConditions:Early in the morning,empty stomach,at the time of rest vBasic Metabolism Rate =(Pulse rate+Pulse pressure)-111GradevNormal:10%vSlightly abnormal:+20%+30%vModerately abno
14、rmal:+30%+60%vSeriously abnormal:+60%TreatmentvAntithyroid drugs,radioactive iodine,or thyroidectomy(甲状腺切除术）甲状腺切除术）.vIndividualized and depends on the age and general state of health，the size of the goiter and the ability to obtain follow-up care.vPartial or complete thyroidectomy may be carried out
15、 as primary treatment.vThe type and extent of the surgery depend on the diagnosis,goal of surgery,and prognosis.Surgical IndicationsvA very large goiter or a multinodular goiter with relatively low radioactive iodine uptakevMalignant thyroid nodule vPsychologically or mentally incompetent patientsSu
16、rgeryvA portion of the thyroid gland is removed,but a total thyroidectomy may be performed(expensive,risks).vIndications for subtotal thyroidectomy:the main advantages are rapid control of the disease and a lower incidence of hypothyroidism than can be achieved with radioiodine treatment.SurgeryvIf
17、a partial thyroidectomy is done,the remaining thyroid tissue should provide adequate amounts of thyroid hormones.vIf a complete thyroidectomy is done,the client will require thyroid hormone replacement for a lifetime.The neck is extended and a symmetrical,gently curved incision is made 1 to 2 cm abo
18、ve the clavicle（锁骨）（锁骨）.Closure of the wound is accomplished by the strap muscles in the midline.A small suction catheter is usually inserted through a stab wound.Complications after surgeryDyspnea,asphyxiaInjury of laryngeal nerveSpasms Thyroid crisis（甲状腺危象）（甲状腺危象）HaemorrhageHaematoma(血肿）血肿）formati
19、on Tracheal collapse（气管塌陷）（气管塌陷）Tracheal mucous accumulationLaryngeal or local tissue edemaCauseComplications after surgeryv Respiratory distress and haemorrhage.Difficulty in respiration which is the occurs within after the surgery.Managementv Surgical evacuation is required.v The first aid by the
20、bed A.cut off the suture B.opened the wound wide C.removed the hematoma v The trachea is cut,apply oxygen v Send to the operation room for further treatment.Preventive interventionsvA tracheostomy set(气管切开包）气管切开包）is kept at the patients bedside at all times,and the surgeon is summoned at the first i
21、ndication of respiratory distress.Injury of laryngeal nervevAny voice changes are noted because they might indicate injury to the recurrent laryngeal nerve（喉返神经）（喉返神经）,which lies just behind the thyroid next to the trachea.vTalk as little as possible.Can be cured spontaneously,or by physical therapy
22、.Spasm The parathyroid glands may be injured or removed disturbance of the calcium metabolism of the body blood calcium level falls spasms of the hands and feet and muscular twitching “tetany”ManagementvTemporaryvLimit taking of meat,eggs which are high in phosphorus（磷）（磷）vUse of the sedative to con
23、trol the pain vIntravenous administration of calcium gluconate葡萄糖酸钙葡萄糖酸钙 Thyroid crisis(storm)vReason:insufficient preoperative preparation,a release of large amounts of thyroid hormone,rare vOutcome:can lead to cardiac,hepatic or renal failure.vStressful factors:surgery,infection or trauma,pregnanc
24、y.vTime of occurring:the first 12 hours postoperative.vClinical manifestation:1.Tachycardia (130 bmp)2.T 39,sometimes 413.Exaggerated symptoms of hyperthyroidism4.Disturbances of a major system u Gastrointestinal (diarrhea,abdominal pain)u Neurologic (psychosis,somnolence,coma)u Cardiovascular (edem
25、a,chest pain,dyspnea,palpitations)vFatalness:The client may develop congestive heart failure and die.vPreventions:The key is to do the preoperative preparation sufficiently,and perform the surgery until the BMR become normal.Medical ManagementvThe physician must be informed immediately.vTransfer the
26、 patient to the intensive care for closer monitoring vIodine 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.v200400mg Hydrocortisone氢化可的松氢化可的松 is prescribed to treat shock or ad
27、renal insufficiency.vThe usage of sedative(luminal鲁米纳鲁米纳 Q6-8h)vReduce body temperature and heart rate and to prevent vascular collapse(37).n A large amount of glucose are needed.nOxygen therapy:Humidified oxygen is administered to improve tissue oxygenation and meet the high metabolic demandsn Card
28、iac problems:arterial fibrillation,and congestive heart failure,sympatholytic agents may be administered,such as propranolol(心得安心得安)Preoperative carePerfect preoperative careBaseline informationPharmacologic therapyMental supportNutritionInstruction Pharmacologic therapynIt is necessary for surgical
29、 treatment,but it can not act as a therapuetic medication.nEncourages 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.n 2 to 5 drops of potassium iodide solution(复方复方碘化钾碘
30、化钾)or Lugols iodine solution(卢戈氏液卢戈氏液)are given in conjunction with propylthiouracil (丙基硫尿嘧啶丙基硫尿嘧啶)to decrease the friability and vascularity of the thyroid,it should be applied until the time of operation and the patient became euthyroid.nRequirement:euthyroid nPatients mood is steady,the sleep tak
31、es a favorable turn,gain weight,pulse rate 90 times/min,Basic Metabolism Rate +20%.n情绪稳定、睡眠正常、体重增加、心跳正常、代谢恢复情绪稳定、睡眠正常、体重增加、心跳正常、代谢恢复NutritionnSeveral well-balanced meals of small amount,even up to six meals a day.n Highly seasoned foods and stimulants,such as coffee,tea,cola,and alcohol are discoura
32、ged.n High-calorie,high-protein foods are encouraged.Preoperative teachingnHow to support the neck with the hands after surgery to prevent stress on the incision.nEye care and protection may become necessary,correct instillation of eye drops or ointment prescribed to soothe the eyes and protect the
33、exposed cornea.Postoperative carePositionObservationOxygenNutritionMedicationHealth instructionObservationn Cardiac and respiratory function are assessed by measuring vital signs and cardiac output,ECG monitor,arterial blood gases.n Surgical dressing are assessed periodically and reinforced when nec
34、essary,especially at the back of the neck for bleeding.nIf there is a drain,approximately of drainage is expected at the 1st day.nIf there is no drainage,the drain must be checked forvLaryngeal nerve:The nurse should encourage voice test for 48 hours postoperatively with voice checks every 2 to 4 ho
35、urs to make certain there is no laryngeal nerve damage.Nutritionn Intravenous fluids are administered during the immediate postoperative period;water may be given by mouth as soon as nausea subsides.n Cold fluids and ice may be taken better than hot fluids.n No difficulty in swallowing,soft diet.Medicationsn 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.n Sedative are administered as prescribed for pain.Health instructionnKnowledgeable about the signs and symptoms of complications that may occur.iodine
