Hyperthyroidism

I. INTRODUCTIONo Objectives

o Reason for choosing the study

II. Nursing History o History of Past Illnesso History of Present Illnesso Lifestyleo Family Health-Illness History

III.PHYSICAL EXAMINATION

o General Survey

o Vital Signs

o Physical Assessment

IV. DIAGNOSTICS AND LABORATORY PROCEDURES

V. THE PATIENT AND HIS ILLNESS

o Anatomy and Physiology

o Pathophysiology (Book-based)

o Synthesis of the Disease

VI. THE PATIENT AND HIS CARE

o Surgical Management

o Pharmacological Management

o Diet

o Activity and Exercise

VII. NURSING CARE PLANS

VIII. CONCLUSION

IX. RECOMMENDATION

X. BIBLIOGRAPHY

Thyroidectomy Page | 1

I. INTRODUCTION

Hyperthyroidism, often referred to as an overactive thyroid, is a condition in which the thyroid gland produces and secretes excessive amounts of the free (not protein bound, and circulating in the blood) thyroid hormones, triiodothyronine (T3) and/or thyroxine (T4). Thyroxine is a body chemical (hormone) made by the thyroid gland. It is carried around the body in the bloodstream. It helps to keep the body's functions (the metabolism) working at the correct pace. The thyroid gland is located in the neck. It controls important metabolic processes, such as growth and energy expenditure. An immune system abnormality called Graves' disease is the most common cause of hyperthyroidism. Other causes include local inflammation (thyroiditis), nodules or lumps.

The radioimmunoassay for T3 is now widely available and is a useful diagnostic tool for hyperthyroidism, especially in T3-thyrotoxicosis. It is an essential tool in the management of hyperthyroidism that persists after treatment with normal T4 serum levels or, in euthyroid cases, with low T4 serum levels. In these conditions, it reflects the metabolic state more accurately than serum levels of T4. A promising new test is the response of radioimmunoassayable TSH to protirelin (TRH) administration. An absent response indicates pituitary suppression and thyroid autonomy as seen in frank hyperthyroidism or euthyroid Graves disease, treated or untreated. It is safer and quicker than the conventional T3 suppression test of thyroid radioactive iodine uptake and may replace it at least partly in the future.(H Haibach, 1976)

Although existing treatments are effective, they are not directed at the root of the problem. Rather, they seek to knock the thyroid out of action, either by surgically removing it or destroying it with radioactive iodine. But most patients receiving these therapies may have to take replacement thyroid hormone for life. A third approach is the use of drugs to block the production of the excess hormone the abnormal gland produces. (Lawrence K. Altman, 1991)


Biochemical signs of hyperthyroidism, or even overt and possibly lethal clinical hyperthyroidism were reported in 2 severely iodine-deficient African countries (Zimbabwe and Democratic Republic of Congo, RDC) soon after the introduction of iodized salt. The 2 countries had access to iodized salt produced in Botswana, as well as 5 other countries in the region, namely Cameroon, Nigeria, Kenya, Tanzania, and Zambia. Therefore, a multicenter study was conducted in these 7 countries to evaluate whether the occurrence of iodine-induced hyperthyroidism (IIH) after the introduction of iodized salt was a general phenomenon or corresponded to specific local situations in the 2 affected countries. Two or 3 areas with a past history of severe iodine deficiency that had recently been supplemented with iodized salt were selected in each of the 7 countries. The prevalence of goiter was determined in 4423 schoolchildren in these areas and the concentration of urinary iodine in 2258. The study showed that iodine deficiency had been eliminated in all areas investigated, and that the prevalence of goiter had markedly decreased since the introduction of iodized salt.

30,000,000 people in the US and 200 million worldwide have a Thyroid Disorder. Of the 30 million people above about half are undiagnosed. 37,000 new cases of Graves' disease are diagnosed each year in the US. 80% of all cases of Graves' disease are diagnosed in females. 20% of Thyroid Storm cases end in death. 80% of all Thyroid Disease cases are diagnosed as Hypothyroidism and 20% Hyperthyroidism. 20% of people with Diabetes will experience an onset of a thyroid disorder. 50% of children with parents having a thyroid disorder may develop a thyroid disorder themselves by age 40.

Moreover, the Philippine Thyroid Disorder Prevalence Survey (PhilTiDeS) made the first national survey in the Philippines on the prevalence of thyroid disorders based on thyroid function tests on the non-pregnant population in 2001. The test revealed that more Filipino adults are affected with subclinical (no symptoms) forms of thyroid disorders than which have obvious symptoms. Among the 5,000 people recruited in the study, 4,897 qualified for the structured interview and physical assessment of the thyroid. After which, the respondents' blood samples were taken and tested for thyroid disorders. Upon analysis of data, it was found out that subclinical thyroid disorders are the more common case of the condition found in the Philippines' adult population.

Untreated hyperthyroidism can shorten your life, but it, in itself, is not going to kill you. The resulting conditions and diseases such as severe


thyroid storm or thyrotoxicosis could if not treated right away. Untreated hyperthyroidism will ruin your appearance, to be sure. They develop very unattractive bulging eyes (exophthalmos) or loose weight to an unhealthy and unattractive state. The thyroid hormones need to be balanced. If hyper or hypo types of thyroid disease develops, it only takes a quick blood test once or twice a year (for a lifetime basis, since it's not curable, only treatable) to test its level, and then one little pill every morning to solve the problem. Diet and exercise will keep it from getting worse. It is important to maintain regular, lifelong visits if a client have hyperthyroidism. Untreated or improperly treated, an overactive thyroid can lead to severe, even life-threatening problems. Complications include irregular heart rhythm (atrial fibrillation), congestive heart failure, miscarriage, osteoporosis and bone fractures (hyperthyroidism causes your bones to lose calcium faster than usual).

Reason for Choosing the Study

We have chosen this study for the intention of obtaining greater understanding about the disease and acquiring knowledge for the improvement of our skills and management if such condition will be encountered. The topics that will be discussed in this study are the development, diagnosis, and treatment of the condition hyperthyroidism. The researchers have made a comprehensive report to be able to determine the truthful information into what causes this condition and how it can lead to thyroidectomy (surgical removal of the thyroid gland). The study will help students that are in the medical field in knowing the proper management of patients under the condition and have an adequate overview of the general information about hyperthyroidism and thyroidectomy.

O bjectives

Define the anatomy and physiology of the Thyroid gland,

particularly those that are linked with the disease.

Define hyperthyroidism and thyroidectomy.

Identify the underlying causes of hyperthyroidism.

Enumerate the signs and symptoms of hyperthyroidism.

Explain the pathophysiologic nature and complications of

Hyperthyroidism.


Determine the prognosis of the disease with the following criteria:

duration of illness, onset, precipitating factors, environmental

factors, and lifestyle.

Interpret the findings from the Nursing Health Assessment and

laboratory examinations with their clinical significance.

Psychomotor:

Relate nursing concepts learned to manage preoperative,

intraoperative and postoperative care in thyroidectomy.

Develop nursing care plan related to the potential and existing

problems effective for the improvement of the management of

disease.

Select the appropriate, immediate nursing management for

hyperthyroidism and thyroidectomy.

Affective:

Express genuine concern for patients with hyperthyroidism.

Pay attention on the importance of developing a practice of

performing accurate and complete assessment findings.

Assert the role in the nursing profession of finding out appropriate

ways to promote a patient’s relief and recovery.

Integrate the knowledge acquired to co-student nurses, increase

awareness and help them for future encounters with a client having

the same condition.

II. Nursing History

A. Demographic Data

B. Socio-economic, Cultural and Environmental Factors


C. History of Past Illness

D. History of Present Illness

E. Lifestyle

E. Family Health-Illness Hi

II. PHYSICAL EXAMINATION

A.General Survey

A client diagnosed with hyperthyroidism often appears extremely

agitated and irritable especially when exposed to hot climate. Despite

a ravenous appetite, weight loss can be observed as a result of the

hypermetabolic state. One of the hallmarks when a assessing a patient


with hyperthyroidism is the presence of enlarged neck and protruding

eyes (exophthalmos). They markedly show hyperkinetic movements

and tremors are apparent even at rest.

B.Vital Signs

B lood P ressure :

o Increased systolic BP

o Widened pulse pressure

T emperature

o Low-grade fever

R espiratory R ate

o Increased RR

o Shortness of breath

P ulse R ate

o Rapid, bounding pulse (>100 bpm)

C.IPPA- Cephalocaudal Assessment

Skin

o Smooth, warm, moist skin

o Diaphoresis (excessive sweating)


Nails

o Brittle nails (that may separate from the nail beds)

o Clubbing of fingers

Hair

o Thinning of scalp hair (patches)

o Shiny hair

Eyes

o Protruding eyes (exophthalmos)

o Red, swollen eyes

o Elevated, retracted upper eye lids

o Dry and irritated cornea (due to inability to completely close the

enlarged eyes)

o Blurred or double vision

o Corneal ulcers or infections

o Increased tears

o Photophobia

Neck

o Enlarged thyroid gland (protrusion in the neck)

o Nodular thyroid gland

o Bruits heard on auscultation (due to the increased blood flow to the

thyroid gland)


Chest and Lungs

o Shortness of breath with or without exertion

o Rapid, shallow respirations

o Decreased vital capacity

Breast

o Enlarged breasts in men

Abdomen

o Enlarged spleen and/or liver

o Increased bowel sounds

Extremities

o Muscle weakness

o Palmar erythema

o Tremors

o unable to perform a full range of motion due to reported weakness

Extremities

o Osteoporosis


III. DIAGNOSTICS AND LABORATORY PROCEDURES

Diagnostic/

Laboratory

Procedure

Indications or Purpose Results Normal Values Analysis and Interpretation

1. Complete Blood Count

A. Hemoglobin

(hgb)

Hgb test measures the amount of

hemoglobin in the blood. Normal 12.5 - 15 g/dl Hemoglobin is normal.

B. Hematocrit (hct) A Hct test indicates whether you

have too few or too many red

blood cells.

Normal 36.0 - 46.0%

Indication of anemia due to

hematuria and decreased

erythropoietin production due to

the damage in the kidneys.

C. White Blood

Cells (WBC)

The WBC count determines the

total number of white cells

(leukocytes) in the blood sample.

Normal 4,500 – 12,000 / mm³ WBC is within normal value.

D. Red Blood Cells

(RBC)

RBC count signifies the number of

red blood cells in a volume of

blood.

Normal 4.0 – 6.0 million /

mm³ RBC is normal.


Diagnostic/

Laboratory

Procedure


Nursing Responsibilities:Before:

1. Explain the test procedure and purpose.2. Explain that slight discomfort may be felt when the skin is punctured.3. Obtain a history of the patient's complaint which includes a list of known allergens.4. Obtain a list of the patient's current medications, including herbs, nutritional supplements, and nutraceuticals.5. Note any recent procedures that can affect with test results.6. Encourage to avoid stress if possible because altered physiologic status influences and changes normal hematologic values.7. Be sensitive to social and cultural issues, as well as concern for modesty, is important in providing psychological support

before, during, and after the procedure.During:

1. Instruct the patient to follow and cooperate with the given directions.2. Instruct the patient to breathe normally and to avoid unnecessary movement.3. Observe standard precautions, and follow the general guidelines.4. Identify the patient, and label the appropriate tubes with the corresponding patient demographics, date, and time of collection.5. Perform a venipuncture and collect the specimen.6. Apply manual pressure and dressings over puncture site to stop bleeding7. Transport the specimen to the laboratory for processing and analysis.

After:1. Monitor the puncture site for oozing or hematoma formation.2. Evaluate test results in relation to the patient's symptoms and other tests performed.


Diagnostic/

Laboratory

Procedure


2. Blood Chemistry

A. Calcium To evaluate bone diseases

and the function of the

parathyroid glands.

Increased 8.5 – 10.5 mg/dl Hypercalcemia (chronically elevated blood

calcium) is most commonly caused by

hyperparathyroidism due to a benign parathyroid

tumor.

B. Fasting Blood

Glucose

To measure the amount of

a sugar called glucose in a

sample of your blood

Increased 70 – 100 mg/dL The excessive thyroid hormone causes increased

glucose production in the liver, rapid absorption

of glucose through the intestines, and

increased insulin resistance.

C. Total

Cholesterol Test

Measures all the

cholesterol in the blood.

Decreased 120 – 200

mg/dL

Cholesterol level is decrease in hyperthyroidism

due to increased bile excretion of cholesterol.

Nursing Responsibilities:Before: 1. Explain the test procedure and purpose. 2. Note any recent procedures and medications that can affect with test resultsDuring: 1. Instruct the patient to follow and cooperate with the given directions. 2. Note that the client may feel moderate pain when the needle is inserted to draw blood.After: 1. Apply pressure (with cotton or gauze) to the puncture site. 2. Monitor for hematoma formation. 3. Advise to resume normal activities and any medications that were withheld before the test.



Diagnostic/

Laboratory Procedure

Indications or

Purpose

Results Normal

Values

Analysis and Interpretation

3. Thyroid Function Tests

A. Thyroid-stimulating hormone (TSH)

assay

TSH blood test is used

to check for thyroid

gland problems.

Decreased 0.4-4.2 mU/L TSH is below normal that may

indicate hyperthyroidism

(overactive) and is producing

too much thyroid hormone.


1. Explain the test procedure and purpose.2. Note those medications taken that may affect results.3. The client should be relaxed and recumbent for 30 minutes before the test.

During:1. Wrap an elastic band around your upper arm to stop the flow of blood.2. Put the needle into the vein and attach a tube to the needle to fill it with blood.3. Remove the band from your arm when enough blood is collected.4. Put a cotton ball over the needle site as the needle is removed and apply pressure on the site.

After:1. Monitor the puncture site for hematoma formation.

B. Radioactive Iodine Uptake Use to determine the

metabolic activity of

the thyroid gland and

may determine

whether the gland is

functioning normally.

Increased24 hours:

15 - 25%

RAIU test

is higher than normal

amounts of iodine in

the thyroid gland due

to hyperthyroidism.


1. Explain the test procedure and purpose.2. Note that it is contraindicated in pregnant women and breastfeeding mothers.3. Instruct the patient not to eat for 2 hours before the test.4. Instruct not to take any antithyroid medicine for 5 to 7 days before the test.5. Inform to sign a consent form saying that the patient understand the risks of the test and agree to have it done.

During:1. Instruct to swallow a liquid or capsule containing radioactive iodine.2. Instruct the patient not to eat for 2 hours before the test.3. After six to 24 hours, the patient will return for a measurement of the radioactivity (uptake) and a picture of your thyroid using a device called a gamma probe.

http://www.webmd.com/hw-popup/milliunits-per-liter-mul

Diagnostic/

Laboratory

Procedure

Indications or

Purpose

Results Normal Values Analysis and

Interpretation

Diagnostic Imaging

Studies

A. Thyroid Scan Injection of radioactive

isotopes used to

identify thyroid gland;

to evaluate the size,

position and

functioning of the

thyroid gland.

The scan show an

enlarged thyroid

gland and thyroid

appears lighter.

Hot nodules:

benign

The thyroid appears

the correct size,

shape, and in the

proper location. It

appears an even gray

color on the

computer image.

The thyroid gland is

enlarged as one of the

s/sx of

hyperthyroidism and

appears lighter due to

thyroid problem

Nursing Responsibilities:Before: 1. Explain the test procedure and purpose. 2. Explain the risks and side effects of the test. 3. Inform patient to sign the consent form. 4. Advise not to eat after midnight the night before the exam. 5. Note that radioactive substance needs time to be absorbed before the scan, wait for 4 to 6 hours if the substance is taken by mouth. 6. Instruct to remove dentures and all jewelry or other metals, because they may interfere with the image. During: 1. Instruct the patient to follow and cooperate with the given directions. 2. Administer a pill that contains radioactive iodine, and wait as the iodine collects in the thyroid. 3. Instruct to lie on his/her back on a movable table with the neck and chest under the scanner. 4. Advise to lie still to let the scanner get a clear image.After: 1. Explain the test result. 2. Advise to drink extra fluids and empty the bladder often to flush out the residual radionuclide.


B. Ultrasonography Provides the best

information about the

shape and structure of

nodules and may be

used to distinguish

cysts from solid

nodules, to determine if

multiple nodules are

present.

Degree of

inhomogeneity is

present with typical

features of

thyrotoxicosis.

Thyroid is of

normal size, shape,

and position.

Normal thyroid

appears

homogenous, with a

characteristic

echogenicity.

The result of the

ultrasound reveal

markedly increased

vascularity throughout

the thyroid gland.

Some degree of

inhomogeneity is also

present with typical

features of

thyrotoxicosis.

Nursing Responsibilities:Before: 1. Explain the test procedure and purpose.

2. Instruct to remove necklaces and other accessories that can block the throat.

During:

1. Instruct the patient to follow and cooperate with the given directions.

2. Instruct to remove the shirt and lie on his/her back.

3. Place a pillow or a pad under the back of the neck for this will tilt the head back and expose the throat.

4. Rub the gel onto the throat for this helps the ultrasound probe, or transducer, glide over the skin.

5. Run the transducer back and forth over the area where the thyroid is located (Images will be visible on a screen and used to have a clear

picture of the thyroid to evaluate).

After:

1. Examine the images.


2. Advise to resume normal activities as soon as it is over.

C. Magnetic Resonance Imaging

(MRI)

Used to visualize gland

size, location, identify

abnormalities.

Enlarged thyroid

gland

Thyroid is of normal

size, shape, and

position.

The thyroid gland is

enlarged because it

produces too much

hormone

(hyperthyroidism).

Nursing Responsibilities:Before: 1. Explain the test procedure and purpose. 2. Note any allergy history. 3. Inform to remove any metal objects, including jewelry, eyeglasses, dentures and hairpins that may affect the MRI images. 4. Advise to wear comfortable, loose-fitting clothing to the exam. 5. Patient may be asked not to eat or drink anything for 4 - 6 hours before the scan.

During: 1. Patient will be asked to remain perfectly still during the time the imaging takes place, but between sequences some minor movement may be allowed. 2.When MRI procedure begins, patient may breathe normally, however, for certain examinations it may be necessary for you to hold your breath for a short period of time.After: 1. Examine the images. 2. Advise to resume normal activities as soon as it is over.


IV. THE PATIENT AND HIS ILLNESS

A. Anatomy and Physiology

The Thyroid

Gland

The thyroid gland lies in the neck, in front of the upper part of the trachea. The thyroid gland is located adjacent to the cranial trachea. Close to the recurrent laryngeal nerve, carotid sheath and sternohyoid and sternothyroid muscles. The Parathyroid Glands are located dorsally to, or within the thyroid gland itself. It is supplied by the cranial thyroid artery which is a branch of the common carotid artery. A subsidiary supply is provided by the caudal thyroid artery. The cranial and caudal thyroid arteries are united by substantial anastamoses along their caudal edge. Venous drainage is provided by the internal jugular vein and lymph drains into the cranial deep cervical nodes.

Two types of hormones are produced, which are the iodine containing hormones; tri-iodothyronine(T3) and thyroxine (T4). Thyroid hormones regulate the basal metabolic rate and are important in the regulation of growth of tissues, particularly nervous tissue. Release stimulated by TSH from the pituitary.

.

Ultrastructure and Histology

The gland consists of varying sized follicles, which are bounded by a single layer of cuboidal epithelial cells (follicular cells} and a basement membrane, surrounding a central lumen filled with a homogenous protein rich colloid (thyrogloblin). The apical surface of the cell membranes is covered with numerous micovilli to increase surface area. The follicular cells are connected by tight junctions, and have a dense capillary network. The colloid is a store of thyroid hormones prior to secretion. The


thyroid gland is the only endocrine gland to store its hormone in large quantities. In the active gland colloid is diminished and epithelial cells are tall and columnar.

Within the connective tissue close to the follicles are C-cells alternatively known as parafollicular cells. They are found in clusters in the interfollicular space and are also known as clear cells as their cytoplasm doesn't stain with H and E. They secrete calcitonin, a hormone which acts to lower plasma Ca2+ levels.

Thyroid Hormone Physiology

Follicular cells synthesize thyroglobulin in their golgi apparatus. This is a glycoprotein consisting of 70 linked tyrosine molecules, 10% of which are iodinated, and is stored in the colloid.

The thyroglobulin is then split to form the two amino acid derivative hormones produced in the thyroid gland which are triiodothyronine (T3) and thyroxine (T4). Thyroxine contains 4 iodine atoms, triiodothyronine contains 3. Creation of these two hormones is the only role of iodine in the body.

The majority (90%) of hormone produced by the follicular cells is T4. T4 can only be made in the thyroid gland. It can then be converted by other tissues into T3.

Iodine Uptake

Iodine circulates within the blood as iodide (I-). It is actively transported into the follicular cells by an Na+/I- symport in the basal membrane. This pump concentrates iodine in the colloid at a level up to 250x greater than the plasma level. This process is known as iodide trapping. The pump is activated by thyroid stimulating hormone (TSH) a hormone from the pituitary gland.

Any excess iodide is excreted via the kidneys.

Secretion of Thyroid Hormones

Colloid uptake into the follicular cells takes place by endocytosis. The intracellular vesicles containing the colloid then fuse with lysosomes, where enzymes split the thyroglobulin into T3 and T4. The hormones


diffuse across the basal plasma membrane into the interstitium (they are lipid soluble hormones).

Transport

Thyroid hormones are lipid soluble, thus need a transporting protein in order to travel in the blood. Half-life in the blood is 1 day for T3, 6 days for T4. 99% of thyroid hormones in circulation are bound. The primary transport protein for thyroid hormones is thyroid binding globulin (TBG). Synthesized in the liver, this protein binds 70-80% of the circulating thyroid hormones. The remainder are carried by thyroxine-binding prealbumin or albumin.

Degradation

Only free T3 and free T4 can enter cells to exert their actions. T4 is deiodinated to T3 in many cells of the body, particularly the liver and kidneys.

The thyroid secretes 90% T4, with 50% of this being deiodinated to T3. The remainder is converted to reverse T3 (rT3). This is an inactive form of T3, and so creation of it is a regulatory mechanism. More rT3 is created when the body needs to reduce the action of T3 and T4.

The hormones are further deiodinated to diiodothyronine and monoiodothyronine in the liver and kidneys. Iodine is recycled or excreted in the urine.


Regulation

The hypothalamus releases thyrotropin releasing hormone (TRH) which stimulates

the adenohypophysis (anterior pituitary gland) to release thyroid stimulating hormone (TSH). This water soluble hormone travels in the

blood to activate the thyroid gland by 5 actions:

1. Increased endocytosis and proteolysis of thyroglobulin from colloid2. Increased activity of the Na+/I- symport3. Increased iodination of tyrosine4. Increased size and secretory activity of thyroid follicular cells5. Increased number of follicular cells

Thyroid Hormone Actions

T3 and T4 have effects on all body systems and at all stages of life. These include: Development where thyroid hormones are vital during


the fetal period and the first few months after birth. T3 and T4 are the hormones for metamorphosis in frogs.

o Thyroid hormones also promote growth as they enhance amino acid uptake by tissues and enzymatic systems involved in protein synthesis thus promoting bone growth.

o They also help with metabolic actions such as carbohydrate metabolism, as thyroid hormones stimulate glucose uptake, glycogenolysis, gluconeogenesis.

o In fat metabolism they mobilise lipids from adipose stores and accelerate oxidation of lipids to produce energy (occurs within mitochondria), as well as increasing the size and number of mitochondria.

o Thyroid hormones also increase basal metabolic rate (BMR) in all tissues except brain, spleen and gonads. The results in increased heat production, increased oxygen consumption. This increased metabolic rate also results in increased utilisation of energy substrates causing weight loss.

o Some of thyroid hormones cardiovascular actions are to increase cardiac output, heart rate and contractility. They affect the respiratory system indirectly through increased BMR causing increased demand for oxygen and increased excretion of carbon dioxide.

o In the nervous system thyroid hormones are required for myelination of neurons during the development. They also enhance the sympathetic nervous system (by increasing epinephrine receptors).

o Reproductive system is affected by reduced levels of thyroid hormone causing irregular cycling and decreased libido.

o Finally, in the alimentary system, thyroid hormone increases appetite and feed intake, increases secretion of pancreatic enzymes and increases motility.


A. Pathophysiology (book-based)

i. Schematic Diagram


Hypothalamus secretes TRH

Modifiable Factors:*Diet – high iodine intake

*Drugs*Infection

Non-modifiable Factors:*Age

*Gender (Women)*Genetic Susceptibility

Signals Pituitary gland to release TSH

THYROID GLAND

Excess thyroid hormone (T3, T4)

Increased iodide uptake

Increased rate of thyroid gland metabolism

Hypervascularity

Increased basal metabolic rate

TRH, TSHSupression

Increased iodide oxidation by enzyme

peroxidase

Iodine incorporated tyrosine residue

Binds to throxine-binding globulin

Goiter

Opthalmopathy

Infiltrative changes

Enlargement of ocular muscles

Upper lid lag

Increased globe gaze, exopthalmos

A

0.5 cm0. 5 cm


Increased basal metabolic rate

Overstimulation of CNS

Emotional lability

Fatigue, restlessness

Insomnia

Decreased attention span

Reproductive

Increase in sex hormone-binding globulin

Increased estrone and

estradiol serum level

Oligomenorrhea, amenorrhea

Decreased libido

Cardiac

Increased beta-adrenergic receptors

Increased Heart rate & Contractility

Peripheral vasodilation due to

heat load

Increased volume & cardiac output

Increase BP, Palpitations and

tachycardia

Endocrine

Disruption of PTH Mechanism

Decreased PTH secretion

Hypercalcemia

Increased insulin degregation

Decreased sensitivity to

exogenous insulin

Gastrointestinal

Rate of glucose, fat, and protein use increases

Lipid are mobilized from adipose tissues

Increased catabolism of cholesterol by

the liver

Decreased blood

Heat Intolerance, diaphoresis,

Weight loss despite of ravenous appetite

Increase in motility and

gastrointestinal

Diarrhea and malabsorption

Increased born resorption

Hypermetabolic State

(Increased BMR)

Increased sensitivity of

neural synapses in

Hyperactive reflexes

A

ii. Synthesis of the Disease

2. Definition of the Disease

Hyperthyroidism is a condition in which an overactive thyroid gland

is producing an excessive amount of thyroid hormones that circulate in

the blood. ("Hyper" means "over" in Greek). Thyrotoxicosis is a toxic

condition that is caused by an excess of thyroid hormones from any cause.

Thyrotoxicosis can be caused by an excessive intake of thyroid hormone

or by overproduction of thyroid hormones by the thyroid gland. The most

common cause of hyperthyroidism is Grave’s disease which accounts to

75% of patients. Some people develop thyrotoxicosis due to inflammation

of the thyroid gland (thyroiditis), which can lead to excessive release of

thyroid hormone already stored in the gland (without the accelerated

hormone production that characterizes hyperthyroidism). Thyrotoxicosis

can also occur after ingestion of excessive amounts of exogenous thyroid

hormone in the form of thyroid hormone supplements, such

as levothyroxine.

3. Predisposing and Precipitating factors with rationale

Predisposing Factors

o Age - Hyperthyroidism can happen at any age, but it is more common in people aged 60 and older. Graves disease is more likely to occur between ages 40-60 years old.

o Gender - more women develop hyperthyroidism than men, with a ratio of approximately 4:1, an effect that is often said to be mediated in some way by more estrogen or less testosterone. There is a large body of evidence that moderate amounts of estrogen enhance immunologic reactivity. However, it is just as likely that the X-chromosome is the


source of the enhanced susceptibility rather than sex steroids since the susceptibility continues after the menopause.

o Genetic susceptibility- The diseases cluster in families. The concordance rate in monozygotic twins is 20 to 40 percent.

o Other Factors- If you had a diet that was deficient in iodine, then start taking iodine supplements, this can increase your risk of hyperthyroidism.

Precipitating Factors

o Drugs- Iodine and iodine-containing drugs such as amiodarone may

precipitate hyperthyroidism in a susceptible individual. Iodine is most

likely to precipitate thyrotoxicosis in an iodine deficient population

simply by allowing the TSHR-Abs to be effective in stimulating more

thyroid hormone to be formed. Whether there is any other

precipitating event is unclear. Iodine and amiodarone may also

damage thyroid cells directly and release thyroid antigens to the

immune system. Interferon alpha treatment of patients with hepatitis C

infection has been widely associated with the development of

autoimmune thyroiditis but Graves' disease may also be precipitated

presumably by influencing the immune repertoire. Alemtuzumab, a

monoclonal antibody against the T-cell antigen CD52 used for

treatment of multiple sclerosis, has been associated with a 10 to 15

percent incidence of new onset Graves’ disease

o Diet - Excess iodine ingestion- causes hyperthyroidism with a low

thyroid radioactive iodine uptake. The etiology may be that the excess

iodine provides substrate for functionally autonomous areas of the

thyroid to produce hormone. Hyperthyroidism usually persists as long

as excess iodine remains in the circulation.


http://www.uptodate.com/contents/alemtuzumab-drug-information?source=see_link

http://www.uptodate.com/contents/amiodarone-drug-information?source=see_link

o Smoking- Smoking greatly increased the risk for Graves'

ophthalmopathy. The effect of smoking was more pronounced in

Graves' patients (particulary in the patients with Graves

Opthalmopathy) than in other thyroid patients. Smoking among

patients with thyroid disease is associated with developing of anxiety

and fright, depression and problems with social relations sphere.

o Inflammatory Processes Nonautoimmune autosomal dominant hyperthyroidism-

manifests during infancy. It results from mutations in the TSH receptor gene that produce continuous thyroid stimulation.

Grave's disease- also known as toxic diffuse goiter enlargement of the thyroid gland and is the most common form of hyperthyroidism in about 75 percent of all cases affecting the entire thyroid gland. Grave's disease is considered an autoimmune disorder.

Plummer's disease- sometimes results from TSH receptor gene mutations causing continuous thyroid activation. Patients with toxic nodular goiter have none of the autoimmune manifestations or circulating antibodies observed in patients with Graves' disease. Also, in contrast to Graves' disease, toxic solitary and multinodular goiters usually do not remit.

Inflammatory thyroid disease (thyroiditis)- includes subacute granulomatous thyroiditis, Hashimoto's thyroiditis, and silent lymphocytic thyroiditis, a variant of Hashimoto's thyroiditis. Hyperthyroidism results from destructive changes in the gland and release of stored hormone, not from increased synthesis.

Signs and Symptoms

Exophthalmos The bulging develops because the tissues in the eyeballs swell, and

the number of cells in the eye increases - resulting in larger eyes which push forward from their orbits, usually cause by something wrong with the thyroid gland.


Sudden Weight loss It is important to maintain proper levels of thyroid hormone so that

the body can perform its natural functions. Hyperthyroid conditions can cause the metabolism to be higher, thus resulting in weight loss.

Heat Intolerance Metabolism and heart rate are increased. By burning up more "fuel"

and faster the body transforms the excess energy into heat.

Nervousness, Anxiety and Irritability The thyroid hormone essentially activates the entire body. Due to

the regional metabolic changes it speeds up your body's metabolism in a way that causes your entire sympathetic nervous system to be more active including mood swings and irritability

Tremors It is usually a fine shaking, tremor of the outstretched fingers. It is

caused by a heightened beta-adrenergic state, it also increases metabolism of dopamine which in effect creates hyperactive reflexes.

Increased Appetite Thyroid hormones stimulate the uptake of glucose, the level of

blood glucose increases rapidly after a meal but then falls rapidly again. Because of increased absorption of these nutrients, the hypothalamus is signaled to compensate by activating the hunger center again.

Hyperactivity Client’s emotions are adversely affected by the turbulent activity

within the body. Excessive hyperactivity in turn leads to extreme fatigue and depression, again followed by episodes of over activity.

Decreased in cholesterol level As an effect of increased in thyroid stimulating hormone, the body

uses more of its lipid deposition to use for energy. This too much uptake causes the liver to release more cholesterol therefore leads cholesterol depletion.


Hyperglycemia Although thyroxine is not a counterregulatory hormone,

hyperthyroidism can interfere with glucose metabolism. It is

associated with both increased sensitivity of pancreatic beta cells to

glucose, resulting in increased insulin secretion, and antagonism to

the peripheral action of insulin. The latter effect usually

predominates, leading to impaired glucose tolerance in untreated

patients


V. THE PATIENT AND HIS CARE

A. Surgical Management

ThyroidectomyThyroidectomy is the removal of all or part of your thyroid gland. Your thyroid is a butterfly-shaped gland located at the base of your neck. It produces hormones that regulate every aspect of your metabolism, from your heart rate to how quickly you burn calories. The surgical removal of part or all of the thyroid gland, thyroidectomy allows treatment of hyperthyroidism, respiratory obstruction from goiter, and thyroid cancer. Subtotal thyroidectomy, used to correct hyperthyroidism when drug therapy fails or radiation therapy is contraindicated, reduces secretion of thyroid hormone. It also effectively treats diffuse goiter. After surgery, the remaining thyroid tissue usually supplies enough thyroid hormone for normal function. Total thyroidectomy may be performed for certain types of thyroid cancers, such as papillary, follicular, medullary, or anaplastic neoplasms. After this surgery, the patient requires lifelong thyroid hormone replacement therapy.

Total Thyroidectomy or the Complete Removal of the Thyroid This is the most common type of Thyroid Surgery and most often used for thyroid cancer. In particular, it is advised for aggressive cancers, such as medullary or anaplastic thyroid cancer. It is also used for goiter and Graves' hyperthyroidism treatment. Post a complete removal of the thyroid gland, the patient has to be on constant medication and daily treatment is needed to keep the body's thyroid needs fulfilled.

Partial Thyroidectomy or Removal of Half of the Thyroid Gland Also known as Subtotal Thyroidectomy, this operation is generally advised for removal of small and non-aggressive cancer and is contained to one side of the gland. After a partial thyroidectomy, the patient's thyroid gland is able to function naturally and normally.


Thyroid Lobectomy or Removal of Only About a Quarter of the Gland A less used approach, this type of Thyroidectomy is advised for very small and non-aggressive cancers as well as in the case of not very severe hyperthyroidism or hypothyroidism. The gland resumes normal functioning

post surgery.

Indications for Surgery

a. Diagnosis of malignant tumor of the thyroid by FNA or prior biopsy

b. Vocal cord paralysis with an associated thyroid mass

c. Palpable fixation of a thyroid mass to surrounding tissues

d. Diagnosis of "follicular neoplasm" of the thyroid by FNA

e. Single solid nodule greater than 3.0 cm

f. Persistent reaccumulation of an apparent cystic mass despite

aspirations or persistent aspiration of blood from an apparently cystic

mass

g. Symptoms of airway or esophageal compression with associated thyroid

mass or goiter

h. Patient desires to have a goiter removed for aesthetic reasons

i. Patient desires to have a nodule removed regardless of presumed

pathology

j. As an adjunct to cervical esophageal surgery for improved access

k. While not an absolute indication for thyroid surgery, a nodule present

with a prior history of radiation to the neck strongly suggests an

aggressive course of treatment

l. Rapid growth of a solid thyroid mass


m. Patient desires surgery rather than medical therapy or radioiodine

treatment of Grave's disease

n. A relative indication for thyroidectomy is the finding of metastatic

thyroid disease in neck nodes without an obvious thyroid mass. The

decision to perform thyroid surgery in this setting depends on the

clinical situation under which the metastatic disease was found. If the

metastatic disease was encountered in a palpable node in the absence

of other head and neck cancer, thyroid surgery is indicated. When well-

differentiated thyroid cancer is seen pathologically in a neck dissection

specimen that also contains metastatic squamous cell cancer and there

is no evidence of a thyroid mass, thyroidectomy is unlikely to alter the

clinical course of the patient if radiation therapy is administered to the

neck postoperatively. Thyroidectomy may be considered at a later date

with sequential follow-up offered as an alternative employing

ultrasound imaging.

Positioning/Skin Preparation/Anesthesia


PositionThe patient is placed in a supine position with the neck extended with cloth roll or sand bag placed under the shoulders.

Anesthesia UsedThyroid surgery is more commonly performed with general anesthesia. Some surgeons are now using local anesthesia, plus a sedative, however, to perform thyroid surgery. The benefits of local anesthesia are that it is associated with a shorter hospital stay, shorter actual surgery time, and less vomiting and nausea after surgery. You will, however, be awake during the surgery, and able to interact with your surgeon.

Skin PreparationThe entire front of neck, from jaw line to nipples is cleaned with Betadine.

DrapingSterile sheets are draped above, below and on either sides of neck, keeping only neck portion visible

Instruments


Discussion of the Procedure

PREOPERATIVE CONSIDERATIONS

Explain to the patient that thyroidectomy will remove diseased thyroid tissue or, if necessary, the entire gland. Tell him that he’ll have an incision in his neck; that he’ll have a dressing, and possibly, a drain in place after surgery; and that he may experience some hoarseness and a sore throat from intubation and anesthesia. Reassure him that he’ll receive analgesics to relieve his discomfort.

If thyroidectomy is being performed to treat hyperthyroidism, ensure that the patient has followed his preoperative drug regimen, which will render the gland euthyroid to prevent thyroid storm during surgery. He probably will have received either


propylthiouracil or methimazole, usually staring 4 to 6 weeks before surgery. Expect him to be receiving iodine as well for 10 to 14 days before surgery to reduce the gland’s vascularity and thus prevent excess bleeding. He may also be receiving propanolol to block adrenergic effects. Notify the physician immediately if the patient has failed to follow his medication regimen.

Collect samples for serum thyroid hormone determinations to check for euthyroidism. If necessary, arrange for an electrocardiogram to evaluate cardiac status.

Ensure that the patient or a legally authorized representative has signed an informed consent form.

1. Skin Incision An incision is made in the skin two finger breadths above the sternal notch between the medial borders of the sternocleidomastoid muscles (two muscles make a V shape in front of the neck). The width of the incision may need to be extended for large masses, or for a lateral lymph node removal.

2. Subplatysmal Flaps Subcutaneous fat and Platysma (triangle sheet of muscle at both sides of the neck) are divided, and asubplatysmal dissection is made


above the incision up to the level of the thyroid cartilage above, and thesternal notch, but remaining superficial to the anterior jugular veins.

3. Separating the Strap Muscles and Exposing the Anterior Surface of the Thyroid The fascia between the sternohyoid, omohyoid and sternothyroid muscles (strap muscles ) is divided along the midline and the muscles retracted laterally. This is an avascular plane but care must be taken not to injure small veins crossing between the anterior jugular veins.

4. Identify the Middle Thyroid Vein. The thyroid gland is rotated medially (using the surgeons fingers). The important vascular structure to identify is the middle thyroid vein (it will be tightly stretched by the medial rotation of the gland), which is then ligated. This permits further mobilisation of the gland and moving the bulk of the lobe out the wound.


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5. Identify the Superior Laryngeal Artery and the External Laryngeal Nerve. Identify the superior laryngeal artery as close to the superior pole of the thyroid parenchyma as possible. Great care should be taken while ligating the superior laryngeal artery so as to avoid injury to the external laryngeal nerve. In some patients the external branch of the superior laryngeal nerve lies on the anterior surface of the thyroid lobe.

6. Identifying The Inferior Parathyroid Gland The inferior parathyroid glands are normally located between the lower pole of the thyroid and the isthmus, most commonly on the anterior or the posterolateral surface of the lower pole of the thyroid. Care must be taken to preserve it in situ and to avoid damaging its inferior thyroid artery.

7. Dividing The Thyroid Isthmus. When doing a thyroid lobectomy, the isthmus, which

is crossing between the two thyroid lobes, is divided.


8. Removing The Thyroid Gland.

The incision is closed in three layers: platysma, subcutaneous tissue, and skin Surgeons typically close

the Platysmal layer using buried interrupted 3-0 Monocryl sutures. This is followed by additional buried interrupted 3-0 Monocryl sutures in the

subcutaneous skin. A final 4-0 Monocryl suture is used in a subcuticular fashion followed by Dermabond. A Queen Anne dressing is applied.

POST-OPERATIVE CONSIDERATIONS

Keep the patient in high Fowler’s position to promote venous return from the head and neck and to decrease oozing into the incision. Check for laryngeal nerve damage by asking the patient to speak as soon as he awakens from anesthesia.

Watch for signs of respiratory distress. Tracheal collapse, tracheal mucus accumulat5ion, laryngeal edema, and vocal cord paralysis can all cause respiratory obstruction, with sudden stridor and restlessness. Keep a tracheotomy tray at the patient’s bedside for 24 hours after surgery, and be prepared to assist with emergency tracheotomy, if necessary.


Assess for signs of hemorrhage, which may cause shock, tracheal compression, and respiratory distress. Check the patient’s dressing and palpate the back of his neck, where drainage tends to flow. Expect about 50 ml of drainage in the first 24 hours; if you find no drainage, check for drain kinking or the need to reestablish suction. Expect only scant drainage after 24 hours.

Assess for hypocalcemia, which may occur when the parathyroid glands are damaged. Test for Chvostek’s and Trousseau’s signs, indicators of neuromuscular irritability from hypocalcemia. Keep calcium gluconate available for emergency IV administration.

Be alert for signs of thyroid storm, a rare but serious complication. As ordered, administer a mild analgesic to relieve a sore neck or throat.

Reassure the patient that his discomfort should resolve within a few days.

If the patient doesn’t have a drain in place, prepare him for discharge the day following surgery as indicated. However, if a drain is in place, the physician will usually remove it, along with half of the surgical clips, on the second day after surgery; the remaining clips, the following day, before discharge.

Nursing Responsibilities

SCRUB NURSEPre-operative Responsibilities1. Assist with the preparation of the room for the designated surgical procedure, including gathering supplies for the procedure.2. Scrub, dry hands, gown, and glove.3. Assist person scrubbed in first position with:

a. Setting up back table, mayo, and basinsb. Arrangement of instrumentsc. Preparation of suture and needlesd. Preparation and counting spongese. Arrangement and preparation of other necessary itemsf. Gowning and gloving surgeon and assistantsg. Assist with drapingh. Arrangement of sterile field

Intra-operative Responsibilities


1. During the procedure, progress from double-scrubbed position. Train self to keep eyes on field, and learn steps of procedure.2. Begin developing methods of anticipating needs of surgeon andassistant.3. After closing the skin:

a. Assist with care of instruments and counts if necessaryb. Care of specimenc. Assist with dressing of wound

Post-operative Responsibilities1. After the completion of the Procedure:

a. Assist with the gathering of all materials used during theprocedure

b. Discard items as necessary being careful to discard sharp itemsin designated placesc. Return all items to respective aread. Assist with cleaning of roome. Clean the materials used properly and arrange them after drying

2. Perform any duties which will speed up the surgical procedure tofollow in that room.

CIRCULATING NURSEPre-operative Responsibilities1. Care for the patient before surgery by:

a. Greeting patient and assist nurse with identificationb. Checking patient's chart, preparation, etc.

2. Prepare the room by:a. Obtaining instruments, supplies, and equipment for the designated operative procedureb. Opening unsterile suppliesc. Assisting in gowningd. Observing breaks in sterile techniquee. Assisting anesthesiologist as necessaryf. Assisting with skin preparation and positioningg. Assisting with forming of the sterile field

3. Count the instruments, sharps and sponges before the procedureand confirm with scrub nurse.

Intra-operative Responsibilities 1. During the Procedure:

a. Remain in room and dispense materials as necessaryb. Observe procedure as closely as possible


c. Begin establishing method of anticipating needs of surgical teamd. Care of specimen as indicatede. Care of operative records as indicatedf. Assist with application of dressingg. Monitor the instruments, sharps and sponges used and take noteof additional instruments.

2. Before the closing of the organ or peritoneum, count all instruments,sharps and sponges and confirm with scrub nurse.3. Inform the surgeon and assistant surgeon of a report of theinstruments.

Post-operative Responsibilities1. Properly document all the necessary information on the patient’schart.2. Assist in the cleaning of the operating room as necessary


B. P harmacological M anagement

Generic Name (Brand Name)

Mechanism of Action

Indications Side Effects/ Adverse Reaction

Contraindications

PROPYLTHIOURA

CIL

HyperthyroidismAdult: PO 300–450

mg/d divided q8h, may need 600–1200 mg/d

initiallyGeriatric: PO 150–300

mg/d divided q8hChild: PO 6–10 y, 50–150 mg/d; >10 y, 150–

300 mg/d or 150 mg/m2/d

Neonates: PO 5–10 mg/kg/d

Thyrotoxic CrisisAdult: PO 200 mg q4–

6h until full control achieved

As an anti-thyroid

drug, PTU inhibits

iodine and

peroxidase from

their normal

interactions with

thyroglobulin to

form T4 and T3.

This action

decreases

production of

thyroid hormone.

PTU also interferes

with the conversion

of T4 to T3, and,

since T3 is more

potent than T4, this

also reduces the

PTU is used to

manage

hyperthyroidism

associated with

Graves' disease in

patients who did not

tolerate methimazole,

and are not able to

receive surgery or

radioactive iodine

therapy. It also is

used to decrease

symptoms of

hyperthyroidism in

preparation for

surgical removal of

the thyroid gland or

before radioactive

iodine therapy in

patients who did not

The most common

side effects are

related to the skin

and

include rash, itchin

g, hives,

abnormal hair loss,

and skin

pigmentation. Other

common side effects

are

swelling, nausea, vo

miting, heartburn,

loss of taste, joint or

muscle aches,

numbness

and headache.

May also cause

agranulocytosis

Contraindicated

with allergy to

antithyroid

drugs,

pregnancy

Use cautiously

with lactation


activity of thyroid

hormones.

.

tolerated

methimazole.

.


NURSING RESPONSIBILITIES Before the administration of drug

Check for medical order

Determine if patient is allergic to the drug

Caution patient on taking blood thinners such as warfarin as this

may cause drug interaction and may potentiate the effect leading to

bleeding.

Instruct patient to avoid use of OTC drugs for asthma, or cough

treatment without checking with the physician because they may

contain iodide.

Give at the same time each day with relation to meals.

If drug is being used to improve thyroid state before radioactive

iodine (RAI) treatment, discontinued 3 or 4 d before treatment to

prevent uptake interference. PTU therapy may be resumed if

necessary 3–5 d after the RAI administration.

Explain possible side effects

During drug administration

Maintain aseptic technique

Check medication, right route, dosage, storage, etc

Stay with the patient while he takes in the drug

Do not exceed the recommended dosage

After the administration of drug

Monitor any untoward effects of the drug

Instruct SO’s to report to the attending nurse if any unusual effects

occur

Arrange for regular, periodic blood test to monitor bone marrow

depression and bleeding tendencies.

Advise patient that drug must not be discontinued unless the

physician told so and it must be taken for a prolonged period to

achieve the desired effects.

Report and record as appropriate.Thyroidectomy Page | 46

Generic Name (Brand Name)

Mechanism of Action

Indications Side Effects/ Adverse Reaction

Contraindications

METHIMAZOLE

(Tapazole)

Hyperthyroidism

Adult: PO 5–15 mg

q8h

Child: PO 0.2–0.4

mg/kg/d divided q8h

Thioamide with

actions and uses

similar to those of

propylthiouracil but

10 times as potent.

Actions are less

consistent, but effects

appear more

promptly than with

propylthiouracil.

Inhibits synthesis of

thyroid hormones as

the drug accumulates

in the thyroid gland.

Does not affect

existing T3 or

T4 levels.

For

Hyperthyroidism

and prior to

surgery or

radiotherapy of the

thyroid; may be

used cautiously to

treat

hyperthyroidism in

pregnancy. Long-

term use of

methimazole may

lead to a remission

of the

hyperthyroidism

GI: hepatotoxicity (rare).

Endocrine: Hypothyroidi

sm.

Hematologic: Leukopeni

a, agranulocytosis,

granulocytopenia,

thrombocytopenia,

pancytopenia, and

aplastic anemia.

Musculoskeletal

:Arthralgia.

CNS: Peripheral

neuropathy, drowsiness,

neuritis, paresthesias,

vertigo.

Skin: Rash, alopecia,

skin hyperpigmentation,

urticaria, and pruritus.

Urogenital: Nephrotic

syndrome.

It is

contraindicate

d in the

presence of

hypersensitivit

y to the drug

or any of the

other product

components.

Pregnancy

(category D),

Use cautiously

in lactating

women


NURSING RESPONSIBILITIES Before the administration of drug Check for medical order Determine if patient is allergic to the drug Caution patient about taking anticoagulant as this can reduce

anticoagulant effects of warfarin; may increase serum levels of digoxin; may alter theophylline levels;

Instruct patient to avoid use of OTC drugs for asthma, or cough treatment without checking with the physician because they may contain iodide.

Give at the same time each day with relation to meals. Explain possible side effects

During drug administration Maintain aseptic technique Check medication, right route, dosage, storage, etc Stay with the patient while he takes in the drug Do not exceed the recommended dosage

After the administration of drug Instruct patient to be aware that skin rash or swelling of cervical

lymph nodes may indicate need to discontinue drug and change to another antithyroid agent.

Ask the patient to notify physician promptly if the following symptoms appear: Bruising, unexplained bleeding, sore throat, fever, jaundice. Drug-induced jaundice may persist up to 10 wk after withdrawal of drug.

Closely monitor PT and INR in patients on oral anticoagulants. Anticoagulant activity may be potentiated.

Report and record as appropriate.


Generic Name

(Brand Name)

Mechanism of

Action

Indications Side Effects/ Adverse

Reaction

Contraindication

s

CARBIMAZOLE

( Neo-Mecrazole)

DOSAGE: 5–40 mg daily

ROUTE: PO

Carbimazole is an

antithyroid agent

that decreases the

uptake and

concentration of

inorganic iodine by

thyroid, it also

reduces the

formation of di-

iodotyrosine and

thyroxine. Once

converted to its

active form of

methimazole, it

prevents the thyroid

peroxidase enzyme

from coupling and

iodinating the

tyrosine residues on

For the

treatment of

hyperthyroidism

and

thyrotoxicosis. It

is also used to

prepare patients

for

thyroidectomy.

It reduces the

amount of

thyroid

hormone.

Sore throat,

fever, uneasiness,

nausea,

loss of taste,

headache, joint pain

and hair loss, Feeling

sick, Dizziness.

Skin rashes

Itching, Bruising,

Stomach upset,

Painful joints,

Liver problems

(jaundice)

Blood disorders,

Muscle pain

Contraindicated in

patients with

goiter and

hypersensitivity.

Should not be

used during

pregnancy

Pregnancy

category (D)

Caution should be

exercised in patients

with history of liver

disease and during

pregnancy and

breast-feeding.


thyroglobulin, hence

reducing the

production of the

thyroid hormones T3

and T4.


NURSING RESPONSIBILITIES

Before the administration of drug


Determine whether patient is sensitive to other corticosteroids

Do not give drug to nursing mothers; drug may be secreted in

breast milk.

Ensure patient is not pregnant before giving this drug; advise

patient to use barrier contraceptives.








Monitor any untoward effects of the drug

Instruct SO’s to report to the attending nurse if any unusual effects

occur

Arrange for regular, periodic blood test to monitor bone marrow

depression and bleeding tendencies.

Advise patient that drug must not be discontinued unless the

physician told so and it must be taken for a prolonged period to

achieve the desired effects.



Generic Name

(Brand Name)

Mechanism of

Action


Reaction

Contraindication

s

LITHIUM CARBONATE( lithobid, carbolith,

lithizine)

ManiaAdult: PO Loading

Dose 600 mg t.i.d. or 900 mg sustained-

release b.i.d. or 30 mL (48 mEq) of solution

t.i.d. PO Maintenance Dose 300 mg t.i.d. or

q.i.d. or 15–20 mL (24–32 mEq) solution in 2–4 divided doses (max: 2.4

g/d)

Child: PO 15–60 mg/kg/d in divided

doses

The lithium ion

behaves in the body

much like the sodium

ion; but its exact

mechanism of action

is unclear. Competes

with various

physiologically

important cations:

Na+, K+, Ca++, Mg++;

therefore, it affects

cell membranes, body

water, and

neurotransmitters. At

the synapse, it

accelerates

catecholamine

destruction, inhibits

the release of

neurotransmitters

and decreases

sensitivity of

Control and

prophylaxis of

acute mania and

the acute manic

phase of mixed

bipolar disorder.

Pre-operative

drug for Grave’s

disease to

control

hyperthyroidism

and attain

euthyroid state.

.

CNS: Dizziness, headache,

lethargy, drowsiness, fatigue, slurred speech,

psychomotor retardation, giddiness, incontinence, restlessness, seizures,

confusion, blackout spells,

disorientation, recent memory loss, stupor, coma, EEG changes.

CV: Arrhythmias, hypotension,

vasculitis, peripheral circulatory collapse, ECG

changes.

Special Senses: Impaired vision,

transient scotomas, tinnitus.

Endocrine: Diffuse thyroid enlargement,

hypothyroidism,

Body as a Whole: Edema, weight

Significant

cardiovascular or

kidney disease,

brain damage,

severe

debilitation,

dehydration or

sodium depletion;

patients on low-

salt diet or

receiving

diuretics;

pregnancy,

especially first

trimester

(category D),

lactation, children

<12 y.


postsynaptic

receptors.

gain (common) or loss, exacerbation of psoriasis;

flu-like symptoms.












Monitor response to drug. Usual lag of 1–2 wk precedes response to

lithium therapy. Keep physician informed of progress.

Lab test: Periodic lithium levels (draw blood sample prior to next dose or

8–12 h after last dose); periodic thyroid function tests.

Monitor for S&S of lithium toxicity (e.g., vomiting, diarrhea, lack of

coordination, drowsiness, muscular weakness, slurred speech when level

is 1.5–2.0 mEq/L; ataxia, blurred vision, giddiness, tinnitus, muscle

twitching, coarse tremors, polyuria when >2.0 mEq/L). Withhold one

dose and call physician. Drug should not be stopped abruptly.

Monitor older adults carefully to prevent toxicity, which may occur at

serum levels ordinarily tolerated by other patients.

Be alert to and report symptoms of hypothyroidism.

Weigh patient daily; check ankles, tibiae, and wrists for edema. Report

changes in I&O ratio, sudden weight gain, or edema.

Report early signs of extrapyramidal reactions promptly to physician.



Generic Name

(Brand Name)

Mechanism of

Action


Reaction

Contraindication

s

DEXAMETHASONE(decadron)

Cerebral EdemaAdult: IV 10 mg

followed by 4 mg q4h, reduce dose after 2–4 d then taper over 5–7 dChild: PO/IV/IM 1–2 mg/kg loading dose, then 1–1.5 mg/kg/d

divided q4–6h (max: 16 mg/d)

ShockAdult: IV 1–6 mg/kg as a single dose or 40 mg

repeated q2–6h if needed

Dexamethasone Suppression Test

Adult: PO 0.5 mg q6h for 48 h

Long-acting synthetic

adrenocorticoid with

intense

antiinflammatory

(glucocorticoid)

activity and minimal

mineralocorticoid

activity. Antiinflam

matory

action: Prevents

accumulation of

inflammatory cells at

sites of infection;

inhibits phagocytosis,

lysosomal enzyme

release, and synthesis

of selected chemical

mediators of

inflammation;

reduces capillary

dilation and

permeability.

It can be used in

the treatment of

hypethyroidism.

At high does it

reduce the

peripheral

conversion of T4

(tetraiodo-

thyronine) to T3

(triiodothyronin

e).

.

Aerosol therapy: Nasal irritation, dryness, epistaxis, rebound

congestion, bronchial asthma, anosomia, perforation of nasal

septum.Systemic Absorption—

CNS: Euphoria, insomnia, convulsions, increased ICP, vertigo,

headache, psychic disturbances.

CV: CHF, hypertension, edema.Endocrine: Menstrual

irregularities, hyperglycemia; cushingoid state; growth suppression in

children; hirsutism.Special

Senses: Posterior subcapsular

cataract, increased IOP, glaucoma,

exophthalmos. GI: Peptic ulcer with possible

perforation, abdominal distension, nausea, increased appetite,

heartburn, dyspepsia, pancreatitis, bowel

Systemic fungal infection, acute

infections, active or resting

tuberculosis, vaccinia, varicella, administration of live virus vaccines (to patient, family members), latent

or active amebiasis.

Ophthalmic use: Primary open-angle glaucoma, eye

infections, superficial ocular herpes simplex,

keratitis and tuberculosis of eye.

Safe use during pregnancy (category

C), lactation, or in children is not established.


perforation, oral candidiasis.





Instruct patient to avoid use of OTC checking with the physician








Monitor for S&S of a hypersensitivity reaction (see Appendix F). The

acetate and sodium phosphate formulations may contain bisulfites,

parabens, or both; these inactive ingredients are allergenic to some

individuals.

Intruct patient to Report lack of response to medication or malaise,

orthostatic hypotension, muscular weakness and pain, nausea, vomiting,

anorexia, hypoglycemic reactions mental depression to physician. These

symptoms may signal hypoadrenocorticism.

Note: Hiccups that occur for several hours following each dose may be a

complication of high-dose oral dexamethasone.

Advise patient that drug must not be discontinued unless the physician

told so and it must be taken for a prolonged period to achieve the

desired effects.



Generic Name

(Brand Name)

Mechanism of

Action


Reaction

Contraindication

s

PROPANOLOL(inderal,detensol)

Adult: PO 40 mg b.i.d., usually need 160–480 mg/d in

divided doses; InnoPran

XL dose 80 mg q hs, may increase to 120

mg hsChild: PO 1

mg/kg/d in 2 divided doses (1–5 mg/kg/d)

Competitively blocks beta-adrenergic receptors in the

heart and juxtaglomerular

apparatus, decreasing the influence of the

sympathetic nervous system on these

tissues, the excitability of the

heart, cardiac workload and oxygen

consumption, and the release of rennin and lowering BP; has

membrane-stabilizing(local

anesthetic)effects that contribute to its

anti arrhythmic action; acts in the

CNS to reduce sympathetic outflow and vasoconstrictor

Management of

cardiac

arrhythmias,

myocardial

infarction,

tachyarrhythmia

s associated

with digitalis

intoxication,

anesthesia, and

thyrotoxicosis,.

.

CV: Palpitation, profound bradycardia, AV

heart block, cardiac standstill, of hands. Special

Senses:Dry eyes (gritty sensation), visual

disturbances, conjunctivitis, tinnitus, hearing loss, nasal stuffiness. GI: Dry mouth, cheilostomatitis, nausea,

vomiting, heartburn, diarrhea, constipation, flatulence, abdominal

cramps, mesenteric arterial thrombosis, ischemic colitis,

pancreatitis.Hematologic: Transient

eosinophilia, thrombocytopenic or nonthrombocytopenic

purpura,agranulocytosis.

Metabolic: Hypoglycemia, hyperglycemia, hypocalcemia

(patients with hyperthyroidism).

Respiratory: Dyspnea, laryn

Greater than first-

degree heart block;

CHF, right

ventricular failure

secondary to

pulmonary

hypertension;

ventricular

dysfunction; sinus

bradycardia,

cardiogenic shock,

significant aortic or

mitral valvular

disease; bronchial

asthma or

bronchospasm,

severe COPD,

pulmonary edema,

allergic rhinitis

during pollen


tone. gospasm, bronchospasm. season; .




Determine if patient is allergic to the drug Be consistent with regard to giving with food or on an empty

stomach to minimize variations in absorption. Take apical pulse and BP before administering drug. Withhold drug

if heart rate <60 bpm or systolic BP <90 mm Hg. Consult physician for parameters.

Ensure that sustained release form is not chewed or crushed. Must be swallowed whole.

Instruct patient to avoid use of OTC checking with the physician Explain possible side effects







Monitor response to drug.

Lab tests: Obtain periodic hematologic, kidney, liver, and cardiac functions when propranolol is given for prolonged periods.

Instruct patient no to discontinue drug abruptly; can precipitate withdrawal syndrome (e.g., tremulousness, sweating, severe headache, malaise, palpitation, rebound hypertension, MI, and life-threatening arrhythmias in patients with angina pectoris).



C. D iet


PRE-OP

NPO

POST-OP

Clear

Liquid diet

Soft diet

Type of diet wherein the client is not

allowed to eat anything for a certain period of time, either fluids or foods.

Medical instruction meaning, to

withhold oral food and fluids from a patient

for various reason

A clear liquid diet consists

of clear liquids, such

as water, broth and

plain gelatin, that are easily digested and

leave no undigested residue in

your intestinal tract.

It is necessary that NPO order

be carried out to assure accuracy

of findings of tests.

A clear liquid

diet may be

prescribed after

surgery to help

maintain

adequate

hydration,

provides some

important

electrolytes,

such as sodium

and potassium,

and gives some

energy at a time

when a full diet

isn't possible or

recommended.

This was

Plain water, Fruit juices without pulp, such as apple juice,

grape juice or cranberry juice,

Strained lemonade or fruit punch, Clear,

fat-free broth (bouillon or

consomme). Clear sodas, Plain gelatin,

Honey, Ice pops without bits of fruit or fruit pulp, Tea or coffee without milk

or cream

Use more sauces


Type of DietGeneral

DescriptionIndication of

PurposeExamples of Allowed

Foods

Diet as Tolerated (DAT)

This diet incorporates food that are moderately low in fiber have a soft texture and moderately

seasoned The diet is

individualized to meet the needs of the patient and varies from

smooth creamy foods.

Diet as tolerated means

to eat what your stomach can tolerate.

The doctor will give you a list of food that

you can eat and will say to eat them as often

as you can tolerate them.

ordered to provide a transitional diet between liquids and regular food for patient who undergone surgery.

This particular diet is only giver when client can now tolerate any

food she/he desires that is

nutritious, if this will not lead to

any complications and if the client needs further

monitoring for lab test

and gravies – moist food is easier to swallow than dry

water, juice, mashed vegetables and potatoes, ice cream, pudding,

milk shakes, eggs, broth, pasta, chile, bean, tender meats,

fish and gelatin.

Vegetables, fruits, grains, meat,

NURSING RESPONSIBILITIES BEFORE, DURING, AND AFTER

Before the Procedure

Check the doctor’s order.

Check the right client.

Be sure that the diet is properly instructed.

Explain the reason for type of diet

During the Procedure


Monitor if the client complies with the given diet.

Be sure patient is taking or eating food he/she can tolerate

After the Procedure

Assess for patient’s condition; how he responded to the diet.


D . A ctivity/ E xercise

Type of Activity

General Desription Indications or Purposes

Semi-

fowler’s

Position

May sit up

on bed &

ambulate

Placement of the patient in an inclined position,

with the upper half of the body raised by elevating

the head of the bed approximately 30 degrees.

The patient may sit up on bed in ambulatory state

slowly and gradually, walking and moving from

one place to another.

To reduce swelling and edema in neck area. Sandbags or pillows used to support clients head or neck. To prevent hyperextension of the neck and protects integrity of the suture line.

To facilitate gradual return of patient in normal activities of

daily living.light activity, such as walking,

is fine. However, there should be no strenuous

activity (exercising, etc) for 2 weeks following the surgery.

NURSING RESPONSIBILITIES

Educate client regarding his activity

Assisting client to his bathroom privileges

Explain the purpose of restrictions in activity and position in bed as

ordered.

Assist the patient to maintain the prescribed position.

Encourage the patient to adhere to ordered activity.

Accomplish necessary documentation of patient’s reaction to the

ordered activity restrictions.


VI. NURSING CARE PLAN

Deficient Knowledge

CUESNURSING DIAGNOSI

S

SCIENTIFIC EXPLANATION

OBJECTIVESNURSING

INTERVENTIONS

RATIONALE

The patient may manifest the following:

o inappropriate or exaggerated behavior

o unfamiliarity to disease condition

o inaccurate follow through of instruction

o incompliance to the treatment regimen

Deficient Knowledge r/t unfamiliarity with information resources

Deficient

Knowledge is

the absence or

deficiency of

cognitive

information

necessary for

the client/SOs to

make informed

choices

regarding the

condition,

treatment or

lifestyle

Short Term:

After 2 hours of nursing interventions, the pt. will be able to Exhibit increased interest/assume responsibility for own learning and begin to look for information and ask question.

Long Term:

After 2 days of Nursing Interventions, the pt. will be able to initiate necessary

Ascertain level of knowledge, including anticipatory needs.

Determine client’s ability to learn

Noted personal factors

Determine Barriers to

To know what is the level of understanding of the person to know what information should be reinforced.

Right timing is important in giving information, knowing the client’s ability gives the nurse idea on what way will he/she present the information.

Personal Factors are important in learning, because learning is individualized


changes. lifestyle changes and participate in treatment regimen.

learning

Identify motivating factors for the individual

Provide information relevant to the situation

Determine patient’s most urgent need

Recognize level of achievement, time factors, and short

term and long term goals.

To make some techniques to avoid being affected by those barriers

This will help the individual to learn

To let the client know about the present situation.

Knowing to prioritize the patient’s learning needs increases the effectivity of the teaching plan

To know what are the purpose of the patient teaching


Risk for Injury (tetany)



CUESNURSING DIAGNOSI

S

SCIENTIFIC EXPLANATION

OBJECTIVESNURSING

INTERVENTIONS

RATIONALE

Patient may

experience:

o Tingling

sensation

around the

mouth

o muscle aches

o weakness or

o twitching,

o difficulty

swallowing

Injury, risk for (tetany)

Risk factors may include: chemical imbalance: excessive CNS stimulation

Temporary post-

thyroidectomy

hypocalcaemia

is a relatively

common

complication,

due to removal,

injury or

devascularizatio

n of the

parathyroid

glands. It may

also be

secondary to

hungry bones

due to

postoperative

reversal of

thyrotoxic

osteodystrophy,

reactive

After 2 hours of nursing interventions, The client will be able to:o Verbalize

understandin

g

of individual

factors that

contribute

to possibility

of injury and

take steps to

correct

o Be free from

injury

associated

with calcium

deficit, as

evidenced by

no falls or

near falls and

no pathologic

fractures.

1. Monitor vital signs

2. Evaluate reflexes

periodically, observe for

neuromascular irritability.

(e,g., twitching, numbness,

paresthesias, positive

Chvostek;s and

trousseau’s signs, seizure

activity.)

3. Keep side rails raised and

padded, bed in low position, and airway at bedside. Avoid

use of restraints.

4. Monitor serum calcium levels

1. Manipulate of gland during

subtotal thyroidectomy may result in increased

hormone release, causing

thyroid storm and altered vital signs

2. Reduces potential for

injury if seizures occur.

3. Reduces potential for

injury if seizures occur.

4. Patients with levels less

Risk for Bleeding


Risk for Impaired Verbal Communication r/t: Vocal cord injury/laryngeal nerve damage

CUESNURSING

DIAGNOSISSCIENTIFIC

EXPLANATIONDESIRED

OUTCOMES

NURSING INTERVENTIO

NSRATIONALE

Patient may

experience

Hoarsnessn

ess

sorethroat

Difficulty in

forming

words/sent

ences

Difficulty

expressing

thoughts

verbally

Difficulty in

comprehen

ding/

maintainin

g usual

Impaired

Verbal

Communication

r/t: Vocal cord

injury/laryngea

l nerve damage

Thyroidectomy is

a surgical

procedure. Apart

from rare

hemorrhagic or

infectious

complications,

thyroid surgery

may also induce

voice disorders

which are

generally

transient but

sometimes

permanent. They

usually occur as a

result of a nerve

lesion (recurrent

or external

After 4 hours

of nursing

interventions,

the patient

will be able

to:

o Verbalize

or indicate

an

understand

ing of the

communica

tion

difficulty

and plans

for ways of

handling

1. Assess speech

periodically;

encourage

voice rest.

2. Keep

communicatio

n simple; ask

yes/no

questions.

3. Provide

alternative

1. Hoarseness

and sore

throat may

occur

secondary to

tissue edema

or surgical

damage to

recurrent

laryngeal

nerve and

may last

several days.

2. Reduces

demand for

response;


communica

tion

pattern.

laryngeal nerves).

Due to the

proximity of the

organs, the

surgery may

bring accidental

damage to the

adjacent organs

which includes

the larynx nerve.

Permanent nerve

damage can occur

(rare) that causes

paralysis of vocal

cords and/or

compression of

the trachea.

o Establish

method of

communica

tion in

which

needs can

beundersto

od

methods of

communicatio

n as

appropriate,

e.g., slate

board,

letter/picture

board..

4. Anticipate

needs as

possible. Visit

patient

frequently.

5. Post notice of

patient’s voice

limitations at

central station

and answer

call bell

promptly.

6. Maintain quiet

promotes

voice rest.

3. Facilitates

expression of

needs and to

easily

understand

the patient.

4. Reduces

anxiety and

patient’s need

to

communicate.

5. Prevents

patient from

straining

voice to make

needs

known/summ


environment on assistance.

6. Enhances

ability to hear

whispered

communicatio

n and reduces

necessity for

patient to

raise/strain

voice to be

heard.


Risk for Ineffective airway clearance: risk factors may include tracheal obstruction –edema, hematoma, laryngeal spasm



CUESNURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

DESIRED

OUTCOMES

NURSING

INTERVENTIO

NS

RATIONALE

Patient may experience:

Changes in

respiratory

rate/

rhythm

Diminished

/

adventitiou

s breath

sounds

(rhonchi)

Orthopnea

Cyanosis

Risk for Ineffective

airway clearance: risk

factors may include tracheal

obstruction –edema,

hematoma, laryngeal

spasm

Respiratory

distress may be

experienced by

a post-operative

thyroidectomy

patient due to

possible airway

obstruction and

tracheal

compression or

closure of glottis

from laryngeal

nerve damage

brought by the

trauma during

surgery or

pressure from

swelling after

surgery.

After 4 hours of nursing

interventions, the patient will be able

to:

o Expectorate sputum effectively

o Demonstrate controlled coughing techniques.

o Demonstrate behaviors to improve or maintain clear airway.

1. Monitor respiratory rate, depth, and work of breathing.

2. Auscultate breath sounds, noting presence of rhonchi.

3. Assess for dyspnea, stridor, “crowing,” and cyanosis. Note quality of voice.

4. Caution patient to avoid bending neck; support

Respirations may remain somewhat rapid, but development of respiratory distress is indicative of tracheal compression from edema or hemorrhage.

Rhonchi may indicate airway obstruction/accumulation of copious thick secretions.

Indicators of tracheal obstruction/laryngeal spasm, requiring prompt evaluation and intervention.

Reduces likelihood of tension on surgical wound.

Acute Pain



CUESNURSING

DIAGNOSISSCIENTIFIC

EXPLANATIONDESIRED

OUTCOMES

NURSING INTERVENTIO

NSRATIONALE

Patient may manifest the following:

o Episodes of pain, verbal reports, swelling, and bruising around the wound area.

o During the first few days, eating and drinking can be associated with some discomfort and pain.

Acute PainMay be related to: Surgical

interruption/manipulation of tissues/muscles

Postoperative edema/ presence of surgical incision

Possibly evidenced by Reports of

pain

Narrowed focus; guarding behavior; restlessness

Autonomic responses

Complex

responses of

tissue and nerve

endings due to

trauma from

surgery(incision

) and cause

hypersensitivity

to the central

nervous system

that causes

unpleasant

physical and

emotional

reactions and

responses.

After 4 hours of nursing interventions, the patient will be able to:o Report

pain is relieved or controlled

o Verbalize non-pharmacological methods that provides relief

o Demonstrate use of relaxation skills and diversional activities.

o Follow prescribed pharmacological regimen.

1. Assess verbal/nonverbal reports of pain, noting location, intensity (0–10 scale), and duration.

2. Monitor vital signs

3. Place in semi-Fowler’s position and support head/neck with sandbags or small pillows.

4. Maintain head/neck in neutral position and support during position changes. Instruct patient to use hands to support neck during movement

Useful in evaluating pain, choice of interventions, effectiveness of therapy.

Usually altered in acute pain

Prevents hyperextension of the neck and protects integrity of the suture line.

Prevents stress on the suture line and reduces muscle tension.

VIII. CONCLUSION

Hyperthyroidism has been described in the literature as the

overfunctioning of the thyroid gland. In the clinical findings, amongst the

etiologies include: infections, autoimmune deficiencies, age, gender,

lifestyle and genetic predispositions. As we all know, the thyroid gland

plays a very intricate role in certain body processes like metabolism and

hormone regulations. Any malfunctions may digress the body’s homeostasis

leading to chain of inflammatory processes although the progression of the

disease varies with age, diet and life-style related factors.

In the recent years, the incidence of hyperthyroidism has decline in

many industrialized countries as a result of breakthroughs in medicine.

These had lead to increased recognition and treatment of the disease’s risk

factors. As a student nurse, we also play a very vital role throughout the

course of the disease. Patient education is focused on prevention,

recognition of clinical manifestations and early treatment of

hyperthyroidism. Information-dissemination may help our patients be

aware of the classic signs and symptoms of hyperthyroidism, which

therefore can help them detect the disease as early as possible and avoid

the risk factors. Our primary goal here is to restore the normal functioning

of the thyroid gland hence prompt recognition of the cause allows early

treatment and management. Better prognosis is achieved if the condition

will be given an immediate attention.


As part of the treatment, thyroidectomy may be necessary if the

disease has progressed to advanced stage. Critical care should be observed

as the client might experience discomforts after the surgery. The

complications post-operatively put the patient in danger if not

distinguished immediately. It is very important that the student nurses are

equipped with adequate knowledge to attend to the immediate needs of the

patient.

IX. RECOMMENDATION

This case study is recommended to the following:

A. To the Philippine Government, they may be aware of the incidence

of the disease condition in our country and that they may help

those who are less fortunate by making the health care services

more affordable and acceptable;

B. To the Department of Health, that they may implement the

effective treatment of hyperthyroidism and that they may have

proper information dissemination about the disease condition;

C. To the health care providers, particularly physicians and nurses,

that they may have the proper knowledge and skills regarding this

medical condition, its management and as well as its treatment;

D. To the medical interns and student nurse, that they become aware

of the current trends and issues in both medicine and nursing field

about hyperthyroidism, its new innovation and treatment as well;


E. To those support groups who are willing to extend their hand for

those unlucky few, that they may give adequate needs in order to

cure the disease condition;

F. To the families who have a member who is suffering from the

disease condition, that they may become aware and conscious

with this kind of condition;

G. And to the Filipino people, that they may have background

regarding the treatment for thyroid diseases in different ages of

patient.

X. BIBLIOGRAPHY

Bahn RS, Burch HB, Cooper DS, et al. Hyperthyroidism and other causes of

thyrotoxicosis: Management Guidelines of the American Thyroid

Association and American Association of Clinical

Endocrinologists. Endocr Pract. 2011;17:457-520.

Davies TF, Larsen PR. Thyrotoxicosis. In: Kronenberg HM, Melmed S,

Polonsky KS, Larsen PR, eds. Williams Textbook of Endocrinology .

11th ed. Philadelphia, Pa: Saunders Elsevier; 2008:chap 11.

Ladenson P, Kim M. Thyroid. In: Goldman L, Ausiello D, eds. Cecil

Medicine . 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 244


Halsted WS. The operative story of goiter. The authors operation. Johns

Hopkins Rep. 1920;19:71- 257.

Hoffman HT, Rojeski M, Funk GF, McCulloch TM. The solitary thyroid

nodule. In Gates GA, ed. Current Therapy in Otolaryngology. St. Louis,

Mo: Mosby: 1994:319-323.

Karlan MS, Catz B, Dunkelman D, Uyeda RY, Gleischman S. A safe

technique for thyroidectomy with complete nerve dissection and

parathyroid preservation. Head Neck. 1984;6:1014- 1019.

https://wiki.uiowa.edu/display/protocols/Thyroidectomy+and+Thyroid+Lob

ectomy

http://khalidalomari.weebly.com/anatomical-steps-of-

thyroidectomy.html


Hyperthyroidism

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