Hyperthyroidism

It include anatomy , physiology of thyroid gland. Hyperthroidism and its causes, risk factors, diagnosis, medical and nursing management, complication.

1. Presentation on Hyperthyroidism P repared by kalpana kawan Roll no. 06 BNS 3rd year

2. General objective At the end of this session , BNS 3rd year students will be able to know about hyperthyroidism.

3. S pecific objectives d efine hyperthyroidism. state the incidence of hyperthyroidism . state the types of hyperthyroidism. list the risk factor of hyperthyroidism . explained the cause of hyperthyroidism.

4. Specific objectives explain pathophysiology of hyperthyroidism. list the clinical manifestation of hyperthyroidism. list the diagnostic procedure state the complication of hyperthyroidism . explain the medical and nursing management of hyperthyroidism.

5. Thyroid Gland Introduction It is part of the endocrine system . It is located at the front of the neck just below the Adam's apple , along the front of the windpipe. It is butterfly-shaped and consists of two lobes located either side of the windpipe (trachea ),

6. Contd..... The thyroid weighs between 20 and 60 grams on average Brownish-red in color, the thyroid is rich with blood vessels.

7. Contd......... It produces two principle hormones Thyroxine(T4) Triiodothyronine(T3) Also secrete calcitonin(responsible for Ca homeostasis)

8. Biosynthesis of thyroid hormones Iodine is essential for synthesis of thyroid hormones . Steps of synthesis Uptake of iodine: Formation of active iodine Thyroglobulin and synthesis of T3 and T4

9. Regulation of thyroid hormone

10. Function of thyroid gland Thyroid hormones affect every cell and all the organs of the body. They: Regulate the rate at which calories are burned, affecting weight loss or weight gain. Can slow down or speed up the heartbeat. Can raise or lower body temperature .

11. Contd........ Influence the rate at which food moves through the digestive tract. Control the way muscles contract. Control the rate at which dying cells are replaced. The brain matures (in children) Growth is promoted (in children). Activation of the nervous system leads to improved concentration and faster reflexes

12. Hyperthyroidism Defination Hyperthyroidism  is the condition that occurs due to excessive production of thyroid hormone  by the thyroid gland.  OR Hyperthyroidism is hyperactivity of thyroid gland leading to sustained increase and excessive synthesis and release of thyroid hormones and accelerated metabolism in the peripheral tissues.

13. Incidence It is the second most common thyroid problem and affects womens eight times more frequently between 20 and 40 years than male.

14. Type 1) Primary hyperthyroidism : Arising from the intrinsic thyroid abnormally. 2)Secondary hyperthyroidism :- Arising from process outside of the thyroid gland such as TSH secreating pituitary tumor.

15. Contd....... 3) Apathetic hyperthyroidism : It is a form of hyperthyroidism occuring in elderly person , >70 years(but can be any age). The typical features of thyroid hormones excess seen in younger patients are blunted. The diagnosis is made during investigation for unexplained weight loss or worsening cv disease .

16. Contd..... The cardinal symptoms are depresson and apathy . The absence of classical signs and symptoms of hyperthyroidism delays the diagnosis and treatment of the diseases, as it is often misdiagnosed as a primary psychiatric disorder.

17. Risks factors A family history of thyroid disease, particularly of graves' disease Female sex A personal history of certain chronic Such as type 1 diabetes mellitus, Pernicious anemias( a vit B 12 deficiency) , primary adrenal insufficiency, also known as addisions diseases.  

18. Contd..... Over the age of 60 Consume an iodine rich diet or medication containing iodine( like amiodarone)) Had thyroid surgery or a thyroid problem such as goiter, also known as swollen thyroid gland. Radiation therapy may predispose a patient to develop hyperthyroidism. Women who smoke nearly double their risk of Grave's diseases.

19. Etiology Graves' disease It is most common causes with 50-80 % worldwide.

20. Contd..... Toxic thyroid adenoma Nodules produces thyroid hormones independently .

21. Contd..... Toxic multinodular goitor also called plummer disease. If there is more than one functioning nodules, the term multinodular goitor is used. It occurs more commonly in elderly, especially with long standing goiter.

22. Contd..... Thyroiditis Inflammation of the thyroid which causes T4 and T3 to leak out of the gland to the blood stream .  

23. Contd..... Excessive intake of thyroid hormone

24. Contd..... Abnormal secreating of TSH A tumors in the putuitary gland may produce an abnormally high secretion of TSH.

25. Contd..... Excessive iodine intake

26. Contd..... Struma ovarii It is a rare form of monodermal teratoma that contains mostly thyroid tissue, which lead to hyperthyroidism .

27. Pathophysiology: Graves disease may be due to excessive stimulation of the adrenergic nervous system or excessive levels of circulating TH . Hyperthyroidism is characterized by loss of the normal regulatory controls of TH secretion. Because the action of THon the body is stimulatory, hypermetabolism results with increased sympathetic nervous system activity.

28. Contd....... Excessive amounts of TH stimulates the cardiac system and increase the number of beta adrenergic responsiveness, and peripheral blood flow . Metabolism increases greatly leading to negetive nitrogen balance, lipid depletion and a state of nutritional deficiency and weight loss. Hyperthyroidism also results in altered secretion and metabolism of hypothalamic pituitary and gonadal hormone. If hyperthyroidism occurs before puberty sexual develop is delayed to both genders.

29. Clinical menifestation

30. Clinical menifestation

31. Clinical menifestation 1) Cardiovascular System Systolic hypertension Bounding, Rapid pulse (90-160 b/m with sinustachycardia) Increased cardiac output Cardiac hypertrophy

32. Contd......... Systolic murmurs Dysrhythmais, Arrhythmia Palpitations, tachycardia, Angina, cardiac hypertrophy

33. Contd......... 2. Respiratory System Increased respiratory rate Dyspnea on mild exertion

34. Contd......... 3. Gastrointestinal System Increased appitite, thirst Weight loss Increased peristalsis, increase bowel sound Diarrhoea, frequent urination Splenomegaly Hepatomegaly

35. Contd......... 4. Integumentary System Warm, smooth, moist skin fine , soft hair Hair loss Palmar erythema Diaphoresis thin soft nailsdetached from nail bed (nydrolysis) poor tolerance of heat, excessive perspiration, skin that is flushed.

36. Contd......... 5. Musculoskeletal System Fatigue Muscle weakness especially proximal dependent edema Osteoporosis, joint pain

37. Contd......... 6. Nervous System Nervousness Fine tremor of fingers and toes, deterioration in hand writing Insomnia Delirium, irritability Restlessness, apprehensiveness

38. Contd......... Lack of ability to concentrate agitation Exhaustion Hyper flexion of tendon reflexes stupur coma

39. Contd......... 7. Reproductive System Menstrual irregularities Amenorrhea Decreased libido erectile dusfunction Gynecomastia in men Decreased fertility

40. Contd......... Others: Exophthalmos (bulging eyes) seen only in Grave's diseases .

41. Diagnosis 1.History taking: Family history , signs and symptoms ( heat intolerance, increase sweating , warm skin etc.) geographical area, dietary pattern , surrent medications . 2. Physical examination : vital signs, weight loss, Tremors of hands soft Eye changes Warm , moist skin Neck examination-Thyroid gland is enlarged

42. Contd......... 3 . Lab test Increase in serum T-4 and T-3 and decrease TSH Free tri-iodothyronine(T3) Free thyroxine(T4) Total T3 Total T4 Cholesterol level Antibody test BMR

43. Contd......... 4. Radiologic exam ultrasound Thyroid scan Iodine thyroid scan 5 . Histologic exam Thyroid biopsy 6. Opthalmological examination - to determine exopthalmos

44. Management Management depends on cause , age of patients, severity of diseases and complication. Goals of therapy is to bring the metabolic rate to normal as soon as possible . Three form of treatment are available: 1. Pharmacotherapy A ntithyroid medications Beta blocker 2.Radiation therapy 3. Surgery

45. Contd......... 1. Pharmacotherapy Antithyroid drugs: which inhibits the synthesis of thyroid hormones such as carbimazole, methimazole, propylthiouracil(PTU ) but they may take several months to be effective, and must be continued for 12-18 months.

46. Contd......... Beta blocker : Medicines such as propanolol, metoprolol etc are used. These medications don’t treat levels of thyroid hormone but can help to reduces symptoms like anxiety, shaking, or a fast heartbeat.

47. Contd....... 2. Radioactive Iodine( 131 I) therapy (radioisotope therapy) A small amount of radioactive iodine taken orally. Overactive thyroid cells absorb it, and it destroys them . This makes your thyroid shrink and your levels of thyroid hormone go down . It may also cause hypothyroidism. This is easier to treat than hyperthyroidism by take a hormone supplement once a day. 

48. Contd ........ 3. Surgery Sub total thyroidectomy and total thyroidectomy is done.

49. Contd....... Surgery (thyroidectomy to remove the whole thyroid or a part of it) is not extensively used because most common forms of hyperthyroidism are quite effectively treated by the radioactive iodine method, and because there is a risk of also removing the parathyroid glands, and of cutting the recurrent laryngeal nerve, making swallowing difficult.

50. Contd....... Thyroidectomy is indicated for individuals who have A large goiter causing tracheal compression Been unresponsive to antithyroid therapy Thyroid cancer Unresposive to radiotherapy

51. Contd....... Endoscopic thyroidectomy It is a minimally invasive procedure. Several small incisions are made, and a scope is inserted. Instruments are passed through the scope to remove thyroid tissue or nodules. Is appropriate procedure for patients with small nodules (less than 3 cm)and no evidence of malignancy. Advantages of over open thyroidectomy include less scaring, less pain and faster return to normal activity.

52. Contd....... Management of Thyrotoxicosis/ thyroid strom Treatment is first directed toward relieving the life-threatening symptoms. Acetaminophen is given for the fever . Aspirin is avoided because it binds with the same serum protein as T4, freeing additional T4 into the circulation. Intravenous fluids and a cooling blanket may be ordered to cool the patient.

53. Contd....... A beta-adrenergic blocker , such as propranolol, is given for tachycardia and symptom control . Oxygen is administered and the head of the bed is elevated because the high metabolic rate requires more oxygen. Once symptoms are controlled and the patient is safe, the underlying thyroid problem is treated.

54. Complications Thyrotoxicosis/ thyroid strom/ thyrotoxic crisis is an acute, severe, and rare condition that occurs when excessive amounts of thyroid hormones are released into the circulation, if untreated is usually fatal but with proper treatment the mortality rate is reduced substantially.

55. Contd.......... Symptoms includes: High fever above 38.5 c tachycardia altered neurologic or mental state Exaggerated symptoms of hyperthyroidism

56. Contd.......... Other complications of hyperthyroidism include: Heart problems such as fast heart rate, abnormal heart rhythm, and heart failure Osteoporosis Hypothyroidism (underactive thyroid) Airway Obstruction Respiratory distress

57. Contd.......... Surgery-related complications, including: Immediate : Haemorrage Short term : infection Long term: Scarring of the neck Hoarseness due to nerve damage to the voice box Hypocalcemia due to damage to the parathyroid glands (located near the thyroid gland) Hypoparathyroidism

58. Nursing Management Nursing assessment Monitor the patient with hyperthyroidism closely until normal thyroid activity is restored. Monitor vital signs and report any increases in pulse or blood pressure to the registered nurse or physician. Monitor lung sounds because crackles can indicate heart failure.

59. Contd.......... Assess level of anxiety and ability to cope with symptoms, Monitor weight, bowel function, and ability to sleep. Assess eyes for risk for injury caused by exophthalmos, and note degree of muscle weakness. Never palpate the thyroid gland of a patient with hyperthyroidism because palpation can stimulate release of thyroid hormone and precipitate a thyrotoxic crisis.

60. NURSING DIAGNOSES, PLANNING AND IMPLEMENTATION 1) Nursing diagnosis: Hyperthermia related to hypermetabolic state as evidenced by elevated temperature. Expected outcome: The patient's body temperature will be within normal limits .

61. CONTD...... Intervention: Monitor temperature. Temperature may be elevated due to hypermetabolic state. Administer acetaminophen as ordered (avoid aspirin) to reduce temperature. Aspirin can cause an increase in circulating thyroid hormone. Apply cooling blanket as ordered. External cooling may be needed if acetaminophen is not effective.

62. Contd If a cooling blanket is needed, set it to 1 to 2 degrees below the current temperature, and wrap the extremities with towels to prevent shivering, w hich can further increase temperature . Offer fluids to replace fluids lost through diaphoresis.

63. Contd 2) Nursing Diagnosis : Diarrhea Related to an increase in peristalsis as evidenced by frequent loose stools. Expected outcome: The patient will maintain fluid and electrolyte balance.

64. Contd...... Intervention Provide a low-fiber diet. Fiber can increase peristalsis and stools. Provide small, frequent meals of bland foods (bananas, rice, applesauce) that are less likely to worsen diarrhea. Monitor electrolytes, especially sodium and potassium. Diarrhea can cause electrolyte loss. Monitor for dehydration. Diarrhea causes fluid loss. Keep skin clean and dry; apply barricr cream to ptotcct skin injury from stool.

65. Contd...... 3) Nursing diagnosis: Imbalanced nutrition less than body requirements related to increased metabolism. Expected outcome : The patient will have balanced nutrition evidenced by stable weight in proportion to height.

66. Contd..... Intervention Determine healthy weight for height, so the expected outconte is realistic for the patient. Monitor weight weekly to make sure interventions are working. Consult dietician for high-calorie diet with six meals per day to meet caloric requirements.

67. Contd..... Diet- The patient with hyperthyroidism needs a high calori, high protein diet to compensate for the hypermetabolic state. A diet of 4000 to 5000 calories with high protein levels may be necessary to prevent negative nitrogen balance and weight loss . Provide quite and calm environment. Monitor I/V infusion when prescribed to maintain fluid and electrolyte balance. Monitor weight, skin turgor, vital signs to evaluate nutritional and fluid status.

68. Contd.. 4 . Nursing diagnosis: Disturbed Sleep Pattern Related to Sympathetic Stimulation as Evidenced by Difficulty Sleeping and not Feeling Rested on Awakening Expected outcome: The patient will have improved sleep as evidenced by stating feeling rested upon awakening .

69. Contd............ Intervention Provide a quiet, restful environment to assist the patient to fall asleep . Ask the patient if music or earplugs are desired to mask environmental noise. Administer propranolol or sedative as ordered to reduce sympathetic stimulation and calm patient.

70. Contd.... 5. Nursing diagnosis: Anxiety Related to Sympathetic Stimulation as Evidenced by Patient Statement Expected outcome : The patient will experience reduced anxiaty as evidenced by patient statement that anxiety is controlled.

71. Contd...... Intervention Provide the patient with accurate information about the disorder and treatment, and explain that proper treatment will correct symptoms. Fear of the unknown can produce anxiety. Administer propranolol or antianxiety agent as ordered to reduce sympathetic stimulation and calm patient, Offer massage, music, or other relaxation techniques preferred by the patient, These may promote relaxation.

72. Contd........ 6. Nursing disgnosis : Risk for Injury Related to Hypermetabolic State and Eye Involvement . Expected outcome: The patient will remain safe and without injury.

73. Contd..... Intervention Report changes in vital signs to RN or physician. Prompt treatment can reduce complications. Administer lubricating saline eyedrops as ordered to protect eyes from drying. Advise use of dark, tight-fitting glasses to protect eyes from light and injury.

74. Contd..... Gently tape eyes shut with nonallergic tape for sleeping. Exophthalntos may prevent t/te patient front fully closing the eyes. Elevate the head of the bed to reduce edema behind the eyes. Provide a low-sodiutn diet. This may decrease edema behind the eyes. Teach patient to notify the physician immediatcly if eye pain or vision changes occur. These can be signs of pressure from edema on optic nerve, which can cause perntanent damage if not corrected.

75. Contd. 7.Nursing diagnosis- Fatigue related to hypermetabolic state with increased energy requirements 8.Nursing diagnosis- Knowledge deficit related to disease process, prognosis, signs and symptoms and treatment

76. Pre operative care (Thyroidectomy) All pre operative nursing care should be provided as in other surgery / Routine pre operative care. The patient must be euthyroid before the operation. Antithyroid drug to supress secretion of TH and iodine preparation to reduce the size and vascularity of the organ therefore surgery may diminishing the chance of hemorrage. Provide nutritious diet to counteract the effect of hyperthyroidism.

77. Contd... Evaluate cardiac status before surgery to screen the cardiac complication of hyperthyroidism. The patient is prepared physically and emotionally in the following ways: Explain the surgical procedures, approximate time or duration etc. Explain that the patient may have drain tubes, I/V line after surgery.

78. Contd...... Post Operative nursing care (Thyroidectomy) All post operative nursing management as in other surgery/ Routine post operative care. Monitor for signs of bleeding such as repeated clearing of throat, swelling of the neck and signs of repiratory distress. Monitor for signs of hypocalcemia such as irritability, twitching, spasm of hands and feet .

79. Contd...... Monitor vital signs frequently, watching for tachycardia, hypotension that indicate hemorrhage. Monitor for signs of hypocalcemic tetany eg. Tingling of toes, and fingers, positive Chvostek’s sign and positive Trousseau’s sign.

80. Contd...... Monitor blood calcium level, and if falls below 7 mg/100 ml, replace calcium IV. Watch for change in voice that indicate laryngeal nerve damage. Keep tracheostomy set ready in bedside for first 48 hours because patient may need emergency tracheostomy for respiratory distress. Move patient carefully and provide adequate support to the neck by sandbags or pillow to prevent tension in suture .

81. Contd...... Keep the patient in a semi fowler's position to facilitate breathing and decrease edema. Administer pain medication as needed. Inspects the neck dressing for drainage (a moderate amount of drainage in expected) Teach patient about the care at home, and encourage follow up and monitoring thyroid hormone replacement.

82. Contd...... Patient and family education on : Teach the patient how to take medications and importance to take medicine regularly. Teach the patient about the disease and symptoms of hyperthyroidism or hypothyroidism to report. Report high fever, tachycardia, extreme irritation, immediately because these are signs and symptoms of thyroid strom. Importance of routine follow-up laboratory testing.

83. Reference Williams L.S. Hopper P.D.(2012).Understanding Medical Surgical Nursing, (4th edition).Jaypee Brothers Medical Publishers (P)Ltd.page no. 897-899 Sharma M.Poudel K. Gautam R.(2015).Essential textbook of Medical Surgical Nursing, (1st edition),Samiksha books Pvt Ltd.Page no. 396-399 Robbins and Cotran.(2015)Pathologic Basis of Disease,South Asian Edition. Vol II,Reed Elsevier India Private Limited.page no.1083-1085

84. Reference Retrived from https://en.wikipedia.org/wiki/Hyperthyroidism on jun 09, 2021. Retrived from https://www.thyroid.org/hyperthyroidism/ Retrived from https://www.webmd.com/a-to-z-guides/overactive-thyroid-hyperthyroidism