Shannon Galey

University of South Florida

Med Surg 1

HYPERTHYROIDISM

Hormones of the thyroid gland T3 and T4 produce and regulate adrenaline, epinephrine, dopamine

T3 and T4 are crucial for brain development

Also regulates metabolism

Works hand in hand with pituitary gland to produce TSH ( pituitary gland controls the amount of TSH released to the body)

Thyroid can be considered the “manager” of the body

Regulates all body organs and functions

THYROID FUNCTIONS

PATHOPHYSIOLOGY

Hyperthyroidism is a disorder that involves the excess secretions of thyroid hormones by the

thyroid gland, this can lead to a hyper metabolic condition called thyrotoxicosis. The most common

forms of hyperthyroidism are graves disease, Plummer disease, (Toxic multinodular goiter) and

toxic adenoma.

Diffuse enlargement of both thyroid lobes, with uniform uptake of isotope and elevated

radioactive iodine uptake

60-80% of all cases of Hyperthyroidism in the US

Peak occurrence in people aged 20-40 years old

GRAVES DISEASE

Irregular areas of relatively diminished and occasionally increased uptake; overall radioactive iodine uptake is mildly to moderately increased

15-20% of all hyperthyroidism cases

Occurs more commonly in places with iodine deficiencies

US adds Iodine to foods so we have less “Plummer disease” then other countries

TOXIC MULTI NODULAR GOITER“PLUMMER DISEASE”

3-5% of all hyperthyroidism cases

growth of a thyroid nodule that produces and secretes excess amounts of thyroid

Many times this nodule may be benign

TOXIC ADENOMA

While seen in both men and women, it is more common in women

A persons chance increases with age presents typically from ages 20-40 years old.

Reoccurring pregnancies can lead to thyroiditis which puts younger women at risk for

Hyperthyroidism.Hyperthyroidism is one of the most frequently

encountered condition in endocrinologyOut of three forms of hyperthyroidism, Graves disease is the most common. 25 million people

Caucasians and Hispanics are more at risk then African Americans

WHO GETS HYPERTHYROID

Preterm labor

Pregnancy induced hypertension

Eclampsia (one or more convulsions in women during pregnancy whom suffer from high blood pressure.

Thyroid storm (is a life-threatening health condition that is associated with untreated or undertreated

hyperthyroidism. During thyroid storm, an individual’s heart rate, blood pressure, and body temperature can soar to dangerously high levels.

Without prompt, aggressive treatment, thyroid storm is often FATAL

Heart Failure

DANGERS OF HYPERTHYROIDISM

Medications

Propylthiouracil

Methimazole

Anti thyroid drugs, they work by blocking thyroids ability to produce

thyroid hormone

Radioactive Iodine (RIA)

Pts whom have been on medication for at least 6 months who have seen

no improvement

550 MBq does of radio active iodine is administered

Majority of the time kills thyroid and pt becomes hypothyroid, or the thyroid will return to normal

TREATMENTS FOR HYPERTHYROIDSIM

Broccoli

Brussel sprouts

Cabbage

Cauliflower

Kale

Mustard greens

Peaches

Pears

Rutabagas

Soybeans

Spinach

Turnips

All of these foods help suppress thyroid function

Can be used with daily medications

DIETARY MODIFICATIONS

NervousnessAnxiety

Increased PerspirationHeat Intolerance

HyperactivityHeart Palpitations

SYMPTOMS

Tachycardia and atrial arrhythmiaCardiac Output can be 50-300% higher in

hyperthyroid pt.Systolic hypertension

Warm, moist and smooth skinLid lag

Fixed stare Hand tremors

Muscle weaknessWeight loss despite increased appetite

Reduction in menstrual flow or oligomenorrheaDiarrhea

SIGNS

Younger patients exhibit sympathetic activation (anxiety, hyper activity and tremors)

Older patients exhibit cardiovascular symptoms (dyspnea, atrial fibrillation) and weight loss

Patients with Graves disease often have more “marked” symptoms then patients with other

forms

Opthalmopathy (periorbital edema, diplopia or proptosis) may indicate Graves disease

CLINICAL PRESENTATION CAN VARY

Thyroid Stimulating Hormone (TSH)

Free Thyroxine (FT4)

Total Triodothyronine (T3)

Thyrotoxicosis is marked by suppressed TSH levels and elevated T3

and T4 levels

Patients with milder thyrotoxicosis may have elevation of T3 levels only

Subclinical hyperthyroidism features decreased TSH and normal T3 and T4

levels

Thyroid Function Test Thyroid Function Studies

DIAGNOSTIC TESTS AND LABS

Anti F thyroid peroxidase (anti-TPO) antibody

Thyroid-stimulating immunoglobulin (TSI)

Graves disease – Significantly elevated anti-TPO, elevated TSI

Toxic multinodular goiter- Low or absent anti-TPO

Toxic adenoma – Low or absent anti-TPO

Patients without active thyroid disease may have mildly positive anti-TPO

Autoantibody tests for hyperthyroidism Autoantibody titers in

hyperthyroidism

DIAGNOSTIC TEST AND LABS CONTINUED

Stabilization of thyroid function (with meds)Radio active Iodine is recommended(hypo is much safer!)

If thyroid ablation totally kills thyroid patient receives thyroid replacement drugs (Synthroid)

Thyroid Hormone causes excess left ventricle thickening (heart failure or death)

Hyperthyroidism has also been linked to dilated cardiomyopathy and pulmonary hypertension.

Graves Disease patients should be concerned with eye disorders and should be checked regularly

All Hyperthyroid patients should be monitored regularly and have blood work every 3-6 months

PROGNOSIS

Activity intolerance r/t increased oxygen need due to increased metabolic rate

Anxiety r/t increased stimulation, loss of control

Diarrhea r/t gastric mobility

Ineffective health maintenance r/t deficient knowledge regarding medications, and coping with stress

Insomnia r/t anxiety, excessive sympathetic discharge

Imbalanced nutrition r/t less then body requirements r/t increased metabolic rate and increased gastrointestinal activity

Risk for injury r/t eye disorders or injuries

NURSING DIAGNOSIS

Energy Management

Exercise therapy

Nutritional Management

Medication Management

Stress Reduction

Assessment of Vital Signs

Education on disorder and Medications

Reporting any changes in signs or symptoms to doctor

NURSING INTERVENTIONS

A) Hoarseness and laryngeal stridor

B) Bulging eyeballs and arrhythmias

C) Elevated temperature and heart failure

D) Lethargy progressing suddenly to impairment of consciousness

A PATIENT IS ADMITTED TO THE HOSPITAL IN THYROTOXIC CRISIS (THYROID STORM). ON PHYSICAL ASSESSMENT OF THE PATIENT THE NURSE

WOULD EXPECT TO FIND?

The Answer is C : Elevated temperature and signs of heart failure

A hyperthyroid crisis results in marked manifestations of hyperthyroidism, with fever tachycardia, heart failure, shock, hyperthermia, agitation, delirium, and

coma. Although exophthalmos (abnormal bulging of eyeballs) may be present in the patient with Graves' disease, it is not a significant factor in hyperthyroid

crisis. Hoarseness and laryngeal stridor are characteristic of hypoparathyroidism, and lethargy progressing to coma is characteristic of myxedema coma, a

complication of hypothyroidism.

RATIONALE

A) Adrenal Gland

B) Pituitary Gland

C) Parathyroid Gland

D) Thyroid Gland

SECRETION OF THYROID STIMULATING HORMONE (TSH) BY WHICH OF THE FOLLOWING GLANDS CONTROLS THE RATE AT WHICH THE THYROID HORMONE IS

RELEASED?

The Answer is B : The Pituitary Gland

By secretion of TSH the pituitary gland controls the amount of thyroid hormone released. The adrenal gland is not involved with the thyroid gland. The

parathyroid gland only secretes parathyroid hormones and influences calcium, depending on the amount of calcium and phosphorus in the blood. The thyroid

gland secretes thyroid hormone but does not control the mount released.

RATIONALE

A) Weight loss , Dyspnea and atrial fibrillation

B) palpitations, heat intolerance and irritability

C) Cold intolerance and weight gain

D) Numbness, cramping and tingling of extremities

WHICH OF THE FOLLOWING GROUP OF SYMPTOMS WOULD YOU EXPECT TO FIND IN AN ELDERLY PATIENT WITH HYPERTHYROIDISM?

The Answer is A : Weight loss, dyspnea and A fib

Most elderly people present with weight loss, A fib and dyspnea. While heat intolerance, palpations and irritability can be seen in younger patients with hyperthyroidism. Cold intolerance, weight gain, numbness and tingling of

extremities are typically associated with Hypothyroidism.

RATIONALE

Balch, Phyllis A. “Part Two – The Disorders. “ Prescription for Nutritional Healing. By James F. Balch. 2nd ed. Garden City Park: Avery Group, 1997.331-32. Print.

Iglesias, P., O. Devora, J. Garcia, P. Tajada, and Diez. “Severe Hyperthyroidisim: Aetiology, Clinical

Features and Treatment Outcome. “Clinical Endocrinology 72 (2010): 551-57. Print.

Khalid, Y.,D.M. Barton, V. Baskar, P. Jones, T.E.T. West, and H.N. Buch. “Efficacy of Fixed High Dose

Radioiodine Therapy for Hyperthyroidism- A 14 year experience. “Britiish Journal of Medical

Practitioners. 4.3 (2011): 7-11 print.

Leuwan, Suchaya, Patom Chakkabut, and Theera Tongsong. “Outcomes of Pregnancy Complicated

with Hypothyroidism”. Materno-Fetal Medicine (2010): 1-6. Print.

Nabbot, Lara, and Richard Robbins. “The Cardiovascular Effects of Hyperthyroidism.” Methodist

DeBakey Cardiovascular Journal 5.2 (2010): 3. Print.

Ackley, Ladwig. Nursing Diagnosis Handbook. “An Evidenced-Based Guide to Planning Care. 9th ed.

St. Louis: Elsevier Inc, 2011. 58-59. Print.

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CITATIONS