Nursing care of patient with hyperthyrodism

Objectives :1. explain the pathophysiology ,etiologies, signs, and

symptoms of hyperthyrodism in order to take care of pt 2. Identify therapeutic treatment of hyperthyrodism in order to

take care of pt 3. Identify data would you collect when caring for patients

with hyperthyrodismin order to take care of pt 4. Identify nursing care will you provide for patients with 4. Identify nursing care will you provide for patients with

hyperthyrodismin order to take care of pt5. Use the nursing process as a framework for care of patients

with hyperthyrodismin order to take care of pt6. Identify the nursing care for pt underwent thyedectomy

Hyperthyroidism

Hyperthyroidism is the second most prevalent endocrine disorder, after diabetes mellitus.

Graves’ disease, the most common type of Graves’ disease, the most common type of hyperthyroidism, results from an excessive output of thyroid hormones.

It affects women eight times more frequently than men

Pathophysiology

Hyperthyroidism results in excessive amounts of circulating thyroid hormone (thyrotoxicosis).

Primary hyperthyroidismPrimary hyperthyroidism

occurs when a problem within the thyroid gland causes excess hormone release.

Secondary hyperthyroidism

Occurs because of excess TSH release from the pituitary, causing overstimulation of the thyroid gland; thyroid gland;

Tertiary hyperthyroidism is caused by excess TRH from the hypothalamus.

A high level of thyroid hormone increases the metabolic rate and increase the number of beta-adrenergic receptor sites in the body, which enhances the activity of norepinephrine. which enhances the activity of norepinephrine.

The resulting fight-or-flight response is the

cause of many of the symptoms of hyperthyroidism.

Etiology

A variety of disorders can cause hyperthyroidism.

Graves’ disease

Multinodular goiter, in which thyroid nodules secrete excess TH

A pituitary tumor .A pituitary tumor .

A thyroid tumor.

Patients taking thyroid hormone for hypothyroidism may take too much.

Heredity may also play a role in autoimmune hyperthyroidism.

Signs and Symptoms

Many signs and symptoms are related to the hypermetabolic state, such as

heat intolerance, increased appetite with

weight loss, and increased frequency of weight loss, and increased frequency of bowel movements. Nervousness, tremor, tachycardia, and palpitations.

Heart failure may occur because of tachycardia and the resulting inefficient pumping of the heart.

If treatment is not begun, the patient may If treatment is not begun, the patient may become manic or psychotic.

Additional signs that occur only with Graves’ disease include thickening of the skin on the anterior legs and exophthalmos (bulging of )the eyesexophthalmos (bulging of )the eyes

Complication

Thyrotoxic crisis also called thyroid storm is sever hyperthroid state that occur in hyperthyroid pt who are untreated or who are experiencing stresser or may occur are experiencing stresser or may occur following thyredectomy

Symptoms include tachycardia, high fever, hypertension (with eventual heart failure and hypotension), dehydration, restlessness, and delirium or coma.and delirium or coma.

If thyrotoxic crisis occurs, treatment is first directed toward relieving the life-threatening symptoms.

Acetaminophen is given for the fever.

Intravenous fluids and a cooling blanket may be ordered to cool the patient

A beta-adrenergic blocker, such as A beta-adrenergic blocker, such as propranolol, is given for tachycardia.

Oxygen is administered and the head of the bed is elevated

Once symptoms are controlled and the patient is safe, the underlying thyroid problem is treated

HYPOTHYROIDISM.

This can occur as a result of treatment. Patients with a history of hyperthyroidism should be monitored for the onset of should be monitored for the onset of hypothyroidism.

Diagnostic Tests

Serum levels of T 3 and T 4 are elevated.

TSH is low in primary hyperthyroidism or high if the cause is pituitary.

A thyroid scan can be done to locate a A thyroid scan can be done to locate a tumor.

The thyroid gland may be enlarged

Therapeutic Interventions

Several medications can be used to treat hyperthyroidism.

Propylthiouracil (PTU) and methimazole(Tapazole) inhibit the synthesis of TH.(Tapazole) inhibit the synthesis of TH.

Propranolol (Inderal) is a beta-blocking medication that relieves the sympathetic nervous system symptoms.

Oral iodine suppresses the release of thyroid hormone.

Radioactive iodine ( RAI) may be used to destroy a portion of the thyroid gland.destroy a portion of the thyroid gland.

Nursing Process for the Patient with hyperthyroidismAssessment/data collection

Monitor the patient with hyperthyroidism closely until normal thyroid activity is restored. restored.

Monitor vital signs and report any increases in pulse and blood pressure to the registered nurse or physician.

Monitor lung sounds because crackles may indicate heart failure.

Assess level of anxiety and ability to cope with symptoms.

Monitor weight and bowel function.

Assess eyes for risk for injury caused by Assess eyes for risk for injury caused by exophthalmos, and note degree of muscle weakness.

Never palpate the thyroid gland of a patient with hyperthyroidism because palpation may stimulate release of thyroid hormone and precipitate a thyrotoxichormone and precipitate a thyrotoxiccrisis.

Nursing diagnosis

Hyperthermia related to hypermetabolicstate

Expected outcomes:

Body temperature will be within normal Body temperature will be within normal limits.

Intervention

Monitor temperature.

aminister acetaminophen as ordered to reduce temperature.

Apply cooling blanket as ordered. Apply cooling blanket as ordered.

External cooling may be necessary if acetaminophen is not effective.

Nursing diagnosis

Diarrhea related to increase in peristalsis

Expected outcomes:

Patient will maintain fluid and electrolyte Patient will maintain fluid and electrolyte balance.

Intervention

Provide a low-fiber diet.

Provide small frequent meals of bland foods (bananas, rice, apple sauce) that are less likely to worsen diarrhea.

Monitor electrolytes, especially sodium Monitor electrolytes, especially sodium and potassium.

Monitor for dehydration.

Keep skin clean and dry; apply barrier cream to protect skin from injury from stool.

Nursing diagnosis

Imbalanced nutrition, less than requirements, related to increased metabolism

Expected outcomes: Expected outcomes:

The patient will maintain weight in proportion to height.

Intervention

• Determine healthy weight for height, so the expected outcome is realistic for the patient.

• Monitor weight weekly to make sure • Monitor weight weekly to make sure interventions are working.

• Consult dietician for high-calorie diet with six meals to meet caloric requirements

Nursing diagnosis

Disturbed sleep pattern related to sympathetic stimulation

Expected outcomes:Expected outcomes:

The patient will state feeling rested upon awakening.

Intervention

• Provide a quiet, restful environment to assist the patient to fall a sleep.

• Ask the patient if music or earplugs are desired to mask environmental noise.desired to mask environmental noise.

• Administer propranolol or sedative as ordered to reduce sympathetic stimulation and calm patient.

Nursing diagnosis

Anxiety related to sympathetic stimulation

Expected outcomes:

Patient will state anxiety is controlled.

Intervention

• Provide the patient with accurate information about the disorder and treatment, and that proper treatment will correct symptoms. correct symptoms.

• Administer propranolol or antianxiety agent as ordered to reduce sympathetic stimulation and calm patient.

• Offer massage, music, or other relaxation techniques preferred by the patient.

Nursing diagnosis

Risk for injury related to hyper metabolic state and eye involvement

Expected outcomes:

Patient will remain safe and without injury.Patient will remain safe and without injury.

• Report changes in vital signs to the physician. Prompt treatment can reduce complications.

• Administer lubricating saline eye drops as • Administer lubricating saline eye drops as ordered to protect eyes from drying.

• Advise use of dark, tight fitting glasses to protect eyes from light and injury.

• Elevate the head of the bed to reduce edema behind the eyes.

• Provide a low-sodium diet.

• Teach patient to notify physician • Teach patient to notify physician immediately if eye pain or vision changes occur.

Patient education.

Teach the patient about the disease and symptoms of hyperthyroidism to report.

Also teach the patient how to take medications and the importance of routine medications and the importance of routine follow-up laboratory testing.

Evaluation

If the plan of care is effective, the patient will remain free from complications or injury.

Eyes will be comfortable and free from injury. injury.

Body temperature will be kept within normal limits

Diarrhea will be controlled, and complications of diarrhea such as skin breakdown and dehydration avoided.

The patient’s weight should remain stable. The patient’s weight should remain stable.

The patient should report that he or she is rested on awakening and that anxiety is controlled.

Nursing care for the Patient Nursing care for the Patient UndergoingUndergoing

ThyroidectomyThyroidectomy

Patients may undergo thyroidectomyfor cancer of the thyroid,

hyperthyroidism, or a goiter that is causing dyspnea or dysphagia.

A total thyroidectomy is usually performed if cancer is present.

After a total thyroidectomy, lifelong replacement hormone must be taken. replacement hormone must be taken.

A subtotal (partial) thyroidectomy

might be done for hyperthyroidism, leaving a portion of the thyroid gland to continue to secrete TH.

Preoperative Care

Before undergoing a thyroidectomy, the patient should be in a euthyroid state to avoid complications during and after surgery.

This is accomplished with the use of antithyroid medication such as methimazoleantithyroid medication such as methimazole(Tapazole).

A saturated solution of potassium iodide may also be administered to decrease the size and vascularity of the gland, reducing the risk of bleeding during surgery.

Perform a baseline assessment of vital signs and voice quality, so you can compare findings postoperatively.

Explain what the patient can expect before, Explain what the patient can expect before, during, and after surgery.

Preoperative teaching should include how to perform gentle range-of-motion exercises of the neck, how to support the neck during position changes, and how to neck during position changes, and how to use an incentive spirometer after surgery.

Postoperative Care

Data collection. Monitor vital signs, oxygen saturation,

drain (if present), and dressing every 15 minutes initially, progressing to every 4 hours, as ordered. hours, as ordered.

Decreased blood pressure with increased pulse should alert you to the possibility of shock related to blood loss.

Tachycardia and fever, along with mental status changes, can indicate thyrotoxic crisis.

Check the back of the neck for pooling of blood. Because of the location of the surgery,

observe for signs of respiratory distress, observe for signs of respiratory distress, including an increase in respiratory rate, dyspnea, or stridor.

Ask the patient to speak to detect

hoarseness of the voice, which can indicate

trauma to the recurrent laryngeal nerve.

Monitor the patient’s serum calcium levels and Monitor the patient’s serum calcium levels and

watch for evidence of tetany .

Report abnormal findings to the RN or physician

immediately.

Nursing diagnoses

Risk for Ineffective Airway Clearance

related to edema at surgical site

Expected outcome:

The patient will maintain a clear airway

as evidenced by easy breathing without

stridor.

Intervention

Notify physician about respiratory distress

immediately; keep a tracheostomy set at

the bedside.

Maintain patient in semi-Fowler’s position Maintain patient in semi-Fowler’s position

to help reduce edema and promote

comfort.

Monitor neck dressing. If the dressing

seems to get tighter, it may be a sign that

the patient’s neck is swelling, which could

impair the airway.impair the airway.

Use room humidifier or humidified

oxygen to keep airways and secretions

moist.

Remind the patient to do coughing and

deep-breathing exercises every hour.

Have suction equipment available in case

patient is unable to cough up secretions patient is unable to cough up secretions

effectively.

Encourage the patient to use the incentive

spirometer to assist with deep breathing

Assess the patient’s swallowing and gag

reflexes before offering clear liquids to

guard against aspiration.

Nursing diagnoses:

Risk for Injury (tetany, thyrotoxic crisis

related to surgical procedure

Expected outcome

Complications will be recognized and

treated quickly.

Intervention

Monitor patient for muscle spasms or

numbness or tingling around the mouth, and

report immediately if theyoccur.

These are symptoms of tetany that must be

treated immediately.

Tetany is most likely to occur 24 to 72 hours

postoperatively.

Monitor vital signs often, and report

changes immediately.

Elevated vital signs may be signs of Elevated vital signs may be signs of

thyrotoxic crisis, which is most likely

to occur up to 18 hours

postoperatively.

Nursing diagnoses

Acute Pain related to surgical procedure

Expected outcome: Expected outcome:

The patient’s pain will be controlled

as evidenced by patient stating pain rating is

acceptable.

Intervention

Administer acetaminophen or opioids as

ordered. Avoid aspirin products. (Aspirin

binds to the same protein as thyroid hormone binds to the same protein as thyroid hormone

and can precipitate a thyrotoxic crisis).

Use pillows or sandbags to support the

patient’s head.

Nursing diagnoses

Risk for Ineffective Self Health Management related

to knowledge deficit

Expected outcome: Expected outcome:

The patient will be able to effectively manage self-care

needs as evidenced by (1) verbalizing understanding

of follow-up care, (2) weight stabilizes at appropriate

weight for height, and (3) TH levels are within normal

limits.

Intervention

Teach the patient to do gentle range-of-motion exercises,

avoiding hyperextension of the neck, which can cause

strain on the incision line. Avoidance of neck movement

due to pain can result in contracture. due to pain can result in contracture.

Consult dietitian to assist the patient with potential

dietary changes needed following surgery.

Teach the patient the importance of follow-up care to avoid

complications:

How to administer replacement hormone if ordered.

How to change the dressing and to report bleeding or signs

of infection at the site.

Importance of immediately reporting unusual irritability,

fever, palpitations, or signs of tetany.

Importance of follow-up lab work for thyroid function and

medication adjustment.

Evaluation

If the plan has been effective, complications

caused by surgery will not occur or will be

recognized and reported early. recognized and reported early.

Pain will be prevented or controlled,

and the patient will demonstrate

understanding of postoperative self-care

Complications

Thyrotoxic crisis.

Thyrotoxic crisis can result from manipulation of the

thyroid gland during surgery, with the subsequent thyroid gland during surgery, with the subsequent

release of large amounts of TH.

This is a rare complication because the use of antithyroid

drugs before surgery has become routine.

Tetany.

Tetany is caused by low calcium levels and is

characterized by tingling in the fingers and characterized by tingling in the fingers and

perioral area (around the mouth), muscle

spasms, twitching, and cardiac dysrhythmias.

Muscle spasms in the larynx can lead to

respiratory obstruction.

Watch carefully for symptoms of tetany and report

them immediately if they occur because if the

problem is not recognized quickly, death can

result.

Tetany can occur if the parathyroid glands are accidentally removed during thyroid surgery.

Because of the proximity of the parathyroid Because of the proximity of the parathyroid glands to the thyroid, it is sometimes difficult for the surgeon to avoid them.

In the absence of parathyroid hormone (PTH), serum calcium levels drop and tetany results. IV calcium gluconate is given to treat acute tetany.given to treat acute tetany.

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