Hyperthyroidism
Drug therapy - what three types of drugs
Useful in treatment of thyrotoxic states Not considered curative - Antithyroid drugs - Iodine - β-Adrenergic blockers Drugs used in the treatment of hyperthyroidism include antithyroid drugs, iodine, and β-adrenergic blockers. These drugs are useful in treating thyrotoxic states, but they are not considered curative.
hyperthyroidism - subclinical hyperthyroidism - overt hyperthyroidism
Subclinical hyperthyroidism (meaning it is there and may have s/s but you may not) - Serum TSH (thyroid stimulating hormone; is just below normal) level below 0.4 mIU/L - Normal T4 and T3 levels Overt hyperthyroidism - Low or undetectable TSH (thyroid stimulating hormone; pituitary gland releases this hormone; pituitary is holding back on TSH but you still have a ton of T4 and T3) - Elevated T4 and T3 levels - Symptoms may or may not be present The patient may or may not have symptoms of hyperthyroidism in overt hyperthyroidism. Since hyperthyroidism may be precipitated by iodinated contrast media used in CT scans and other radiological studies, those who are at-risk for hyperthyroidism should be monitored closely after iodinated contrast media exposure.
Nursing assessment - subjective data continued
Subjective Data - Decreased libido - Impotence - Gynecomastia - Amenorrhea - Emotional lability, irritability, restlessness - Personality changes (more depressed, more anxious, more irritable; reasons for these changes) , delirium Obtain the following important health information related to pertinent functional health patterns: Sexuality-reproductive: decreased libido; impotence; gynecomastia (in men); amenorrhea (in women) Coping-stress tolerance: emotional lability, irritability, restlessness, personality changes, delirium
Acropachy
(clubbing of the digits) may occur with advanced disease.
Continuum of thyroid dysfunction
(hyper side) Thyrotoxicosis- hyperthyroidism- euthyroid- hypothyroidism- myxedema coma (hypo side) Hypo means you don't have enough of a hormone or whatever you need Hyper= too much hypo=too little Most thyroid problems occur in women
Hyperthyroidism - what is it - seen more in who - what ages
- A sustained increase in synthesis and release of thyroid hormones by thyroid gland - Occurs more often in women - Highest frequency between ages 20 to 40 years Hyperthyroidism is hyperactivity of the thyroid gland with sustained increase in synthesis and release of thyroid hormones. It occurs in women more than men, with the highest frequency in persons 20 to 40 years old. Hyperthyroidism means you have sustained increase in the release and production of thyroid hormones Most often occurs in younger women but can occur in any age If older sometimes signs and symptoms can be associated with typical signs and symptoms of aging
Nursing diagnoses
Activity intolerance Imbalanced nutrition: less than body requirements Nursing diagnoses for the patient with hyperthyroidism include, but are not limited to, the following: • Activity intolerance related to fatigue and heat intolerance • Imbalanced nutrition: less than body requirements related to hypermetabolism and inadequate food intake
Nursing implementation preoperative care
Administer medications to achieve euthyroidism Administer iodine to ↓ vascularity Assess for signs of iodine toxicity Patient teaching - Comfort and safety measures - Leg exercises, head support, neck ROM - Routine postoperative care When subtotal thyroidectomy is the treatment of choice, the patient must be adequately prepared to avoid postoperative complications. Before surgery, antithyroid drugs, iodine, and β-adrenergic blockers may be given to achieve a euthyroid state. Iodine reduces vascularization of the thyroid gland, thereby reducing the risk of hemorrhage. Preoperatively, teach the patient about routine postoperative care, and comfort and safety measures. Teach the patient the importance of performing leg exercises. Instruct the patient how to support the head manually while turning in bed, because this maneuver minimizes stress on the suture line after surgery. Range-of-motion exercises of the neck should be practiced. Tell the patient that talking is likely to be difficult for a short time after surgery. If undergoing thyroidectomy they cannot put extra pulling pressure at incision Will be limited in range of motion Don't want to put extra tension on that suture line Need to be taught how to limit range of motion and keep head supported If suture line breaks GO TO HOSPITAL
Nursing implementation - postoperative care continued
Assess every 2 hours during first 24 hours for signs of hemorrhage or tracheal compression (ABC's) Semi-Fowler's position Support head with pillows (pillows are behind and also to the side so their neck is supported) Avoid neck flexion and tension on suture line Important nursing interventions after a thyroidectomy include the following: Assess the patient every 2 hours for 24 hours for signs of hemorrhage or tracheal compression such as irregular breathing, neck swelling, frequent swallowing, choking, blood on the dressings, and sensations of fullness at the incision site. Expect some hoarseness for 3 or 4 days after surgery because of edema. Place the patient in a semi-Fowler's position, support the patient's head with pillows, and avoid flexion of the neck and any tension on the suture lines.
Etiology and pathophysiology - Grave's disease what is it ( _____ disease) diffuse ___ enlargement excessive _____ ____ secretion associated with the presence of what other diseases
Autoimmune disease - Diffuse thyroid enlargement - Excess thyroid hormone secretion Precipitating factors interact with genetic factors Women are 5 times more likely than men to develop Graves' disease Graves' disease is an autoimmune disease of unknown etiology characterized by diffuse thyroid enlargement and excess thyroid hormone secretion. In Graves' disease the patient develops antibodies to the TSH receptor. These antibodies attach to the receptors and stimulate the thyroid gland to release T3, T4, or both. Graves' disease accounts for up to 75% of the cases of hyperthyroidism. Women are five times more likely than men to develop Graves' disease. Precipitating factors such as insufficient iodine supply, cigarette smoking, infection, and stressful life events may interact with genetic factors to cause Graves' disease. The disease is characterized by remissions and exacerbations with or without treatment. It may progress to destruction of the thyroid tissue, ultimately causing hypothyroidism. Graves' disease is associated with the presence of other autoimmune disorders, including rheumatoid arthritis, pernicious anemia, SLE, Addison's disease, celiac disease, and vitiligo If damage, infection, trauma, surgery to thyroid or under extreme amount of stress could cause you to have a thyroid problem
clinical manifestations - cardiovascular system
Cardiovascular system - Systolic hypertension - Bounding, rapid pulse; palpitations - ↑ Cardiac output (part of the reason they are warm all the time and sweat a lot) - Cardiac hypertrophy (cardiac muscle gets bigger) - Systolic murmurs - Dysrhythmias - Angina
nursing implementation acute care
Discharge teaching - Monitor hormone balance periodically - Decrease caloric intake - Adequate but not excessive iodine intake(where does iodine come from that is also not in the salt) - Regular exercise - Avoid ↑ environmental temperature (b/c hot a lot of the time they don't want to be outside until hormones are balanced) The patient and caregiver need to be aware that thyroid hormone balance should be monitored periodically. Most patients experience a period of relative hypothyroidism soon after surgery because of the substantial reduction in the size of the thyroid. However, the remaining tissue usually hypertrophies over time and recovers the capacity to produce hormones. The administration of thyroid hormone is avoided because the use of exogenous hormone inhibits pituitary production of TSH and delays or prevents the restoration of normal gland function and tissue regeneration. To prevent weight gain, caloric intake must be substantially reduced below the amount that was required before surgery. Adequate iodine is necessary to promote thyroid function, but excesses can inhibit the thyroid gland. Seafood once or twice a week or normal use of iodized salt should provide sufficient iodine intake. Encourage regular exercise to stimulate the thyroid gland. Teach the patient to avoid high environmental temperatures because they inhibit thyroid regeneration.
Nursing implementation acute care continued
Discharge teaching (Synthroid is the drug of choice for those with long term care) - Regular follow-up care - Complete thyroidectomy -- Symptoms of hypothyroidism -- Need for lifelong thyroid hormone replacement Regular follow-up care is necessary. The patient should be seen by the HCP biweekly for a month and then at least semiannually to assess thyroid function. Tell the patient who had a complete thyroidectomy about the need for lifelong thyroid hormone replacement. Teach the patient the signs and symptoms of thyroid failure and to seek medical care promptly if these develop.
Nursing implementation - acute thyrotoxicosis continued
Establish trusting relationships Ensure adequate rest - Calm, quiet room - Cool room - Light bed coverings (dry sheets only because very hot to the touch) Ensuring adequate rest may be a challenge because of the patient's irritability and restlessness. Provide a calm, quiet room because increased metabolism and sensitivity of the sympathetic nervous system causes sleep disturbances. Other interventions may include placing the patient in a cool room away from very ill patients and noisy, high-traffic areas. Use light bed coverings and changing the linen frequently if the patient is diaphoretic. Encourage and assist with exercise involving large muscle groups (tremors can interfere with small-muscle coordination) to allow the release of nervous tension and restlessness. It is important to establish a supportive, trusting relationship to help the patient who is irritable, restless, and anxious to cope.
Clinical manifestations - GI system
GI system (everything is in overdrive with hyperthyroidism) - ↑ Appetite, thirst - Weight loss - Diarrhea - Splenomegaly - Hepatomegaly
Radioactive iodine therapy (RAI) continued - what should you make sure you do if oral care for thyroiditis
Given on outpatient basis (its an outpatient procedure) Patient teaching - Oral care for thyroiditis/parotiditis -- Make sure rinse your mouth cause it can stain teeth -- Make sure people know you are radioactive --Can also destroy more than intended Radiation precautions Symptoms of hypothyroidism RAI therapy is usually given on an outpatient basis. A pregnancy test is done on all women who experience menstrual cycles before starting therapy. Tell the patient that radiation thyroiditis and parotiditis are possible and may cause dryness and irritation of the mouth and throat. Relief may be obtained with frequent sips of water, ice chips, or the use of a salt-and-soda gargle three or four times per day. This gargle is made by dissolving 1 teaspoon of salt and 1 teaspoon of baking soda in 2 cups of warm water. The discomfort should subside in 3 to 4 days. A mixture of antacid (Mylanta or Maalox), diphenhydramine (Benadryl), and viscous lidocaine can be used to swish and spit, allowing for better patient comfort during eating. Patients are asked to follow some radiation precautions after treatment in order to limit radiation exposure to others. Teach the patient receiving RAI on the importance of home precautions, including the following: Use private toilet facilities, if possible, and flush two to three times after each use. Separately launder towels, bed linens, and clothes daily at home. Do not prepare food for others that requires prolonged handling with bare hands. Avoid being close to pregnant women and children for 7 days after therapy. Because of the high frequency of hypothyroidism after RAI therapy, teach the patient and family about the symptoms of hypothyroidism and to seek medical help if these symptoms occur.
Interprofessional care - goals
Goals - Block adverse effects of thyroid hormones - Suppress hormone oversecretion - Prevent complications The goal of management of hyperthyroidism is directed toward blocking the adverse effects of excessive thyroid hormone, suppressing oversecretion of thyroid hormone, and preventing complications.
Nutritional therapy - what to increase - what to avoid
High-calorie diet (4000 to 5000 cal/day) - Six full meals/day with snacks in between - Protein intake: 1 to 2 g/kg ideal body weight - Increased carbohydrate intake Avoid highly seasoned and high-fiber foods, caffeine Dietitian referral' With the increased metabolic rate in hyperthyroid patients, there is a high potential for the patient to have a nutritional deficit. A high-calorie diet (4000 to 5000 cal/day) may be needed to satisfy hunger, prevent tissue breakdown, and decrease weight loss. This can be accomplished with six full meals a day and snacks high in protein, carbohydrates, minerals, and vitamins. The protein content should be 1 to 2 g/kg of ideal body weight. Increase carbohydrate intake to compensate for increased metabolism. Carbohydrates provide energy and decrease the use of body-stored protein. Teach the patient to avoid highly seasoned and high-fiber foods because these foods can further stimulate the already hyperactive GI tract. Have the patient avoid caffeine-containing liquids such as coffee, tea, and cola to decrease the restlessness and sleep disturbances associated with these fluids. Refer the patient to a dietitian for help in meeting individual nutritional needs. Need six full meals a day with snacks; essentially eat what you want Watch high fiber foods because already may be having diarrhea don't need any caffeine cause already in overdrive High calorie meals that help them while they go through therapy Taper off as thyroid levels come back to normal If you don't taper the diet will gain a lot of weight
Nursing implementation - acute thyrotoxicosis if exophthalmos present: - what interventions - what meds
If exophthalmos present: - Apply artificial tears to relieve eye discomfort - Salt restriction and elevate head of bed (keep head of bed elevated so breathing isn't impacted) - Dark glasses - Tape eyelids closed if needed for sleep ROM of intraocular muscles If exophthalmos is present, there is a potential for corneal injury related to irritation and dryness. The patient may have orbital pain. To relieve eye discomfort and prevent corneal ulceration, apply artificial tears to soothe and moisten conjunctival membranes. Salt restriction may help reduce periorbital edema. Elevate the patient's head to promote fluid drainage from the periorbital area. The patient should sit upright as much as possible. Dark glasses reduce glare and prevent irritation from smoke, air currents, dust, and dirt. If the eyelids cannot be closed, they should be lightly taped shut for sleep. To maintain flexibility, teach the patient to exercise the intraocular muscles several times a day by turning the eyes in the complete range of motion. Good grooming can be helpful in reducing the loss of self-esteem that can result from an altered body image. If the exophthalmos is severe, treatment options include corticosteroids, radiation of retroorbital tissues, orbital decompression, and corrective lid or muscle surgery.
Surgical therapy - indications
Indications (maybe cannot control hyperthyroidism with the drug; maybe pregnant so cannot do radioactive activity; goiter is so large so causing breathing problems; maybe have cancer so want to get rid of cells) -Large goiter causing tracheal compression - Unresponsive to antithyroid therapy - Thyroid cancer - Not a candidate for RAI Rapid reduction in T3 and T4 levels - These people that have surgery you want to make sure you stay up to date on Thyroidectomy is indicated for those who (1) have a large goiter causing tracheal compression, (2) have been unresponsive to antithyroid therapy, or (3) have thyroid cancer. In addition, surgery may be done when a person is not a candidate for RAI. One advantage that thyroidectomy has over RAI is a more rapid reduction in T3 and T4 levels.
clinical manifestations - integumentary system
Integumentary system - Warm, smooth, moist skin - Thin, brittle nails - Hair loss - Clubbing of fingers; palmar erythema - Fine, silky hair; premature graying - Diaphoresis - Vitiligo (very common of people with darker complexion, melana gets decreased and causes lighter patches ) - pretibial myxedema (infiltrative dermopathy)
other clinical manifestations
Intolerance to heat Elevated basal temperature Lid lag, stare Eyelid retraction Rapid speech ( can almost not understand them)
Nursing implementation - postoperative care
Monitor for complications - Hypocalcemia - Hemorrhage - Laryngeal nerve damage - Thyrotoxic crisis - Infection Postoperative complications include hypothyroidism; damage to or inadvertent removal of parathyroid glands, causing hypoparathyroidism and hypocalcemia; hemorrhage; injury to the recurrent or superior laryngeal nerve; thyrotoxic crisis; and infection. Maintain patent airway - Oxygen, suction equipment, tracheostomy tray in patient's room - Monitor for laryngeal stridor (a loud noise that sounds like snoring; accompanied by a patient who lo0ks like they are in distress; airway has shut off somewhere) - IV calcium readily available Recurrent laryngeal nerve damage leads to vocal cord paralysis. If both cords are paralyzed, spastic airway obstruction will occur, necessitating an immediate tracheostomy. Although not common, airway obstruction after thyroid surgery is an emergency situation. Oxygen, suction equipment, and a tracheostomy tray should be readily available in the patient's room. Respiration may become difficult because of excess swelling of the neck tissues, hemorrhage, and hematoma formation. Laryngeal stridor (harsh, vibratory sound) may occur during inspiration and expiration because of edema of the laryngeal nerve. Laryngeal stridor may also be related to tetany from hypocalcemia, which occurs if the parathyroid glands were removed or damaged during surgery. To treat tetany, IV calcium salts (e.g., calcium gluconate) should be available.
Nursing assessment - objective data contined...
Objective Data - Tachypnea, dyspnea on exertion - Tachycardia, bounding pulse - Murmurs, dysrhythmias, hypertension, bruit - ↑ Bowel sounds, ↑ appetite, diarrhea, weight loss - Hepatosplenomegaly Possible focused assessment findings include the following: Respiratory: tachypnea, dyspnea on exertion Cardiovascular: tachycardia, bounding pulse, systolic murmurs, dysrhythmias, hypertension, bruit over the thyroid gland Gastrointestinal: increased bowel sounds; increased appetite, diarrhea, weight loss, hepatosplenomegaly Neurologic: hyperreflexia; diplopia; fine tremors of hands, tongue, eyelids Musculoskeletal: muscle wasting
Nursing implementation - postop care
Monitor vital signs and calcium levels Signs of hypocalcemia - Difficulty speaking and hoarseness - Trousseau's and Chvostek's signs (also need to assess for hypocalcemia; if you impacted parathyroid gland you could have some calcium problems so need to know how to assess for this) - Analgesics - Ambulation - Psychosocial support Monitor vital signs and calcium levels. Assess for signs of tetany secondary to hypoparathyroidism (e.g., tingling in toes, fingers, around the mouth; muscular twitching; apprehension) and any difficulty in speaking and hoarseness. Monitor for Trousseau's sign and Chvostek's sign. Control postoperative pain by giving medication. If postoperative recovery is uneventful, the patient ambulates within hours after surgery and is permitted fluids as soon as tolerated. A soft diet starts the day after surgery. The appearance of the incision may be distressing to the patient. Reassure the patient that the scar will fade in color and eventually look like a normal neck wrinkle. A scarf, jewelry, a high collar, or other covering can effectively camouflage the scar.
hyperthyroidism - most common form - other causes
Most common form - Graves' disease (75%) Other causes - Toxic nodular goiter - Thyroiditis - Excess iodine intake - Pituitary tumors - Thyroid cancer
Clinical manifestations - musculoskeletal system
Musculoskeletal system - Fatigue - Weakness - Proximal muscle wasting - Dependent edema - Osteoporosis
Nursing implementation - Acute thyrotoxicosis
Necessitates aggressive treatment Medications to block thyroid hormone production and SNS (have to get that system out of overdrive) Monitoring for dysrhythmias Ensuring adequate oxygenation Fluid and electrolyte replacement (I and O's are important b/c thirsty and hungry and sweating and diarrhea, etc.) Patients who have hyperthyroidism are usually treated in an outpatient setting. However, those who develop acute thyrotoxicosis (thyroid storm) or undergo thyroidectomy require hospitalization and acute care. Acute thyrotoxicosis is a systemic syndrome that necessitates aggressive treatment, often in an intensive care unit. Administer medications (previously discussed) that block thyroid hormone production and the sympathetic nervous system. Provide supportive therapy to the patient. This includes monitoring for cardiac dysrhythmias and decompensation, ensuring adequate oxygenation, and giving IV fluids to replace fluid and electrolyte losses. This is especially important in a patient who experiences fluid losses as a result of vomiting and diarrhea.
clinical manifestations - nervous system
Nervous system - Nervousness, fine tremors - Insomnia , exhaustion (imagine yourself on mega doses of caffeine) - Lability of mood, delirium - Hyperreflexia of tendon reflexes - Inability to concentrate - Stupor, coma (can end up in a coma with too much or too little thyroid) Hyperthyroidism affects the nervous system with the following manifestations: Nervousness Fine tremor (of fingers and tongue) Insomnia Exhaustion Lability of mood, delirium Personality changes of irritability, agitation Depression, fatigue Hyperreflexia of tendon reflexes Lack of ability to concentrate Stupor, coma
Nursing assessment - objective data
Objective Data - Agitation -Rapid speech - Anxiety, restlessness - Hyperthermia - Enlarged or nodular thyroid gland - Exophthalmos - Eyelid retraction, infrequent blinking Possible focused assessment findings include the following: General observation: agitation, rapid speech and body movements; anxiety, restlessness, hyperthermia, enlarged or nodular thyroid gland Eyes: exophthalmos, eyelid retraction; infrequent blinking
nursing assessment - objective data continued
Objective Data - Hyperreflexia, diplopia - Fine tremors - Muscle wasting - Menstrual irregularities Infertility - Impotence (in the male who is not older) - Gynecomastia Possible focused assessment findings include the following: Neurologic: hyperreflexia; diplopia; fine tremors of hands, tongue, eyelids Musculoskeletal: muscle wasting Reproductive: menstrual irregularities, infertility; impotence, gynecomastia in men
Nursing assessment - objective data continued
Objective Data - Warm, diaphoretic, velvety skin - Thin, loose nails - Fine, silky hair and hair loss - Palmar erythema - Clubbing - Vitiligo - Edema Possible focused assessment findings include the following: Integumentary: warm, diaphoretic, velvety skin; thin, loose nails; fine, silky hair and hair loss; palmar erythema; clubbing; white pigmentation of skin (vitiligo); diffuse edema of legs and feet
Objective data - lab findings
Objective Data - ↑ T3, ↑ T4 - ↑ T3 resin uptake - ↓ Or undetectable TSH - Chest x-ray showing enlarged heart (can have hypertrophy from increased levels of hormones) - ECG findings of tachycardia Possible diagnostic findings include the following: ↑ T3, ↑ T4; ↑ T3 resin uptake; ↓ or undetectable TSH; chest x-ray showing enlarged heart; ECG findings of tachycardia
clinical manifestations continued
Ophthalmopathy - Abnormal eye appearance or function Exophthalmos - Increased fat deposits and fluid -Eyeballs forced outward Another common finding is ophthalmopathy, a term used to describe abnormal eye appearance or function. A classic finding in Graves' disease is exophthalmos, a protrusion of the eyeballs from the orbits that is usually bilateral. Exophthalmos results from increased fat deposits and fluid (edema) in the orbital tissues and ocular muscles. The increased pressure forces the eyeballs outward. The upper lids are usually retracted and elevated, with the sclera visible above the iris. When the eyelids do not close completely, the exposed corneal surfaces become dry and irritated. Serious consequences, such as corneal ulcers and eventual loss of vision, can occur. The changes in the ocular muscles result in muscle weakness, causing diplopia. Can complain of double vision, have trouble with extra ocular movements and may have trouble completing this, exophthalmos is when the eyes are literally bulging out of their head. Don't see as much eyelid on the upper part because the eyelids have been pulled back Can complain of dry eye, difficulty blinking, irritation to corneas,
Planning - overall goals
Overall Goals - Experience relief of symptoms - Have no serious complications related to disease or treatment - Maintain nutritional balance Cooperate with therapeutic plan The overall goals are that the patient with hyperthyroidism will (1) experience relief of symptoms, (2) have no serious complications related to the disease or treatment, (3) maintain nutritional balance, and (4) cooperate with the therapeutic plan.
Iodine - what meds -what do they do (2 things) - what do you give them with - what do you look out for
Potassium iodine (SSKI) and Lugol's solution Inhibit synthesis of T3 and T4 and block their release into circulation Decreases vascularity of thyroid gland (if decrease vascularity then I can decrease size of the goiter to take it out) Maximal effect within 1 to 2 weeks Used before surgery and to treat crisis Iodine is available as saturated solution of potassium iodine (SSKI) and Lugol's solution. Iodine is used with other antithyroid drugs to prepare the patient for thyroidectomy or for treatment of thyrotoxicosis. Rapidly giving large doses of iodine inhibits synthesis of T3 and T4 and blocks the release of these hormones into circulation. It also decreases the vascularity of the thyroid gland, making surgery safer and easier. The maximal effect is usually seen within 1 to 2 weeks. Because of a reduction in the therapeutic effect, long-term iodine therapy is not effective in controlling hyperthyroidism. Iodine is mixed with water or juice, sipped through a straw, and given after meals. Assess the patient for signs of iodine toxicity such as swelling of the buccal mucosa and other mucous membranes, excessive salivation, nausea and vomiting, and skin reactions. If toxicity occurs, discontinue iodine administration and notify the HCP.
Antithyroid drugs - what is the #1 drug - what do these drugs do
Propylthiouracil and methimazole (Tapazole) (#1 antthyroid drug) Inhibit synthesis of thyroid hormone (stops the production of the hormone) Improvement in 1 to 2 weeks Good results in 4 to 8 weeks (should be at normal thyroid for 4-8 weeks) Therapy for 6 to 15 months (but keep it here so we make sure you are stable) The first-line antithyroid drugs are propylthiouracil and methimazole (Tapazole). These drugs inhibit the synthesis of thyroid hormones. Indications for use include Graves' disease in young patients, hyperthyroidism during pregnancy, and the need to achieve a euthyroid state before surgery or radiation therapy. PTU is generally given to patients who are in the first trimester of pregnancy, who have had an adverse reaction to methimazole, or for whom a rapid reduction in symptoms is required. PTU is also considered first line in thyrotoxic crisis as it also blocks the peripheral conversion of T4 to T3. The advantage of PTU is that it achieves the therapeutic goal of a euthyroid state more quickly, but it must be taken three times per day. In contrast, methimazole is given in a single daily dose. Improvement usually begins 1 to 2 weeks after the start of drug therapy. Good results are usually seen within 4 to 8 weeks. Therapy is usually continued for 6 to 15 months to allow for spontaneous remission, which occurs in 20% to 40% of patients. Emphasize to the patient the importance of adhering to the drug regimen. Abruptly discontinuing drug therapy can result in a return of hyperthyroidism. Have to do blood tests on a regular basis
clinical manifestations - what assessment finding do you see
Related to effect of thyroid hormone excess ↑ Metabolism ↑ Tissue sensitivity to stimulation by sympathetic nervous system Goiter - Inspection - Auscultation: bruits Clinical manifestations of hyperthyroidism are related to the effect of excess circulating thyroid hormone. It directly increases metabolism and tissue sensitivity to stimulation by the sympathetic nervous system. Palpation of the thyroid gland may reveal a goiter. When the thyroid gland is excessively large, a goiter may be noted on inspection. Auscultating the thyroid gland may reveal bruits, a reflection of increased blood supply. People will eat full meals every couple hours and they can't seem to keep weight on them If you have a lot of blood flowing through goiter then you Can hear a bruit from it
Nursing management - evaluation
Relief of symptoms No serious complications related to disease or treatment Cooperate with therapeutic plan The expected outcomes are that the patient with hyperthyroidism will Experience relief of symptoms Have no serious complications related to the disease or treatment Cooperate with the therapeutic plan
clinical manifestations - reporductive system
Reproductive system (may complain of things not typical of their age) - Menstrual irregularities - Amenorrhea - Decreased libido - Impotence - Gynecomastia in men - Decreased fertility
clinical manifestations - respiratory system
Respiratory system - Dyspnea on mild exertion - Increased respiratory rate Patients with hyperthyroidism may experience dyspnea on mild exertion and have an increased respiratory rate.
Manifestations of acute thyrotoxicosis
Severe tachycardia, heart failure Shock Hyperthermia Agitation Seizures Abdominal pain, vomiting, diarrhea Delirium, coma In acute thyrotoxicosis, all the symptoms of hyperthyroidism are prominent and severe. Manifestations include severe tachycardia, heart failure, shock, hyperthermia (up to 106º F [41.1º C]), agitation, delirium, seizures, abdominal pain, vomiting, diarrhea, and coma.
nursing assessment - subjective data continued...
Subjective Data - Dyspnea on exertion - Palpitations - Muscle weakness, fatigue - Insomnia - Chest pain - Nervousness - Heat intolerance, pruritus Obtain the following important health information related to pertinent functional health patterns: Activity-exercise: dyspnea on exertion; palpitations; muscle weakness, fatigue Sleep-rest: insomnia Cognitive-perceptual: Chest pain; nervousness; heat intolerance; pruritus
nursing assessment - subjective data continued
Subjective Data - Family history - Iodine intake - Weight loss - Increased appetite, thirst - Nausea/vomiting - Diarrhea, polyuria - Sweating Obtain the following important health information related to pertinent functional health patterns: Health perception-health management: positive family history of thyroid or autoimmune disorders Nutritional-metabolic: iodine intake; weight loss; increased appetite, thirst; nausea, vomiting Elimination: diarrhea; polyuria; sweating
Nursing assessment - subjective data
Subjective Data Past health history - Goiter, recent infection or trauma, immigration from iodine-deficient area, autoimmune disease Medications - Thyroid hormones, herbal therapies Obtain the following important health information from the patient: Past health history: preexisting goiter; recent infection or trauma; immigration from iodine-deficient area; autoimmune disease Medications: use of thyroid hormones, herbal therapies that may contain thyroid hormone
Surgical therapy - subtotal thyroidectomy
Subtotal thyroidectomy - Preferred surgical procedure - Involves removal of 90% of thyroid - Can be done using minimally invasive procedures -- Endoscopic thyroidectomy -- Robotic surgery A subtotal thyroidectomy is the preferred surgical procedure. It involves removing a significant portion (90%) of the thyroid gland. Some patients may undergo minimally invasive endoscopic or robotic thyroidectomy. Endoscopic thyroidectomy is an appropriate procedure for patients with small nodules (less than 3 cm) and no evidence of cancer. Robotic surgery is best for those who are not overweight and have small nodules on only one side of the gland. Advantages of endoscopic and robotic procedures over open thyroidectomy include less scarring, less pain, and a faster return to normal activity.
B- Adrenergic Blockers (Beta blockers)
Symptomatic relief of thyrotoxicosis (treating symptoms; if you have hypertension, if you have palpitations then treats that) Block effects of sympathetic nervous stimulation Propranolol (Inderal) Atenolol (Tenormin) β-Adrenergic blockers are used for symptomatic relief of thyrotoxicosis. These drugs block the effects of sympathetic nervous stimulation, thereby decreasing tachycardia, nervousness, irritability, and tremors. Propranolol (Inderal) is usually given with antithyroid agents. Atenolol (Tenormin) is the preferred β-adrenergic blocker for use in hyperthyroid patients with asthma or heart disease.
Interprofessional care - three primary treatment options
Three primary treatment options - Antithyroid medications -Radioactive iodine therapy (RAI) - Surgery (can remove thyroid all together) (can snag a nerve or blood vessel so has its risks) Go least invasive to most invasive Thyroid medications first, radioactive iodine destroys tissue but have to go in and implant and affecting those around you with radiation There are several treatment options, including antithyroid medications, radioactive iodine therapy, and surgical intervention. The choice of treatment is influenced by the patient's age and preferences, coexistence of other diseases, and pregnancy status.
Acute thyrotoxicosis - what is it - what is rare if treated early - results from what; give examples - what patients are at risk
Thyrotoxic crisis or thyroid storm - Excessive amounts hormones released - Life-threatening emergency - Death rare when treatment initiated (with treatment fast enough you can safe their life; can give hormone if too little or block it if too much) - Results from stressors - Thyroidectomy patients at risk (they had to have thyroid taken out of some taken out and all of a sudden you have release of all this extra hormone) Acute thyrotoxicosis (also called thyrotoxic crisis or thyroid storm) is an acute, severe, and rare condition that occurs when excessive amounts of thyroid hormones are released into the circulation. Though considered a life-threatening emergency, death is rare when treatment is initiated early. It is thought to result from stressors (e.g., infection, trauma, surgery) in a patient with preexisting hyperthyroidism. Patients undergoing thyroidectomy are at risk because manipulation of the hyperactive thyroid gland results in an increase in hormones released.
hyperthyroidism - thyrotoxicosis
Thyrotoxicosis (clinical effects you see with hyperthyroidism; these are the signs and symptoms from hyperthyroidism) - Physiologic effects/clinical syndrome of hypermetabolism - Results from increased circulating levels of T3, T4, or both Hyperthyroidism and thyrotoxicosis usually occur together The term thyrotoxicosis refers to the physiologic effects or clinical syndrome of hypermetabolism resulting from excess circulating levels of T4, T3, or both. Hyperthyroidism and thyrotoxicosis usually occur together.
Radioactve iodine therapy
Treatment of choice in nonpregnant adults (destroy that tissue that is making too much of thyroid hormone; less invasive then doing surgery) Damages or destroys thyroid tissue (if destroy some of that tissue maybe that will be good enough, even after destroying stuff still may need thyroid surgery) Delayed response of up to 3 months Treated with antithyroid drugs and β-blocker before and during first 3 months of RAI Radioactive iodine (RAI) therapy is the treatment of choice for most nonpregnant adults. RAI damages or destroys thyroid tissue, thus limiting thyroid hormone secretion. RAI has a delayed response. The maximum effect may not be seen for up to 3 months. For this reason, the patient is usually treated with antithyroid drugs and propranolol before and during the first 3 months after the initiation of RAI until the effects of irradiation become apparent. While RAI is usually effective, 80% of patients have posttreatment hypothyroidism; thus the need for thyroid hormone therapy may be lifelong.
Diagnostic studies - what two things will you find - what differentiates graves disease from thyroiditis (radioactive ____ uptake) - what specific TSH levels indicate this
↓ TSH and ↑ free thyroxine (free T4) Total T3 and T4 Radioactive iodine uptake (RAIU) - Differentiates Graves' disease from other forms of thyroiditis The two primary laboratory findings used to confirm the diagnosis of hyperthyroidism are low or undetectable TSH levels (< 0.4 mIU/L) and elevated free thyroxine (free T4) levels. Total T3 and T4 levels may also be assessed, but they are not as definitive. Total T3 and T4 determine both free and bound (to protein) hormone levels. The free hormone is the only biologically active form of these hormones. The RAIU test is used to differentiate Graves' disease from other forms of thyroiditis. The patient with Graves' disease will show a diffuse, homogeneous uptake of 35% to 95%, whereas the patient with thyroiditis will show an uptake of less than 2%. The person with a nodular goiter will have an uptake in the high normal range. Blood tests: low levels of TSH because body saying that they don't need anymore but high levels of T3 or T4 In graves disease you have a nice consistent uptake of radioactive iodine into thyroid; with thyroiditis you do not
