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Hyperthyroidism

Hyperthyroidism. Chapter 50. Case Study. M.S., a 28-year-old woman, visits her primary care provider’s office. She states she is always hungry, yet has lost 15 lb in the past few months. She also claims to always be tired. Her past medical history is unremarkable.

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Hyperthyroidism

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  1. Hyperthyroidism Chapter 50

  2. Case Study • M.S., a 28-year-old woman, visits her primary care provider’s office. • She states she is always hungry, yet has lost 15 lb in the past few months. • She also claims to always be tired. • Her past medical history is unremarkable. • She smokes 1 pack/day. iStockphoto/Thinkstock

  3. Case Study • Health care provider suspects M.S. may have hyperthyroidism. • What is hyperthyoidism? • What risk factors does M.S. have? iStockphoto/Thinkstock

  4. Hyperthyroidism • A sustained increase in synthesis and release of thyroid hormones by thyroid gland • Occurs more often in women • Highest frequency between ages 20 to 40 years

  5. Continuum of Thyroid Dysfunction

  6. Hyperthyroidism • Most common form • Graves’ disease • Other causes • Toxic nodular goiter • Thyroiditis • Excess iodine intake • Pituitary tumors • Thyroid cancer

  7. Etiology and PathophysiologyGraves’ Disease • Antibodies to TSH receptor stimulate release of T3, T4, or both • Leads to clinical manifestations of thyrotoxicosis • Remissions and exacerbations • May progress to destruction of thyroid tissue

  8. Hyperthyroidism • Thyrotoxicosis • Physiologic effects/clinical syndrome of hypermetabolism • Results from increased circulating levels of T3, T4, or both • Hyperthyroidism and thyrotoxicosis usually occur together

  9. Etiology and PathophysiologyGraves’ Disease • Autoimmune disease • Diffuse thyroid enlargement • Excessive thyroid hormone secretion • Accounts for 80% of hyperthyroidism cases • Precipitating factors interact with genetic factors • Cigarette smoking increases risk

  10. Case Study • M.S. says she is always warm and “sweats a lot.” • She has also noticed that her nails have become brittle.

  11. Case Study • She has a bounding pulse and a slight heart murmur. • Her BP is 120/84, heart rate is 92, respiratory rate is 20. • Palpation of her thyroid reveals a nodular goiter. iStockphoto/Thinkstock

  12. Case Study • What clinical manifestations of hyperthyoidism does M.S. display? • For what other manifestations will you assess M.S. ? iStockphoto/Thinkstock

  13. Clinical Manifestations • Related to effect of thyroid hormone excess • ↑ Metabolism • ↑ Tissue sensitivity to stimulation by sympathetic nervous system • Goiter • Inspection • Auscultation: bruits

  14. Clinical Manifestations • Ophthalmopathy • Abnormal eye appearance or function • Exophthalmos • Increased fat deposits and fluid • Eyeballs forced outward

  15. Exophthalmos and Goiter of Graves’ Disease

  16. Clinical Manifestations • Cardiovascular system • Systolic hypertension • Bounding, rapid pulse; palpitations • ↑ Cardiac output • Cardiac hypertrophy • Systolic murmurs • Dysrhythmias (e.g., atrial fibrillation ) • Angina

  17. Clinical Manifestations • Respiratory system • Increased respiratory rate • Dyspnea on mild exertion

  18. Clinical Manifestations • GI system • ↑ Appetite, thirst • Weight loss • Diarrhea • Splenomegaly • Hepatomegaly

  19. Clinical Manifestations • Integumentary system • Warm, smooth, moist skin • Thin, brittle nails • Hair loss • Clubbing of fingers; palmar erythema • Fine, silky hair; premature graying • Diaphoresis • Vitiligo

  20. Acropachy

  21. Clinical Manifestations • Musculoskeletal system • Fatigue • Muscle weakness • Proximal muscle wasting • Dependent edema • Osteoporosis

  22. Clinical Manifestations • Nervous system • Nervousness, fine tremors • Insomnia , exhaustion • Lability of mood, delirium • Hyperreflexia of tendon reflexes • Inability to concentrate • Stupor, coma

  23. Clinical Manifestations • Reproductive system • Menstrual irregularities • Amenorrhea • Decreased libido • Impotence • Gynecomastia in men • Decreased fertility

  24. Clinical Manifestations • Intolerance to heat • Elevated basal temperature • Lid lag, stare • Eyelid retraction • Rapid speech

  25. Thyrotoxicosis (Thyrotoxic Crisis) • Excessive amounts hormones released • Life-threatening emergency • Death rare when treatment initiated • Results from stressors • Thyroidectomy patients at risk

  26. Thyrotoxicosis • Manifestations • Tachycardia, heart failure • Shock • Hyperthermia • Restlessness, irritability • Seizures • Abdominal pain, vomiting, diarrhea • Delirium, coma

  27. Thyrotoxicosis • Treat by reducing circulating hormones • Supportive therapy • Manage respiratory distress • Reduce fever • Replace fluids • Eliminate or manage initiating stressor

  28. Case Study • What diagnostic studies would you expect the health care provider to order for M.S. in relation to thyroid function? iStockphoto/Thinkstock

  29. Diagnostic Studies • ↓ TSH and ↑ free thyroxine (free T4) • Total T3 and T4 • Radioactive iodine uptake (RAIU) • Differentiates Graves’ disease from other forms of thyroiditis

  30. Case Study • M.S.’s diagnostic studies reveal a decreased TSH level and an increased free thyroxine (free T4) level. • These findings support the diagnosis of hyperthyroidism. • What treatments may M.H. require? iStockphoto/Thinkstock

  31. Collaborative Care • Goals • Block adverse effects of thyroid hormones • Suppress hormone oversecretion • Prevent complications

  32. Collaborative Care • Three primary treatment options • Antithyroid medications • Radioactive iodine therapy (RAI) • Surgery

  33. Drug Therapy • Useful in treatment of thyrotoxic states • Not considered curative • Antithyroid drugs • Iodine • β-Adrenergic blockers

  34. Antithyroid Drugs • Propylthiouracil (PTU) and methimazole (Tapazole) • Inhibit synthesis of thyroid hormone • Improvement in 1 to 2 weeks • Good results in 4 to 8 weeks • Therapy for 6 to 15 months

  35. Iodine • Potassium iodine (SSKI) and Lugol’s solution • Inhibit synthesis of T3 and T4 and block their release into circulation • Decreases vascularity of thyroid gland • Maximal effect within 1 to 2 weeks • Used before surgery and to treat crisis

  36. β-Adrenergic Blockers • Symptomatic relief of thyrotoxicosis • Block effects of sympathetic nervous stimulation • Propranolol (Inderal) • Atenolol (Tenormin)

  37. Radioactive Iodine Therapy (RAI) • Treatment of choice in nonpregnant adults • Damages or destroys thyroid tissue • Delayed response of 2 to 3 months • Treated with antithyroid drugs and β-blocker before and during first 3 months of RAI

  38. Radioactive Iodine Therapy (RAI) • Given on outpatient basis • Patient teaching • Oral care for thyroiditis/parotiditis • Radiation precautions • Symptoms of hypothyroidism

  39. Surgical Therapy • Indications • Large goiter causing tracheal compression • Unresponsive to antithyroid therapy • Thyroid cancer • Not a candidate for RAI • More rapid reduction in T3 and T4 levels

  40. Surgical Therapy • Subtotal thyroidectomy • Preferred surgical procedure • Involves removal of 90% of thyroid • Can be done endoscopically

  41. Subtotal Thyroidectomy

  42. Case Study • What dietary instructions will you provide M.S. as she awaits definitive treatment of her hyperthyroidism? iStockphoto/Thinkstock

  43. Nutritional Therapy • High-calorie diet (4000 to 5000 cal/day) • Six full meals/day with snacks in between • Protein intake: 1 to 2 g/kg ideal body weight • Increased carbohydrate intake • Avoid highly seasoned and high-fiber foods, caffeine • Dietitian referral

  44. Nursing Assessment • Subjective data • Past health history • Goiter, recent infection or trauma, immigration from iodine-deficient area, autoimmune disease • Medications • Thyroid hormones, herbal therapies

  45. Nursing Assessment • Subjective data • Family history • Iodine intake • Weight loss • Increased appetite, thirst • Nausea/vomiting • Diarrhea, polyuria • Sweating

  46. Nursing Assessment • Subjective data • Dyspnea on exertion • Palpitations • Muscle weakness, fatigue • Insomnia • Chest pain • Nervousness • Heat intolerance, pruritus

  47. Nursing Assessment • Subjective data • Decreased libido • Impotence • Gynecomastia • Amenorrhea • Emotional lability, irritability, restlessness • Personality changes, delirium

  48. Nursing Assessment • Objective data • Agitation • Rapid speech • Anxiety, restlessness • Hyperthermia • Enlarged or nodular thyroid gland • Exophthalmos • Eyelid retraction, infrequent blinking

  49. Nursing Assessment • Objective data • Warm, diaphoretic, velvety skin • Thin, loose nails • Fine, silky hair and hair loss • Palmar erythema • Clubbing • Vitiligo • Edema

  50. Nursing Assessment • Objective data • Tachypnea, dyspnea on exertion • Tachycardia, bounding pulse • Murmurs, dysrhythmias, HTN, bruit • ↑ Bowel sounds, ↑ appetite, diarrhea, weight loss • Hepatosplenomegaly

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