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INTRODUCTION

Thyroid hormones are essential for the body to function normally. To achieve
this purpose, the thyroid hormones must be present in the body in the correct
amount -- not too little and not too much.

Hyperthyroidism is the term for overactive tissue within the thyroid gland,
resulting in overproduction and thus an excess of circulating free thyroid hormones:
thyroxine (T4), triiodothyronine (T3), or both. Thyroid hormone is important at a
cellular level, affecting nearly every type of tissue in the body. It is the second
common endocrine disorder, and Grave’s disease is the most common type. Long-
acting thyroid stimulator (LATS) is found in significant concentrations in the serum
of many of these patient’s.

The disorder affects women eight times more frequently than men and peaks
between the second and fourth decades of life. It may appear after an emotional
shock, stress, or infection, but the exact significance of these relationships is not
understood. Other common causes include thyroiditis and excessive ingestion of
thyroid hormone.
ASSESSMENT

CAUSES

Functional thyroid tissue producing an excess of thyroid hormone


occurs in a number of clinical conditions.
The major causes in humans are:
• Graves' disease (the most common etiology with 70-80%)
• Toxic thyroid adenoma
• Toxic multinodular goitre
High blood levels of thyroid hormones (most accurately termed
hyperthyroxinemia) can occur for a number of other reasons:
• Inflammation of the thyroid is called thyroiditis. There are a number of
different kinds of thyroiditis including Hashimoto's thyroiditis (immune
mediated), and subacute thyroiditis (DeQuervain's). These may be
initially associated with secretion of excess thyroid hormone, but
usually progress to gland dysfunction and thus, to hormone deficiency
and hypothyroidism.
• Oral consumption of excess thyroid hormone tablets is possible, as is
the rare event of consumption of ground beef contaminated with
thyroid tissue, and thus thyroid hormone (termed "hamburger
hyperthyroidism").
• Amiodarone, an anti-arrhythmic drug is structurally similar to thyroxine
and may cause either under- or overactivity of the thyroid.
• Postpartum thyroiditis (PPT) occurs in about 7% of women during the
year after they give birth. PPT typically has several phases, the first of
which is hyperthyroidism. This form of hyperthyroidism usually corrects
itself within weeks or months without the need for treatment.

LABORATORY EXAMS

1. radioactive iodine (rai) uptake test: high in graves’ disease and toxic
nodular goiter; low in thyroiditis.
2. serum t4 and t3: increased in hyperthyroidism. normal t4 with elevated
t3 indicates thyrotoxicosis.
3. thyroid-stimulating hormone (tsh): suppressed (except when etiology is
a tsh-secreting pituitary tumor or pituitary
resistant to thyroid hormone). does not respond to thyrotropin-
releasing hormone (trh).
4. thyroglobulin: increased.
5. trh stimulation: hyperthyroidism is indicated if tsh fails to rise after
administration of trh.
6. thyroid t3 uptake: normal to high.
7. protein-bound iodine: increased.
8. serum glucose: elevated (related to adrenal involvement).
9. plasma cortisol: low levels (less adrenal reserve).
10. alkaline phosphatase and serum calcium: increased.
11. liver function tests: abnormal.
12. electrolytes: hyponatremia may reflect adrenal response or dilutional
effect in fluid replacement therapy. Hypokalemia occurs because of gi
losses and diuresis.
13. serum catecholamines: decreased.
14. urine creatinine: increased.
15. ecg: atrial fibrillations; shorter systole time; cardiomegaly, heart
enlarged with fibrosis and necrosis (late signs or in elderly with masked
hyperthyroidism).

PATHOPHYSIOLOGY

In Grave’s disease, thyroid stimulating antibodies binds to and


stimulate the TSH receptors of the thyroid gland. The trigger for this
autoimmune response is unclear. Grave’s disease is also associated with the
production of several antibodies formed because of a defect in the
suppressor t-lymphocyte function.

NURSING MANAGEMENT

– NURSING DIAGNOSIS

1. Low self-esteem related to changes in appearance, excessive appetite,


and weight loss.

NURSING INTERVENTION

Imbalanced nutrition, less than body requirements related to


exaggerated metabolic rate, excessive appetite, and increase
gastrointestinal activities.

Actions/Intervention Rationale
continued weight loss in face of
adequate caloric intake
independent
may indicate failure of antithyroid
monitor daily food intake. weigh daily
therapy.
and report losses.

aids in keeping caloric intake high


encourage patient to eat and
enough to keep up with
increase number of meals
rapid expenditure of calories caused
and snacks, using high-calorie foods
by hypermetabolic
that are easily
state.
digested.

increased motility of GI tract may


avoid foods that increase peristalsis
result in diarrhea and
(e.g., tea, coffee,
impair absorption of needed
fibrous and highly seasoned foods)
nutrients.
and fluids that cause

diarrhea (e.g., apple/prune juice).

dependent

consult with dietitian to provide diet


high in calories, may need assistance to ensure
adequate intake of
protein, carbohydrates, and vitamins.
nutrients, identify appropriate
supplements.
administer medications as indicated:

glucose, vitamin b complex;


given to meet energy requirements
and prevent or correct

hypoglycemia.

insulin (small doses).


aids in controlling serum glucose if
elevated.

knowledge, deficient regarding condition, prognosis,

treatment, self-care, and discharge needs related to unfamiliarity with


information resources

Actions/Intervention Rationale

independent

review disease process and future expectations. provides knowledge base from which patient can
make

informed choices.

provide information appropriate to individual


situation. severity of condition, cause, age, and concurrent

complications determine course of treatment.

identify stressors and discuss precipitators to psychogenic factors are often of prime
thyroid importance in the

crises, e.g., personal/social and job concerns, occurrence/exacerbation of this disease.


infection,

pregnancy.

patient who has been treated for hyperthyroidism


provide information about signs/symptoms of needs to

hypothyroidism and the need for continuing be aware of possible development of


follow-up hypothyroidism,

care. which can occur immediately after treatment or


as long as 5 yr later.

antithyroid medication (either as primary therapy


or in

discuss drug therapy, including need for adhering preparation for thyroidectomy) requires
to adherence to a

regimen, and expected therapeutic and side medical regimen over an extended period to
effects. inhibit

hormone production. agranulocytosis is the most


serious

side effect that can occur, and alternative drugs


may be

given if problems arise.

identify signs/symptoms requiring medical early identification of toxic reactions (thiourea


evaluation, therapy)

e.g., fever, sore throat, and skin eruptions. and prompt intervention are important in
preventing

development of agranulocytosis.

explain need to check with physician/pharmacist


before antithyroid medications can affect or be affected
by
taking other prescribed or otc drugs.
numerous other medications, requiring monitoring
of

medication levels, side effects, and interactions.

emphasize importance of planned rest periods.

prevents undue fatigue; reduces metabolic


demands. as

euthyroid state is achieved, stamina and activity


level will
review need for nutritious diet and periodic review
increase.
of

nutrient needs; avoid caffeine, red/yellow food


dyes, provides adequate nutrients to support
hypermetabolic
artificial preservatives.
state. a hormonal imbalance is corrected, diet will
need to

be readjusted to prevent excessive weight gain.


irritants

and stimulants should be limited to avoid


cumulative
stress necessity of continued medical follow-up.
systemic effects.

necessary for monitoring effectiveness of therapy


and

prevention of potentially fatal complications.

Fatigue related to hypermetabolic state with increased energy requirements

Actions/ Interventions Rationale

Independent

monitor vital signs, noting pulse rate at rest and pulse is typically elevated and, even at rest,
when tachycardia

active. (up to 160 beats/min) may be noted.

note development of tachypnea, dyspnea, pallor, o2 demand and consumption are increased in
and
hypermetabolic state, potentiating risk of hypoxia
cyanosis. with

activity.

provide for quiet environment; cool room, reduces stimuli that may aggravate agitation,
decreased
hyperactivity, and insomnia.
sensory stimuli, soothing colors, quiet music.
encourage patient to restrict activity and rest in helps counteract effects of increased metabolism.
bed as

much as possible.

provide comfort measures, e.g., judicious


touch/massage, may decrease nervous energy, promoting
relaxation.
cool showers.

provide for diversional activities that are calming,


e.g., allows for use of nervous energy in a constructive
manner and may reduce anxiety.
reading, radio, television.

increased irritability of the cns may cause patient


avoid topics that irritate or upset patient. discuss to be
ways to
easily excited, agitated, and prone to emotional
respond to these feelings. outbursts.

understanding that the behavior is physically


based may
discuss with so reasons for fatigue and emotional
lability enhance coping with current situation and
encourage so to

respond positively and provide support for


patient.