DEFINITION:-
Hyperthyroidism is the hyper metabolic, clinical
& biochemical state caused by excessive production of thyroid hormone. Hyperthyroidism (overactive thyroid) is
a condition in which thyroid gland produces too much of the thyroid hormones
which can accelerate body’s metabolism significantly, causing sudden weight
loss, a rapid or irregular heartbeat, sweating and nervousness or irritability.
INCIDENCE AND PREVALENCE:-
Hyperthyroidism
is the second most prevalent endocrine disorder, after Diabetes Mellitus. Like
other thyroid conditions, it is a disorder that predominantly affects women (female
to male ratio 4:1) especially women between 20 and 40 years. Incidence rate is
0.02% to 0.06%.
PATHOPHYSIOLOGY:-
Any process that causes an increase in the peripheral circulation
of unbound thyroid hormone can cause signs and symptoms of hyperthyroidism.
Disturbances of the normal homeostatic mechanism can occur at the level of the
hypothalamus, the pituitary gland and the thyroid gland. Defect of hypothalamus
and pituitary gland can be hyper-secreting of hormone which can induce
excessive secretion of thyroid hormone causing hyperthyroidism. Hyper-secretion
may be due to certain tumor or any other defects.
Defect also can be originated from the thyroid gland itself.
Hyper-secreting of thyroid hormone may be one of the causes with absent of
goitre. Other than that, is Graves’s Disease which is the common cause of
hyperthyroidism Last causes of hyperthyroidism are Apathetic Hyperthyroidism
which refers to thyrotoxicosis occurring . Thyroid hormone can cause three
major effects that is hyper metabolic state, over stimulation of sympathetic
nervous system and cardiac effect as compensatory mechanism of certain
condition caused by increased thyroid hormone.
Normally, thyroid hormone participated in inducing synthesis and
degradation of carbohydrate, fat and protein. However, overall metabolic
effects of thyroid hormone at normal physiologic level are to favor the
consumption rather than storage of body fuel. So, when thyroid hormone becomes
abnormally high, it will increase the overall basal metabolic rate by
increasing rate of degradation.
Thyroid hormones has sympathomimetic action which the actions are
similar to one produced by sympathetic nervous system. Normally, thyroid
hormone stimulates proliferation of specific cathecholamines target cell
receptors which can induce sympathomimetic effect. Increased in thyroid hormone
can induce overstimulation of sympathetic effects which can lead to condition
known as ‘Thyroid Storm’ which is an abrupt onset of acute hyperthyroidism.
Thyroid Storm is a medical emergency situation which significant number of
untreated patients led to cardiac arrhythmias.
Overstimulation of gut will induce hypermotility which led to
diarrhea and eventually malabsoption. Overstimulation of levator palpebrae
superioris of the eye will result in ocular manifestation of wide, gaze,
starring and lid lag of the eyes. Overstimulation of neuromuscular will lead to
nervousness, irritability and tremor. Nearly 50% develop proximal muscle weakness
called thyroid myopathy. Heart rate and contractility of heart muscle will be
increase due to increase in heart’s responsiveness towards circulating
cathecolamines.
Hyperthyroidism also results
in altered secretion and metabolism of hypothalamic, pituitary, and gonadal
hormones. If hyperthyroidism occurs before puberty, sexual development is
delayed in both sexes and if after puberty, it results in decreased libido and
will also cause menstrual irregularity and decreased fertility in women.
ETIOLOGY:-
Hyperthyroidism may be due to over functioning
of the entire gland or less commonly to single or multiple functioning adenomas
of thyroid cancer.
The causes are:-
1. Auto
immune disorder or Graves disease (toxic diffuse goitre):- In this serum of the
patients have an antibody that binds to TSH receptors in the thyroid follicles
and causes the thyroid cells to hyper function. Or we may say that development of antibodies against various antigens
within the thyroid gland, by insufficient iodine supply, infection, stress
leads to Graves disease.
2. Toxic multinodular goiter (plummer’s disease) common
in iodine deficient area.
3. Toxic adenoma
4. Thyroiditis: Is an inflammatory process in the thyroid
by bacterial or fungal infection,
5. T3 thyrotoxicism: T3 level elevated but cause is
unknown.
6. Hyperthyroidism caused by metastatic thyroid cancer.
7. Pituitary
hyperthyroidism: Rare pituitary adenomas.
8. Iodine induced
hyperthyroid over production by administration of supplemental iodine to a
person with endemic goiter.
9. Ingestion of thyroid hormone and
ingestion of Amiodraone hydrochloride (Thyrotoxicosis
factitia
10.
Family history and
Smoking cigarettes is also counted as a risk factor.
PATHOPHYSIOLOGY:-
Any process that causes an increase in the peripheral circulation
of unbound thyroid hormone can cause signs and symptoms of hyperthyroidism.
Disturbances of the normal homeostatic mechanism can occur at the level of the
hypothalamus, the pituitary gland and the thyroid gland. Defect of hypothalamus
and pituitary gland can be hyper-secreting of hormone which can induce
excessive secretion of thyroid hormone causing hyperthyroidism. Hyper-secretion
may be due to certain tumor or any other defects.
Defect also can be originated from the thyroid gland itself.
Hyper-secreting of thyroid hormone may be one of the causes with absent of
goitre. Other than that, is Graves’s Disease which is the common cause of
hyperthyroidism Last causes of hyperthyroidism are Apathetic Hyperthyroidism
which refers to thyrotoxicosis occurring . Thyroid hormone can cause three
major effects that is hyper metabolic state, over stimulation of sympathetic
nervous system and cardiac effect as compensatory mechanism of certain
condition caused by increased thyroid hormone.
Normally, thyroid hormone participated in inducing synthesis and
degradation of carbohydrate, fat and protein. However, overall metabolic
effects of thyroid hormone at normal physiologic level are to favor the
consumption rather than storage of body fuel. So, when thyroid hormone becomes
abnormally high, it will increase the overall basal metabolic rate by
increasing rate of degradation.
Thyroid hormones has sympathomimetic action which the actions are
similar to one produced by sympathetic nervous system. Normally, thyroid
hormone stimulates proliferation of specific cathecholamines target cell
receptors which can induce sympathomimetic effect. Increased in thyroid hormone
can induce overstimulation of sympathetic effects which can lead to condition
known as ‘Thyroid Storm’ which is an abrupt onset of acute hyperthyroidism.
Thyroid Storm is a medical emergency situation which significant number of
untreated patients led to cardiac arrhythmias.
Overstimulation of gut will induce hypermotility which led to
diarrhea and eventually malabsoption. Overstimulation of levator palpebrae
superioris of the eye will result in ocular manifestation of wide, gaze,
starring and lid lag of the eyes. Overstimulation of neuromuscular will lead to
nervousness, irritability and tremor. Nearly 50% develop proximal muscle weakness
called thyroid myopathy. Heart rate and contractility of heart muscle will be
increase due to increase in heart’s responsiveness towards circulating
cathecolamines.
Hyperthyroidism also results
in altered secretion and metabolism of hypothalamic, pituitary, and gonadal
hormones. If hyperthyroidism occurs before puberty, sexual development is
delayed in both sexes and if after puberty, it results in decreased libido and
will also cause menstrual irregularity and decreased fertility
CLINICAL
MANIFESTATIONS:-
Cardiovascular:
Hypertension; increased rate and force of cardiac
contractions; rapid pulse; increased cardiac output; arrhythmias; palpitations;
angina, blood pressure systolic increased and diastolic decreased
Respiratory:
Increased respiratory rate, dyspnoea on mild exertion.
Musculoskeletal:
Fatigue, muscle weakness, dependent oedemas,
osteoporosis.
Gastrointestinal:
Increased
appetite, thirst, weight loss, increased peristalsis, diarrhoea, increased
bowel sound, spleenomegaly, hepatomegaly.
Integumentary:
Warm, smooth, moist
skin; thin brittle nails
Thyroid acropathy of nails which includes
clubbing and osteoarthropathy of nails,
Onchylosis which
means detachment of nails, hair loss, palmer erythema; fine silky hair, thyroid
dermopathy which includes fine and skin colours papules and plaque on shin (front
part of leg below knee joint)
Nervous System
Difficulty in
focussing eyes. Nervousness, fine
tremor(of fingers and tongue), insomnia,
liability of mood, restlessness, personality changes, depression, fatigue,
apathy, lack of ability to concentrate, stupor, coma.
Reproductive:
Menstrual
irregularities, oligomenorrhea, amenorrhoea, decreased libido
Ophthalmologic changes:-
Soft tissue involvement:Lacrimation, Redness, Burning
sensation, Photophobiia, Gritty sensation. Proptosis (exophtalmos) and lagophthalmos,keratitis, Extra-ocular
muscle dysfunction, diplopia, Optic neuropathy, blindness
Others:
Intolerance to heat; Temp., Increased oxygen consumption
Diabetes mellitus may be exacerbated
Decreased Serum cholesterol
Decreased plasma triglycerides
DIAGNOSTIC EVALUATION:-
1. Blood test
Ø Markedly suppressed TSH (<0.05 µIU/mL) and also decreased TRH level
Ø Elevated serum T4 and T3
Ø Thyroid antibodies – Thyroid stimulating immunoglobulin(TSI)
2. Thyroid scan
It shows
how and where iodine is distributed in thyroid which helps to identify cause of
hyperthyroidism through images of nodules and other possible thyroid
irregularities. It is done by injecting radioactive isotope intravenously then images
of thyroid by special scanner using computer screen are taken in lie down
position of patient.
3. Radioactive
iodine uptake test
It measures amount of
iodine thyroid collects from bloodstream. Pt. is given small oral dose of
radioactive iodine. As we know that iodine collects in thyroid gland to
manufacture TH. Pt. will be checked after two, six or 24 hours and sometimes after
all three time period to determine how much iodine thyroid gland has absorbed.
Low level of iodine uptake for hypothyroidism and high level uptake for
hyperthyroidism indication.
4. Nuclear
Scintigraphy:- It is a form of test used in nuclear medicine, wherein
radioisotopes are taken internally and the emitted radiation is captured by
external detectors’ in form of two dimensional images
MANAGEMENT
OF HYPERTHYROIDISM:-
v Medical management
v Surgical management
v Dietary management
v Nursing management
MEDICAL
MANAGEMENT:- Treatment
of hyperthyroidism is directed toward reducing thyroid hyperactivity to relieve
symptoms and remove the cause of important complications. Treatment depends on
the cause of the hyperthyroidism and may require a combination of therapeutic
approaches.
A.
Antithyride or thyionamide:- Inhibits the biosynthesis of
thyroid hormone Stops the production step of
iodination Eg: Propypyl
thiouracil (PT4) &
methimazole are most frequently used drugs.
B.
Iodides:- Iodides reduce the metabolic rate
rapidly because they block the release and synthesis of thyroid hormone. Eg: Lugol’s solution and saturated
solution of potassium iodide are used.
C.
Alternative to iodide:- Lithium: Ability to block the
release of thyroid hormone
Dexamethasone: Effective in blocking hormone release in
patients with Grave’s disease
D.
Thyroid blockers or antagonists;-Treat the symptoms from
increased sympathetic nervous system stimulationin hyperthyroidism such as
tachycardia, dysarrythmias, and angina eg Atenolol, Inderal, propanolol,
metaprolol
RADIOACTIVE
(IODINE) ISOTOPE THERAPY:-
It works on the principal that thyroid cells
are the only cells in our body that can absorb iodine. Radioactive iodine is
given by mouth which gets into blood stream and is absorbed by overactive
thyroid cells and thyroid cells will die as a result of poisoning due to
radioactive iodine. The amount of radioactive iodine is calculated after an
iodine scan and calculated amount is given. It is a widely recommended
permanent treatment for hyperthyroidism because-
v
Can
be given in an outpatient basis
v
Is
safer for a wider range of patients, including elderly
v
reported because
hypothyroidism may occur up to 15 yearsCan result in faster improvement in thyroid function than
antithyroid drug therapy
Care of the patient receiving radioactive
iodine:-
Limit time spent with the patient and
maintain a safe distance when providing direct care. Pregnant caregivers should
avoid caring for patients receiving radioactive iodine. Urine, vomitus, and
other body secretions are contaminated and should be disposed of according to
hospital policy. Flush the toilet twice following disposal of contaminated
material
At home, the patient is instructed to
avoid close contact with family members for about a week and to use careful
hand washing after urinating. Oral contact with others should be avoided, and
eating utensils should be washed thoroughly with soap and water. If the
treatment is being administered for hyperthyroidism, inform the patient that
symptoms will subside in about 6 to 8 weeks.
Side effects are rare, and may include
a sore throat or nausea. Encourage the patient to drink plenty of fluids to
help remove the RAI from the body.
SURGICAL
MANAGEMENT:-
Surgery is reserved for special circumstances like
Ø
Pregnant women who are allergic to
antithyroid medications
Ø
Patients with large goiters
Ø
Patients who are unable to take
antithyroid agents
Ø
Patients with a need for rapid
normalization of thyroid function
The surgical removal of about five sixths of the
thyroid tissue (subtotal thyroidectomy) reliably results in a prolonged
remission in most patients with exophthalmic goiter. Before surgery oral
antithyroid drugs with adjuvant therapy is given for normalization of thyroid function and to
minimize postoperative complications. Medications that may prolong clotting (eg,
aspirin) are stopped several weeks before surgery to reduce the risk for
postoperative bleeding.
DIETARY MANAGEMENT:-
Ø High calorie diet-400 to 500 kcal
should be ordered to satisfy hunger & prevent tissue breakdown
Ø High protein, vitamins and minerals-
1to 2gm\kg body weight, minerals and particularly vitamin A, B6, &
C.
Ø Avoid cola and caffeine
Ø Include milk in diet as it provides
calcium and protein in rich amount.
NURSING MANAGEMENT:-
Assessment:-
These
include the patient’s and family’s report of irritability and increased
emotional reaction and impact of these changes on family, friends, and co-workers.
The history includes other stressors and the patient’s ability to cope with
stress. The nurse assesses the patient’s nutritional status and the presence of
symptoms. Symptoms related to excessive nervous system output and changes in
vision and appearance of the eyes are noted. The nurse periodically assesses
and monitors the patient’s cardiac status, including heart rate, blood
pressure, and heart sounds, and peripheral pulses. Because emotional changes
are associated with hyperthyroidism, the patient’s emotional state and
psychological status are evaluated.
NURSING
CARE PLAN:-
1.Nursing
diagnosis:- Altered body temperature R/T hyper metabolic state
Goal:- Maintain
normal body temperature
Interventions:-.
ü Monitor temperature. Temperature may be elevated
ü Maintain environment cool and comfortable for patient
ü Bedding and clothing should be change as per need
ü Apply cooling blanket as ordered
ü Administer antipyretics as per prescription
ü Reason for patient’s discomfort and importance of providing cool
environment should be explain to the family members also
2.Nursing
diagnosis:-Disturbances in normal bowel pattern R/T increase in peristalsis
Goal:- Reduce patient discomfort and maintain
fluid and electrolyte balance.
Interventions:-
ü Provide
a low-fibre diet. Fibre can increase peristalsis and stools.
ü Provide
small frequent meals of bland foods (bananas, rice, apple, sauce) that are less
likely to worsen diarrhoea.
ü To
reduce diarrhoea highly seasoned foods and stimulants like coffee, tea, cola,
alcohol are discouraged.
ü Monitor
electrolytes, especially sodium and potassium. Diarrhoea can cause electrolyte
loss.
ü Monitor
for dehydration. Replace fluid loss as diarrhoea causes fluid loss.
ü Keep
skin clean and dry; apply barrier cream to protect skin from injury from stool.
3.Nursing diagnosis:-Altered nutrition less than body requirements
related to increased metabolic needs and excessive appetite
Goal: Improve nutritional status & maintains current activity level.
Interventions:-
ü
Assess the weight of the patient weekly
ü
Help to plan high calorie, high protein
high carbohydrate diet with selection from all food groups
ü
Suggest small & frequent diet like six
small meals per day or between meal snacks
ü
Serve food according to his or her choice
4.Nursing diagnosis:-Ineffective individual coping R/T irritability,
hyper excitability, apprehension and emotional instability
Goal : Enhancing coping measures
Interventions :-
ü
Discuss the reasons for this type of
symptom both with patient and family and reassure them that they will be
expected to disappear with treatment
ü
Maintain calm, relaxed environment
ü
Stressful experiences are minimized and
relaxing activities are encouraged
5.Nursing diagnosis:-Sensory\ perceptual changes (potential visual)
related to infiltrative changes associated with hyperthyroidism
Goal: Improve the vision & to prevent worsening of
the vision.
Interventions:-
ü
Assess visual activity, ability to close eyes,
photophobia
ü
Protect the eyes
ü
Use patches or glasses when in high wind
ü
Use artificial tears as prescribed
ü
Instruct the patient not to lie prone.
ü
Teach patient about correct method of eye drops
instillation.
6.NURSING DIAGNOSES:-Disturbance
in self-esteem R/T changes in appearance, excessive appetite, and weight loss
Goal:-To improve self-esteem
Interventions:-
ü Patient and family
should be informed that these changes are due to dysfunction of thyroid gland
and out of patient control
ü If changes in appearance
are very disturbing to patient then cover or remove mirrors
ü Provide privacy while
eating as patient will annoyed on any comment about his need of large amount of
meal
7.Nursing diagnosis:-Knowledge deficit
related to disease condition, treatment & prognosis.
Goal: Improve knowledge level.
Intervention :-
•
Assess
the knowledge of the patient
•
Clear
all his doubts
•
Impart
education about disease & treatment
•
Adequate
teaching should be given related to home care & follow up care
8.Nursing diagnosis:-
Collaborative problems/potential complications
Goal:-Absence of complications.
Interventions:-
Thyrotoxicosis or thyroid storm-
Ø It is a potentially fatal, acute
episode of increased thyroid activity
Ø Sign and symptoms are high fever,
severe tachycardia, delirium, and extreme irritability.
Ø Causing factors are untreated hyperthyroidism,
infection, thyroid ablation, metabolic catastrophes, surgery, trauma, labour
and delivery, MI, pulmonary embolus, medication overdoses etc.
Ø It is a clinical diagnosis also called as
thyroid crisis.
Ø Cardiac and respiratory
functions are assessed by measuring vital signs and cardiac output, ECG
monitoring, arterial blood gases, and pulse oximetry.
Ø Oxygen is administered
to prevent hypoxia, to improve tissue oxygenation, and to meet the high
metabolic demands.
Ø Intravenous fluids may
be necessary to maintain blood glucose levels and to replace lost fluid.
Ø Antithyroid medications
with adjuvant therapy should also be continued
Ø If shock develops,
treatment strategies must be implemented.
For Hypothyroidism
Hypothyroidism is likely
to occur with any of the treatments used to treat hyperthyroidism. Therefore,
periodically monitoring of patient is needed.
PROMOTING HOME AND COMMUNITY-BASED CARE
Teaching Patients Self-Care
The nurse teaches the patient with
hyperthyroidism how and when to take prescribed medication, and provides
instruction about the essential role of the medication in the broader
therapeutic plan. The type and amount of information given depend on the
patient’s stress and anxiety levels. The patient and family members receive
verbal and written information about the actions and possible side effects of
the medications. If patient have Graves ophthalmology may need to use eye drop
to moisten eyes and wear sunglasses to protect eyes.
Continuing Care
The nurse reinforces to the patient and family
the importance of long-term follow-up because of the risk for hypothyroidism
after thyroidectomy or treatment with antithyroid medications or radioactive iodine.
Besides this
ü Avoid stress
ü Avoid caffeine
ü Avoid smoking
CONCLUSION:-
Hyperthyroidism is not a common occurring disease but
its prevalence is increasing & sometimes its manifestations can be
confusing so proper knowledge about the disease is very important for its
timely & proper treatment.
Bibliography:-
Ø Smeltzer
C Suzanne ,Bare G Brenda ,Hinkle L Janice ,Cheever H Kerry ,editor, Brunner and
Suddarth’s Text Book Of Medical Surgical Nursing.12th Edition
.India; Lippincott Williams and wilkins;2010.
- Ø Black
.M.J ,Hawks H.J .Medical Surgical Nursing Clinical Management For Positive
Outcomes .8th Edition. India ;Elsevier ; 2013
- Ø Williams
Linda S.Hooper Paula.Understanding medical surgical nursing.3rd
ed.FA Davis company;Philadelphia;2007
- Ø Ansari
Javed.Kaur Manjeet.Text book of Medical Surgical Nursing.Vikas
publications;Jhalandhar.India;2012.
