Focus on Hyperthyroidism (Relates to Chapter 50, “Nursing Management: Endocrine Problems,” in...

Focus on Hyperthyroidism

(Relates to Chapter 50, “Nursing Management: Endocrine Problems,”

in the textbook)

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 2

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

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.


Hyperthyroidism

Most common form Graves’ disease

Other causes Thyroiditis Toxic nodular goiter Exogenous iodine excess Pituitary tumors Thyroid cancer



Hyperthyroidism

Thyrotoxicosis Physiologic effects/clinical

syndrome of hypermetabolism resulting from increased circulating levels of T3, T4

Hyperthyroidism and thyrotoxicosis occur together as Graves’ disease.



Etiology and PathophysiologyGraves’ disease Autoimmune disease of

unknown origin Diffuse thyroid enlargement Excessive thyroid hormone

secretion



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



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



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



Clinical Manifestations

Related to effect of thyroid hormone excess ↑ metabolism ↑ tissue sensitivity to

stimulation by sympathetic nervous system




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



Exophthalmos and Goiter of Graves’ Disease


Fig. 50-6. Exophthalmos and goiter of Graves’ disease.



Cardiovascular system Bruit over thyroid gland Systolic hypertension ↑ cardiac output Dysrhythmias Cardiac hypertrophy Atrial fibrillation




GI system ↑ appetite, thirst Weight loss Diarrhea Splenomegaly Hepatomegaly




Integumentary system Warm, smooth, moist skin Thin, brittle nails Hair loss Clubbing of fingers Diaphoresis Vitiligo



Acropachy


Fig. 50-9. Thyroid acropachy. Digital clubbing and swelling of fingers.



Musculoskeletal system Fatigue Muscle weakness Proximal muscle wasting Dependent edema Osteoporosis




Nervous system Fine tremors Insomnia Ability of mood, delirium Hyperreflexia of tendon

reflexes Inability to concentrate




Reproductive system Menstrual irregularities Amenorrhea Decreased libido Impotence Gynecomastia in men Decreased fertility




Intolerance to heat ↑ sensitivity to stimulant

drugs Elevated basal temperature



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.


Complications

Thyrotoxic crisis Manifestations include

Tachycardia Heart failure Shock Hyperthermia Restlessness



Complications

Thyrotoxic crisis Manifestations (cont’d)

Agitation Seizures Abdominal pain Nausea



Complications

Thyrotoxic crisis Manifestations (cont’d)

Vomiting Diarrhea Delirium Coma



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



Diagnostic Studies

History Physical examination Ophthalmologic examination ECG Radioactive iodine uptake

(RAIU) Indicated to differentiate

Graves’ disease from other forms of thyroiditis



Diagnostic Studies

Laboratory tests TSH Free thyroxine (free T4) Total T3 and T4



Collaborative Care

Goals Block adverse effects of

thyroid hormones. Stop hormone oversecretion.



Collaborative Care

Three primary treatment options Antithyroid medications Radioactive iodine therapy

(RAI) Subtotal thyroidectomy



Collaborative Care

Drug therapy Useful in treatment of

thyrotoxic states Not considered curative

Antithyroid drugs Iodine β-adrenergic blockers



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



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)



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.



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)

Lugol’s solutionCopyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.


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.



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



Collaborative Care

RAI (cont’d) High incidence of

posttreatment hypothyroidism

Need for lifelong thyroid hormone replacement



Collaborative Care

Surgical therapy Indications

Unresponsive to drug therapy Large goiters causing tracheal compression

Possible malignancy Individual not a good candidate for RAI



Collaborative Care

Surgical therapy (cont’d) Subtotal thyroidectomy

Preferred surgical procedure Involves removal of significant portion of thyroid

90% removed to be effective



Collaborative Care

Surgical therapy (cont’d) Endoscopic thyroidectomy

appropriate with small nodules and no malignancy

Less scarring, pain, and recovery time



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



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



Nursing ManagementNursing Assessment

Health history Preexisting goiter Recent infection or trauma Immigration from iodine-

deficient area Medications Family history of thyroid or

autoimmune disorders




Weight loss Nausea Diarrhea Dyspnea on exertion Muscle weakness Insomnia Heat intolerance




Decreased libido Impotence Amenorrhea Irritability Personality changes Delirium




Objective Data Agitation Hyperthermia Enlarged or nodular thyroid

gland Eyelid retraction Diaphoretic skin




Brittle nails Edema Tachypnea Tachycardia Hepatosplenomegaly




Hyperreflexia Fine tremors Muscle wasting Coma Menstrual irregularities Infertility



Nursing ManagementNursing Diagnoses

Activity intolerance Risk for injury Imbalanced nutrition: Less

than body requirements Anxiety Insomnia



Nursing ManagementPlanning

Overall goals Experience relief of

symptoms. Have no serious

complications related to disease or treatment.

Maintain nutritional balance. Cooperate with therapeutic

plan.



Nursing ManagementNursing Implementation

Acute intervention Usually treated in outpatient

setting Those with acute

thyrotoxicosis or undergoing thyroidectomy require hospitalization and acute care.




Acute thyrotoxicosis Requires aggressive

treatment Administer medications to

block thyroid hormone production.

Administer IV fluids. Ensure adequate

oxygenation.




Acute thyrotoxicosis (cont’d) Calm, quiet room Cool room Light bed coverings




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.




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.




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.




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




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




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.




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.



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



Nursing ManagementEvaluation

Relief of symptoms No serious complications

related to disease or treatment

Cooperate with therapeutic plan.



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


Case Study

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 63


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.



Case Study

She also claims to always be tired.

Her skin is warm and moist.

Her nails have become brittle.



Case Study

She has a bounding pulse and a slight heart murmur.

Palpation of her thyroid reveals a nodular goiter.



Case Study

Labs reveal ↓ TSH ↑ free thyroxine (free T4)



Discussion Questions

1.What problem do her symptoms and lab values suggest?

2.What treatments may the patient require?



Discussion Questions

3. What follow-up will she need with these treatments?

4. What important patient teaching should you do following these treatments?


Date post:	11-Jan-2016
Category:	Documents
Upload:	buck-kelley
View:	213 times
Download:	0 times

Focus on Hyperthyroidism (Relates to Chapter 50, “Nursing Management: Endocrine Problems,” in...

Documents