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T3: Thyroid

Hyperthyroidism

QuestionAnswer
Hyperactivity of the thyroid gland with sustained increase in synthesis and release of thyroid hormones. hyperthyroidism
What is the most common form of hyperthyroidism? Graves disease
Besides Graves disease what are some other causes of hyperthyroidism? Toxic nodular goiter, thyroiditis, excess iodine intake, pituitary tumors, thyroid cancer
In Graves disease the patient develops antibodies to what? the TSH receptor
In Graves disease the patient's antibodies attach to the TSH receptors and stimulates what? the thyroid gland to release T3, T4, or both
The excessive release of thyroid hormones leads to what? clinical manifestations associated with thyrotoxicosis
Graves disease is characterized by what? By remissions and exacerbations with or without treatment.
Graves disease may progress to what? destruction of the thyroid tissue causing hypothyroidism
Refers to the physiologic effects or clinical syndrome of hypermetabolism that results from excess circulating levels of T3, T4, or both. thyrotoxicosis
Hyperthyroidism and thyrotoxicosis usually occur? together, as in Graves disease
This autoimmune disease is of unknown etiology and is characterized by diffuse thyroid enlargement and excessive thyroid hormone secretion. Graves disease
Who is more likely to develop Graves disease? women
What are some precipitating factors that can interact with genetic factors that can cause Graves disease? Insufficient iodine supply, infection, and stressful life events.
This increases the risk of Graves disease and the development of what associated with the disease? cigarette smoking; eye problems
The CM of hyperthyroidism are related to what? The effect of excess circulating thyroid hormone. It directly increases metabolism and tissue sensitivity to stimulation by the sympathetic nervous system.
Palpation of the thyroid gland may reveal what? a goiter; when the thyroid gland is excessively large, a goiter may be noted on inspection.
Auscultation of the thyroid gland may reveal this which is a reflection of increased blood supply. bruits
This is a protrusion of the eyeballs from the orbits that is usually bilateral often found in Graves disease. exopthalmus (bug eyes)
Exopthalmos results from what? Increased fat deposits and fluid (edema) in the orbital tissues & ocular muscles. The inc. pressure forces the eyeballs outward. The upper lids are usu retracted & elevated w/sclera visible above the iris.
With exopthalmos the eyelids do not close completely so what can happen with the cornea? The exposed corneal surfaces become dry and irritated. Corneal ulcers and eventual loss of vision can occur. The changes in the ocular muscles result in muscle weakness, causing diplopia.
CM of hyperthyroidism systolic htn; bounding, rapid pulse; palpitations; inc. CO; cardiac hypertrophy; systolic murmurs; dysrhythmias; Afib; angina; inc. RR; dyspnea w/mild exertion; inc appetite, thirst; wt loss; diarrhea; spleno/hepatomegaly
Integumentary CM of hyperthyroidism warm, smooth, moist skin; thin, brittle nails; hair loss; clubbing of fingers (acropachy); palmar erythema; fine, silky hair; premature graying; diaphoresis; vitiligo; pretibial myxedema (infiltrative dermopathy)
Musculoskeletal CM of hyperthyroidism fatigue; muscle weakness; proxima muscle wasting; dependent edema; osteoporosis
Nervous system CM of hyperthyroidism nervousness, fine tremors; insomnia, exhaustion; lability of mood, delirium: personality changes-irritability, agitation, depression, fatigue, apathy; hyperreflexia of tendon reflexes; inability to concentrate; stupor, coma
Reproductive system CM of hyperthyroidism menstrual irregularities; amenorrhea; decreased libido; impotence in men; gynecomastia in men; decreased fertility
Other CM of hyperthyroidism intolerance to heat, elevated basal temperature; lid lag, stare; eyelid retraction; rapid speech
An acute, severe, and rare condition that occurs when excessive amounts of thyroid hormones are released into the circulation. thyrotoxicosis (thyroid storm or thyrotoxic crisis)
Thyrotoxicosis is thought to result from what? stressors (infection, trauma, surgery) in a patient w/preexisting hyperthyroidism, either diagnosed or undiagnosed
What patients are at risk for thyrotoxicosis? Patients undergoing thyroidectomy due to the manipulation of the hyperactive thyroid gland can result in an increase in hormones released.
CM of thyrotoxicosis (thyroid storm) tachycardia, HF; shock; hyperthermia (up to 105.3); restlessness, irritability; seizures; abdominal pain, vomiting, diarrhea; delirium, coma
Treatment for thyroid storm Reduce circulating thyroid hormone levels & reduce the CM w/appropriate drug therapy. Supportive therapy: managing respiratory distress, fever reduction, fluid replacement, & elimination/management of the initiating stressors.
What are the 2 primary lab findings used to confirm the diagnosis of hyperthyroidism? decreased TSH levels and elevated free thyroxin (free T4) levels
What tests is used to differentiate Graves disease from other forms of thyroiditis? the radioactive iodine uptake (RAIU) test
Describe how the RAIU test works. The pt w/Graves disease will show a diffuse homogenous uptake of 35%-95%, whereas the pt w/thyroiditis will show an uptake of less than 2%. The pt w/a nodular goiter will have an uptake in the high normal range.
What is the goal of managing hyperthyroidism? Toward blocking the adverse effects of excessive thyroid hormone, suppressing oversecretion of thyroid hormone, and preventing complications.
What are the 3 primary treatment options for hyperthyroidism? antithyroid medications, radioactive iodine therapy (RAI), surgery
What drugs are used in the treatment of hyperthyroidism? antithyroid drugs, iodine, and beta adrenergic blockers
What are the first-line antithyroid drugs? propylthiouracil (PTU) and methimazole (Tapazole)
What are the functions of propylthiouracil (PTU) and methimazole (Tapazole)? Inhibit the synthesis of thyroid hormones.
What are some indications for use of antithyroid drugs? Graves disease in young patients, hyperthyroidism during pregnancy, and the need to achieve a euthyroid state before surgery or radiation therapy.
When is propylthiuracil (PTU) generally given? To patients who are in their first trimester of pregnancy, who have an adverse reaction to methimazole, or for whom a rapid reduction in symptoms is required.
What drug is considered first line in thyroid storm and why? PTU b/c it blocks the peripheral conversion of T4 to T3.
What is the advantage of PTU? It achieves the therapeutic goal of a euthyroid state more quickly but it must be taken 3 times per day while methimazole is given in a single daily dose.
Abrupt discontinuation of drug therapy can result in what? a return of hyperthyroidism
What form is iodine available? Saturated solution of potassium iodine (SSKI) and Lugol's solution
What occurs with the administration of iodine in large doses? It rapidly inhibits synthesis of T3 and T4 and blocks the release of these hormones into circulation. It also decreases the vascularity of the thyroid gland, making surgery safer and easier.
Iodine is used with other antithyroid drugs to prepare the pt for what? thyroidectomy or for treatment of thyrotoxicosis crisis
What are B-adrenergic blocker used for in hyperthyroidism? symptomatic relief of thyrotoxicosis
What do B-adrenergic blockers do in hyperthyroidism?/ Block the effects of sympathetic nervous stimulation thereby decreasing tachycardia, nervousness, irritability, and tremors.
What B-blocker is usually administered with other antithyroid agents? propanolol (Inderal)
This B-blocker is the preferred B-blocker for use in hyperthyroid patients with asthma or heart disease. atenolol (Tenormin)
What is the treatment of choice for most nonpregnant adults? radioactive iodine (RAI) therapy
What does RAI do to thyroid tissue? It damages or destroys thyroid tissue, thus limiting thyroid hormone secretion.
What type of response does RAI have? It has a delayed response,, and the maximum effect may not be seen for up to 3 mths.
What are the patients treated with before and during the first 3 months after the initiation of RAI until the effects of irradiation become apparent? antithyroid drugs and B-blockers (propanolol)
What should be done to all women before initiation of RAI therapy? a pregnancy test
You should inform the patient that RAI may cause radiation thyroiditis and parotiditis which may cause what to happen? Dryness and irritation of the mouth and throat.
How should you care for thyroiditis/parotiditis? Relief w/freq sips of H2O, ice chips, or salt&soda gargle 3-4x/day. Discomfort should subside in 3-4 days. Mix of antacid (Mylanta/Maalox), diphenhydradmine (Benadryl), & viscous lidocaine can be used to swish & spit, allow comfort during eating.
What are some radiation precautions you should inform the patient? Use private toilet facilities & flush 2-3x/use. Seperately launder towels, linens, & clothes daily at home. Don't prepare food for other that require prolonged handling w/bare hands. Avoid pregnant women & kids for 7 days.
You should teach the pt and family the s/s of this because of its high frequency after RAI therapy. hypothyroidism
When would a thyroidectomy be indicated? For pts who have a lge goiter causing tracheal compression; pts who have been unresponsive to antithyroid therapy; or pts that have thyroid cancer.
What is one advantage that thyroidectomy has over RAI? It is a more rapid reduction in T3 and T4 levels.
What surgery is often preferred for hyperthyroidism and what does it involve? A subtotal thyroidectomy involves the removal of a significant portion (90%) of the thyroid gland.
In this procedure, several small incisions are made, and an endoscope is inserted. Instruments are passed through the endoscope to remove thyroid tissue or nodules. endoscopic thyroidectomy
When is an endoscopic thyroidectomy an appropriate procedure for patients? Patients with small nodules (<3 cm) whom there is no evidence of malignancy.
What are the advantages of endoscopic thyroidectomy over open thyroidectomy? Less scarring, less pain, and a faster return to normal activity.
What kind of diet would a patient with hyperthyroidism have and why? High calorie diet (4000-5000 cal/day), 6 full meals/day w/snacks in b/t, protein intake 1-2g/kg ideal body wt. Inc carbs to compensate for inc metabolism. Avoid highly seasoned & high fiber foods to not further stimulate already hyperactive GI tract.
What should you instruct a patient with hyperthyroidism to avoid and why? Avoid caffeine containing liquids such as coffee, tea, and cola to decrease the restlessness and sleep disturbances associated with these fluids.
What are some interventions if exopthalmos is present? Apply artificial tears to relieve eye discomfort. Salt restriction & elevate HOB. Dark glasses. Tape eyelids closed if needed for sleep. ROM exercises for intraocular muscles to maintain flexibility.
If exophthalmos is severe what treatment options are available? Corticosteroids, radiation of retroorbital tissues, orbital decompression, and corrective lid or muscle surgery.
If surgery is needed what should be done before the surgery? Administer antithyroid drugs, iodine, and B-adrenergic blockers to achieve a euthyroid state.
What is iodine used for? Iodine reduces vascularization of the thyroid gland, thereby reducing the risk of hemorrhage.
What are the s/s of iodine toxicity? swelling of the buccal mucosa and other mucuous membranes, excessive salivation, nausea, vomiting, & skin reactions
If iodine toxicity occurs what should you do? Discontinue iodine administration and notify HCP.
What are some post-operative complications you should monitor for? hypothyroidism; damage to or inadvertent removal of parathyroid glands, causing hypoparathyroidism & hypocalcemia; hemorrhage; injury to the recurrent or superior laryngeal nerve; thyrotoxic crisis; and infection.
Recurrent laryngeal nerve damage leads to what? vocal cord paralysis
If both cords are paralyzed what can occur? Spastic airway obstruction, necessitating an immediate tracheostomy.
What equipment should be readily available in the patient's room after surgery? oxygen, suction equipment, and a tracheostomy tray
Respiration may also become difficult because of what? Excess swelling of the neck tissues, hemorrhage, and hematoma formation.
This sound may occur during inspiration and expiration as a result of edema of the laryngeal nerve. laryngeal stridor (harsh, vibratory sound)
Laryngeal stridor may also be related to tetany, which occurs when? The parathyroid glands are removed or damaged during surgery, leading to hypocalcemia.
How do you treat tetany? IV calcium salts (calcium gluconate, calcium gluceptate)
What should you assess for every 2 hours during the first 24 hours? Signs of hemorrhage or tracheal compression such as irregular breathing, neck swelling, frequent swallowing, sensations of fullness at the incision site, choking, and blood on the anterior or posterior dressings.
What is the proper placement you should position the patient and why? Place the patient in a semi-Fowler's position, support the patient's head with pillows, and avoid flexion of the neck and any tension on the suture lines.
S/S of hypocalcemia paresthesia (tingling) in extremities or around mouth; twitching; tetany; positive Chvostek & Trousseau's sign
What should you teach the patient upon discharge? Monitor hormone balance periodically; decrease caloric intake; adequate but not excessive iodine intake; regular exercise (stimulate the thyroid gland); avoid high environmental temps (inhibits thyroid regeneration); reg f/u care
If a complete thyroidectomy has been performed what should you teach the patient? The need for lifelong thyroid hormone replacement. S/S of progressive thyroid failure.
Created by: eblanc1