Hyperthyroidism
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| Hyperactivity of the thyroid gland with sustained increase in synthesis and release of thyroid hormones. | hyperthyroidism
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| What is the most common form of hyperthyroidism? | Graves disease
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| Besides Graves disease what are some other causes of hyperthyroidism? | Toxic nodular goiter, thyroiditis, excess iodine intake, pituitary tumors, thyroid cancer
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| In Graves disease the patient develops antibodies to what? | the TSH receptor
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| In Graves disease the patient's antibodies attach to the TSH receptors and stimulates what? | the thyroid gland to release T3, T4, or both
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| The excessive release of thyroid hormones leads to what? | clinical manifestations associated with thyrotoxicosis
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| Graves disease is characterized by what? | By remissions and exacerbations with or without treatment.
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| Graves disease may progress to what? | destruction of the thyroid tissue causing hypothyroidism
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| Refers to the physiologic effects or clinical syndrome of hypermetabolism that results from excess circulating levels of T3, T4, or both. | thyrotoxicosis
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| Hyperthyroidism and thyrotoxicosis usually occur? | together, as in Graves disease
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| This autoimmune disease is of unknown etiology and is characterized by diffuse thyroid enlargement and excessive thyroid hormone secretion. | Graves disease
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| Who is more likely to develop Graves disease? | women
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| What are some precipitating factors that can interact with genetic factors that can cause Graves disease? | Insufficient iodine supply, infection, and stressful life events.
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| This increases the risk of Graves disease and the development of what associated with the disease? | cigarette smoking; eye problems
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| 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.
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| Palpation of the thyroid gland may reveal what? | a goiter; when the thyroid gland is excessively large, a goiter may be noted on inspection.
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| Auscultation of the thyroid gland may reveal this which is a reflection of increased blood supply. | bruits
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| This is a protrusion of the eyeballs from the orbits that is usually bilateral often found in Graves disease. | exopthalmus (bug eyes)
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| 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.
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| 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.
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| 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
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| 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)
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| Musculoskeletal CM of hyperthyroidism | fatigue; muscle weakness; proxima muscle wasting; dependent edema; osteoporosis
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| 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
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| Reproductive system CM of hyperthyroidism | menstrual irregularities; amenorrhea; decreased libido; impotence in men; gynecomastia in men; decreased fertility
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| Other CM of hyperthyroidism | intolerance to heat, elevated basal temperature; lid lag, stare; eyelid retraction; rapid speech
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| 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)
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| Thyrotoxicosis is thought to result from what? | stressors (infection, trauma, surgery) in a patient w/preexisting hyperthyroidism, either diagnosed or undiagnosed
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| 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.
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| CM of thyrotoxicosis (thyroid storm) | tachycardia, HF; shock; hyperthermia (up to 105.3); restlessness, irritability; seizures; abdominal pain, vomiting, diarrhea; delirium, coma
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| 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.
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| What are the 2 primary lab findings used to confirm the diagnosis of hyperthyroidism? | decreased TSH levels and elevated free thyroxin (free T4) levels
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| What tests is used to differentiate Graves disease from other forms of thyroiditis? | the radioactive iodine uptake (RAIU) test
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| 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.
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| What is the goal of managing hyperthyroidism? | Toward blocking the adverse effects of excessive thyroid hormone, suppressing oversecretion of thyroid hormone, and preventing complications.
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| What are the 3 primary treatment options for hyperthyroidism? | antithyroid medications, radioactive iodine therapy (RAI), surgery
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| What drugs are used in the treatment of hyperthyroidism? | antithyroid drugs, iodine, and beta adrenergic blockers
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| What are the first-line antithyroid drugs? | propylthiouracil (PTU) and methimazole (Tapazole)
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| What are the functions of propylthiouracil (PTU) and methimazole (Tapazole)? | Inhibit the synthesis of thyroid hormones.
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| 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.
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| 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.
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| What drug is considered first line in thyroid storm and why? | PTU b/c it blocks the peripheral conversion of T4 to T3.
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| 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.
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| Abrupt discontinuation of drug therapy can result in what? | a return of hyperthyroidism
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| What form is iodine available? | Saturated solution of potassium iodine (SSKI) and Lugol's solution
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| 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.
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| Iodine is used with other antithyroid drugs to prepare the pt for what? | thyroidectomy or for treatment of thyrotoxicosis crisis
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| What are B-adrenergic blocker used for in hyperthyroidism? | symptomatic relief of thyrotoxicosis
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| What do B-adrenergic blockers do in hyperthyroidism?/ | Block the effects of sympathetic nervous stimulation thereby decreasing tachycardia, nervousness, irritability, and tremors.
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| What B-blocker is usually administered with other antithyroid agents? | propanolol (Inderal)
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| This B-blocker is the preferred B-blocker for use in hyperthyroid patients with asthma or heart disease. | atenolol (Tenormin)
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| What is the treatment of choice for most nonpregnant adults? | radioactive iodine (RAI) therapy
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| What does RAI do to thyroid tissue? | It damages or destroys thyroid tissue, thus limiting thyroid hormone secretion.
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| 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.
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| 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)
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| What should be done to all women before initiation of RAI therapy? | a pregnancy test
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| 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.
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| 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.
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| 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.
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| You should teach the pt and family the s/s of this because of its high frequency after RAI therapy. | hypothyroidism
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| 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.
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| What is one advantage that thyroidectomy has over RAI? | It is a more rapid reduction in T3 and T4 levels.
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| 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.
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| 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
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| When is an endoscopic thyroidectomy an appropriate procedure for patients? | Patients with small nodules (<3 cm) whom there is no evidence of malignancy.
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| What are the advantages of endoscopic thyroidectomy over open thyroidectomy? | Less scarring, less pain, and a faster return to normal activity.
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| 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.
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| 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.
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| 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.
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| If exophthalmos is severe what treatment options are available? | Corticosteroids, radiation of retroorbital tissues, orbital decompression, and corrective lid or muscle surgery.
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| If surgery is needed what should be done before the surgery? | Administer antithyroid drugs, iodine, and B-adrenergic blockers to achieve a euthyroid state.
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| What is iodine used for? | Iodine reduces vascularization of the thyroid gland, thereby reducing the risk of hemorrhage.
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| What are the s/s of iodine toxicity? | swelling of the buccal mucosa and other mucuous membranes, excessive salivation, nausea, vomiting, & skin reactions
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| If iodine toxicity occurs what should you do? | Discontinue iodine administration and notify HCP.
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| 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.
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| Recurrent laryngeal nerve damage leads to what? | vocal cord paralysis
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| If both cords are paralyzed what can occur? | Spastic airway obstruction, necessitating an immediate tracheostomy.
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| What equipment should be readily available in the patient's room after surgery? | oxygen, suction equipment, and a tracheostomy tray
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| Respiration may also become difficult because of what? | Excess swelling of the neck tissues, hemorrhage, and hematoma formation.
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| This sound may occur during inspiration and expiration as a result of edema of the laryngeal nerve. | laryngeal stridor (harsh, vibratory sound)
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| Laryngeal stridor may also be related to tetany, which occurs when? | The parathyroid glands are removed or damaged during surgery, leading to hypocalcemia.
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| How do you treat tetany? | IV calcium salts (calcium gluconate, calcium gluceptate)
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| 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.
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| 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.
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| S/S of hypocalcemia | paresthesia (tingling) in extremities or around mouth; twitching; tetany; positive Chvostek & Trousseau's sign
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| 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
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| 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.
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