Hyperthyroidism

I.
INTRODUCTION
o Objectives o Reason for choosing the study
II. Nursing History

o o o o
History of Past Illness History of Present Illness Lifestyle Family Health-Illness History
III. PHYSICAL EXAMINATION

o General Survey o Vital Signs o Physical Assessment
IV. DIAGNOSTICS AND LABORATORY PROCEDURES
V. THE PATIENT AND HIS ILLNESS

o Anatomy and Physiology o Pathophysiology (Book-based) o Synthesis of the Disease
VI.
THE PATIENT AND HIS CARE

o Surgical Management o Pharmacological Management o Diet o Activity and Exercise
VII. NURSING CARE PLANS VIII. CONCLUSION IX. X. RECOMMENDATION BIBLIOGRAPHY
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I. INTRODUCTION
Hyperthyroidism, often referred to as an overactive thyroid, is a condition in which the thyroid gland produces and secretes excessive amounts of the free (not protein bound, and circulating in the blood) thyroid hormones, triiodothyronine (T3) and/or thyroxine (T4). Thyroxine is a body chemical (hormone) made by the thyroid gland. It is carried around the body in the bloodstream. It helps to keep the body's functions (the metabolism) working at the correct pace. The thyroid gland is located in the neck. It controls important metabolic processes, such as growth and energy expenditure. An immune system abnormality called Graves' disease is the most common cause of hyperthyroidism. Other causes include local inflammation (thyroiditis), nodules or lumps. The radioimmunoassay for T3 is now widely available and is a useful diagnostic tool for hyperthyroidism, especially in T3-thyrotoxicosis. It is an essential tool in the management of hyperthyroidism that persists after treatment with normal T4 serum levels or, in euthyroid cases, with low T4 serum levels. In these conditions, it reflects the metabolic state more accurately than serum levels of T4. A promising new test is the response of radioimmunoassayable TSH to protirelin (TRH) administration. An absent response indicates pituitary suppression and thyroid autonomy as seen in frank hyperthyroidism or euthyroid Graves disease, treated or untreated. It is safer and quicker than the conventional T3 suppression test of thyroid radioactive iodine uptake and may replace it at least partly in the future. (H Haibach, 1976) Although existing treatments are effective, they are not directed at the root of the problem. Rather, they seek to knock the thyroid out of action, either by surgically removing it or destroying it with radioactive iodine. But most patients receiving these therapies may have to take replacement thyroid hormone for life. A third approach is the use of drugs to block the production of the excess hormone the abnormal gland produces. (Lawrence K. Altman, 1991) Biochemical signs of hyperthyroidism, or even overt and possibly lethal clinical hyperthyroidism were reported in 2 severely iodine-deficient African countries (Zimbabwe and Democratic Republic of Congo, RDC) soon after the introduction of iodized salt. The 2 countries had access to iodized salt produced in Botswana, as well as 5 other countries in the region, namely Cameroon, Nigeria, Kenya, Tanzania, and Zambia. Therefore, a multicenter study was conducted in these 7 countries to evaluate whether the occurrence of iodine-induced hyperthyroidism (IIH) after the introduction of iodized salt was a general phenomenon or corresponded to specific local situations in the 2 affected countries. Two or 3 areas with a past history of severe iodine deficiency that had recently been supplemented with iodized salt were selected in each of the 7 countries. The prevalence of goiter was determined in 4423 schoolchildren in these areas and the concentration of urinary iodine in 2258. The study showed that iodine deficiency had been
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eliminated in all areas investigated, and that the prevalence of goiter had markedly decreased since the introduction of iodized salt. 30,000,000 people in the US and 200 million worldwide have a Thyroid Disorder. Of the 30 million people above about half are undiagnosed. 37,000 new cases of Graves' disease are diagnosed each year in the US. 80% of all cases of Graves' disease are diagnosed in females. 20% of Thyroid Storm cases end in death. 80% of all Thyroid Disease cases are diagnosed as Hypothyroidism and 20% Hyperthyroidism. 20% of people with Diabetes will experience an onset of a thyroid disorder. 50% of children with parents having a thyroid disorder may develop a thyroid disorder themselves by age 40. Moreover, the Philippine Thyroid Disorder Prevalence Survey (PhilTiDeS) made the first national survey in the Philippines on the prevalence of thyroid disorders based on thyroid function tests on the non-pregnant population in 2001. The test revealed that more Filipino adults are affected with subclinical (no symptoms) forms of thyroid disorders than which have obvious symptoms. Among the 5,000 people recruited in the study, 4,897 qualified for the structured interview and physical assessment of the thyroid. After which, the respondents' blood samples were taken and tested for thyroid disorders. Upon analysis of data, it was found out that subclinical thyroid disorders are the more common case of the condition found in the Philippines' adult population. Untreated hyperthyroidism can shorten your life, but it, in itself, is not going to kill you. The resulting conditions and diseases such as severe thyroid storm or thyrotoxicosis could if not treated right away. Untreated hyperthyroidism will ruin your appearance, to be sure. They develop very unattractive bulging eyes (exophthalmos) or loose weight to an unhealthy and unattractive state. The thyroid hormones need to be balanced. If hyper or hypo types of thyroid disease develops, it only takes a quick blood test once or twice a year (for a lifetime basis, since it's not curable, only treatable) to test its level, and then one little pill every morning to solve the problem. Diet and exercise will keep it from getting worse. It is important to maintain regular, lifelong visits if a client have hyperthyroidism. Untreated or improperly treated, an overactive thyroid can lead to severe, even life-threatening problems. Complications include irregular heart rhythm (atrial fibrillation), congestive heart failure, miscarriage, osteoporosis and bone fractures (hyperthyroidism causes your bones to lose calcium faster than usual). Reason for Choosing the Study We have chosen this study for the intention of obtaining greater understanding about the disease and acquiring knowledge for the improvement of our skills and management if such condition will be encountered. The topics that will be discussed in this study are the development, diagnosis, and treatment of the condition hyperthyroidism. The researchers have made a comprehensive report to be able to determine the truthful information into what causes this condition and how it can lead to thyroidectomy (surgical removal of the thyroid gland). The study will help students that are in the medical field in knowing the proper management of patients
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under the condition and have an adequate overview of the general information about hyperthyroidism and thyroidectomy.
Objectives
Define the anatomy and physiology of the Thyroid gland, particularly those that are linked with the disease. Define hyperthyroidism and thyroidectomy. Identify the underlying causes of hyperthyroidism. Enumerate the signs and symptoms of hyperthyroidism. Explain the pathophysiologic nature and complications of Hyperthyroidism. Determine the prognosis of the disease with the following criteria: duration of illness, onset, precipitating factors, environmental factors, and lifestyle. Interpret the findings from the Nursing Health Assessment and laboratory examinations with their clinical significance. Psychomotor: Relate nursing concepts learned to manage preoperative, intraoperative and postoperative care in thyroidectomy. Develop nursing care plan related to the potential and existing problems effective for the improvement of the management of disease. Select the appropriate, immediate nursing management for hyperthyroidism and thyroidectomy. Affective: Express genuine concern for patients with hyperthyroidism. Pay attention on the importance of developing a practice of performing accurate and complete assessment findings. Assert the role in the nursing profession of finding out appropriate ways to promote a patients relief and recovery. Integrate the knowledge acquired to co-student nurses, increase awareness and help them for future encounters with a client having the same condition.
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II. Nursing History

A. Demographic Data B. Socio-economic, Cultural and Environmental Factors C. History of Past Illness
D. History of Present Illness E. Lifestyle
E. Family Health-Illness Hi
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II. PHYSICAL
EXAMINATION
A.
General Survey
A client diagnosed with hyperthyroidism often appears extremely agitated and irritable
especially when exposed to hot climate. Despite a ravenous appetite, weight loss can be observed as a result of the hypermetabolic state. One of the hallmarks when a assessing a patient with hyperthyroidism is the presence of enlarged neck and protruding eyes (exophthalmos). They markedly show hyperkinetic movements and tremors are apparent even at rest.
B.
Vital Signs
Blood Pressure:
o Increased systolic BP o Widened pulse pressure
Temperature
o Low-grade fever
Respiratory Rate
o Increased RR o Shortness of breath
Pulse Rate
o Rapid, bounding pulse (>100 bpm)
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C.
Skin
IPPA- Cephalocaudal Assessment
o Smooth, warm, moist skin o Diaphoresis (excessive sweating) Nails o Brittle nails (that may separate from the nail beds) o Clubbing of fingers
Hair o Thinning of scalp hair (patches) o Shiny hair
Eyes o Protruding eyes (exophthalmos) o Red, swollen eyes o Elevated, retracted upper eye lids o Dry and irritated cornea (due to inability to completely close the enlarged eyes) o Blurred or double vision o Corneal ulcers or infections o Increased tears o Photophobia Neck o Enlarged thyroid gland (protrusion in the neck) o Nodular thyroid gland
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o Bruits heard on auscultation (due to the increased blood flow to the thyroid gland)
Chest and Lungs o Shortness of breath with or without exertion o Rapid, shallow respirations o Decreased vital capacity
Breast o Enlarged breasts in men
Abdomen o Enlarged spleen and/or liver o Increased bowel sounds
Extremities o Muscle weakness o Palmar erythema o Tremors o unable to perform a full range of motion due to reported weakness
Extremities
o Osteoporosis
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III.
DIAGNOSTICS AND LABORATORY PROCEDURES

Indications or Purpose Results Normal Values Analysis and Interpretation
Diagnostic/ Laboratory Procedure 1. Complete Blood Count A. Hemoglobin (hgb) B. Hematocrit (hct)
Hgb test measures the amount of hemoglobin in the blood. A Hct test indicates whether you have too few or too many red blood cells. Normal 36.0 - 46.0% Normal 12.5 - 15 g/dl Hemoglobin is normal. Indication of anemia due to hematuria and decreased erythropoietin production due to the damage in the kidneys.
C. White Blood Cells (WBC)
The WBC count determines the total number of white cells (leukocytes) in the blood sample. Normal 4,500 12,000 / mm WBC is within normal value.
D. Red Blood Cells (RBC)
RBC count signifies the number of red blood cells in a volume of blood.
Normal
4.0 6.0 million / mm RBC is normal.
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Nursing Responsibilities: Before: 1. Explain the test procedure and purpose. 2. Explain that slight discomfort may be felt when the skin is punctured. 3. Obtain a history of the patient's complaint which includes a list of known allergens. 4. Obtain a list of the patient's current medications, including herbs, nutritional supplements, and nutraceuticals. 5. Note any recent procedures that can affect with test results. 6. Encourage to avoid stress if possible because altered physiologic status influences and changes normal hematologic values. 7. Be sensitive to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure. During: 1. Instruct the patient to follow and cooperate with the given directions. 2. Instruct the patient to breathe normally and to avoid unnecessary movement. 3. Observe standard precautions, and follow the general guidelines. 4. Identify the patient, and label the appropriate tubes with the corresponding patient demographics, date, and time of collection. 5. Perform a venipuncture and collect the specimen. 6. Apply manual pressure and dressings over puncture site to stop bleeding 7. Transport the specimen to the laboratory for processing and analysis. After: 1. Monitor the puncture site for oozing or hematoma formation. 2. Evaluate test results in relation to the patient's symptoms and other tests performed.
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Diagnostic/ Laboratory Procedure 2. Blood Chemistry A. Calcium
Indications or Purpose
Results
Normal Values
Analysis and Interpretation
To evaluate bone diseases and the function of the parathyroid glands.
Increased
8.5 10.5 mg/dl
Hypercalcemia (chronically elevated blood calcium) is most commonly caused by hyperparathyroidism due to a benign parathyroid tumor.
B. Fasting Blood Glucose
To measure the amount of a sugar called glucose in a sample of your blood
Increased
70 100 mg/dL
The excessive thyroid hormone causes increased glucose production in the liver, rapid absorption of glucose through the intestines, and increased insulin resistance.
C. Total Cholesterol Test
Measures all the cholesterol in the blood.
Decreased
120 200 mg/dL
Cholesterol level is decrease in hyperthyroidism due to increased bile excretion of cholesterol.
Nursing Responsibilities: Before: 1. Explain the test procedure and purpose. 2. Note any recent procedures and medications that can affect with test results During: 1. Instruct the patient to follow and cooperate with the given directions. 2. Note that the client may feel moderate pain when the needle is inserted to draw blood. After: 1. Apply pressure (with cotton or gauze) to the puncture site. 2. Monitor for hematoma formation. 3. Advise to resume normal activities and any medications that were withheld before the test.
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Diagnostic/ Laboratory Procedure 3. Thyroid Function Tests A. Thyroid-stimulating hormone (TSH) assay
Results
Normal Values
TSH blood test is used to check for thyroid gland problems.
Decreased
0.4-4.2 mU/L
TSH is below normal that may indicate hyperthyroidism (overactive) and is producing too much thyroid hormone.
Nursing Responsibilities: Before: 1. Explain the test procedure and purpose. 2. Note those medications taken that may affect results. 3. The client should be relaxed and recumbent for 30 minutes before the test. During: 1. Wrap an elastic band around your upper arm to stop the flow of blood. 2. Put the needle into the vein and attach a tube to the needle to fill it with blood. 3. Remove the band from your arm when enough blood is collected. 4. Put a cotton ball over the needle site as the needle is removed and apply pressure on the site. After: 1. Monitor the puncture site for hematoma formation.
B. Radioactive Iodine Uptake
Use to determine the metabolic activity of the thyroid gland and may determine whether the gland is functioning normally. Increased 24 hours: 15 - 25%
RAIU test is higher than normal amounts of iodine in the thyroid gland due to hyperthyroidism.
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Nursing Responsibilities: Before: 1. Explain the test procedure and purpose. 2. Note that it is contraindicated in pregnant women and breastfeeding mothers. 3. Instruct the patient not to eat for 2 hours before the test. 4. Instruct not to take any antithyroid medicine for 5 to 7 days before the test. 5. Inform to sign a consent form saying that the patient understand the risks of the test and agree to have it done. During: 1. Instruct to swallow a liquid or capsule containing radioactive iodine. 2. Instruct the patient not to eat for 2 hours before the test. 3. After six to 24 hours, the patient will return for a measurement of the radioactivity (uptake) and a picture of your thyroid using a device called a gamma probe. 4. Instruct to remove dentures and all jewelry or metal objects from around the neck and upper body. 5. Instruct to lie on a table while the scanner moves over the neck. After: 1. Explain the test result. 2. Instruct to go back to a normal diet when the test is finished.
FT4 is carried out to C. Free Thyroxine (FT4) concentration evaluate thyroid function, to help diagnose hyperthyroidism. This test is more accurate as it is not affected by protein level. A direct measurement D. Thyroxine (T4) of total amount of T4 present in blood. Increased 4.0 to 12.0 mcg/dL Increased 0.8 to 2.3 ng/dL
FT4 is high that indicates an overactive thyroid gland, otherwise known as hyperthyroidism.
T4 result is above normal due to high thyroid hormone levels and indicates hyperthyroidism
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E. Triiodothyronine (T3) radioimmunoassay
Measures small amount of potent thyroid hormones; T3 is active form of thyroid hormones.
Increased
100 200 ng/dL
T3 is high as a sign of overactive thyroid gland.
Measures T3 that is F. T3 resin uptake (T3 RU) protein bound. Increased 24 - 37%
T3 RU is high due to hyperthyroidism; in hyperthyroidism, TBG is relatively saturated, so a higher than usual fraction of I-T3 goes to the resin binder.
Measures T4 that is G. Thyroid-binding globulins (TBGs) protein bound; Measure the level of a protein that moves thyroid hormone throughout the body. Increased 1.3 - 2.0 mg/100 mL TBG is above normal.
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Nursing Responsibilities: Before: 1. Explain the test procedure and purpose. 2. Note that some medications may need to stop taking certain drugs temporarily before the test to help ensure accurate results. 3. Recommend fasting. During: 1. Clean with alcohol the puncture site. 2. Note that the client may feel moderate pain when the needle is inserted to draw blood. After: 1. Note that afterward, there may be some throbbing. 2. Explain the test result.
Test confirms H. Thyrotropin-releasing hormone presence of thyrotoxicosis by measuring response of the pituitary glands production of TSH.
Doubling of baseline TSH 30 minutes after IV injection of 500mcg TRH
TSH rises approximately twice its normal.
No TSH response
Nursing Responsibilities: Before: 1. Explain the test procedure and purpose. 2. Advise patient that 3 to 4 weeks prior to test, thyroid medication should be discontinued. 3. Obtain baseline BP and pulse. 4. Inform about the risks and side effects of the test. During: 1. Wrap an elastic band around your upper arm to stop the flow of blood. 2. Blood is drawn and a baseline TSH level is measured. 3. Administer TRH via a vein. 4. After 15 and 30 minutes blood is drawn again and the levels of TSH are measured and compared to the baseline. After: 1. Monitor puncture site for hematoma formation. 2. Explain the test result.
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Diagnostic/ Laboratory Procedure Diagnostic Imaging Studies A. Thyroid Scan
Results
Normal Values
Injection of radioactive isotopes used to identify thyroid gland; to evaluate the size, position and functioning of the thyroid gland.
The scan show an enlarged thyroid gland and thyroid appears lighter.
The thyroid appears the correct size, shape, and in the proper location. It appears an even gray
The thyroid gland is enlarged as one of the s/sx of hyperthyroidism and appears lighter due to thyroid problem
Hot nodules: benign
color on the computer image.
Nursing Responsibilities: Before: 1. Explain the test procedure and purpose. 2. Explain the risks and side effects of the test. 3. Inform patient to sign the consent form. 4. Advise not to eat after midnight the night before the exam. 5. Note that radioactive substance needs time to be absorbed before the scan, wait for 4 to 6 hours if the substance is taken by mouth. 6. Instruct to remove dentures and all jewelry or other metals, because they may interfere with the image. During: 1. Instruct the patient to follow and cooperate with the given directions. 2. Administer a pill that contains radioactive iodine, and wait as the iodine collects in the thyroid. 3. Instruct to lie on his/her back on a movable table with the neck and chest under the scanner. 4. Advise to lie still to let the scanner get a clear image. After: 1. Explain the test result. 2. Advise to drink extra fluids and empty the bladder often to flush out the residual radionuclide.
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B. Ultrasonography
Provides the best information about the shape and structure of nodules and may be used to distinguish cysts from solid nodules, to determine if multiple nodules are present.
Degree of inhomogeneity is present with typical features of thyrotoxicosis.
Thyroid is of normal size, shape, and position. Normal thyroid appears homogenous, with a characteristic echogenicity.
The result of the ultrasound reveal markedly increased vascularity throughout the thyroid gland. Some degree of inhomogeneity is also present with typical features of thyrotoxicosis.
Nursing Responsibilities: Before: 1. Explain the test procedure and purpose. 2. Instruct to remove necklaces and other accessories that can block the throat. During: 1. Instruct the patient to follow and cooperate with the given directions. 2. Instruct to remove the shirt and lie on his/her back. 3. Place a pillow or a pad under the back of the neck for this will tilt the head back and expose the throat. 4. Rub the gel onto the throat for this helps the ultrasound probe, or transducer, glide over the skin. 5. Run the transducer back and forth over the area where the thyroid is located (Images will be visible on a screen and used to have a clear picture of the thyroid to evaluate). After: 1. Examine the images. 2. Advise to resume normal activities as soon as it is over.
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C. Magnetic Resonance Imaging (MRI)
Used to visualize gland size, location, identify abnormalities.
Enlarged thyroid gland
Thyroid is of normal size, shape, and position.
The thyroid gland is enlarged because it produces too much hormone (hyperthyroidism).
Nursing Responsibilities: Before: 1. Explain the test procedure and purpose. 2. Note any allergy history. 3. Inform to remove any metal objects, including jewelry, eyeglasses, dentures and hairpins that may affect the MRI images. 4. Advise to wear comfortable, loose-fitting clothing to the exam. 5. Patient may be asked not to eat or drink anything for 4 - 6 hours before the scan. During: 1. Patient will be asked to remain perfectly still during the time the imaging takes place, but between sequences some minor movement may be allowed. 2.When MRI procedure begins, patient may breathe normally, however, for certain examinations it may be necessary for you to hold your breath for a short period of time. After: 1. Examine the images. 2. Advise to resume normal activities as soon as it is over.
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IV.
THE PATIENT AND HIS ILLNESS
A. Anatomy and Physiology
The Thyroid Gland

The thyroid gland lies in the neck, in front of the upper part of the trachea. The thyroid gland is located adjacent to the cranial trachea. Close to the recurrent laryngeal nerve, carotid sheath and sternohyoid and sternothyroid muscles. The Parathyroid Glands are located dorsally to, or within the thyroid gland itself. It is supplied by the cranial thyroid artery which is a branch of the common carotid artery. A subsidiary supply is provided by the caudal thyroid artery. The cranial and caudal thyroid arteries are united by substantial anastamoses along their caudal edge. Venous drainage is provided by the internal jugular vein and lymph drains into the cranial deep cervical nodes. Two types of hormones are produced, which are the iodine containing hormones; triiodothyronine(T3) and thyroxine (T4). Thyroid hormones regulate the basal metabolic rate and are important in the regulation of growth of tissues, particularly nervous tissue. Release stimulated by TSH from the pituitary. . Ultrastructure and Histology The gland consists of varying sized follicles, which are bounded by a single layer of cuboidal epithelial cells (follicular cells} and a basement membrane, surrounding a central lumen filled with a homogenous protein rich colloid (thyrogloblin). The apical surface of the cell membranes is covered with numerous micovilli to increase surface area. The follicular cells are connected by tight junctions, and have a dense capillary network. The colloid is a store of thyroid hormones prior to secretion. The thyroid gland is the only endocrine gland to store its hormone in large quantities. In the active gland colloid is diminished and epithelial cells are tall and columnar. Within the connective tissue close to the follicles are C-cells alternatively known as parafollicular cells. They are found in clusters in the interfollicular space and are also known as clear cells as their cytoplasm doesn't stain with H and E. They secrete calcitonin, a hormone which acts to lower plasma Ca2+ levels. Page | 21
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Thyroid Hormone Physiology

Follicular cells synthesize thyroglobulin in their golgi apparatus. This is a glycoprotein consisting of 70 linked tyrosine molecules, 10% of which are iodinated, and is stored in the colloid. The thyroglobulin is then split to form the two amino acid derivative hormones produced in the thyroid gland which are triiodothyronine (T3) and thyroxine (T4). Thyroxine contains 4 iodine atoms, triiodothyronine contains 3. Creation of these two hormones is the only role of iodine in the body. The majority (90%) of hormone produced by the follicular cells is T4. T4 can only be made in the thyroid gland. It can then be converted by other tissues into T3.
Iodine Uptake
Iodine circulates within the blood as iodide (I-). It is actively transported into the follicular cells by an Na+/I- symport in the basal membrane. This pump concentrates iodine in the colloid at a level up to 250x greater than the plasma level. This process is known as iodide trapping. The pump is activated by thyroid stimulating hormone (TSH) a hormone from the pituitary gland. Any excess iodide is excreted via the kidneys.
Secretion of Thyroid Hormones

Colloid uptake into the follicular cells takes place by endocytosis. The intracellular vesicles containing the colloid then fuse with lysosomes, where enzymes split the thyroglobulin into T3 and T4. The hormones diffuse across the basal plasma membrane into the interstitium (they are lipid soluble hormones).
Transport
Thyroid hormones are lipid soluble, thus need a transporting protein in order to travel in the blood. Half-life in the blood is 1 day for T3, 6 days for T4. 99% of thyroid hormones in circulation are bound. The primary transport protein for thyroid hormones is thyroid binding globulin (TBG). Synthesized in the liver, this protein binds 70-80% of the circulating thyroid hormones. The remainder are carried by thyroxine-binding prealbumin or albumin.
Degradation
Only free T3 and free T4 can enter cells to exert their actions. T4 is deiodinated to T3 in many cells of the body, particularly the liver and kidneys.
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The thyroid secretes 90% T4, with 50% of this being deiodinated to T3. The remainder is converted to reverse T3 (rT3). This is an inactive form of T3, and so creation of it is a regulatory mechanism. More rT3 is created when the body needs to reduce the action of T3 and T4. The hormones are further deiodinated to diiodothyronine and monoiodothyronine in the liver and kidneys. Iodine is recycled or excreted in the urine.
Regulation
The hypothalamus releases thyrotropin releasing hormone (TRH) which stimulates the adenohypophysis (anterior pituitary gland) to release thyroid stimulating hormone (TSH). This water soluble hormone travels in the blood to activate the thyroid gland by 5 actions: 1. 2. 3. 4. 5. Increased endocytosis and proteolysis of thyroglobulin from colloid Increased activity of the Na+/I- symport Increased iodination of tyrosine Increased size and secretory activity of thyroid follicular cells Increased number of follicular cells
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Thyroid Hormone Actions T3 and T4 have effects on all body systems and at all stages of life. These include: Development where thyroid hormones are vital during the fetal period and the first few months after birth. T3 and T4 are the hormones for metamorphosis in frogs. o Thyroid hormones also promote growth as they enhance amino acid uptake by tissues and enzymatic systems involved in protein synthesis thus promoting bone growth. o They also help with metabolic actions such as carbohydrate metabolism, as thyroid hormones stimulate glucose uptake, glycogenolysis, gluconeogenesis. o In fat metabolism they mobilise lipids from adipose stores and accelerate oxidation of lipids to produce energy (occurs within mitochondria), as well as increasing the size and number of mitochondria. o Thyroid hormones also increase basal metabolic rate (BMR) in all tissues except brain, spleen and gonads. The results in increased heat production, increased oxygen consumption. This increased metabolic rate also results in increased utilisation of energy substrates causing weight loss. o Some of thyroid hormones cardiovascular actions are to increase cardiac output, heart rate and contractility. They affect the respiratory system indirectly through increased BMR causing increased demand for oxygen and increased excretion of carbon dioxide. o In the nervous system thyroid hormones are required for myelination of neurons during the development. They also enhance the sympathetic nervous system (by increasing epinephrine receptors). o Reproductive system is affected by reduced levels of thyroid hormone causing irregular cycling and decreased libido. o Finally, in the alimentary system, thyroid hormone increases appetite and feed intake, increases secretion of pancreatic enzymes and increases motility.
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A. Pathophysiology (book-based)
i. Schematic Diagram
Modifiable Factors: *Diet high iodine intake *Drugs *Infection
Non-modifiable Factors: *Age *Gender (Women) *Genetic Susceptibility
Hypothalamus secretes TRH Signals Pituitary gland to release TSH
THYROID GLAND
Excess thyroid hormone (T3, T4)
Increased iodide uptake

Increased iodide oxidation by enzyme peroxidase Iodine incorporated tyrosine residue Binds to throxine-binding globulin
Increased rate of thyroid gland metabolism

Hypervascularity Increased basal metabolic rate Goiter
TRH, TSH Supression
Opthalmopathy
Infiltrative changes
Enlargement of ocular muscles
Upper lid lag Thyroidectomy
Increased globe gaze, exopthalmos
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Peripheral vasodilation due to heat load
Decreased libido 0.5 cm0. 5 cm Oligomenorrhea, amenorrhea Increased estrone and estradiol serum level Increase in sex hormone-binding globulin Reproductive
Increase BP, Palpitations and tachycardia Increased volume & cardiac output Increased Heart rate & Contractility
Increased beta-adrenergic receptors

Cardiac
Diarrhea and malabsorption Increase in motility and gastrointestinal secretions Gastrointestinal Hypermetabolic State (Increased BMR)
Rate of glucose, fat, and protein use increases
Increased basal metabolic rate

Overstimulation of CNS Increased sensitivity of neural synapses in spinal cord Hyperactive reflexes Decreased attention span Emotional lability Fatigue, restlessness Insomnia
Endocrine Disruption of PTH Mechanism Decreased PTH secretion
Hypercalcemia Increased born resorption
Lipid are mobilized from adipose tissues Increased catabolism of cholesterol by the liver Decreased blood cholesterol levels Weight loss despite of ravenous appetite Heat Intolerance, diaphoresis, flushed skin Page | 26
Increased insulin degregation Decreased sensitivity to exogenous insulin
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ii. Synthesis of the Disease 2. Definition of the Disease Hyperthyroidism is a condition in which an overactive thyroid gland is producing an excessive amount of thyroid hormones that circulate in the blood. ("Hyper" means "over" in Greek). Thyrotoxicosis is a toxic condition that is caused by an excess of thyroid hormones from any cause. Thyrotoxicosis can be caused by an excessive intake of thyroid hormone or by overproduction of thyroid hormones by the thyroid gland. The most common cause of hyperthyroidism is Graves disease which accounts to 75% of patients. Some people develop thyrotoxicosis due to inflammation of the thyroid gland (thyroiditis), which can lead to excessive release of thyroid hormone already stored in the gland (without the accelerated hormone production that characterizes hyperthyroidism). Thyrotoxicosis can also occur after ingestion of excessive amounts of exogenous thyroid hormone in the form of thyroid hormone supplements, such as levothyroxine.
3. Predisposing and Precipitating factors with rationale
Predisposing Factors
o Age - Hyperthyroidism can happen at any age, but it is more common in people aged 60 and older. Graves disease is more likely to occur between ages 40-60 years old. o Gender - more women develop hyperthyroidism than men, with a ratio of approximately 4:1, an effect that is often said to be mediated in some way by more estrogen or less testosterone. There is a large body of evidence that moderate amounts of estrogen enhance immunologic reactivity. However, it is just as likely that the X-chromosome is the source of the enhanced susceptibility rather than sex steroids since the susceptibility continues after the menopause. o Genetic susceptibility- The diseases cluster in families. The concordance rate in monozygotic twins is 20 to 40 percent. o Other Factors- If you had a diet that was deficient in iodine, then start taking iodine supplements, this can increase your risk of hyperthyroidism. Page | 27
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Precipitating Factors
o Drugs- Iodine and iodine-containing drugs such as amiodarone may precipitate
hyperthyroidism in a susceptible individual. Iodine is most likely to precipitate thyrotoxicosis in an iodine deficient population simply by allowing the TSHR-Abs to be effective in stimulating more thyroid hormone to be formed. Whether there is any other precipitating event is unclear. Iodine and amiodarone may also damage thyroid cells directly and release thyroid antigens to the immune system. Interferon alpha treatment of patients with hepatitis C infection has been widely associated with the development of autoimmune thyroiditis but Graves' disease may also be precipitated presumably by influencing the immune repertoire. Alemtuzumab, a monoclonal antibody against the T-cell antigen CD52 used for treatment of multiple sclerosis, has been associated with a 10 to 15 percent incidence of new onset Graves disease o Diet - Excess iodine ingestion- causes hyperthyroidism with a low thyroid radioactive iodine uptake. The etiology may be that the excess iodine provides substrate for functionally autonomous areas of the thyroid to produce hormone. Hyperthyroidism usually persists as long as excess iodine remains in the circulation. o Smoking- Smoking greatly increased the risk for Graves' ophthalmopathy. The effect of smoking was more pronounced in Graves' patients (particulary in the patients with Graves Opthalmopathy) than in other thyroid patients. Smoking among patients with thyroid disease is associated with developing of anxiety and fright, depression and problems with social relations sphere.
o Inflammatory Processes Nonautoimmune autosomal dominant hyperthyroidism- manifests during infancy. It results from mutations in the TSH receptor gene that produce continuous thyroid stimulation. Grave's disease- also known as toxic diffuse goiter enlargement of the thyroid gland and is the most common form of hyperthyroidism in about 75 percent of all cases affecting the entire thyroid gland. Grave's disease is considered an autoimmune disorder. Thyroidectomy Page | 28
Plummer's disease- sometimes results from TSH receptor gene mutations causing continuous thyroid activation. Patients with toxic nodular goiter have none of the autoimmune manifestations or circulating antibodies observed in patients with Graves' disease. Also, in contrast to Graves' disease, toxic solitary and multinodular goiters usually do not remit. Inflammatory thyroid disease (thyroiditis)- includes subacute granulomatous thyroiditis, Hashimoto's thyroiditis, and silent lymphocytic thyroiditis, a variant of Hashimoto's thyroiditis. Hyperthyroidism results from destructive changes in the gland and release of stored hormone, not from increased synthesis.
Signs and Symptoms

Exophthalmos The bulging develops because the tissues in the eyeballs swell, and the number of cells in the eye increases - resulting in larger eyes which push forward from their orbits, usually cause by something wrong with the thyroid gland. Sudden Weight loss It is important to maintain proper levels of thyroid hormone so that the body can perform its natural functions. Hyperthyroid conditions can cause the metabolism to be higher, thus resulting in weight loss. Heat Intolerance Metabolism and heart rate are increased. By burning up more "fuel" and faster the body transforms the excess energy into heat. Nervousness, Anxiety and Irritability The thyroid hormone essentially activates the entire body. Due to the regional metabolic changes it speeds up your body's metabolism in a way that causes your entire sympathetic nervous system to be more active including mood swings and irritability Tremors It is usually a fine shaking, tremor of the outstretched fingers. It is caused by a heightened beta-adrenergic state, it also increases metabolism of dopamine which in effect creates hyperactive reflexes.
Increased Appetite Thyroid hormones stimulate the uptake of glucose, the level of blood glucose increases rapidly after a meal but then falls rapidly again. Because of increased absorption of these Thyroidectomy Page | 29
nutrients, the hypothalamus is signaled to compensate by activating the hunger center again. Hyperactivity Clients emotions are adversely affected by the turbulent activity within the body. Excessive hyperactivity in turn leads to extreme fatigue and depression, again followed by episodes of over activity. Decreased in cholesterol level As an effect of increased in thyroid stimulating hormone, the body uses more of its lipid deposition to use for energy. This too much uptake causes the liver to release more cholesterol therefore leads cholesterol depletion. Hyperglycemia Although thyroxine is not a counterregulatory hormone, hyperthyroidism can interfere with glucose metabolism. It is associated with both increased sensitivity of pancreatic beta cells to glucose, resulting in increased insulin secretion, and antagonism to the peripheral action of insulin. The latter effect usually predominates, leading to impaired glucose tolerance in untreated patients
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V. THE PATIENT AND HIS CARE

A. Surgical Management
Thyroidectomy
Thyroidectomy is the removal of all or part of your thyroid gland. Your thyroid is a butterfly-shaped gland located at the base of your neck. It produces hormones that regulate every aspect of your metabolism, from your heart rate to how quickly you burn calories. The surgical removal of part or all of the thyroid gland, thyroidectomy allows treatment of hyperthyroidism, respiratory obstruction from goiter, and thyroid cancer. Subtotal thyroidectomy, used to correct hyperthyroidism when drug therapy fails or radiation therapy is contraindicated, reduces secretion of thyroid hormone. It also effectively treats diffuse goiter. After surgery, the remaining thyroid tissue usually supplies enough thyroid hormone for normal function. Total thyroidectomy may be performed for certain types of thyroid cancers, such as papillary, follicular, medullary, or anaplastic neoplasms. After this surgery, the patient requires lifelong thyroid hormone replacement therapy.
Total Thyroidectomy or the Complete Removal of the Thyroid This is the most common type of Thyroid Surgery and most often used for thyroid cancer. In particular, it is advised for aggressive cancers, such as medullary or anaplastic thyroid cancer. It is also used for goiter and Graves' hyperthyroidism treatment. Post a complete removal of the thyroid gland, the patient has to be on constant medication and daily treatment is needed to keep the body's thyroid needs fulfilled. Partial Thyroidectomy or Removal of Half of the Thyroid Gland Also known as Subtotal Thyroidectomy, this operation is generally advised for removal of small and non-aggressive cancer and is contained to one side of the gland. After a partial thyroidectomy, the patient's thyroid gland is able to function naturally and normally. Thyroid Lobectomy or Removal of Only About a Quarter of the Gland A less used approach, this type of Thyroidectomy is advised for very small and non-aggressive cancers as well as in the case of not very severe hyperthyroidism or hypothyroidism. The gland resumes normal functioning post surgery.
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Indications for Surgery

a. Diagnosis of malignant tumor of the thyroid by FNA or prior biopsy b. Vocal cord paralysis with an associated thyroid mass c. Palpable fixation of a thyroid mass to surrounding tissues d. Diagnosis of "follicular neoplasm" of the thyroid by FNA e. Single solid nodule greater than 3.0 cm f. Persistent reaccumulation of an apparent cystic mass despite aspirations or persistent aspiration of blood from an apparently cystic mass g. Symptoms of airway or esophageal compression with associated thyroid mass or goiter h. Patient desires to have a goiter removed for aesthetic reasons i. j. Patient desires to have a nodule removed regardless of presumed pathology As an adjunct to cervical esophageal surgery for improved access
k. While not an absolute indication for thyroid surgery, a nodule present with a prior history of radiation to the neck strongly suggests an aggressive course of treatment l. Rapid growth of a solid thyroid mass
m. Patient desires surgery rather than medical therapy or radioiodine treatment of Grave's disease n. A relative indication for thyroidectomy is the finding of metastatic thyroid disease in neck nodes without an obvious thyroid mass. The decision to perform thyroid surgery in this setting depends on the clinical situation under which the metastatic disease was found. If the metastatic disease was encountered in a palpable node in the absence of other head and neck cancer, thyroid surgery is indicated. When well-differentiated thyroid cancer is seen pathologically in a neck dissection specimen that also contains metastatic squamous cell cancer and there is no evidence of a thyroid mass, thyroidectomy is unlikely to alter the clinical course of the patient if radiation therapy is administered to the neck postoperatively. Thyroidectomy Thyroidectomy Page | 32
may be considered at a later date with sequential follow-up offered as an alternative employing ultrasound imaging.
Positioning/Skin Preparation/Anesthesia
Position The patient is placed in a supine position with the neck extended with cloth roll or sand bag placed under the shoulders. Anesthesia Used Thyroid surgery is more commonly performed with general anesthesia. Some surgeons are now using local anesthesia, plus a sedative, however, to perform thyroid surgery. The benefits of local anesthesia are that it is associated with a shorter hospital stay, shorter actual surgery time, and less vomiting and nausea after surgery. You will, however, be awake during the surgery, and able to interact with your surgeon. Skin Preparation The entire front of neck, from jaw line to nipples is cleaned with Betadine. Draping Sterile sheets are draped above, below and on either sides of neck, keeping only neck portion visible
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Instruments
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Discussion of the Procedure

PREOPERATIVE CONSIDERATIONS Explain to the patient that thyroidectomy will remove diseased thyroid tissue or, if necessary, the entire gland. Tell him that hell have an incision in his neck; that hell have a dressing, and possibly, a drain in place after surgery; and that he may experience some hoarseness and a sore throat from intubation and anesthesia. Reassure him that hell receive analgesics to relieve his discomfort. If thyroidectomy is being performed to treat hyperthyroidism, ensure that the patient has followed his preoperative drug regimen, which will render the gland euthyroid to prevent thyroid storm during surgery. He probably will have received either propylthiouracil or methimazole, usually staring 4 to 6 weeks before surgery. Expect him to be receiving iodine as well for 10 to 14 days before surgery to reduce the glands vascularity and thus prevent excess bleeding. He may also be receiving propanolol to block adrenergic effects. Notify the physician immediately if the patient has failed to follow his medication regimen. Collect samples for serum thyroid hormone determinations to check for euthyroidism. If necessary, arrange for an electrocardiogram to evaluate cardiac status. Ensure that the patient or a legally authorized representative has signed an informed consent form.
1. Skin Incision An incision is made in the skin two finger breadths above the sternal notch between the medial borders of the sternocleidomastoid muscles (two muscles make a V shape in front of the neck). The width of the incision may need to be extended for large masses, or for a lateral lymph node removal.
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2. Subplatysmal Flaps Subcutaneous fat and Platysma (triangle sheet of muscle at both sides of the neck) are divided, and asubplatysmal dissection is made above the incision up to the level of the thyroid cartilage above, and thesternal notch, but remaining superficial to the anterior jugular veins.
3. Separating the Strap Muscles and Exposing the Anterior Surface of the Thyroid The fascia between the sternohyoid, omohyoid and sternothyroid muscles (strap muscles ) is divided along the midline and the muscles retracted laterally. This is an avascular plane but care must be taken not to injure small veins crossing between the anterior jugular veins.
4. Identify the Middle Thyroid Vein. The thyroid gland is rotated medially (using the surgeons fingers). The important vascular structure to identify is the middle thyroid vein (it will be tightly stretched by the medial rotation of the gland), which is then ligated. This permits further mobilisation of the gland and moving the bulk of the lobe out the wound.
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5. Identify the Superior Laryngeal Artery and the External Laryngeal Nerve. Identify the superior laryngeal artery as close to the superior pole of the thyroid parenchyma as possible. Great care should be taken while ligating the superior laryngeal artery so as to avoid injury to the external laryngeal nerve. In some patients the external branch of the superior laryngeal nerve lies on the anterior surface of the thyroid lobe.
6. Identifying The Inferior Parathyroid Gland The inferior parathyroid glands are normally located between the lower pole of the thyroid and the isthmus, most commonly on the anterior or the posterolateral surface of the lower pole of the thyroid. Care must be taken to preserve it in situ and to avoid damaging its inferior thyroid artery.
7. Dividing The Thyroid Isthmus. When doing a thyroid lobectomy, the isthmus, which is crossing between the two thyroid lobes, is divided.
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8. Removing The Thyroid Gland.
The incision is closed in three layers: platysma, subcutaneous tissue, and skin Surgeons typically close the Platysmal layer using buried interrupted 3-0 Monocryl sutures. This is followed by additional buried interrupted 3-0 Monocryl sutures in the subcutaneous skin. A final 4-0 Monocryl suture is used in a subcuticular fashion followed by Dermabond. A Queen Anne dressing is applied. POST-OPERATIVE CONSIDERATIONS Keep the patient in high Fowlers position to promote venous return from the head and neck and to decrease oozing into the incision. Check for laryngeal nerve damage by asking the patient to speak as soon as he awakens from anesthesia.
Watch for signs of respiratory distress. Tracheal collapse, tracheal mucus accumulat5ion, laryngeal edema, and vocal cord paralysis can all cause respiratory obstruction, with sudden stridor and restlessness. Keep a tracheotomy tray at the patients bedside for 24 hours after surgery, and be prepared to assist with emergency tracheotomy, if necessary.
Assess for signs of hemorrhage, which may cause shock, tracheal compression, and respiratory distress. Check the patients dressing and palpate the back of his neck, where drainage tends to flow. Expect about 50 ml of drainage in the first 24 hours; if you find no drainage, check for drain kinking or the need to reestablish suction. Expect only scant drainage after 24 hours.
Assess for hypocalcemia, which may occur when the parathyroid glands are damaged. Test for Chvosteks and Trousseaus signs, indicators of neuromuscular irritability from hypocalcemia. Keep calcium gluconate available for emergency IV administration. Thyroidectomy Page | 38
Be alert for signs of thyroid storm, a rare but serious complication. As ordered, administer a mild analgesic to relieve a sore neck or throat. Reassure the patient that his discomfort should resolve within a few days. If the patient doesnt have a drain in place, prepare him for discharge the day following surgery as indicated. However, if a drain is in place, the physician will usually remove it, along with half of the surgical clips, on the second day after surgery; the remaining clips, the following day, before discharge.
Nursing Responsibilities
SCRUB NURSE Pre-operative Responsibilities 1. Assist with the preparation of the room for the designated surgical procedure, including gathering supplies for the procedure. 2. Scrub, dry hands, gown, and glove. 3. Assist person scrubbed in first position with: a. Setting up back table, mayo, and basins b. Arrangement of instruments c. Preparation of suture and needles d. Preparation and counting sponges e. Arrangement and preparation of other necessary items f. Gowning and gloving surgeon and assistants g. Assist with draping h. Arrangement of sterile field Intra-operative Responsibilities 1. During the procedure, progress from double-scrubbed position. Train self to keep eyes on field, and learn steps of procedure. 2. Begin developing methods of anticipating needs of surgeon andassistant.3. After closing the skin: a. Assist with care of instruments and counts if necessary b. Care of specimen c. Assist with dressing of wound Post-operative Responsibilities 1. After the completion of the Procedure: a. Assist with the gathering of all materials used during theprocedure b. Discard items as necessary being careful to discard sharp items in designated places c. Return all items to respective area d. Assist with cleaning of room e. Clean the materials used properly and arrange them after drying Thyroidectomy Page | 39
2. Perform any duties which will speed up the surgical procedure tofollow in that room. CIRCULATING NURSE Pre-operative Responsibilities 1. Care for the patient before surgery by: a. Greeting patient and assist nurse with identification b. Checking patient's chart, preparation, etc. 2. Prepare the room by: a. Obtaining instruments, supplies, and equipment for the designated operative procedure b. Opening unsterile supplies c. Assisting in gowning d. Observing breaks in sterile technique e. Assisting anesthesiologist as necessary f. Assisting with skin preparation and positioning g. Assisting with forming of the sterile field 3. Count the instruments, sharps and sponges before the procedureand confirm with scrub nurse. Intra-operative Responsibilities 1. During the Procedure: a. Remain in room and dispense materials as necessary b. Observe procedure as closely as possible c. Begin establishing method of anticipating needs of surgical team d. Care of specimen as indicated e. Care of operative records as indicated f. Assist with application of dressing g. Monitor the instruments, sharps and sponges used and take noteof additional instruments. 2. Before the closing of the organ or peritoneum, count all instruments,sharps and sponges and confirm with scrub nurse. 3. Inform the surgeon and assistant surgeon of a report of theinstruments. Post-operative Responsibilities 1. Properly document all the necessary information on the patientschart. 2. Assist in the cleaning of the operating room as necessary
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B. Pharmacological Management Generic Name (Brand Name) Mechanism of Action Indications Side Effects/ Adverse Reaction Contraindications
PROPYLTHIOURACIL Hyperthyroidism Adult: PO 300450 mg/d divided q8h, may need 6001200 mg/d initially Geriatric: PO 150300 mg/d divided q8h Child: PO 610 y, 50150 mg/d; >10 y, 150300 mg/d or 150 mg/m2/d Neonates: PO 510 mg/kg/d Thyrotoxic Crisis Adult: PO 200 mg q46h until full control achieved
As an anti-thyroid drug, PTU inhibits iodine and peroxidase from their normal interactions with thyroglobulin to form T4 and T3. This action decreases production of thyroid hormone. PTU also interferes with the conversion of T4 to T3, and, since T3 is more potent than T4, this also reduces the activity of thyroid hormones. .
PTU is used to manage hyperthyroidism associated with Graves' disease in patients who did not tolerate methimazole, and are not able to receive surgery or radioactive iodine therapy. It also is used to decrease symptoms of hyperthyroidism in preparation for surgical removal of the thyroid gland or before radioactive iodine therapy in patients who did not tolerated methimazole.
The most common side effects are related to the skin and include rash, itching, hiv es, abnormal hair loss, and skin pigmentation. Other common side effects are swelling, nausea, vomitin g, heartburn, loss of taste, joint or muscle aches, numbness and headache. May also cause agranulocytosis .
Contraindicated with allergy to antithyroid drugs, pregnancy

Use cautiously with
lactation
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NURSING RESPONSIBILITIES Before the administration of drug
Check for medical order Determine if patient is allergic to the drug Caution patient on taking blood thinners such as warfarin as this may cause drug interaction and may potentiate the effect leading to bleeding. Instruct patient to avoid use of OTC drugs for asthma, or cough treatment without checking with the physician because they may contain iodide. Give at the same time each day with relation to meals. If drug is being used to improve thyroid state before radioactive iodine (RAI) treatment, discontinued 3 or 4 d before treatment to prevent uptake interference. PTU therapy may be resumed if necessary 35 d after the RAI administration.
Explain possible side effects
During drug administration Maintain aseptic technique Check medication, right route, dosage, storage, etc Stay with the patient while he takes in the drug Do not exceed the recommended dosage
After the administration of drug Monitor any untoward effects of the drug Instruct SOs to report to the attending nurse if any unusual effects occur Arrange for regular, periodic blood test to monitor bone marrow depression and bleeding tendencies. Advise patient that drug must not be discontinued unless the physician told so and it must be taken for a prolonged period to achieve the desired effects. Report and record as appropriate.
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Generic Name (Brand Name)
Mechanism of Action
Indications
Side Effects/ Adverse Reaction
Contraindications
METHIMAZOLE (Tapazole) Hyperthyroidism Adult: PO 515 mg q8h Child: PO 0.20.4 mg/kg/d divided q8h
Thioamide with actions and uses similar to those of propylthiouracil but 10 times as potent. Actions are less consistent, but effects appear more promptly than with propylthiouracil. Inhibits synthesis of thyroid hormones as the drug accumulates in the thyroid gland. Does not affect existing T3 or T4 levels.
For Hyperthyroidism and prior to surgery or radiotherapy of the thyroid; may be used cautiously to treat hyperthyroidism in pregnancy. Long-term use of methimazole may lead to a remission of the hyperthyroidism
GI: hepatotoxicity (rare). Endocrine: Hypothyroidism. Hematologic: Leukopenia, agr anulocytosis, granulocytopenia, thrombocytopenia, pancytopenia, and aplastic anemia. Musculoskeletal:Arthralgia. CNS: Peripheral neuropathy, drowsiness, neuritis, paresthesias, vertigo. Skin: Rash, alopecia, skin hyperpigmentation, urticaria, and pruritus. Urogenital: Nephrotic syndrome.
It is contraindicated in the presence of hypersensitivity to the drug or any of the other product components. Pregnancy (category D), Use cautiously in lactating women
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NURSING RESPONSIBILITIES Before the administration of drug Check for medical order Determine if patient is allergic to the drug Caution patient about taking anticoagulant as this can reduce anticoagulant effects of warfarin; may increase serum levels of digoxin; may alter theophylline levels; Instruct patient to avoid use of OTC drugs for asthma, or cough treatment without checking with the physician because they may contain iodide. Give at the same time each day with relation to meals. Explain possible side effects During drug administration Maintain aseptic technique Check medication, right route, dosage, storage, etc Stay with the patient while he takes in the drug Do not exceed the recommended dosage After the administration of drug Instruct patient to be aware that skin rash or swelling of cervical lymph nodes may indicate need to discontinue drug and change to another antithyroid agent. Ask the patient to notify physician promptly if the following symptoms appear: Bruising, unexplained bleeding, sore throat, fever, jaundice. Drug-induced jaundice may persist up to 10 wk after withdrawal of drug. Closely monitor PT and INR in patients on oral anticoagulants. Anticoagulant activity may be potentiated. Report and record as appropriate.
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Generic Name (Brand Name) CARBIMAZOLE ( Neo-Mecrazole) DOSAGE: 540 mg daily ROUTE: PO
Mechanism of Action
Indications
Contraindications
Carbimazole is an antithyroid agent that decreases the uptake and concentration of inorganic iodine by thyroid, it also reduces the formation of di-iodotyrosine and thyroxine. Once converted to its active form of methimazole, it prevents the thyroid peroxidase enzyme from coupling and iodinating the tyrosine residues on thyroglobulin, hence reducing the production of the thyroid hormones T3 and T4.
For the treatment of hyperthyroidism and thyrotoxicosis. It is also used to prepare patients for thyroidectomy. It reduces the amount of thyroid hormone.
Sore throat, fever, uneasiness, nausea, loss of taste, headache, joint pain and hair loss, Feeling sick, Dizziness. Skin rashes Itching, Bruising, Stomach upset, Painful joints, Liver problems (jaundice) Blood disorders, Muscle pain
Contraindicated in patients with goiter and hypersensitivity.
Should not be used during pregnancy Pregnancy category (D) Caution should be exercised in patients with history of liver disease and during pregnancy and breastfeeding.
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NURSING RESPONSIBILITIES Before the administration of drug Check for medical order Determine whether patient is sensitive to other corticosteroids Do not give drug to nursing mothers; drug may be secreted in breast milk. Ensure patient is not pregnant before giving this drug; advise patient to use barrier contraceptives. Explain possible side effects
After the administration of drug Monitor any untoward effects of the drug Instruct SOs to report to the attending nurse if any unusual effects occur Arrange for regular, periodic blood test to monitor bone marrow depression and bleeding tendencies. Advise patient that drug must not be discontinued unless the physician told so and it must be taken for a prolonged period to achieve the desired effects. Report and record as appropriate.
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Mechanism of Action The lithium ion behaves
Indications
Contraindications
LITHIUM CARBONATE ( lithobid, carbolith, lithizine) Mania Adult: PO Loading Dose 600 mg t.i.d. or 900 mg sustained-release b.i.d. or 30 mL (48 mEq) of solution t.i.d. PO Maintenance Dose 300 mg t.i.d. or q.i.d. or 1520 mL (2432 mEq) solution in 24 divided doses (max: 2.4 g/d) Child: PO 1560 mg/kg/d in divided doses
CNS: Dizziness, headache, lethargy, drowsiness, fatigue, slur sodium ion; but its exact prophylaxis of acute red speech, psychomotor mechanism of action is mania and the acute retardation, giddiness, incontinence, restlessness, unclear. Competes with manic phase of mixed seizures, confusion, blackout various physiologically bipolar disorder. spells, disorientation, recent memory loss, stupor, coma, EEG important cations: Na+, changes. K+, Ca++, Mg++; therefore, Pre-operative drug CV: Arrhythmias, it affects cell membranes, for Graves disease to hypotension, body water, and control vasculitis, peripheral circulatory collapse, ECG neurotransmitters. At the hyperthyroidism and changes. synapse, it accelerates attain euthyroid state. Special Senses: Impaired catecholamine vision, transient scotomas, destruction, inhibits the tinnitus. release of neurotransmitters and decreases sensitivity of postsynaptic receptors. . Endocrine: Diffuse thyroid enlargement, hypothyroidism, Body as a Whole: Edema, weight gain (common) or loss, exacerbation of psoriasis; flulike symptoms.
in the body much like the
Control and
Significant cardiovascular or kidney disease, brain damage, severe debilitation, dehydration or sodium depletion; patients on low-salt diet or receiving diuretics; pregnancy, especially first trimester (category D), lactation, children <12 y.
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NURSING RESPONSIBILITIES Before the administration of drug Check for medical order Determine if patient is allergic to the drug Explain possible side effects
After the administration of drug Monitor response to drug. Usual lag of 12 wk precedes response to lithium therapy. Keep physician informed of progress. Lab test: Periodic lithium levels (draw blood sample prior to next dose or 812 h after last dose); periodic thyroid function tests. Monitor for S&S of lithium toxicity (e.g., vomiting, diarrhea, lack of coordination, drowsiness, muscular weakness, slurred speech when level is 1.52.0 mEq/L; ataxia, blurred vision, giddiness, tinnitus, muscle twitching, coarse tremors, polyuria when >2.0 mEq/L). Withhold one dose and call physician. Drug should not be stopped abruptly. Monitor older adults carefully to prevent toxicity, which may occur at serum levels ordinarily tolerated by other patients. Be alert to and report symptoms of hypothyroidism. Weigh patient daily; check ankles, tibiae, and wrists for edema. Report changes in I&O ratio, sudden weight gain, or edema. Report early signs of extrapyramidal reactions promptly to physician. Report and record as appropriate.
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Generic Name (Brand Name) DEXAMETHASONE (decadron)
Mechanism of Action Long-acting synthetic adrenocorticoid with intense antiinflammatory
Indications
Contraindications
It can be used in the treatment of hypethyroidism. At high does it reduce the peripheral conversion of T4 (tetraiodo-thyronine) to T3 (triiodothyronine). .
Cerebral Edema (glucocorticoid) activity Adult: IV 10 mg followed by and minimal 4 mg q4h, reduce dose after 24 d then taper over 57 d mineralocorticoid Child: PO/IV/IM 12 activity. Antiinflammator mg/kg loading dose, then 1 1.5 mg/kg/d divided q46h y action: Prevents (max: 16 mg/d) accumulation of Shock Adult: IV 16 mg/kg as a single dose or 40 mg repeated q26h if needed Dexamethasone Suppression Test Adult: PO 0.5 mg q6h for 48 h inflammatory cells at sites of infection; inhibits phagocytosis, lysosomal enzyme release, and synthesis of selected chemical mediators of inflammation; reduces capillary dilation and permeability.
Aerosol therapy: Nasal Systemic fungal irritation, dryness, epistaxis, infection, acute rebound congestion, bronchial infections, active or asthma, anosomia, perforation resting tuberculosis, of nasal septum. vaccinia, varicella, Systemic Absorption administration of live CNS: Euphoria, insomnia, virus vaccines (to convulsions, increased ICP, vertigo, headache, psychic patient, family disturbances. members), latent or CV: CHF, active amebiasis. hypertension, edema. Endocrine: Menstrual Ophthalmic irregularities, hyperglycemia; c use: Primary open-angle ushingoid state; growth glaucoma, eye infections, suppression in children; superficial ocular herpes hirsutism. Special Senses: Posterior simplex, keratitis and subcapsular cataract, increased tuberculosis of eye. Safe IOP, glaucoma, use during pregnancy exophthalmos. GI: Peptic (category C), lactation, ulcer with possible perforation, or in children is not abdominal distension, nausea, established. increased appetite, heartburn, dyspepsia, pancreatitis, bowel perforation, oral candidiasis.
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Check for medical order Determine if patient is allergic to the drug Instruct patient to avoid use of OTC checking with the physician Explain possible side effects
After the administration of drug Monitor for S&S of a hypersensitivity reaction (see Appendix F). The acetate and sodium phosphate formulations may contain bisulfites, parabens, or both; these inactive ingredients are allergenic to some individuals. Intruct patient to Report lack of response to medication or malaise, orthostatic hypotension, muscular weakness and pain, nausea, vomiting, anorexia, hypoglycemic reactions mental depression to physician. These symptoms may signal hypoadrenocorticism. Note: Hiccups that occur for several hours following each dose may be a complication of highdose oral dexamethasone. Advise patient that drug must not be discontinued unless the physician told so and it must be taken for a prolonged period to achieve the desired effects. Report and record as appropriate.
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Mechanism of Action Competitively blocks betaadrenergic receptors in the heart and juxtaglomerular apparatus, decreasing the influence of the sympathetic nervous system on these tissues, the excitability of the heart, cardiac workload and oxygen consumption, and the release of rennin and lowering BP; has membrane-stabilizing(local anesthetic)effects that contribute to its anti arrhythmic action; acts in the CNS to reduce sympathetic outflow and vasoconstrictor tone.
Indications Management of cardiac arrhythmias, myocardial infarction, tachyarrhythmias associated with digitalis intoxication, anesthesia, and thyrotoxicosis,.
Side Effects/ Adverse Reaction CV: Palpitation, profound bradycardia, AV heart block, cardiac standstill, of hands. Special Senses:Dry eyes (gritty sensation), visual disturbances, conjunctivitis, tinnitus, hearing loss, nasal stuffiness. GI: Dry mouth, cheilostomatitis, nausea, vomiting, heartburn, diarrhea, constipation, flatulence, abdominal cramps, mesenteric arterial thrombosis, ischemic colitis, pancreatitis. Hematologic: Transient eosinophilia, thrombocytopenic or nonthrombocytopenic purpura,agranulocytosis. Metabolic: Hypoglycemia, hyperglycemia, hypocalcemia (patients with hyperthyroidism). Respiratory: Dyspnea, laryngospas m, bronchospasm.
Contraindications
PROPANOLOL (inderal,detensol) Adult: PO 40 mg b.i.d., usually need 160480 mg/d in divided doses; InnoPran XL dose 80 mg q hs, may increase to 120 mg hs Child: PO 1 mg/kg/d in 2 divided doses (15 mg/kg/d)
Greater than first-degree heart block; CHF, right ventricular failure secondary to pulmonary hypertension; ventricular dysfunction; sinus bradycardia, cardiogenic shock, significant aortic or mitral valvular disease; bronchial asthma or bronchospasm, severe COPD, pulmonary edema, allergic rhinitis during pollen season; .
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Check for medical order Determine if patient is allergic to the drug Be consistent with regard to giving with food or on an empty stomach to minimize variations in absorption. Take apical pulse and BP before administering drug. Withhold drug if heart rate <60 bpm or systolic BP <90 mm Hg. Consult physician for parameters. Ensure that sustained release form is not chewed or crushed. Must be swallowed whole. Instruct patient to avoid use of OTC checking with the physician Explain possible side effects
After the administration of drug Monitor response to drug. Lab tests: Obtain periodic hematologic, kidney, liver, and cardiac functions when propranolol is given for prolonged periods. Instruct patient no to discontinue drug abruptly; can precipitate withdrawal syndrome (e.g., tremulousness, sweating, severe headache, malaise, palpitation, rebound hypertension, MI, and life-threatening arrhythmias in patients with angina pectoris). Report and record as appropriate.
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C.
Diet
General Description Type of diet wherein the client is not allowed to eat anything for a certain period of time, either fluids or foods. Medical instruction meaning, to withhold oral food and fluids from a patient for various reason Indication of Purpose It is necessary that NPO order be carried out to assure accuracy of findings of tests. Examples of Allowed Foods
Type of Diet PRE-OP NPO
POST-OP Clear Liquid diet
A clear liquid diet consists of clear liquids, such as water, broth and plain gelatin, that are easily digested and leave no undigested residue in your intestinal tract.
A clear liquid diet may Plain water, Fruit juices be prescribed after without pulp, such as apple surgery to help juice, grape juice or maintain adequate cranberry juice, Strained lemonade or fruit punch, hydration, provides Clear, fat-free broth some important (bouillon or consomme). electrolytes, such as Clear sodas, Plain gelatin, sodium and Honey, Ice pops without potassium, and gives bits of fruit or fruit pulp, some energy at a time Tea or coffee without milk or cream when a full diet isn't possible or recommended. This was ordered to
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Soft diet
This diet incorporates food that are moderately low in fiber have a soft texture and moderately seasoned The diet is individualized to meet the needs of the patient and varies from smooth creamy foods.
provide a transitional diet between liquids and regular food for patient who undergone surgery.
Use more sauces and gravies moist food is easier to swallow than dry water, juice, mashed vegetables and potatoes, ice cream, pudding, milk shakes, eggs, broth, pasta, chile, bean, tender meats, fish and gelatin.
Diet as Tolerated (DAT)
Diet as tolerated means to eat what your stomach can tolerate. The doctor will give you a list of food that you can eat and will say to eat them as often as you can tolerate them.
This particular diet is only giver when client can now tolerate any food she/he desires that is nutritious, if this will not lead to any complications and if the client needs further monitoring for lab test
Vegetables, fruits, grains, meat,
NURSING RESPONSIBILITIES BEFORE, DURING, AND AFTER
Before the Procedure

Check the doctors order. Check the right client. Be sure that the diet is properly instructed. Explain the reason for type of diet Monitor if the client complies with the given diet. Be sure patient is taking or eating food he/she can tolerate Assess for patients condition; how he responded to the diet.
During the Procedure
After the Procedure
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D. Activity/Exercise
Type of Activity Semi-fowlers Position General Desription Indications or Purposes
Placement of the patient in an inclined position, with the upper half of the body raised by elevating the head of the bed approximately 30 degrees.
To reduce swelling and edema in neck area. Sandbags or pillows used to support clients head or neck. To prevent hyperextension of the neck and protects integrity of the suture line.
May sit up on bed & ambulate
The patient may sit up on bed in ambulatory state slowly and gradually, walking and moving from one place to another.
To facilitate gradual return of patient in normal activities of daily living. light activity, such as walking, is fine. However, there should be no strenuous activity (exercising, etc) for 2 weeks following the surgery.
NURSING RESPONSIBILITIES

Educate client regarding his activity Assisting client to his bathroom privileges Explain the purpose of restrictions in activity and position in bed as ordered. Assist the patient to maintain the prescribed position. Encourage the patient to adhere to ordered activity. Accomplish necessary documentation of patients reaction to the ordered activity restrictions.
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VI. NURSING CARE PLAN

Deficient Knowledge
CUES
NURSING DIAGNOSIS
SCIENTIFIC EXPLANATION Deficient Knowledge is the absence or
OBJECTIVES Short Term:
NURSING INTERVENTIONS Ascertain level of knowledge, including anticipatory needs.
RATIONALE To know what is the level of understanding of the person to know what information should be reinforced. Right timing is important in giving information, knowing the clients ability gives the nurse idea on what way will he/she present the information. Personal Factors are important in learning, because learning is individualized To make some techniques to avoid being affected by those barriers This will help the
Deficient The patient may Knowledge r/t manifest the following: unfamiliarity with o inappropriate information or exaggerated resources behavior o unfamiliarity to disease condition o inaccurate follow through of instruction o incompliance to the treatment regimen
After 2 hours of nursing interventions, deficiency of the pt. will be able to cognitive information Exhibit increased Determine clients ability to learn interest/assume necessary for the responsibility for own learning and begin to client/SOs to make look for information and ask question. informed choices regarding the condition, treatment or lifestyle changes. Long Term: After 2 days of Nursing Interventions, the pt. will be able to initiate necessary lifestyle changes and participate in treatment regimen.
Noted personal factors
Determine Barriers to learning
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Identify motivating
factors for the individual
individual to learn
Provide information relevant to the situation
To let the client know about the present situation.
Determine patients most urgent need
Knowing to prioritize the patients learning needs increases the effectivity of the teaching plan To know what are the purpose of the patient teaching
Recognize level of achievement, time factors, and short term and long term goals.
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Risk for Injury (tetany) CUES Patient may experience: NURSING DIAGNOSIS Injury, risk for (tetany) Risk factors may include: chemical imbalance: excessive CNS stimulation SCIENTIFIC EXPLANATION Temporary postthyroidectomy hypocalcaemia is a relatively common complication, due to removal, injury or devascularization of the parathyroid glands. It may also be secondary to hungry bones due to postoperative reversal of thyrotoxic osteodystrophy, reactive Thyroidectomy o Be free from injury associated with calcium deficit, as evidenced by no falls or near falls and no pathologic fractures. Page | 58 OBJECTIVES After 2 hours of nursing interventions, The client will be able to: o Verbalize understanding of individual factors that contribute to possibility of injury and take steps to correct 2. Evaluate reflexes periodically, observe for neuromascular irritability. (e,g., twitching, numbness, paresthesias, positive Chvostek;s and trousseaus signs, seizure activity.) 3. Keep side rails raised and padded, bed in low position, and airway at bedside. Avoid use of restraints. NURSING INTERVENTIONS 1. Monitor vital signs RATIONALE 1. Manipulate of gland during subtotal thyroidectomy may result in increased hormone release, causing thyroid storm and altered vital signs 2. Reduces potential for injury if seizures occur.
o Tingling sensation around the mouth o muscle aches o weakness or o twitching, o difficulty swallowing
3. Reduces potential for injury if seizures occur.
hypoparathyroidism due to relative hypercalcaemia in thyrotoxic patients or calcitonin release due to operative manipulation of the thyroid glands.
4. Monitor serum calcium levels
4. Patients with levels less than 7.5mg/100ml generally require replacement therapy 5. Corrects deficiency which is usually temporary but may be permanent. 6. Helpful in lowering elevated phosphorus levels associated with hypocalcemia. 7. Promotes rest, reducing exogenous stimulation 8. Controls seizures activity until corrective therapy is successful.
5. Prepare medication at bedside. Administer medications as indicated: calcium (gluconate, lactate) 6. Prepare and administer Phosphate-binding agents as ordered 7. Carry out any orders of Sedatives administration 8. In case of seizure, administer Anticonvulsants as ordered.
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Risk for Bleeding
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Risk for Impaired Verbal Communication r/t: Vocal cord injury/laryngeal nerve damage
CUES NURSING DIAGNOSIS SCIENTIFIC EXPLANATION Thyroidectomy is a surgical procedure. Apart from rare hemorrhagic or infectious complications, thyroid surgery may also induce voice disorders which are generally transient but sometimes permanent. They usually occur as a result of a nerve lesion (recurrent or external laryngeal nerves). Due to the proximity of the organs, the surgery may bring accidental Thyroidectomy damage to the o Establish method of communicatio n in which needs can beunderstood Page | 61 3. Provide alternative methods of communication as appropriate, e.g., slate board, letter/picture 3. Facilitates expression of needs and to easily understand the patient. DESIRED OUTCOMES After 4 hours of nursing interventions, the patient will be able to: o Verbalize or indicate an understanding of the communicatio n difficulty and plans for ways of handling 2. Keep communication simple; ask yes/no questions. 2. Reduces demand for response; promotes voice rest. NURSING INTERVENTIONS 1. Assess speech periodically; encourage voice rest. RATIONALE
Patient may experience Impaired Verbal Hoarsnessness sorethroat Difficulty in forming words/sentenc es Difficulty expressing thoughts verbally Difficulty in comprehendin g/ maintaining usual communicatio n pattern. Communication r/t: Vocal cord injury/laryngeal nerve damage
1. Hoarseness and sore throat may occur secondary to tissue edema or surgical damage to recurrent laryngeal nerve and may last several days.
adjacent organs which includes the larynx nerve. Permanent nerve damage can occur (rare) that causes paralysis of vocal cords and/or compression of the trachea.
board.. 4. Anticipate needs as possible. Visit patient frequently. 5. Post notice of patients voice limitations at central station and answer call bell promptly. 6. Maintain quiet environment 4. Reduces anxiety and patients need to communicate. 5. Prevents patient from straining voice to make needs known/summon assistance. 6. Enhances ability to hear whispered communication and reduces necessity for patient to raise/strain voice to be heard.
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Risk for Ineffective airway clearance: risk factors may include tracheal obstruction edema, hematoma, laryngeal spasm CUES NURSING DIAGNOSIS SCIENTIFIC EXPLANATION Respiratory distress Patient may experience: Changes in respiratory rate/ rhythm Diminished/ adventitious breath sounds (rhonchi) Orthopnea
Cyanosis
DESIRED OUTCOMES
NURSING INTERVENTIONS
RATIONALE
Risk for After 4 hours of 1. Monitor respiratory may be experienced Ineffective nursing rate, depth, and airway clearance: interventions, the work of breathing. by a post-operative risk factors may patient will be able include tracheal to: thyroidectomy patient obstruction due to possible edema, hematoma, o Expectorate laryngeal spasm sputum airway obstruction effectively and tracheal compression or closure of glottis from laryngeal nerve damage brought by the trauma during surgery or pressure from swelling after surgery. o Demonstrate controlled coughing techniques. o Demonstrate behaviors to improve or maintain clear airway.
Respirations may remain somewhat rapid, but development of respiratory distress is indicative of tracheal compression from edema or hemorrhage.
2. Auscultate breath sounds, noting presence of rhonchi.
Rhonchi may indicate airway obstruction/accumula tion of copious thick secretions.
3. Assess for dyspnea, stridor, crowing, and cyanosis. Note quality of voice.
Indicators of tracheal obstruction/laryngeal spasm, requiring prompt evaluation and intervention. Reduces likelihood of tension on surgical wound.
4. Caution patient to avoid bending neck; support head Page | 64
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with pillows. 5. Assist with repositioning, deep breathing exercises, and/or coughing as indicated. Maintains clear airway and ventilation. Although routine coughing is not encouraged and may be painful, it may be needed to clear secretions.
6. Suction mouth and trachea as indicated, noting color and characteristics of sputum. 7. Check dressing frequently, especially posterior portion.
Edema/pain may impair patients ability to clear own airway.
If bleeding occurs, anterior dressing may appear dry because blood pools dependently. May indicate edema/sequestered bleeding in tissues surrounding operative site.
8. Investigate reports of difficulty swallowing, drooling of oral secretions.
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9. Keep tracheostomy Compromised airway may create a lifetray at bedside. threatening situation requiring emergency procedure.
10. Assist with/ prepare for procedures, e.g.: Tracheostomy; Return to surgery.
May be necessary to maintain airway if obstructed by edema of glottis or hemorrhage.May require ligation of bleeding vessels.
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Acute Pain
CUES Patient may manifest the following: o Episodes of pain, verbal reports, swelling, and bruising around the wound area.
NURSING DIAGNOSIS Acute Pain May be related to: Surgical interruption/m anipulation of tissues/muscles
SCIENTIFIC EXPLANATION
DESIRED OUTCOMES
NURSING INTERVENTIONS 1. Assess verbal/nonverbal reports of pain, noting location, intensity (010 scale), and duration. 2. Monitor vital signs
RATIONALE Useful in evaluating pain, choice of interventions, effectiveness of therapy.
o During the first few days, eating and drinking can be associated with Possibly some discomfort and evidenced by pain. Reports of pain
Postoperative edema/ presence of surgical incision
Narrowed focus; guarding behavior; restlessness Autonomic responses
After 4 hours of nursing interventions, the of tissue and nerve patient will be able endings due to to: o Report pain is trauma from relieved or surgery(incision) and controlled o Verbalize noncause hypersensitivity pharmacologic to the central nervous al methods that provides system that causes relief unpleasant physical o Demonstrate use of and emotional relaxation reactions and skills and diversional responses. activities. o Follow prescribed pharmacologic al regimen. Complex responses
Usually altered in acute pain
3. Place in semiFowlers position and support head/neck with sandbags or small pillows.
Prevents hyperextension of the neck and protects integrity of the suture line.
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4. Maintain head/neck in neutral position and support during position changes. Instruct patient to use hands to support neck during movement and
Prevents stress on the suture line and reduces muscle tension.
to avoid hyperextension of neck.
5. Keep call bell and frequently needed items within easy reach.
Limits stretching, muscle strain in operative area.
6. Give cool liquids or soft foods, such as ice cream or popsicles.
Although both may be soothing to sore throat, soft foods may be tolerated better than liquids if patient experiences difficulty swallowing. Helps refocus attention and assists patient to manage pain/discomfort more effectively.
7. Encourage patient to use relaxation techniques, e.g., guided imagery, soft music, progressive relaxation.
8. Administer Thyroidectomy Page | 68
Reduces pain and
analgesics and/or analgesic throat sprays/lozenges as necessary. 9. Provide ice collar if indicated.
discomfort; enhances rest.
Reduces tissue edema and decreases perception of pain.
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VIII. CONCLUSION
Hyperthyroidism has been described in the literature as the overfunctioning of the thyroid gland. In the clinical findings, amongst the etiologies include: infections, autoimmune deficiencies, age, gender, lifestyle and genetic predispositions. As we all know, the thyroid gland plays a very intricate role in certain body processes like metabolism and hormone regulations. Any malfunctions may digress the bodys homeostasis leading to chain of inflammatory processes although the progression of the disease varies with age, diet and life-style related factors.
In the recent years, the incidence of hyperthyroidism has decline in many industrialized countries as a result of breakthroughs in medicine. These had lead to increased recognition and treatment of the diseases risk factors. As a student nurse, we also play a very vital role throughout the course of the disease. Patient education is focused on prevention, recognition of clinical manifestations and early treatment of hyperthyroidism. Information-dissemination may help our patients be aware of the classic signs and symptoms of hyperthyroidism, which therefore can help them detect the disease as early as possible and avoid the risk factors. Our primary goal here is to restore the normal functioning of the thyroid gland hence prompt recognition of the cause allows early treatment and management. Better prognosis is achieved if the condition will be given an immediate attention.
As part of the treatment, thyroidectomy may be necessary if the disease has progressed to advanced stage. Critical care should be observed as the client might experience discomforts after the surgery. The complications post-operatively put the patient in danger if not distinguished immediately. It is very important that the student nurses are equipped with adequate knowledge to attend to the immediate needs of the patient. Page | 70
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IX. RECOMMENDATION
This case study is recommended to the following: A. To the Philippine Government, they may be aware of the incidence of the disease condition in our country and that they may help those who are less fortunate by making the health care services more affordable and acceptable; B. To the Department of Health, that they may implement the effective treatment of hyperthyroidism and that they may have proper information dissemination about the disease condition; C. To the health care providers, particularly physicians and nurses, that they may have the proper knowledge and skills regarding this medical condition, its management and as well as its treatment; D. To the medical interns and student nurse, that they become aware of the current trends and issues in both medicine and nursing field about hyperthyroidism, its new innovation and treatment as well; E. To those support groups who are willing to extend their hand for those unlucky few, that they may give adequate needs in order to cure the disease condition; F. To the families who have a member who is suffering from the disease condition, that they may become aware and conscious with this kind of condition; G. And to the Filipino people, that they may have background regarding the treatment for thyroid diseases in different ages of patient.
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X. BIBLIOGRAPHY
Bahn RS, Burch HB, Cooper DS, et al. Hyperthyroidism and other causes of thyrotoxicosis: Management Guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Endocr Pract. 2011;17:457-520. Davies TF, Larsen PR. Thyrotoxicosis. In: Kronenberg HM, Melmed S, Polonsky KS, Larsen PR, eds. Williams Textbook of Endocrinology . 11th ed. Philadelphia, Pa: Saunders Elsevier; 2008:chap 11.
Ladenson P, Kim M. Thyroid. In: Goldman L, Ausiello D, eds. Cecil Medicine . 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 244
Halsted WS. The operative story of goiter. The authors operation. Johns Hopkins Rep. 1920;19:71257.
Hoffman HT, Rojeski M, Funk GF, McCulloch TM. The solitary thyroid nodule. In Gates GA, ed. Current Therapy in Otolaryngology. St. Louis, Mo: Mosby: 1994:319-323.
Karlan MS, Catz B, Dunkelman D, Uyeda RY, Gleischman S. A safe technique for thyroidectomy with complete nerve dissection and parathyroid preservation. Head Neck. 1984;6:10141019.
https://wiki.uiowa.edu/display/protocols/Thyroidectomy+and+Thyroid+Lobectomy http://khalidalomari.weebly.com/anatomical-steps-of-thyroidectomy.html
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I.

II. Nursing History

III. PHYSICAL EXAMINATION

IV. DIAGNOSTICS AND LABORATORY PROCEDURES

V. THE PATIENT AND HIS ILLNESS

THE PATIENT AND HIS CARE

VII. NURSING CARE PLANS VIII. CONCLUSION IX. X. RECOMMENDATION BIBLIOGRAPHY

II. Nursing History

D. History of Present Illness E. Lifestyle

IPPA- Cephalocaudal Assessment

Hair o Thinning of scalp hair (patches) o Shiny hair

Breast o Enlarged breasts in men

Abdomen o Enlarged spleen and/or liver o Increased bowel sounds

DIAGNOSTICS AND LABORATORY PROCEDURES

C. White Blood Cells (WBC)

D. Red Blood Cells (RBC)

4.0 6.0 million / mm RBC is normal.

Diagnostic/ Laboratory Procedure 2. Blood Chemistry A. Calcium

Analysis and Interpretation

To evaluate bone diseases and the function of the parathyroid glands.

8.5 10.5 mg/dl

B. Fasting Blood Glucose

To measure the amount of a sugar called glucose in a sample of your blood

C. Total Cholesterol Test

Measures all the cholesterol in the blood.

120 200 mg/dL

Cholesterol level is decrease in hyperthyroidism due to increased bile excretion of cholesterol.

Analysis and Interpretation

TSH blood test is used to check for thyroid gland problems.

B. Radioactive Iodine Uptake

E. Triiodothyronine (T3) radioimmunoassay

100 200 ng/dL

T3 is high as a sign of overactive thyroid gland.

Doubling of baseline TSH 30 minutes after IV injection of 500mcg TRH

TSH rises approximately twice its normal.

Diagnostic/ Laboratory Procedure Diagnostic Imaging Studies A. Thyroid Scan

Analysis and Interpretation

Hot nodules: benign

color on the computer image.

Degree of inhomogeneity is present with typical features of thyrotoxicosis.

C. Magnetic Resonance Imaging (MRI)

Used to visualize gland size, location, identify abnormalities.

Enlarged thyroid gland

Thyroid is of normal size, shape, and position.

THE PATIENT AND HIS ILLNESS

A. Anatomy and Physiology

The Thyroid Gland

Thyroid Hormone Physiology

Secretion of Thyroid Hormones

Modifiable Factors: *Diet high iodine intake *Drugs *Infection

Non-modifiable Factors: *Age *Gender (Women) *Genetic Susceptibility

Hypothalamus secretes TRH Signals Pituitary gland to release TSH

Excess thyroid hormone (T3, T4)

Increased iodide uptake

Increased rate of thyroid gland metabolism

TRH, TSH Supression

Enlargement of ocular muscles

Upper lid lag Thyroidectomy

Increased globe gaze, exopthalmos

Peripheral vasodilation due to heat load

Increased beta-adrenergic receptors

Increased basal metabolic rate

Endocrine Disruption of PTH Mechanism Decreased PTH secretion

Modifiable Factors: Diet high iodine intake Drugs *Infection

Non-modifiable Factors: Age Gender (Women) *Genetic Susceptibility