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Hyperthyrodism

Description

  1. Hyperthyroidism is a hyperthyroid state resulting from hypersecretion of thyroid hormones (T3 and T4).
  2. Hyperthyroidism is characterized by an increased rate of body metabolism.
  3. A common cause is Graves’ disease, also known as toxic diffuse goiter.

Clinical manifestations are referred to as thyrotoxicosis.

Causes

Graves’ disease has an autoimmune derivation and is caused by circulating anti-TSH autoantibodies that displace TSH from the thyroid receptors and mimic TSH by activating the TSH receptor to release additional thyroid hormones. Graves’ disease is also associated with Hashimoto’s disease, a chronic inflammation of the thyroid gland that usually causes hypothyroidism but can also cause symptoms similar to those of Graves’ disease. Thyrotoxicosis has several different pathophysiological causes, including autoimmune disease, functioning thyroid adenoma, and infection.

Assessment

  1. Enlarged thyroid gland (goiter)
  2. Palpatations, cardiac dysrhythmias, such as tachycardia or atrial fibrillation
  3. Protruding eyeballs (exophthalmos) possibly present
  4. Hypertension
  5. Heat intolerance
  6. Diaphoresis
  7. Weight loss
  8. Diarrhea
  9. Smooth, soft skin and hair
  10. Nervousness and fine tremors of hands
  11. Personality changes
  12. Irritability and agitation
  13. Mood swings
  14. Oligomenorrhea (Irregular menstrual periods in women)

Complications

Thyroid crisis (storm), also called thyrotoxicosis, is a sudden worsening of hyperthyroidism symptoms that may occur with infection or stress. Fever, decreased mental alertness, and abdominal pain may occur. Immediate hospitalization is needed.

Other complications related to hyperthyroidism include:

  • Heart-related complications including:
    • Rapid heart rate
    • Congestive heart failure
    • Atrial fibrillation
  • Increased risk for osteoporosis, if hyperthyroidism is present for a long time
  • Surgery-related complications, including:
    • Scarring of the neck
    • Hoarseness due to nerve damage to the voice box
    • Low calcium level due to damage to the parathyroid glands (located near the thyroid gland)
  • Treatments for hypothyroidism, such as radioactive iodine, surgery, and medications to replace thyroid hormones can have complications.

Primary Nursing Diagnosis

  • Activity intolerance related to exhaustion and fatigue

Diagnostic Evaluation

  • Thyroid-stimulating hormone (TSH) assay reveals a decrease in result (normal TSH: 0.5–1.5 mU/L). Elevation of thyroid hormones decreased TSH secretion by negative feedback.
  • Elevated Thyroxine (T4) radioimmunoassay (normal values: 5.0–12.0 μg/dL). Elevation reflects overproduction of thyroid hormones; monitors response to therapy.
  • Elevated Tri-iodothyronine (T3) radioimmunoassay (normal values: 80–230 ng/dL).Elevation reflects overproduction of thyroid hormones.
  • Other Tests: 24-hr radioactive iodine uptake; thyroid autoantibodies; antithyroglobulin; electrocardiogram (ECG)

Medical Management

Treatment is directed toward reducing thyroid hyperactivity for symptomatic relief and removing the cause of complications. Three forms of treatment are available:

  • Irradiation involving the administration of 131I or 123I for destructive effects on the thyroid gland
  • Pharmacotherapy with antithyroid medications
  • Surgery with the removal of most of the thyroid gland

Radioactive Iodine (131I) 

  • 131I is given to destroy the overactive thyroid cells (most common treatment in the elderly).
  • 131I is contraindicated in pregnancy and nursing mothers because radioiodine crosses the placenta and is secreated in breast milk.

Pharmacotherapy

  • The objective of pharmacotherapy is to inhibit hormone synthesis or release and reduce the amount of thyroid tissue.
  • The most commonly used medications are propylthiouracil (Propacil, PTU) and methimazole (Tapazole) until patient is euthyroid.
  • Maintenance dose is establish, followed by gradual withdrawal of the medication over the next several months.
  • Antithyroid drugs are contraindicated in late pregnancy because of a risk for goiter and cretinism in the fetus.
  • Thyroid hormone may be administered to put the thyroid to rest.

Adjunctive Therapy

  • Potassium iodide, Lugol’s solution, and saturated solution of potassium iodide (SSKI) may be added.
  • Beta- adrenergic agents may be used to control the sympathetic nervous system, effects that occur in hyperthyroidism; for example, propranolol is used for nervousness, tachycardia, tremor, anxiety, and heat intolerance.

Surgery

  • Surgical treatment with thyroidectomy is no longer the preferred choice of therapy for Graves’ disease but is an alternative therapeutic approach in some situations. In particular, it is used for patients who cannot tolerate antithyroid drugs, have significant ophthalmopathy, have large goiters, or cannot undergo radioiodine therapy.

Pharmacologic Highlights

  • Propylthiouracil (PTU) an antithyroid agent is given to return the patient to the euthyroid (normal) state. PTU inhibits use of iodine by thyroid gland; blocks oxidation of iodine and inhibitis thyroid hormone synthesis
  • Methimazole (Tapazole) an antithyroid agent is given to return the patient to the euthyroid (normal) state by inhibiting use of iodine by thyroid gland.
  • Other Drugs: Beta-adrenergic blockers, corticosteroids, radioactive iodine

Nursing Interventions

  1. Provide adequate rest.
  2. Administer sedatives as prescribed.
  3. Provide a cool and quiet environment.
  4. Obtain weight daily.
  5. Provide a high-calorie diet.
  6. Avoid the administration of stimulants.
  7. Administer antithyroid medications (propylthiouracil [PTU]) that block thyroid synthesis, as prescribed.
  8. Administer iodine preparations that inhibit the release of thyroid hormone as prescribed.
  9. Administer propranolol (INderal) for tachycardia as prescribed.
  10. Prepare the client for radioactive iodine therapy, as prescribed, to destroy thyroid cells.
  11. Prepare the client for thyroidectomy if prescribed.

Documentation Guidelines

  • Physical findings: Cardiovascular status (resting pulse, blood pressure, presence of angina or palpitations), bowel activity, edema, condition of skin, and activity tolerance
  • Physical findings: Hypermetabolism, eye status, heat intolerance, activity level
  • Response to medications, skin care regimen, nutrition, body weight, comfort
  • Psychosocial response to changes in bodily function, including mental acuity, behavioral patterns, emotional stability

Discharge and Home Healthcare Guidelines

  • DISEASE PROCESS. Provide a clear explanation of the role of the thyroid gland, the disease process, and the treatment plan. Explain possible side effects of the treatment.
  • MEDICATIONS. Be sure that the patient understands all medications, including the dosage, route, action, adverse effects, and the need for any laboratory monitoring of thyroid medications. If patients are taking propylthiouracil or methimazole, encourage them to take the medications with meals to limit gastric irritation. If the patient is taking an iodine solution, mix it with milk or juice to limit gastric irritation and have the patient use a straw to limit the risk of teeth discoloration.
  • COMPLICATIONS. Have the patient report any signs and symptoms of thyrotoxicosis immediately: rapid heart rate, palpitations, perspiration, shakiness, tremors, difficulty breathing, nausea, vomiting. Teach the patient to report increased neck swelling, difficulty swallowing, or weight loss.

Source:

http://www.rnpedia.com/home/notes/medical-surgical-nursing-notes/hyperthyrodism

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