hyperthyroidism case

8/8/2019 Hyperthyroidism case

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Republic of the PhilippinesNUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY

College of NursingCabanatuan City

INTENSIVE CARE PRACTICUM

Singalat, Palayan City

By:

NICANOR M. DOMINGO III

ETHEL JOY F. FABROSSubmitted to:

HEIDI FAJARDO, R.N.Clinical Instructor


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November 2009

CHAPTER I.

I. Introduction

II. Objectivesa. generalb. specificc. nurse-centered

III. Patient ProfileIV. Past Medical HistoryV. Present Medical HistoryVI. Patient Family HistoryVII. Activities of Daily Living and other factorsVIII. Physical Examination

CHAPTER II.

I. DefinitionII. ClassificationIII. Anatomy and PhysiologyIV. PathophysiologyV. Risk factorsVI. Signs and SymptomsVII. Treatment PreventionVIII. Diagnostic Tests

CHAPTER III.

Collaborative ProblemsNursing DiagnosesIndicators

Collaborative InterventionsNursing Care PlanRecommendationEvaluation

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I. INTRODUCTION

Hyperthyroidism is the second most prevalent endocrine disorder

after diabetes mellitus. The most common type of hyperthyroidism

results from an excessive output of thyroid hormones caused by

abnormal stimulation of thyroid gland by circulating immunoglobulins.

It affects women eight times more frequently than men, with onset

usually between the second and fourth decades. It may appear after

an emotional shock, stress, or an infection, but the exact significance

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of these relationships is not understood.

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II. OBJECTIVES

GENERAL OBJECTIVES

To improve our ability to become an effective health care

provider in preventing potential complications especially in clients

having hyperthyroidism.

SPECIFIC OBJECTIVES

Client-Centered

At the end of our Intensive Care Practicum, the client would be able to:

1. Know the importance of having knowledge regarding her disease;

2. Know the importance of seeking medical treatment and or

consultation with regards the improvement of her health status.

Student-Centered

At the end of our Intensive Care Practicum, we would be able to:

1. Provide effective nursing intervention to the client regarding the

disease, in home basis.

2. Improve our student nurse abilities, skills, knowledge and attitude in

dealing with community clients who have this diagnosis.

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III. PATIENT PROFILE

Name (Initial): Mrs. M.A.

Address: Purok 3, Barangay Singalat, Palayan City, Nueva Ecija

Birth date: May 21, 1972

Age: 37 years old

Sex: Female

Height: 5 feet and 2 inches

Weight: 46.3 kilograms

Civil Status: Married

Religion: Roman Catholic

Nationality: Filipino

No. of Children:Five (5)

OB Score: G11P5

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IV. PAST HISTORY

1991 When Mrs. M.A. was at 19th year of age, she was been

confirmed pregnant for the first time and had check-up on Dr.

PJGMRMC (Cabanatuan City). Upon medical laboratories done, it

revealed that it was a stillbirth. Another sequence of laboratories were

ordered/done and her physician explains Hyperthyroidism Goiter is

the reason why her first pregnancy failed; thus, diagnosis of

Hyperthyroidism had been made. She has been prescribed to have

Propylthiouracil (PTU) and metoprolol.

1992 Mrs. M.A. had undergone X-ray and ECG as follow-up

laboratory/check-up and revealed an enlarged heart (cardiomegaly) as

a result of her hyperthyroidism.

V. PRESENT HISTORY OF ILLNESS

Mrs. M.A. had complaints of changes in bowel frequency and her

menstrual cycle. She is disturbed by her goiter (feels like theres

consistent phlegm upon gulping), increased appetite but still does not

gain weight. For all these symptoms and ailments, she still has not

consulted to a physician regarding her disease.

VI. FAMILY HISTORY OF ILLNESS

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The patients mother had hypertension and died because of

Stroke at 81st year of age. His father has bronchial asthma. There was

no other history of illness on the family identified by the

interviewers/observers upon actual series of interviews.

VII. ACTIVITIES OF DAILY LIVING AND

OTHER FACTORS

HEALTH PERCEPTION/HEALTH

MANAGEMENT

Non-compliance with the

medication regimen after

completed the first prescription.

Eh pagtapos nung sampong

piraso, di ko na tinuloy.

Pag may sumasakit o nilalagnat,

ayon, bumibili lang ako ng gamut

sa tindahan.

NUTRITIONAL/METABOLIC

PATTERN

Breakfast: Bread and coffee

Lunch: Rice and vegetable

Supper: Rice and Fish

Food Restrictions: None

Usual fluid intake: 8-10 glasses

(160cc x 8-10 = 1280 1600cc)

per day

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Any food supplement: None

ELIMINATION PATTERN

BLADDER:

Usual Frequency: 4-5 times per

day

BOWEL:

Usual Pattern per day:

Time: Morning and night

Frequency: Twice a day, once or

none

Color: Brownish

Consistency: Semi-formed to

formed

ACTIVITY-EXERCISE PATTERN

Usual daily activities: walking

every morning at the front of their

house

Doing household chores, keeping

her children

Limitations to physical activities:

None.

COGNITIVE-PERCEPTUAL

PATTERN

The patient stated: Wala

namang problema sa pagbabasa

ko, walang nanlalabo.

The patient is alert.

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SLEEP-REST PATTERN

Usual sleep pattern on bedtime:

8:00 pm

Usual awakening time: 4:00 am

Average hours slept: 8 hours

Sleep routine: side-lying to semi

fowlers position

SELF-PERCEPTION/SELF-

CONCEPT PATTERN

The patient is conscious about

her goiter in her mid-twenties but

when she had children to rear, it

became a normal perception to

her that this is just a part of her

body. She has little concern about

her health.

The patient verbalizes

contentment on her health status,

so she perceived medical check-

up is of low concern.

ROLE-RELATIONSHIP

The patient has a good

communication and relationship

with her husband and children,

also of her sisters.

The patient verbalizes Eh,

talagang ganito, sanay na mag-

alaga ng mga bata, eh minsan

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nga pinapagalitan ko at

makukulit.

SEXUAL-REPRODUCTIVE

Wala naman problema, Eh liban

na lang kasi ilang beses na din

akong nakunan, as the patient

verbalizes.

COPING/STRESS TOLERANCE

PATTERN

Kapag may dumadating na

problema, nakakayanan naman,

kaso dapat hinay-hinay lang kasi

nga yung dibdib ko nga eh parang

titibok ng malakas, minsan

sinasabi ko sa asawa ko,

nakakaluwag din ng loob, as

patient verbalizes.

VALUES-BELIEF PATTERN

The patient verbalized:

Nagdadasal din, at nagsisimba

pag lingo, nagpapasalamat nga

ako at may nakakain kami araw-

araw.

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DATE HT.Weig

ht

NeckCircumfer

ence

BloodPressure

Temperat

ure

Pulserate

Respiraory rate

11-18-

09

52 46.3kg

12 in. 110/90

mmHg

36.8C 96 bpm 21 cpm

11-23-

09

52 46.0

kg

12.7 in. 120/70

mmHg

36.8C 94 bpm 22 cpm

BMI: 18.5

Weight: 46.0 kg (101.2 lbs.)

Height: 52

VIII. PHYSICAL EXAMINATION

BODY PART ACTUAL FINDING NORMAL FINDINGS

SKULL Round, normocephalic,

Symmetrical with no

palpable masses

Round upon palpation,

normocephalic and

symmetrical

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HAIR Normally distributed,

black in color

Thin in texture

Evenly distributed upon

inspection

FACE Symmetrical, no

involuntary movements

Inspection: symmetrical,

facial expression is

dependent on feeling

and no involuntary

muscle movement

EYES Parallel and evenly placed

PERRLA, with slight

redness and shiny

bulbar conjunctivae

Inspection: parallel and

evenly placed,

symmetrical, non-

protruding, clear sclerae

VISUAL No visual difficulties nor

blurring

No visual difficulties nor

blurring

EARS Skin color is same with

that of the face,

symmetrical, flexible and

with no discharges

Color is the same with

the face, symmetrically

aligned. Auricle equally

in line with outer

canthus of the eyes

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digits

LOWER

EXTREMITIES

Complete digits, no

deformities, with

obvious varicose veins

on both posterior legs

Equal in length, no

lesions, no area of

deformity; complete

digits

SKIN Dry, thin

NAILS With slight clubbing,

pale

Symmetrical and

straight

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CHAPTER II. CASE DISCUSSION

I. DEFINITION

GOITER, HYPERTHYROIDISM (GRAVES DISEASE)

A goitre (BrE), or goiter (AmE) (Latingutteria, struma), also called a

bronchocele, is a swelling in the thyroid gland, which can lead to a

swelling of the neck or larynx (voice box). Goitre usually occurs when

the thyroid gland is not functioning properly.

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.

Thyroid hormone functions as a stimulus to metabolism and is critical

to normal function of the cell. In excess, it both overstimulates

metabolism and exacerbates the effect of the sympathetic nervous

system, causing "speeding up" of various body systems and symptoms

resembling an overdose ofepinephrine (adrenaline). These include fast

heart beat and symptoms ofpalpitations, nervous system tremor and

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http://en.wikipedia.org/wiki/British_Englishhttp://en.wikipedia.org/wiki/American_Englishhttp://en.wikipedia.org/wiki/Latinhttp://en.wikipedia.org/wiki/Thyroidhttp://en.wikipedia.org/wiki/Larynxhttp://en.wikipedia.org/wiki/Voice_boxhttp://en.wikipedia.org/wiki/Thyroidhttp://en.wikipedia.org/wiki/Thyroxinehttp://en.wikipedia.org/wiki/Triiodothyroninehttp://en.wikipedia.org/wiki/Sympathetic_nervous_systemhttp://en.wikipedia.org/wiki/Sympathetic_nervous_systemhttp://en.wikipedia.org/wiki/Epinephrinehttp://en.wikipedia.org/wiki/Palpitationhttp://en.wikipedia.org/wiki/Tremorhttp://en.wikipedia.org/wiki/British_Englishhttp://en.wikipedia.org/wiki/American_Englishhttp://en.wikipedia.org/wiki/Latinhttp://en.wikipedia.org/wiki/Thyroidhttp://en.wikipedia.org/wiki/Larynxhttp://en.wikipedia.org/wiki/Voice_boxhttp://en.wikipedia.org/wiki/Thyroidhttp://en.wikipedia.org/wiki/Thyroxinehttp://en.wikipedia.org/wiki/Triiodothyroninehttp://en.wikipedia.org/wiki/Sympathetic_nervous_systemhttp://en.wikipedia.org/wiki/Sympathetic_nervous_systemhttp://en.wikipedia.org/wiki/Epinephrinehttp://en.wikipedia.org/wiki/Palpitationhttp://en.wikipedia.org/wiki/Tremor


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anxiety symptoms, digestive system hypermotility (diarrhea), and

weight loss.

Graves' disease is a thyroid-specific autoimmune disorder in which the

body makes antibodies to the thyroid-stimulating hormone receptor

(TSHR), leading to hyperthyroidism, or an abnormally strong release of

hormones from the thyroid gland. Normally, the release of thyroid

hormones is mediated by thyroid-stimulating hormone (TSH), a

hormone secreted by the pituitary gland that binds to TSHR to

stimulate the thyroid to release thyroid hormones. This normal cycle is

self-regulating: the hormones secreted by the thyroid keep more TSH

from being produced (Janeway, 2001).

The autoantibodies produced in Graves' disease are not subject to

negative feedback, so they continue to be produced and bind to TSHR

even when thyroid hormone levels rise too high. These antibodies act

as agonists, stimulating more hormones to be released and thus

leading to hyperthyroidism.

II. CLASSIFICATION

Goiter

I - palpation struma - in normal posture of head it cannot be

seen. Only found when palpating.

II - struma is palpative and can be easily seen.

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III - struma is very big and is retrosternal. Pressure and

compression marks.

Types of hyperthyroidism:

Graves' disease (diffuse toxic goiter)

Graves' disease is most often associated with hyperthyroidism.

Researchers believe Graves' disease is caused by an antibody

which stimulates the thyroid too much, in turn causing the

excess production of thyroid hormone. Graves' disease is

categorized as an autoimmune disorder (a dysfunction of the

body's immune system). The disease is most common in young

to middle-aged women and tends to run in families.

Symptoms of Graves' disease are identical to hyperthyroidism,

with the addition of three other symptoms. However, each

individual may experience symptoms differently. The three

additional symptoms include:

o goiter (enlarged thyroid which may cause a bulge in the

neck)

o bulging eyes (exophthalmos)

o thickened skin over the shin area

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Classification of Graves Eye Disease

Mnemonic: "NO SPECS"

Class 0: No signs or symptoms

Class 1: Only signs (limited to upper lid retraction and stare, with or

without lid lag)

Class 2: Soft tissue involvement (oedema of conjunctivae and lids,

conjunctival injection, etc)

Class 3: Proptosis

Class 4: Extraocular muscle involvement (usually with diplopia)

Class 5: Corneal involvement (primarily due to lagophthalmos)

Class 6: Sight loss (due to optic nerve involvement)

Toxic Nodular Goiter (also called multinodular goiter)

Hyperthyroidism caused by toxic nodular goiter is a condition in

which one or more nodules of the thyroid becomes overactive.

The overactive nodules actually act as benign thyroid tumors.

Symptoms of toxic nodular goiter do not include bulging eyes or

skin problems, as in Graves' disease. The cause of toxic nodular

goiter is not known.

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Thyroiditis

Thyroiditis causes temporary hyperthyroidism, usually followed

with hypothyroidism (an underactive thyroid). Thyroiditis is an

inflammation of the thyroid gland. There are three types of

thyroiditis:

o Hashimoto's thyroiditis

o Subacute Granulomatous Thyroiditis

o Silent Lymphocytic Thyroiditis

Hypothyroidism is the disease state in humans caused by insufficient

production ofthyroid hormone by the thyroid gland. Cretinism is a form

of hypothyroidism found in infants.

Causes

About three percent of the general population is hypothyroidic. Factors

such as iodine deficiency or exposure to Iodine-131 (I-131) can

increase that risk. There are a number of causes for hypothyroidism.

Historically, and still in many developing countries, iodine deficiency is

the most common cause of hypothyroidism worldwide. In iodine-

replete individuals, hypothyroidism is mostly caused by Hashimoto's

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thyroiditis, or by a lack of the thyroid gland or a deficiency of

hormones from either the hypothalamus or the pituitary.

Hypothyroidism can result from postpartum thyroiditis, a condition that

affects about 5% of all women within a year after giving birth. The first

phase is typically hyperthyroidism. Then, the thyroid either returns to

normal or a woman develops hypothyroidism. Of those women who

experience hypothyroidism associated with postpartum thyroiditis, one

in five will develop permanent hypothyroidism requiring life-long

treatment.

Hypothyroidism can also result from sporadic inheritance, sometimes

autosomal recessive.

Hypothyroidism is also a relatively common disease in domestic dogs,

with some specific breeds having a definite predisposition. Temporary

hypothyroidism can be due to the Wolff-Chaikoff effect. A very high

intake of iodine can be used to temporarily treat hyperthyroidism,

especially in an emergency situation. Although iodine is substrate for

thyroid hormones, high levels prompt the thyroid gland to take in less

of the iodine that is eaten, reducing hormone production.

Hypothyroidism is often classified by the organ of origin:

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Symptoms

In adults, hypothyroidism is associated with the following symptoms:[5]

[7][8]

Early symptoms

Poor muscle tone (muscle

hypotonia)

Fatigue

Cold intolerance,

increased sensitivity to

cold

Depression

Muscle cramps andjoint

pain

Carpal Tunnel Syndrome

Goiter

Thin, brittle fingernails

Thin, brittle hair

Paleness

Decreased sweating

Dry, itchy skin

Weight gain and water

retention

Bradycardia (low heart

rate less than sixty beats

per minute)

Constipation

Late symptoms

Slow speech and a hoarse, breaking voice deepening of the

voice can also be noticed

Dry puffy skin, especially on the face

Thinning of the outer third of the eyebrows (sign of Hertoghe)

Abnormal menstrual cycles

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Low basal body temperature

Less common symptoms

Impaired memory

Impaired cognitive function (brain fog) and inattentiveness

A slow heart rate with ECG changes including low voltage

signals. Diminished cardiac output and decreased contractility.

Reactive (or post-prandial) hypoglycemia

Sluggish reflexes

Hair loss

Diagnostic testing

To diagnose primary hypothyroidism, many doctors simply measure

the amount of thyroid-stimulating hormone (TSH) being produced by

the pituitary gland. High levels of TSH indicate that the thyroid is not

producing sufficient levels ofthyroid hormone (mainly as thyroxine (T4)

and smaller amounts of triiodothyronine (T3)). However, measuring just

TSH fails to diagnose secondary and tertiary hypothyroidism, thus

leading to the following suggested blood testing if the TSH is normal

and hypothyroidism is still suspected:

Free triiodothyronine (fT3)

Free levothyroxine (fT4)

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Total T3

Total T4

Additionally, the following measurements may be needed:

24 hour urine free T3[17]

Antithyroid antibodies for evidence ofautoimmune diseases

that may be damaging the thyroid gland

Serum cholesterol which may be elevated in hypothyroidism

Prolactin as a widely available test of pituitary function

Testing for anemia, including ferritin

Basal body temperature

III. ANATOMY AND PHYSIOLOGY

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The thyroid gland is a butterfly-shaped organ and is composed of two

cone-like lobes or wings: lobus dexter (right lobe) and lobus sinister

(left lobe), and is also connected with the isthmus. The organ is

situated on the anterior side of the neck, lying against and around the

larynx and trachea, reaching posteriorly the esophagus and carotid

sheath. It starts cranially at the oblique line on the thyroid cartilage

(just below the laryngeal prominence or Adam's apple) and extends

inferiorly to the fifth or sixth tracheal ring. It is difficult to demarcate

the gland's upper and lower border with vertebral levels because it

moves position in relation to these during swallowing.

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At the microscopic level, there are three primary features of the

thyroid:

Feature Description

Follicles

The thyroid is composed of spherical follicles that

selectively absorb iodine (as iodide ions, I-) from the

blood for production of thyroid hormones. Twenty-

five percent of all the body's iodide ions are in the

thyroid gland. Inside the follicles, colloid serves as a

reservoir of materials for thyroid hormone

production and, to a lesser extent, act as a reservoir

for the hormones themselves. Colloid is rich in a

protein called thyroglobulin.

Thyroid epithelial c

ells

(or "follicular

cells")

The follicles are surrounded by a single layer of

thyroid epithelial cells, which secrete T3 and T4.

When the gland is not secreting T3/T4 (inactive), the

epithelial cells range from low columnar to cuboidal

cells. When active, the epithelial cells become tall

columnar cells.

Parafollicular cells

(or "C cells")

Scattered among follicular cells and in spaces

between the spherical follicles is another type of

thyroid cell, parafollicular cells, which secrete

calcitonin.

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IV. PATHOPHYSIOLOGY

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CTLA-4A

T-cells/B-cells

roduce antibodies

Anti-TSRH antibodies

Destruction/

TSRHTSH bindin

FREE T3 T4

SHBG

Estradiol

concentration

LH

Amenorrhea/

oligomenorrhea

Cell

metabolism/activity

SNS activit

Changes inbowel

Ca, P lossOsteoclast

activity

hypercalcemia Susceptibility to Fx

and Osteoporosis

Muscular activit

tremors cardiomegaly

Cardiacdecom ensation

Tissue erfusion

Brittle hair

h ocalcemia

Calcitoninrelease

O2 demand

Pathophysiogic paradigm -

HYPERTHYROIDISM

Goiter

Hypertrophy

Thyroid gland activity

hyperhidrosis

Appetitedespite

wt.

d s nea

palpitations

pallor

BMR

fati ue


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V. RISK FACTORS

AGE

The riskiest age for developing Graves' disease and hyperthyroidism is

between 20 and 40.

--------------------------------------------------------------------

HISTORY

Having any past history of thyroid problems, autoimmune disease, or

endocrine disease yourself or in your family puts you at greater risk for

developing Graves' disease and hyperthyroidism.

---------------------------------------------------------------

GENDER

Graves' disease and hyperthyroidism affect women 8 times more often

than men.

---------------------------------------------------------------

PREGNANCY

Pregnancy and the year after childbirth are both times of greater risk

for Graves' disease and hyperthyroidism

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EXPOSURE TO OR EXCESS OF IODINE/IODINE DRUGS

Being exposed to or ingesting an excess of iodine, whether through

medical tests, topical exposure, or ingesting of iodine or supplements

containing iodine can trigger hyperthyroidism.

---------------------------------------------------------------

TRAUMA TO THE THYROID

Thyroid trauma can trigger hyperthyroidism in some people. The types

of trauma include vigorous manipulation or palpation of the thyroid;

surgery to the thyroid, parathyroids, or the area surrounding the

thyroid; injection to the thyroid; biopsy of the thyroid; and neck injury,

i.e., whiplash, or from an automobile seat belt after a crash

---------------------------------------------------------------

MAJOR STRESS

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Stress is a factor that appears to trigger the onset of Graves' disease

in some patients. Researchers have documented a definite connection

between major life stressors -- i.e., death of a spouse, divorce or

separation, loss of a job, death of close family member, major

accident/personal injury, moving, marriage -- and the onset of Graves'

disease.

---------------------------------------------------------------

SMOKING

There is an increased risk of Graves' disease in smokers. Smokers with

Graves' ophthalmopathy tend to have more severe symptoms that are

more resistant to treatment.

---------------------------------------------------------------

EXCESSIVE INTAKE OF THYROID HORMONE

Taking too much prescription thyroid hormone -- whether by accident

or by deliberate self-medication can cause hyperthyroidism.

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VI. SIGNS AND SYPMTOMS

BY THE BOOK:

Nervousness

Irritability

Palpitations

Heat intolerance

Increased perspiration

Flushed skin

Exophthalmos/Eye

symptoms

Increased appetite

Weight loss

Fatigability

Amenorrhea/menstrual

disturbance

Change in bowel

Cardiac decompensation

Osteoporosis

Tremors

Goiter

BY THE PATIENT:

Palpitations

Increased appetite

Change in bowel

frequency

Amenorrhea

Goiter

Heart enlargement

Erythema and edema of

eyelids (bulbar

conjunctivae)

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VII. TREATMENT

THYROSTATICS

Thyrostatics are drugs that inhibit the production of thyroid

hormones, such as carbimazole (used in UK) and methimazole (used in

US), and propylthiouracil. Thyrostatics are believed to work by

inhibiting the iodination of thyroglobulin by thyroperoxidase, and thus,

the formation of tetra-iodothyronine (T4). Propylthiouracil also works

outside the thyroid gland, preventing conversion of (mostly inactive) T4

to the active form T3. Because thyroid tissue usually contains a

substantial reserve of thyroid hormone, thyrostatics can take weeks to

become effective, and the dose often needs to be carefully titrated

over a period of months.

A very high dose is often needed early in treatment, but if too

high a dose is used persistently, patients can develop symptoms of

hypothyroidism.

BETA-BLOCKERS

Many of the common symptoms of hyperthyroidism such as

palpitations, trembling, and anxiety are mediated by increases in beta

adrenergic receptors on cell surfaces. Beta blockers are a class of drug

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which offset this effect, reducing rapid pulse associated with the

sensation of palpitations, and decreasing tremor and anxiety. This

doesn't help the underlying problem of excess thyroid hormone, but

makes the symptoms much more manageable, particularly as

definitive treatment with thryostatic drugs can take a number of

months to work. Propranolol in the US, and Metoprolol in the UK, are

most frequently used to augment treatment for hyperthyroid patients.

Permanent treatments

SURGERY

Surgery (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.

However, some Graves' disease patients who cannot tolerate

medicines for one reason or another, patients who are allergic to

iodine, or patients who refuse radioiodine opt for surgical intervention.

Also, some surgeons believe that radioiodine treatment is unsafe in

patients with unusually large gland, or those whose eyes have begun

to bulge from their sockets, claiming that the massive dose of iodine

needed will only exacerbate the patient's symptoms.

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RADIOIODINE

In iodine-131 (Radioiodine) radioisotope therapy, radioactive

iodine-131 is given orally (either by pill or liquid) on a one-time basis to

destroy the function of a hyperactive gland. Patients who do not

respond to the first dose are sometimes given an additional radioactive

iodine treatment in a larger dose. The iodine given for ablative

treatment is different from the iodine used in a scan. Radioactive

iodine is given after a routine iodine scan, and uptake of the iodine is

determined to confirm hyperthyroidism. The radioactive iodine is

picked up by the active cells in the thyroid and destroys them. Since

iodine is only picked up by thyroid cells (and picked up more readily by

over-active thyroid cells), the destruction is local, and there are no

widespread side effects with this therapy. Radioactive iodine ablation

has been safely used for over 50 years, and the only major reasons for

not using it are pregnancy and breast-feeding.

A common outcome following radioiodine is a swing to the easily

treatable hypothyroidism, and this occurs in 78% of those treated for

Graves' thyrotoxicosis and in 40% of those with toxic multinodular

goiter or solitary toxic adenoma. Use of higher doses of radioiodine

reduces the incidence of treatment failure, with the higher response to

treatment consisting mostly of higher rates of hypothyroidism.There is

increased sensitivity to radioiodine therapy in thyroids appearing on

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ultrasound scans as more uniform (hypoechogenic), due to densely

packed large cells, with 81% later becoming hypothyroid, compared to

just 37% in those with more normal scan appearances

(normoechogenic).

PREVENTION

Detecting the early warning signs and symptoms of Graves

disease and take charge of health, rather than wait until it (or the

drugs used to treat Graves disease) has ravaged your health, making

it more difficult to heal is the only known prevention for it is an

autoimmune disorder.

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VIII. DIAGNOSTIC EXAMINATION

Thyroid hormone blood tests:

Thyroid-stimulating hormone (TSH): Test first done to evaluate

thyroid function and considered a reliable method of detecting a

thyroid problem. TSH is suppressed in hyperthyroidism to < 0.1 U /mL

(except when etiology is a TSH-secreting pituitary tumor or pituitary

resistant to thyroid hormone). Hyperthyroidism is indicated if TSH fails

to rise after administration of thyrotropin-releasing hormone (TRH).

(Normal TSH is 0.4-4.5 rnilli-intemational units/liter.)

Thyroxine (T4): Produced by the thyroid gland when the pituitary

gland releases TSH. Free T4 can be measured directly (FT) or calculated

by index (FTI). Total T4 measures both bound and free T4.

Triiodothyronine (T3): Small amount produced directly by thyroid

gland. Most T3 is made by other tissues that convert T4 into T3. T4 has a

greater effect on metabolism than T3 even though T3 is normally

present in lower amounts than T4. Total T3 measures both bound and

free T3 (FT3). (Normal total T3 is 70-195 [nanograms per deciliter].)

Both T3 and T4 are increased in hyperthyroidism; however, T3 appears

to be the more accurate diagnostic indicator of hyperthyroidism than

T4.

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Triiodothyronine uptake (T3U): An indirect measurement of the

amount of the protein thyroxine-binding globulin (TBG) that can bind T3

and T4. A high T4 value combined with a high T3U value usually

confirms the presence of hyperthyroidism.

Thyroid scan: Differentiates between Graves' disease and Plummer's

disease, both of which result in hyperthyroidism.

Needle or open biopsy: May be done to determine cause of

hyperthyroidism, differentiate cysts or tumors, diagnose enlargement

of thyroid gland.

ECG: Atrial fibrillations, shorter systole time, cardiomegaly, heart

enlarged with fibrosis and necrosis (late signs or in elderly with masked

hyperthyroidism).

Serum glucose: Elevated (related to adrenal involvement).

Alkaline phosphatase and serum calcium: Increased.

Electrolytes: Hyponatremia may reflect adrenal response or dilutional

effect in fluid replacement therapy. Hypokalemia occurs because of GI

losses and diuresis.

Urine creatinine: Increased.

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THYROIDECTOMY

Nursing Interventions

Preoperative1. Informed Consent

2. Deep Breathing exercises

3. Leg exercises

4. Support head

5. ROM exercises of neck

6. Instructing patient to lessen talking after surgery

7. Positioning the patient: neck slightly extended

Nursing Interventions

Post operative

1. O2, suction equipment, tracheostomy tray

2. Calcium carbonate at bedside

3. Assess for hematoma formation

4. Assess laryngeal stridor during respirations

5. Assess chvostek and trosseaus sign, hyperactive DTR report if

seen/observed.

6. Semi-Fowlers position/pillow-lubricate neck incision

7. NPO on the day of surgery

8. Blood transfusion can be ordered; nursing responsibilities in

administering BT:

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- The nurse has to get consent forms signed by the patient or a qualified

representative of the patient, except in the cases of trauma or life saving

situations if the patient is unable to make that decision;

- The nurse is responsible for insuring that the right unit of blood is to be

administered to the right patient after typing and cross-matching by the lab.

This is done by checking the lot, serial numbers, blood type, and expiration

date with another nurse or qualified lab personnel;

- The nurse has to take a complete set of vital signs for a baseline data;

- After starting the transfusion, the vital signs must be checked after 15 minutes,

then 30 minutes from then, then at one hour. Then vital signs must be checked

every hour, according to hospital protocol;- The vital signs are checked this often to monitor for a reaction to the blood. If

a reaction occurs, then the transfusion must be stopped immediately and

normal saline infused;

- The nurse should monitor if the patient took the pre-Blood Transfusion

medications if then ordered

9. Monitor VS including pain control (Fever at 3rd day indicates

infection)

10. Sutures are usually removed at 5th day post surgery

Patient Teaching

Caloric intake

Adequate iodine intake

Regular exercise

If complete thyroidectomy will need life long pharmocologigic

thyroid replacement therapy

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POST OPERATIVE ADVICE for the Patient:

Following your surgery

1. Your wound will not be covered with a dressing. This allows the

nursing staff to check your neck for bleeding or swelling.

2. Your observations will be checked post operatively for the first 4

hours. Blood pressure and pulse.

3. It is quite normal to notice some bruising around the site. You

may also experience some numbness and/ or tingling. The initial

redness of the scar will gradually fade over the next 6 months

until it becomes a pale white line.

4. You may experience some mild to moderate pain, which can be

relieved by taking the painkillers.

5. You are advised to avoid any heavy lifting or contact sports for 4

weeks.

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CHAPTER III:

NURSING CARE PLAN

I. COLLABORATIVE PROBLEMS

1. HYPOTHYROIDISM

Hypothyroidism occurs when the thyroid gland does not produce enough thyroid

hormone to meet the bodys needs. Without enough thyroid hormone, many of the

bodys functions slow down.

2. THYROTOXICOSIS, THYROID STORM (THYROTOXIC CRISIS)

Thyrotoxicosis (hyperthyroidism, Graves' disease) is a condition in which the

thyroid gland produces excess thyroid hormone (thyroxine) which results in effects

on the whole body.

3. FRACTURES

Hyperthyroidism interferes with your normal metabolism. This can lead to a loss

of bone mass and even osteoporosis. In severe cases of osteoporosis, compression

fractures can result. A compression fracture occurs when the vertebrae are jarred hard

enough to cause one or more to break. Normally, it takes a powerful jolt to cause a

compression fracture, but if the bones are brittle from osteoporosis, even everyday

activities can cause a break.

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II. NURSING CARE PLANS

1. Risk for decreased Cardiac Output

2. Fatigue

3. Risk for disturbed Thought Process

4. Deficient Knowledge/Knowledge deficit

III. NURSING GOAL

- The patient will be free from complications of

Hyperthyroidism

IV. INDICATORS

1. (Body Mass Index) BMI: (Wt. 46 kg; Ht. 52)27.5 and above - high risk23-27.4 - moderate risk18.5 - 22.9 - low risk

below 18.5 - risk of nutritional deficiency diseases

2. BP -


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11. Erythema and edema of eyelids (bulbar conjunctivae)

COLLABORATIVE PROBLEMS

1. HYPOTHYROIDISM

Monitor patient for signs ofincreasing severity of signs andsymptoms of hypothyroidism

a. decreased level ofconsciousness

b. decreased vital signs

c. increasing difficulty inawakening or arousing patient

Extreme hypothyroidism may leadto myedema, myedema coma,

slowing of all body systems if leftuntreated

Monitor respiratory rate, depth,pattern, pulse oximetry, and ABG

Identifies patients baseline tomonitor further changes and

evaluate effectiveness ofinterventions

Explain rationale for thyroidhormone replacement

Provides rationale for patient touse thyroid hormone replacement

as prescribed

Encourage increased fluid intakeand intake of high fiber foods

Hypothyroidism can result inconstipation due to decrease in

peristalsis, increasing the bulk ofstools promotes passage of soft

stools

Provide extra layer of clothing Hypothyroidism results coldintolerance due to hypoactive cell

metabolism and heat production;minimizes heat loss

Promote independence in selfcare activities.

a. space activities to promote rest

Encouragement needed infatigued, often depressed patient

a. encourages activities while

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and exercise as tolerated.

b. assist woth self-care activitieswhen patient is fatigued.

c. provide stimulation throughconversation and non-stressfulactivities.

d. monitor patients response toincreasing activities.

allowing time for adequate rest

b. permits patient to participate tothe extent possible in self-care

activities

c. promotes interest without overlystressing the patient.

d. guards against over and underexertion by the patient.

Monitor for signs of fracture, pin

sites for areas of increasedpain/burning sensation, or

presence of edema, foul odor anddischarge

May indicate onset of local

infection and can lead to otherbone diseases

Assess for muscle tone, reflexes Muscle rigidity, tonic spasms mayreflect development of tetanus

Monitor vital signs. Notepresence of chills, fever, malaise

and changes in sensation

Hypotension, tachycardia, chillsand fever may reflect development

of serious complications

Assess degree of immobilityproduced by injury/treatment andpatients perception of immobility

Patient may be restricted by self-view, self-perception with actual

physical limitations, requiringinformation/intervention topromote progress towards

wellness

Encourage participation indiversional activities. Maintain

stimulating environment

Provides opportunity for release ofenergy, refocuses attention,

enhancing pt. sense of self-controland decreases social isolation

Encourage isometric exercisesstarting with unaffected site/limb

Isometric exercises contractmuscles without bending joints

and help maintain muscle strength

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Assist with or encourage self-careactivities

Improves muscle strength andcirculation; enhances self-control

in situation and promotes self-directed wellness

Encourage to increase oral fluidintake to 2000-3000 ml per day

(within cardiac tolerance)

Keeps the body well-hydrated.Decreases the risk of urinary

infection, constipation

Provide diet high in protein,carbohydrates, vitamins and

minerals

In the presence of musculo-skeletal injuries, nutrients are

required for healing are rapidlydepleted, often results in weight

loss as much as 20-30 lb

2. THYROTOXIC CRISIS

Monitor for signs of thyrotoxiccrisis (High fever, extreme

tachycardia, altered neurologic ormental state)

Severe action of cell metabolismexaggerates disturbances onmajor systems such ascardiovascular and neurologicwhich can cause seriouscomplications (coma death)

Humidified oxygen isadministered

Oxygen is administered to meetand improve high metabolicdemands.

Start Intravenous fluids containingdextrose

Sugar-containing intravenousfluids are administered to replaceliver glycogen stores that havebeen decreased in hyperthyroidclient

Monitor vital signs. ContinuousTepid sponge bath for patientsexperiencing fever. Note for

increasing fever

Independent nursing actions areneeded in times of fever, tepidsponge bath lowers body heat bymeans of evaporation of surfaceheat produced by increasedmetabolism of the body

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Administer PTU or methimazole PTU and methimazole impedeformation of thyroid hormone andblock conversion of T4 to T3, themore active form of thyroid

hormone

3. FRACTURES

Monitor for signs of fracture, pinsites for areas of increasedpain/burning sensation, or

presence of edema, foul odor anddischarge

May indicate onset of localinfection and can lead to other

bone diseases

Assess for muscle tone, reflexes Muscle rigidity, tonic spasms mayreflect development of tetanus

Monitor vital signs. Notepresence of chills, fever, malaise

and changes in sensation

Hypotension, tachycardia, chillsand fever may reflect development

of serious complications

Assess degree of immobilityproduced by injury/treatment andpatients perception of immobility

Patient may be restricted by self-view, self-perception with actual

physical limitations, requiringinformation/intervention topromote progress towards

wellness

Encourage participation indiversional activities. Maintain

stimulating environment

Provides opportunity for release ofenergy, refocuses attention,

enhancing pt. sense of self-controland decreases social isolation

Encourage isometric exercisesstarting with unaffected site/limb

Isometric exercises contractmuscles without bending joints

and help maintain muscle strength

Assist with or encourage self-careactivities

Improves muscle strength andcirculation; enhances self-control

in situation and promotes self-directed wellness

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Encourage to increase oral fluidintake to 2000-3000 ml per day

(within cardiac tolerance)

Keeps the body well-hydrated.Decreases the risk of urinary

infection, constipation

Provide diet high in protein,carbohydrates, vitamins and

minerals

In the presence of musculo-skeletal injuries, nutrients are

required for healing are rapidlydepleted, often results in weight

loss as much as 20-30 lb

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NURSING CAREPLAN

NURSING DIAGNOSIS: risk fordecreased Cardiac Output

INTERVENTION

Monitor BP lying, sitting, andstanding, if able. Note widenedpulse pressure.

RATIONALE

General/objective hypotensionmay occur as a result of excessive

peripheral vasodilation anddecreased circulating volume.Widened pulse pressure reflectscompensatory increase in strokevolume and decreased systematicvascular resistance.

Investigate reports of chest painor angina

May reflect increased myocardialoxygen demands/ischemia

Auscultate heart sounds, notingextra heart sounds, development

of gallops and systolic murmurs

Prominent S1 and murmurs areassociated with forceful cardiac

output of hyper metabolic state;development of S3 may warn animpending cardiac failure.

Monitor electrocardiogram (ECG),noting rate/rhythm. Documentdysrhythmias

Tachycardia may reflect directmyocardial stimulation by thyroidhormone. Dysrhythmias oftenoccur and compromise cardiacoutput/function.

Auscultate breath sounds, notingadventitious sounds

Early sign of pulmonarycongestion, reflecting developing

cardiac failure.Monitor temperature, provide coolenvironment, limit bedlinens/clothes, and administertepid sponge baths.

Fever (may exceed 100 F) canoccur as a result of excessivehormone levels increasingdiuresis/dehydration, causingincreased peripheral vasodilation,venous pooling, and hypotension

Observe signs/symptoms ofsevere thirst, dry mucousmembranes, weak, thready pulse,

poor capillary refill, decreasedurinary output, and hypotension

Rapid dehydration can occur,which reduces circulating volumeand compromises cardiac output.

Weigh daily. Encourage chairrest/bedrest; limit non-essentialactivity

Activity increasesmetabolic/circulatory demands,which may potentiate cardiacfailure

Provide supplemental oxygen asindicated.

May be necessary to supportincreased metabolic demand /oxygen consumption.

Provide hypothermia blanket as

indicated.

Occasionally used to lower

uncontrolled hyperthermia (104Fand higher) to reduce metabolic

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RECOMMENDATION

A simple mnemonics for Hyperthyroidism (Graves Disease)

H eat intolerance, provide coolenvironment

Y ou should increase fluid intake

P TU, methimazole, (Thyrostatics)

E ducation about the diseaseR adioiodine

T hyroidectomy

H ave pt. properly referred to anendocrinologist

Y ield for proper treatment regimen

R est when symptoms exacerbates

O bserve weight, report increasinglosses

I nstruct self-care remedies

D iscuss to SOs in case of emotionallability

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I nstruct importance of managingS/Sx

S ymptomatic treatment such as -blockers

M onitor BP, HR/PR, ECG

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EVALUATION

At the end of our group exposure to the community

setting for Intensive Care Practicum (ICP), our client willknowledgably understand the disease that she has. By giving

her certain important health teachings and encouraging her for

proper referral, she will manage her disease and maintain her

wellness thru application of nursing intervention regarding

hyperthyroidism.

At the end of the group exposure, we had learned the

gravity of having a case study in community setting, perhaps,

different from hospital, it still had inculcated our skills towards

nursing interventions, knowledge about certain diseases and

application of appropriate attitude in dealing with patients in

the community.

-Nicanor M. Domingo III

Ethel Joy F. Fabros

NEUST BSN IV-A 2010

Barangay Singalat, City of Palayan

To:

HEIDI FAJARDO, R.N.

LORY CRISANTO, R.N., M.A.N.

Critiques/Panel of Evaluators

52

hyperthyroidism case

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