THE CLIENT WITH ENDOCRINE HEALTH PROBLEMS THYROID GLAND DISORDER

HYPERTHYROIDISM
(GRAVE’S DISEASE or THYROTOXICOSIS)

Data Base
A. General information: Etiology and Pathophysiology
1. Excessive concentration of thyroid hormones in the blood as a result of thyroid disease or increased TSH; leads to
hypermetabolic state
2. Etiology of Grave’s disease is mediated by immunoglobulin G (IgG) antibody that activates TSH receptors on the surface of
the thyroid cells
3. Etiology of Grave’s disease is unknown but may also believed to be involved with an autoimmune process of impaired
regulation; associated with to other autoimmune disorders
4. The gland may also enlarge (goiter) as a result of decreased iodine intake; no increase in secretion of thyroid is present
5. Most seen in women between ages 30-50 years of age

B. Clinical findings
1. Subjective: polyphagia; emotional liability; apprehension; heat intolerance
2. Objective
a. Weight loss despite of appetite and adequate caloric intake; loose stools; tremors, hyperactive reflexes; diaphoresis;
diarrhea; insomnia; exophthalmos (protrusion of the eyeballs), corneal ulceration; increased systolic blood pressure,
temperature, pulse, and respiration; warm, smooth skin; fine, soft hair; pliable nails, hypertension and tachycardia; mood
problem (irritability)
b. In women, there are changes in the menstrual interval, diminished menstrual flow (oligomenorrhea), or even the absence
of menstruation (amenorrhea) may result from hormonal imbalances of thyrotoxicosis
c. Decreased libido and impotence in men are common features of thyrotoxicosis
d. Decreased TSH levels if thyroid disorder; increased TSH levels if secondary to a pituitary disorder
e. Grave’s disease generally involves hyperthyroidism, goiter, and exophthalmos
f. Thyrotoxic crisis (thyroid storm): a state of hypermetabolism (raising the pulse and temperature) that may lead to heart
failure; usually precipitated by a period of severe physiologic or psychologic stress, thyroid surgery, or radioactive
iodine therapy
3. Diagnostic tests
a. Blood chemistry shows increased serum triiodothyronine (T 3), thyroxine (T4), free T4 levels, protein-bound iodine (PBI);
Long-acting thyroid simulator (LATS), elevated serum concentrations of thyroid hormones and suppressed serum TSH.
b. Radioactive iodine uptake is increased
c. Thyroid scan shows nodules

C. Medical management
1. Drug therapy
a. Antithyroid drugs (Propylthiouracil [PTU] and Methimazole [Tapazole]): block synthesis of thyroid hormone; toxic
effects include agranulocytosis and leucopenia which usually occur within the 3 months of treatment; the client should
be taught to promptly report to the health care provider any signs and symptoms of infection, such as a sore throat and
fever; any client complaining of a sore throat and fever should have an immediate white blood cell (WBC) count and
differential performed, and the drug must be held until the results are obtained
b. Adrenergic blocking agents (commonly propanolol [Inderal]): used to decrease sympathetic activity and alleviate
symptoms such as tachycardia
2. Radioactive iodine (RAI) therapy
a. Radioactive isotope of iodine (e.g., in the form of sodium iodide 131I) given to destroy the thyroid gland, thereby
decreasing production of thyroid hormone; the patient should remain in the outpatient department for about 2 hours to be
monitored for vomiting
b. Used in middle-aged or older clients who are resistant to, or develop toxicity from, drug therapy
c. Permanent hypothyroidism is a potential major complication. At that time, the client will need to be able to recognize
symptoms hypothyroidism, not hyperthyroidism
d. The clients need to be educated about the need for lifelong thyroid hormone replacement; lifelong medical follow-up and
thyroid replacement are warranted
e. The client does not need to be immobilized after RAI treatment
3. Surgery: thyroidectomy performed in younger clients for whom drug therapy has not been effective

D. Treatment
1. High-protein, high-carbohydrate, high-calorie diet, restricting stimulants, such as coffee and caffeine
2. Radiation therapy
3. Thyroidectomy

E. Therapeutic intervention
1. Antithyroid medications such as prophylthiouracil (PTU) and methimazole (Tapazole) to block the synthesis of thyroid
hormone

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THE CLIENT WITH ENDOCRINE HEALTH PROBLEMS THYROID GLAND DISORDER

2. Antithyroid medications such as iodine (saturated solution of potassium iodide, SSKI) to reduce the Vascularity of the
thyroid gland; frequently prescribed preoperatively for the client; should be diluted well in milk, water, juice, or a carbonated
beverage before administration to help disguise the strong, bitter taste. Also, this drug is irritating to mucosa if taken
undiluted. The client should sip the diluted preparation through a drinking straw to help prevent staining of the teeth.
3. Radioactive iodine 131I to destroy thyroid gland cells, thereby decreasing the production of thyroid hormone (atomic cocktail)
4. Medications to relieve the symptoms related to the increased metabolic rate such as adrenergic blocking agents
5. Well-balanced, high-calorie diet with vitamin and mineral supplements
6. Surgical intervention involves a subtotal or total thyroidectomy

Nursing Care of Clients with Hyperthyroidism

A. ASSESSMENT
1. History of weight loss, diarrhea, insomnia, emotional lability, palpitations, and heat intolerance
2. Eyes for exophthalmos, tearing, and sensitivity to light
3. Neck palpation for enlarged thyroid gland
4. Weight and vital signs to establish baseline

B. ANALYSIS/NURSING DIAGNOSES
1. Ineffective coping related to emotional lability
2. Risk for Ineffective Therapeutic Regimen Management R/T lack of knowledge about disease
3. Imbalanced nutrition: less than body requirements related to increased metabolic needs

C. PLANNING/IMPLEMENTATION
1. Monitor vital signs, daily weights
2. Use measure such as decreased stimulation, medications, and back rub to establish a climate for uninterrupted rest
3. Protect the client from stress-producing situations
4. Keep the room cool
5. DIET: Provide foods high in calories, proteins, and carbohydrates with supplemental feedings between meals and at bedtime;
vitamin and mineral supplements should be given as prescribed; avoid beverages containing caffeine, which may increase
thyroid activity; high-fiber foods should be avoided as it increases peristalsis
6. Understand that the client is upset by lability of mood and exaggerated response to environmental stimuli; take time to
explain disease process involved
7. Provide eye drops or patches as needed; teach the client to prevent corneal irritation from mild exophthalmos by wearing
dark-colored glasses; treatment of ophthalmopathy should be performed in consultation with an ophthalmologist
8. Care for the client before a thyroidectomy
a. Administer prescribed antithyroid medications to achieve euthyroid state
b. Teach deep breathing exercises and use of hands to support neck and to avoid strain ion suture line
9. Care for the client following a thyroidectomy
a. Observe for signs of respiratory distress and laryngeal stridor caused by tracheal edema (keep tracheotomy set available)
b. Provide humidity with cold steam nebulizer to keep secretions moist when at home
c. Keep the bed in a semi-Fowler’s position
d. Observe dressings at the operative site and back of the neck and shoulders for signs of hemorrhage
e. Observe for signs of thyroid storm such as high fever, tachycardia, irritability, delirium, coma; may result from
manipulation of the gland during surgery, which releases thyroid hormone into bloodstream
f. Notify the physician immediately if signs of thyroid storm occur; administer propanolol (Inderal), iodides,
propylthiouracil, and steroids as ordered
g. Observe for signs of tetany such as numbness or twitching of extremities, spasm of the glottis;
h. Hypocalcemia can occur after accidental trauma or removal of the parathyroid glands; if tetany occurs, give calcium
gluconate or calcium chloride (IV) as prescribed
i. Assess for hoarseness; may result from endotracheal intubation or laryngeal nerve damage; laryngeal nerve damage is a
potential complication of thyroid surgery because of the proximity of the thyroid gland to the recurrent laryngeal nerve.
Asking the client to speak helps assess for signs of laryngeal nerve damage; persistent or worsening hoarseness and
weak voice are signs of laryngeal nerve damage and should be reported to the physician immediately; laryngeal nerve
damage can result in vocal cord spasm and respiratory obstruction
10. Provide teaching regarding radioactive iodine therapy
a. Following therapy client returns to the community
b. Hospitalization in isolation may be required for several days if larger doses are used
c. Symptoms of hyperthyroidism may take 3 to 4 weeks to subside
11. Teach client signs and symptoms of:
a. Hypothyroidism as a result of treatment
b. Hyperthyroidism as a result of thyroid storm or overmedication with thyroid hormone replacement therapy
12. Teach the importance of taking antithyroid medications regularly and to observe for adverse effects.

D. EVALUATION/OUTCOMES
1. The client’s weight and vital signs are within normal limits
2. The client verbalizes understanding and follows the recommended treatment
3. Establishes regular routine of activity and rest

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