GRAVES DISEASE

Marian T. GadugdugBSN-3A

What is Graves Disease?A multisystem autoimmune disorder characterized by pronounced hyperthyroidism usually associated with an enlarged thyroid gland and exophthalmos (abnormal protrusion of the eyeball). Usually associated with thyroid stimulating antibodies that bind to TSH receptors, and stimulate thyroid secretion.

Pathophysiology of Graves DiseaseHyperthyroidism is a clinical syndrome in which there is a sustained increase in synthesis and release of thyroid hormones by the thyroid gland Graves disease indicates that normal regulatory mechanisms are overridden by abnormal immunologic mechanism Negative Feed Back

The most common form of hyperthyroidism. An autoimmune disease that increases T4 production, enlarges the thyroid gland and causes multisystem changes. In Graves disease, a thyroid-stimulating hormone receptor autoantibody stimulates the thyroid gland to produce high concentrations of T3 and T4.

Clinical Manifestations

PalpitationsHeat intoleranceNervousnessInsomniaBreathlessnessIncreased bowel movementsLight or absent menstrual periodsFast heart rateTrembling hands

Muscle weaknessWarm, moist skinHair lossStarring gazeFatigueClinical Manifestations of Graves DiseaseNervousnessFine tremor of the handsWeight lossFatigue

Dyspnea PalpitationsAtrial arrythmias Exophthalmos Enlarged thyroid glandIncreased heat toleranceIncreased metabolic rate

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Assessment

Thyroid gland is enlarged; it is soft and may pulsate; a thrill may be felt and a bruit heard over thyroid arteries.Obtain a health history, including family history of hyperthyroidism, and note reports of irritability or increased emotional reaction and the impact of these changes on patients interaction with family, friends, and co-workers.

Assess stressors and patients ability to cope with stress.Evaluate nutritional status and presence of symptoms; note excessive nervousness and changes in vision and appearance of eyes.Assess and monitor cardiac status periodically (heart rate, blood pressure, heart sounds, and peripheral pulses).Assess emotional state and psychological status.

Diagnostic Tests

Thyroid Uptake Scan: Evaluates size, position, and function of thyroid glandPerformed with radioactive iodine (usually in conjunction with RAI) Iodide I 123 is the most commonly used because of short half-life and low radiation exposureScans are taken 20 minutes 2-4hours after oral dose of radioactive iodine

Used to differentiate between Graves disease and other thyroid conditions and evaluate thyroid functionClient is placed in supine position on scan table and scanning is performed over the neckAdditional scan can be taken for oral doses can be performed in 24 hoursResults:Hyperthyroidism & Graves Disease: Indicated by area of diffuse increased uptake

2) Radioactive iodine uptake (RAIU)Measures ability of gland to concentrate and retain ironWhen radioactive iodine administered is rapidly absorbed into bloodstreamMeasures rate of accumulation, incorporation, and release of iodine by the thyroidRate of absorption of radioactive iodine(determined by increase in radioactivity of thyroid gland) measures ability of thyroid to concentrate iodine from blood plasma

Uptake measured in % by dividing amount of uptake over dosage administeredUseful in diagnosis of hyperthyroidism and hypothyroidismUptake by thyroid gland should be:1-13% after 2h5-2-% after 6 h15-40% after 24h

3) Blood tests:TSHT4T3Radioactive iodine uptake of the gland may be tested

Lab Values

Lab ValueNormalT4(Free Thyroxine)0.7-2.0ng/dLT3(Free Triiodothyronine)260-480 pg/dLTSH(Thyroid Stimulating Hormone)0.4-4.2 nU/mL

Treatment1) Beta-BlockersMechanism of action- Inhibit adrenergic effects Indications- Prompt control of symptoms; treatment of choice for thyroiditis; first-line therapy before surgery, radioactive iodine, and antithyroid drugs; short-term therapy in pregnancy Contraindications and complications- Use with caution in older patients and in patients with pre-existing heart disease, chronic obstructive pulmonary disease, or asthma

2) IodidesMechanism of action: Black the conversion of T4 to T3 and inhibit hormone releaseIndications: Rapid decrease in thyroid hormone levels; preoperatively when other medications are ineffective or contraindicated; during preg-nancy when antithyroid drugs are not tolerated; with antithyroid drugs to treat amiodarone- (Cordarone-) induced hyperthyroidismContraindications/Complications: Paradoxical increases in hormone release with prolonged use; common side effects of sialadenitis, conjunctivitis, or acneform rash; interferes with the response to radioactive iodine; prolongs the time to achieve euthyroidism with antithyroid drugs

3) Antithyroid DrugsMechanism of Action: Interferes with the organification of iodine; PTU can block peripheral conversion of T4 to T3 in large dosesIndications: Long-term treatment of Graves' disease (preferred first-line treatment in Europe, Japan, and Australia); PTU is treatment of choice in patients who are pregnant and those with severe Graves' disease; preferred treatment by many endocrinologists for children and for adults who refuse radioactive iodine; pretreatment of older and cardiac patients before radioactive iodine or surgery; both medications considered safe for use while breastfeeding

Contraindications/Complications: High relapse rate; relapse more likely in smokers, patients with large goiters, and patients with positive thyroid-stimulating antibody levels at end of therapy; major side effects include polyarthritis (1 to 2 percent), agranulocytosis (0.1 to 0.5 percent); PTU can cause elevated liver enzymes (30 percent), and immunoallergic hepatitis (0.1 to 0.2 percent); methimazole can cause rare cholestasis and rare congenital abnormalities; minor side effects (less than 5 percent) include rash, fever, gastrointestinal effects, and arthralgia

4) Radioactive Iodine TreatmentMechanism of Action: Concentrates in the thyroid gland and destroys thyroid tissueIndications: High cure rates with single-dose treatment (80 percent); treatment of choice for Graves' disease in the United States, multinodular goiter, toxic nodules in patients older than 40 years, and relapses from antithyroid drugs

Contraindications/Complications: Delayed control of symptoms; posttreatment hypothyroidism in majority of patients with Graves' disease regardless of dosage (82 percent after 25 years); contraindicated in patients who are pregnant or breastfeeding; can cause transient neck soreness, flushing, and decreased taste; radiation thyroiditis in 1 percent of patients; may exacerbate Graves' ophthalmopathy; may require pretreatment with antithyroid drugs in older or cardiac patients

5) Surgical Removal of the GlandMechanism of Action: Reduces Thyroid MassIndications: Treatment of choice for patients who are pregnant and children who have had major adverse reactions to antithyroid drugs, toxic nodules in patients younger than 40 years, and large goiters with compressive symptoms; can be used for patients who are noncompliant, refuse radioactive iodine, or fail antithyroid drugs, and in patients with severe disease who could not tolerate recurrence; may be done for cosmetic reasons

Contraindication/Complications: Risk of hypothyroidism (25 percent) or hyperthyroid relapse (8 percent); temporary or permanent hypoparathyroidism or laryngeal paralysis (less than 1 percent); higher morbidity and cost than radioactive iodine; requires patient to be euthyroid preoperatively with antithyroid drugs or iodides to avoid thyrotoxic crisis

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Nursing Responsibilities

Educate patient regarding importance of a well-balanced, high-calorie diet, and discourage food that increase peristalsis and thus results in diarrhea.Provide several small, well-balanced meals (up to six meals a day) to satisfy patients increased appetite.Provide quiet atmosphere during mealtime to aid digestion.Monitor patients weightAdvise patient to notify the health care provider when a weight loss of more than 2 kg occurs

Teach the patient to stay in a cool environment, primarily because heat intolerance is common. Reassure the patient that the emotional reactions being experienced are a result of the disorder and that with effective treatment those symptoms will be controlled.Provide eye protection if patient experiences eye changes secondary to hyperthyroidism; instruct regarding correct instillation of eyedrops or ointment to soothe the eyes.

Give cool baths and provide cool fluids; monitor body temperature.Monitor closely for signs and symptoms indicative of thyroid storm. Administer medications as ordered (PTU, hydrocoritcosteroids, methimazole) Stress long-term follow-up care.Remind the patient and family about the importance of health promotion activities and recommended health screening.Nursing Diagnoses: HyperthyroidismImbalanced Nutrition, less than body requirements r/t exaggerated metabolic rate, excessive appetite, and increased gastrointestinal activityIneffective coping r/t irritability, hyperexcitability, apprehension, and emotional instabilityLow self-esteem r/t changes in appearance, excessive appetite, and weight lossAltered body temperature Activity intoleranceSleep pattern disturbance

Nursing DiagnosesImbalanced Nutrition, less than body requirements r/t exaggerated metabolic rate, excessive appetite, and increased gastrointestinal activityIneffective coping r/t irritability, hyperexcitability, apprehension, and emotional instabilityLow self-esteem r/t changes in appearance, excessive appetite, and weight lossAltered body temperature Activity intoleranceSleep pattern disturbance

Post-op Care if Surgical Removal of the gland is done:

Monitor VS including pain controlMonitor and assess drainsProvide a fluid dietMonitor blood calcium levels, to ensure parathyroid glands are intact and functioningAdminister IV antibiotics as ordered Assess for hemorrhageMonitor for signs of low blood calcium- Numbness of fingers or lips, muscle cramps, facial twitchingPosition in Semi-Fowlers

Monitor for damage to vocal cordsDischarge OrdersAnalgesic- Acetaminophen 325 mg prn Antibiotics- Erythromycin Thyroid Hormone Replacement- Synthroid 0.125 mg QDNo driving until 1 week after surgeryFollow-up appointment 7-10 days after surgery

Health Teaching

1) MedicineBeta-blockersIodidesAntithyroid Drugs

2) ExerciseExercises that strengthen your heart and improve circulation and muscle tone are needed to keep your cardiovascular system functioning well and keep you physically fit. Walking continues to be the most overall beneficial physical activity, and it is available to everyone.

3) TreatmentRadioactive IodineSurgery

4) Home careTeach patient how the medication regimen fits in with the boarder therapeutic plan.Instruct patient and family about the importance of continuing therapy indefinitely after discharge and about the consequences of failing to take medication.

5) Out-patient follow-up check-upFollow-up appointment is depending on the physicians order.6) DietFocus on fresh fruits and vegetables. These will give you the most vitamins and minerals for your efforts and offer the balance you need. Fish and chicken will be better for you rather than excessive amounts of pork and beef. Limit rich sauces and cheeses.

7) Spiritual careProvide therapeutic communicationPastoral careInclude patient to our personal prayer

*Anne?**Could delete slide?!?!*