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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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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28
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
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