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Focus on Hyperthyroidism
(Relates to Chapter 50, “Nursing Management: Endocrine Problems,”
in the textbook)
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Hyperthyroidism
A sustained increase in synthesis and release of thyroid hormones by thyroid gland
Occurs more often in women
Highest frequency in 20- to 40-year-olds
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Hyperthyroidism
Most common form Graves’ disease
Other causes Thyroiditis Toxic nodular goiter Exogenous iodine excess Pituitary tumors Thyroid cancer
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Hyperthyroidism
Thyrotoxicosis Physiologic effects/clinical
syndrome of hypermetabolism resulting from increased circulating levels of T3, T4
Hyperthyroidism and thyrotoxicosis occur together as Graves’ disease.
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Etiology and PathophysiologyGraves’ disease Autoimmune disease of
unknown origin Diffuse thyroid enlargement Excessive thyroid hormone
secretion
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Etiology and PathophysiologyGraves’ disease (cont’d) Precipitating factors
Insufficient iodine supply Infection Stressful life events
interacting with genetic factors
Accounts for 75% of cases of hyperthyroidism
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Etiology and PathophysiologyGraves’ disease (cont’d) Antibodies are developed
to TSH receptor. Leads to clinical
manifestations of thyrotoxicosis
May progress to destruction of thyroid tissue, causing hypothyroidism
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Etiology and PathophysiologyToxic nodular goiters Thyroid hormone–secreting nodules
independent of TSH If associated with
hyperthyroidism, termed toxic Multiple or single nodules Usually benign follicular adenomas Occur equally in men and women
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Clinical Manifestations
Related to effect of thyroid hormone excess ↑ metabolism ↑ tissue sensitivity to
stimulation by sympathetic nervous system
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Clinical Manifestations
Ophthalmopathy Abnormal eye appearance or
function Exophthalmos
Protrusion of eyeballs from the orbits
Impaired drainage from orbit Increased fat and edema in
retroorbital tissues Seen in 20% to 40% of patients
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Exophthalmos and Goiter of Graves’ Disease
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Fig. 50-6. Exophthalmos and goiter of Graves’ disease.
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Clinical Manifestations
Cardiovascular system Bruit over thyroid gland Systolic hypertension ↑ cardiac output Dysrhythmias Cardiac hypertrophy Atrial fibrillation
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Clinical Manifestations
GI system ↑ appetite, thirst Weight loss Diarrhea Splenomegaly Hepatomegaly
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Clinical Manifestations
Integumentary system Warm, smooth, moist skin Thin, brittle nails Hair loss Clubbing of fingers Diaphoresis Vitiligo
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Acropachy
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Fig. 50-9. Thyroid acropachy. Digital clubbing and swelling of fingers.
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Clinical Manifestations
Musculoskeletal system Fatigue Muscle weakness Proximal muscle wasting Dependent edema Osteoporosis
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Clinical Manifestations
Nervous system Fine tremors Insomnia Ability of mood, delirium Hyperreflexia of tendon
reflexes Inability to concentrate
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Clinical Manifestations
Reproductive system Menstrual irregularities Amenorrhea Decreased libido Impotence Gynecomastia in men Decreased fertility
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Clinical Manifestations
Intolerance to heat ↑ sensitivity to stimulant
drugs Elevated basal temperature
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Complications
Thyrotoxic crisis Acute, rare condition, where
all manifestations are heightened
Life-threatening emergency Death rare when treatment
initiated Presumed causes are
additional stressors.Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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Complications
Thyrotoxic crisis Manifestations include
Tachycardia Heart failure Shock Hyperthermia Restlessness
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Complications
Thyrotoxic crisis Manifestations (cont’d)
Agitation Seizures Abdominal pain Nausea
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Complications
Thyrotoxic crisis Manifestations (cont’d)
Vomiting Diarrhea Delirium Coma
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Complications
Thyrotoxic crisis Treatment
↓ Thyroid hormone levels and clinical manifestations with drug therapy
Therapy Aimed at managing respiratory
distress, fever reduction, fluid replacement, and management of stressors
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Diagnostic Studies
History Physical examination Ophthalmologic examination ECG Radioactive iodine uptake
(RAIU) Indicated to differentiate
Graves’ disease from other forms of thyroiditis
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Diagnostic Studies
Laboratory tests TSH Free thyroxine (free T4) Total T3 and T4
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Collaborative Care
Goals Block adverse effects of
thyroid hormones. Stop hormone oversecretion.
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Collaborative Care
Three primary treatment options Antithyroid medications Radioactive iodine therapy
(RAI) Subtotal thyroidectomy
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Collaborative Care
Drug therapy Useful in treatment of
thyrotoxic states Not considered curative
Antithyroid drugs Iodine β-adrenergic blockers
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Collaborative Care
Antithyroid drugs Inhibit synthesis of thyroid
hormone Improvement in 1 to 2 weeks Good results in 4 to 8 weeks Therapy for 6 to 15 months
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Collaborative Care
Antithyroid drugs (cont’d) Disadvantages include
Patient noncompliance Increased rate of recurrence
First-line examples Propylthiouracil (PTU)
Also blocks conversion of T4 to T3 Methimazole (Tapazole)
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Collaborative Care
Iodine Used with other antithyroid
drugs in preparation for thyroidectomy or treatment of crisis
Large doses rapidly inhibit synthesis of T3 and T4 and block their release into circulation.
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Collaborative Care
Iodine (cont’d) ↓ vascularity of thyroid gland Maximal effect seen within 1
to 2 weeks Long-term iodine therapy is
not effective. Examples
Saturated solution of potassium iodine (SSKI)
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Collaborative Care
β-adrenergic blockers Symptomatic relief of
thyrotoxicosis resulting from β-adrenergic receptor stimulation
Propranolol (Inderal) administered with other antithyroid agents
Atenolol (Tenormin) is the preferred β-adrenergic blocker for patients with asthma or heart disease.
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Collaborative Care
Radioactive iodine therapy (RAI) Treatment of choice in
nonpregnant adults Damages or destroys thyroid tissue
Delayed response 2 to 3 months
Treated with antithyroid drugs and Inderal before and during first 3 months of RAI
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Collaborative Care
RAI (cont’d) High incidence of
posttreatment hypothyroidism
Need for lifelong thyroid hormone replacement
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Collaborative Care
Surgical therapy Indications
Unresponsive to drug therapy Large goiters causing tracheal compression
Possible malignancy Individual not a good candidate for RAI
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Collaborative Care
Surgical therapy (cont’d) Subtotal thyroidectomy
Preferred surgical procedure Involves removal of significant portion of thyroid
90% removed to be effective
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Collaborative Care
Surgical therapy (cont’d) Endoscopic thyroidectomy
appropriate with small nodules and no malignancy
Less scarring, pain, and recovery time
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Collaborative Care
Surgical therapy (cont’d) Before surgery
Antithyroid drugs, iodine, and β-adrenergic blockers may be administered
To achieve euthyroid state To control symptoms
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Collaborative Care
Nutritional therapy High-calorie diet may be
ordered For hunger and prevention of tissue breakdown
Protein allowance 1 to 2 g/kg ideal body weight
Avoid caffeine, highly seasoned foods, and high-fiber foods
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Nursing ManagementNursing Assessment
Health history Preexisting goiter Recent infection or trauma Immigration from iodine-
deficient area Medications Family history of thyroid or
autoimmune disorders
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Nursing ManagementNursing Assessment
Weight loss Nausea Diarrhea Dyspnea on exertion Muscle weakness Insomnia Heat intolerance
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Nursing ManagementNursing Assessment
Decreased libido Impotence Amenorrhea Irritability Personality changes Delirium
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Nursing ManagementNursing Assessment
Objective Data Agitation Hyperthermia Enlarged or nodular thyroid
gland Eyelid retraction Diaphoretic skin
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Nursing ManagementNursing Assessment
Brittle nails Edema Tachypnea Tachycardia Hepatosplenomegaly
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Nursing ManagementNursing Assessment
Hyperreflexia Fine tremors Muscle wasting Coma Menstrual irregularities Infertility
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Nursing ManagementNursing Diagnoses
Activity intolerance Risk for injury Imbalanced nutrition: Less
than body requirements Anxiety Insomnia
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Nursing ManagementPlanning
Overall goals Experience relief of
symptoms. Have no serious
complications related to disease or treatment.
Maintain nutritional balance. Cooperate with therapeutic
plan.
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Nursing ManagementNursing Implementation
Acute intervention Usually treated in outpatient
setting Those with acute
thyrotoxicosis or undergoing thyroidectomy require hospitalization and acute care.
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Nursing ManagementNursing Implementation
Acute thyrotoxicosis Requires aggressive
treatment Administer medications to
block thyroid hormone production.
Administer IV fluids. Ensure adequate
oxygenation.
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Nursing ManagementNursing Implementation
Acute thyrotoxicosis (cont’d) Calm, quiet room Cool room Light bed coverings
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Nursing ManagementNursing Implementation
Acute thyrotoxicosis (cont’d) Change linens frequently if
diaphoretic. Encourage and assist with
exercise. Establish supportive relationship. Apply artificial tears to relieve
eye discomfort. Elevate HOB and salt restriction
for edema.
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Nursing ManagementNursing Implementation
Acute thyrotoxicosis (cont’d) Do eye exercises. Tape eyelids shut for sleep if
they cannot close. Wear dark glasses to reduce
glare and prevent environmental irritants.
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Nursing ManagementNursing Implementation
Thyroid surgery Preoperative care
Alleviate signs/symptoms of thyrotoxicosis.
Control cardiac problems. Assess for signs of iodine toxicity.
Oxygen, suction equipment, and tracheostomy tray are available in room.
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Nursing ManagementNursing Implementation
Thyroid surgery (cont’d) Preoperative teaching
Coughing, deep breathing, and leg exercises
Supporting head while turning in bed
Range-of-motion exercises of neck
Speaking difficulty for a short time after surgery
Routine postop care
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Nursing ManagementNursing Implementation
Thyroid surgery (cont’d) Postoperative care
Every 2 hours for 24 hours Assess for signs of hemorrhage. Assess for tracheal compression.
Irregular breathing, neck swelling, frequent swallowing, choking
Semi-Fowler’s position Support head with pillows. Avoid flexion of neck. Tension on suture lines
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Nursing ManagementNursing Implementation
Thyroid surgery (cont’d) Postoperative care
Monitor vitals. Control pain. Check for tetany.
Trousseau’s and Chvostek’s signs should be monitored.
Monitor for 72 hours. Evaluate difficulty in speaking/hoarseness.
Some hoarseness is expected for 3 to 4 days.
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Nursing ManagementNursing Implementation
Ambulatory and home care Discharge teaching
Monitor hormone balance periodically.
Decrease caloric intake to prevent weight gain.
Adequate iodine Perform regular exercise. Avoid ↑ environmental temperature.
Avoid goitrogens.Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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Nursing ManagementNursing Implementation
Ambulatory and home care (cont’d) Discharge teaching
Regular follow-up care Biweekly for a month and then
semiannually After complete thyroidectomy
Lifelong thyroid replacement instruction
Signs/symptoms thyroid failure
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Nursing ManagementEvaluation
Relief of symptoms No serious complications
related to disease or treatment
Cooperate with therapeutic plan.
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When assessing a patient who is returned to the surgical unit following a thyroidectomy, the nurse would be most concerned if the patient:
1. Complains of thirst. 2. States her throat is sore.3. Holds her head when she moves in bed. 4. Makes harsh, vibratory sounds when she breathes.
Audience Response Question
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Case Study
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Case Study
28-year-old woman visits her primary care physician’s office.
She states she is always hungry, yet has lost 15 lbs in the past few months.
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Case Study
She also claims to always be tired.
Her skin is warm and moist.
Her nails have become brittle.
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Case Study
She has a bounding pulse and a slight heart murmur.
Palpation of her thyroid reveals a nodular goiter.
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Case Study
Labs reveal ↓ TSH ↑ free thyroxine (free T4)
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Discussion Questions
1.What problem do her symptoms and lab values suggest?
2.What treatments may the patient require?
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Discussion Questions
3. What follow-up will she need with these treatments?
4. What important patient teaching should you do following these treatments?
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