It include anatomy , physiology of thyroid gland. Hyperthroidism and its causes, risk factors, diagnosis, medical and nursing management, complication.

1. Presentation
on
Hyperthyroidism
Prepared by
kalpana kawan
Roll no. 06
BNS 3rd year

2. General objective
• At the end of this session , BNS 3rd year students will be able to know
about hyperthyroidism.

3. Specific objectives
• define hyperthyroidism.
• state the incidence of hyperthyroidism.
• state the types of hyperthyroidism.
• list the risk factor of hyperthyroidism.
• explained the cause of hyperthyroidism.

4. Specific objectives
• explain pathophysiology of hyperthyroidism.
• list the clinical manifestation of hyperthyroidism.
• list the diagnostic procedure
• state the complication of hyperthyroidism.
• explain the medical and nursing management of hyperthyroidism.

5. Thyroid Gland
Introduction
• It is part of the endocrine system.
• It is located at the front of the neck just below the Adam's apple,
along the front of the windpipe.
• It is butterfly-shaped and consists of two lobes located either side of
the windpipe (trachea),

6. Contd.....
• The thyroid weighs between 20 and 60 grams on average
• Brownish-red in color, the thyroid is rich with blood vessels.

7. Contd.........
• It produces two principle hormones
• Thyroxine(T4)
• Triiodothyronine(T3)
• Also secrete calcitonin(responsible for Ca homeostasis)

8. Biosynthesis of thyroid hormones
• Iodine is essential for synthesis of thyroid hormones.
• Steps of synthesis
• Uptake of iodine:
• Formation of active iodine
• Thyroglobulin and synthesis of T3 and T4

9. Regulation of thyroid hormone

10. Function of thyroid gland
Thyroid hormones affect every cell and all the organs of the body.
They:
• Regulate the rate at which calories are burned, affecting weight loss or
weight gain.
• Can slow down or speed up the heartbeat.
• Can raise or lower body temperature.

11. Contd........
• Influence the rate at which food moves through the digestive tract.
• Control the way muscles contract.
• Control the rate at which dying cells are replaced.
• The brain matures (in children)
• Growth is promoted (in children).
• Activation of the nervous system leads to improved concentration and
faster reflexes

12. Hyperthyroidism
Defination
• Hyperthyroidism is the condition that occurs
due to excessive production of thyroid hormone
by the thyroid gland. OR
• Hyperthyroidism is hyperactivity of thyroid gland leading to sustained
increase and excessive synthesis and release of thyroid hormones and
accelerated metabolism in the peripheral tissues.

13. Incidence
• It is the second most common thyroid problem and affects womens
eight times more frequently between 20 and 40 years than male.

14. Type
1) Primary hyperthyroidism: Arising from the intrinsic thyroid
abnormally.
2)Secondary hyperthyroidism:- Arising from process outside of the
thyroid gland such as TSH secreating pituitary tumor.

15. Contd.......
3) Apathetic hyperthyroidism :
• It is a form of hyperthyroidism occuring in elderly person , >70
years(but can be any age).
• The typical features of thyroid hormones excess seen in younger
patients are blunted.
• The diagnosis is made during investigation for unexplained weight
loss or worsening cv disease.

16. Contd.....
• The cardinal symptoms are depresson and apathy.
• The absence of classical signs and symptoms of hyperthyroidism
delays the diagnosis and treatment of the diseases, as it is often
misdiagnosed as a primary psychiatric disorder.

17. Risks factors
• A family history of thyroid disease, particularly of graves' disease
• Female sex
• A personal history of certain chronic Such as type 1 diabetes mellitus,
Pernicious anemias( a vit B 12 deficiency) , primary adrenal
insufficiency, also known as addisions diseases.

18. Contd.....
• Over the age of 60
• Consume an iodine rich diet or medication containing iodine( like
amiodarone))
• Had thyroid surgery or a thyroid problem such as goiter, also known as
swollen thyroid gland.
• Radiation therapy may predispose a patient to develop
hyperthyroidism.
• Women who smoke nearly double their risk of Grave's diseases.

19. Etiology
• Graves' disease
It is most common
causes with
50-80% worldwide.

20. Contd.....
• Toxic thyroid adenoma
Nodules produces thyroid
hormones independently.

21. Contd.....
• Toxic multinodular goitor
 also called plummer disease.
If there is more than one
functioning nodules, the term
multinodular goitor is used.
It occurs more commonly in elderly, especially with long standing
goiter.

22. Contd.....
• Thyroiditis
 Inflammation of the thyroid which
causes T4 and T3 to leak out of the gland
to the blood stream .

23. Contd.....
• Excessive intake of thyroid hormone

24. Contd.....
• Abnormal secreating of TSH
 A tumors in the putuitary gland
may produce an abnormally high
secretion of TSH.

25. Contd.....
• Excessive iodine intake

26. Contd.....
• Struma ovarii
It is a rare form of monodermal teratoma that contains mostly thyroid
tissue, which lead to hyperthyroidism .

27. Pathophysiology:
• Graves disease may be due to excessive stimulation of the adrenergic
nervous system or excessive levels of circulating TH.
• Hyperthyroidism is characterized by loss of the normal regulatory
controls of TH secretion. Because the action of THon the body is
stimulatory, hypermetabolism results with increased sympathetic
nervous system activity.

28. Contd.......
• Excessive amounts of TH stimulates the cardiac system and increase
the number of beta adrenergic responsiveness, and peripheral blood
flow.
• Metabolism increases greatly leading to negetive nitrogen balance,
lipid depletion and a state of nutritional deficiency and weight loss.
• Hyperthyroidism also results in altered secretion and metabolism of
hypothalamic pituitary and gonadal hormone. If hyperthyroidism
occurs before puberty sexual develop is delayed to both genders.

29. Clinical menifestation

30. Clinical menifestation

31. Clinical menifestation
1) Cardiovascular System
• Systolic hypertension
• Bounding, Rapid pulse (90-160 b/m
with sinustachycardia)
• Increased cardiac output
• Cardiac hypertrophy

32. Contd.........
• Systolic murmurs
• Dysrhythmais, Arrhythmia
• Palpitations, tachycardia,
• Angina, cardiac hypertrophy

33. Contd.........
2. Respiratory System
• Increased respiratory rate
• Dyspnea on mild exertion

34. Contd.........
3. Gastrointestinal System
• Increased appitite, thirst
• Weight loss
• Increased peristalsis, increase bowel sound
• Diarrhoea, frequent urination
• Splenomegaly
• Hepatomegaly

35. Contd.........
4. Integumentary System
• Warm, smooth, moist skin
• fine , soft hair
• Hair loss
• Palmar erythema
• Diaphoresis
• thin soft nailsdetached from nail bed (nydrolysis)
• poor tolerance of heat, excessive perspiration, skin that is flushed.

36. Contd.........
5. Musculoskeletal System
• Fatigue
• Muscle weakness especially
proximal
• dependent edema
• Osteoporosis, joint pain

37. Contd.........
6. Nervous System
• Nervousness
• Fine tremor of fingers and toes, deterioration in hand writing
• Insomnia
• Delirium, irritability
• Restlessness, apprehensiveness

38. Contd.........
• Lack of ability to concentrate
• agitation
• Exhaustion
• Hyper flexion of tendon reflexes
• stupur
• coma

39. Contd.........
7. Reproductive System
• Menstrual irregularities
• Amenorrhea
• Decreased libido
• erectile dusfunction
• Gynecomastia in men
• Decreased fertility

40. Contd.........
• Others:
• Exophthalmos (bulging eyes) seen only in Grave's diseases.

41. Diagnosis
1.History taking: Family history , signs and symptoms ( heat
intolerance, increase sweating , warm skin etc.) geographical area,
dietary pattern , surrent medications.
2. Physical examination : vital signs, weight loss, Tremors of hands
soft Eye changes Warm, moist skin
• Neck examination-Thyroid gland is enlarged

42. Contd.........
3. Lab test
• Increase in serum T-4 and T-3 and decrease TSH
• Free tri-iodothyronine(T3)
• Free thyroxine(T4)
• Total T3
• Total T4
• Cholesterol level
• Antibody test
• BMR

43. Contd.........
4. Radiologic exam
• ultrasound
• Thyroid scan
• Iodine thyroid scan
5. Histologic exam
• Thyroid biopsy
6. Opthalmological examination- to determine exopthalmos

44. Management
Management depends on cause , age of patients, severity of
diseases and complication. Goals of therapy is to bring the metabolic
rate to normal as soon as possible.
• Three form of treatment are available:
1. Pharmacotherapy
Antithyroid medications
Beta blocker
2.Radiation therapy
3. Surgery

45. Contd.........
1. Pharmacotherapy
• Antithyroid drugs:
which inhibits the synthesis of thyroid hormones
such as carbimazole, methimazole,
propylthiouracil(PTU) but they may take several
months to be effective, and must be continued for
12-18 months.

46. Contd.........
• Beta blocker:
Medicines such as propanolol, metoprolol etc are used.
These medications don’t treat levels of thyroid hormone
but can help to reduces symptoms like anxiety, shaking, or a
fast heartbeat.

47. Contd.......
2. Radioactive Iodine( 131 I) therapy (radioisotope therapy)
• A small amount of radioactive iodine taken orally.
• Overactive thyroid cells absorb it, and it destroys them.
• This makes your thyroid shrink and your levels of thyroid hormone go
down .
• It may also cause hypothyroidism. This is easier to treat than
hyperthyroidism by take a hormone supplement once a day.

48. Contd........
3. Surgery
• Sub total thyroidectomy and total thyroidectomy is done.

49. Contd.......
• Surgery (thyroidectomy to remove the whole thyroid or a part of it) is
not extensively used because most common forms of hyperthyroidism
are quite effectively treated by the radioactive iodine method, and
because there is a risk of also removing the parathyroid glands, and
of cutting the recurrent laryngeal nerve, making swallowing
difficult.

50. Contd.......
• Thyroidectomy is indicated for individuals who have
A large goiter causing tracheal compression
Been unresponsive to antithyroid therapy
Thyroid cancer
Unresposive to radiotherapy

51. Contd.......
• Endoscopic thyroidectomy
It is a minimally invasive procedure. Several small incisions are
made, and a scope is inserted. Instruments are passed through the
scope to remove thyroid tissue or nodules.
Is appropriate procedure for patients with small nodules (less than 3
cm)and no evidence of malignancy.
Advantages of over open thyroidectomy include less scaring, less
pain and faster return to normal activity.

52. Contd.......
Management of Thyrotoxicosis/ thyroid strom
Treatment is first directed toward relieving the life-threatening
symptoms.
Acetaminophen is given for the fever.
 Aspirin is avoided because it binds with the same serum protein as
T4, freeing additional T4 into the circulation.
Intravenous fluids and a cooling blanket may be ordered to cool the
patient.

53. Contd.......
• A beta-adrenergic blocker, such as propranolol, is given for
tachycardia and symptom control.
• Oxygen is administered and the head of the bed is elevated because
the high metabolic rate requires more oxygen.
• Once symptoms are controlled and the patient is safe, the underlying
thyroid problem is treated.

54. Complications
Thyrotoxicosis/ thyroid strom/ thyrotoxic crisis
• is an acute, severe, and rare condition that occurs when excessive
amounts of thyroid hormones are released into the circulation, if
untreated is usually fatal but with proper treatment the mortality rate is
reduced substantially.

55. Contd..........
• Symptoms includes:
High fever above 38.50c
tachycardia
altered neurologic or mental state
Exaggerated symptoms of hyperthyroidism

56. Contd..........
• Other complications of hyperthyroidism include:
Heart problems such as fast heart rate, abnormal heart rhythm, and
heart failure
Osteoporosis
Hypothyroidism (underactive thyroid)
Airway Obstruction
Respiratory distress

57. Contd..........
• Surgery-related complications, including:
Immediate: Haemorrage
Short term : infection
Long term:
Scarring of the neck
Hoarseness due to nerve damage to the voice box
Hypocalcemia due to damage to the parathyroid glands (located near
the thyroid gland)
Hypoparathyroidism

58. Nursing Management
• Nursing assessment
Monitor the patient with hyperthyroidism closely until normal thyroid
activity is restored.
 Monitor vital signs and report any increases in pulse or blood
pressure to the registered nurse or physician.
Monitor lung sounds because crackles can indicate heart failure.

59. Contd..........
• Assess level of anxiety and ability to cope with symptoms, Monitor
weight, bowel function, and ability to sleep.
• 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 can stimulate release of thyroid hormone and
precipitate a thyrotoxic crisis.

60. NURSING DIAGNOSES, PLANNING
AND IMPLEMENTATION
1) Nursing diagnosis: Hyperthermia related to hypermetabolic state as
evidenced by elevated temperature.
Expected outcome:The patient's body temperature will be within
normal limits.

61. CONTD......
Intervention:
• Monitor temperature. Temperature may be elevated due to
hypermetabolic state.
• Administer acetaminophen as ordered (avoid aspirin) to reduce
temperature. Aspirin can cause an increase in circulating thyroid
hormone.
•Apply cooling blanket as ordered. External cooling may be needed if
acetaminophen is not effective.

62. Contd
•If a cooling blanket is needed, set it to 1 to 2 degrees below the current
temperature, and wrap the extremities with towels to prevent shivering,
which can further increase temperature.
•Offer fluids to replace fluids lost through diaphoresis.

63. Contd
2) Nursing Diagnosis: Diarrhea Related to an increase in peristalsis as
evidenced by frequent loose stools.
Expected outcome: The patient will maintain fluid and electrolyte
balance.

64. Contd......
Intervention
• Provide a low-fiber diet. Fiber can increase peristalsis and stools.
• Provide small, frequent meals of bland foods (bananas, rice,
applesauce) that are less likely to worsen diarrhea.
• Monitor electrolytes, especially sodium and potassium. Diarrhea can
cause electrolyte loss.
• Monitor for dehydration. Diarrhea causes fluid loss.
• Keep skin clean and dry; apply barricr cream to ptotcct skin injury
from stool.

65. Contd......
3) Nursing diagnosis: Imbalanced nutrition less than body
requirements related to increased metabolism.
Expected outcome: The patient will have balanced nutrition evidenced
by stable weight in proportion to height.

66. Contd.....
Intervention
• Determine healthy weight for height, so the expected outconte is
realistic for the patient.
• Monitor weight weekly to make sure interventions are working.
• Consult dietician for high-calorie diet with six meals per day to meet
caloric requirements.

67. Contd.....
• Diet-The patient with hyperthyroidism needs a high calori, high
protein diet to compensate for the hypermetabolic state. A diet of 4000
to 5000 calories with high protein levels may be necessary to prevent
negative nitrogen balance and weight loss.
• Provide quite and calm environment.
• Monitor I/V infusion when prescribed to maintain fluid and electrolyte
balance.
• Monitor weight, skin turgor, vital signs to evaluate nutritional and
fluid status.

68. Contd..
4. Nursing diagnosis: Disturbed Sleep Pattern Related to Sympathetic
Stimulation as Evidenced by Difficulty Sleeping and not Feeling Rested
on Awakening
Expected outcome: The patient will have improved sleep as evidenced
by stating feeling rested upon awakening.

69. Contd............
Intervention
• Provide a quiet, restful environment to assist the patient to fall asleep.
• Ask the patient if music or earplugs are desired to mask environmental
noise.
• Administer propranolol or sedative as ordered to reduce sympathetic
stimulation and calm patient.

70. Contd....
5.Nursing diagnosis: Anxiety Related to Sympathetic Stimulation as
Evidenced by Patient Statement
Expected outcome: The patient will experience reduced anxiaty as
evidenced by patient statement that anxiety is controlled.

71. Contd......
Intervention
• Provide the patient with accurate information about the disorder and
treatment, and explain that proper treatment will correct symptoms.
Fear of the unknown can produce anxiety.
• 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, These may promote relaxation.

72. Contd........
6. Nursing disgnosis: Risk for Injury Related to Hypermetabolic State
and Eye Involvement .
Expected outcome: The patient will remain safe and without injury.

73. Contd.....
Intervention
• Report changes in vital signs to RN or physician.
• Prompt treatment can reduce complications.
• Administer lubricating saline eyedrops as ordered to protect eyes from
drying.
• Advise use of dark, tight-fitting glasses to protect eyes from light and
injury.

74. Contd.....
• Gently tape eyes shut with nonallergic tape for sleeping.
Exophthalntos may prevent t/te patient front fully closing the eyes.
• Elevate the head of the bed to reduce edema behind the eyes.
• Provide a low-sodiutn diet. This may decrease edema behind the eyes.
• Teach patient to notify the physician immediatcly if eye pain or vision
changes occur. These can be signs of pressure from edema on optic
nerve, which can cause perntanent damage if not corrected.

75. Contd.
7.Nursing diagnosis- Fatigue related to hypermetabolic state with
increased energy requirements
8.Nursing diagnosis- Knowledge deficit related to disease process,
prognosis, signs and symptoms and treatment

76. Pre operative care (Thyroidectomy)
• All pre operative nursing care should be provided as in other surgery /
Routine pre operative care.
• The patient must be euthyroid before the operation. Antithyroid drug
to supress secretion of TH and iodine preparation to reduce the size
and vascularity of the organ therefore surgery may diminishing the
chance of hemorrage.
• Provide nutritious diet to counteract the effect of hyperthyroidism.

77. Contd...
• Evaluate cardiac status before surgery to screen the cardiac
complication of hyperthyroidism.
• The patient is prepared physically and emotionally in the following
ways:
Explain the surgical procedures, approximate time or duration etc.
Explain that the patient may have drain tubes, I/V line after surgery.

78. Contd......
Post Operative nursing care (Thyroidectomy)
• All post operative nursing management as in other surgery/ Routine
post operative care.
• Monitor for signs of bleeding such as repeated clearing of throat,
swelling of the neck and signs of repiratory distress.
• Monitor for signs of hypocalcemia such as irritability, twitching,
spasm of hands and feet.

79. Contd......
• Monitor vital signs frequently, watching for tachycardia, hypotension
that indicate hemorrhage.
• Monitor for signs of hypocalcemic tetany eg. Tingling of toes, and
fingers, positive Chvostek’s sign and positive Trousseau’s sign.

81. Contd......
• Monitor blood calcium level, and if falls below 7 mg/100 ml, replace
calcium IV.
• Watch for change in voice that indicate laryngeal nerve damage.
• Keep tracheostomy set ready in bedside for first 48 hours because
patient may need emergency tracheostomy for respiratory distress.
• Move patient carefully and provide adequate support to the neck by
sandbags or pillow to prevent tension in suture.

82. Contd......
• Keep the patient in a semi fowler's position to facilitate breathing and
decrease edema.
• Administer pain medication as needed.
• Inspects the neck dressing for drainage (a moderate amount of
drainage in expected)
• Teach patient about the care at home, and encourage follow up and
monitoring thyroid hormone replacement.

83. Contd......
Patient and family education on :
• Teach the patient how to take medications and importance to take
medicine regularly.
• Teach the patient about the disease and symptoms of hyperthyroidism
or hypothyroidism to report.
• Report high fever, tachycardia, extreme irritation, immediately
because these are signs and symptoms of thyroid strom.
• Importance of routine follow-up laboratory testing.

84. Reference
• Williams L.S. Hopper P.D.(2012).Understanding Medical Surgical
Nursing, (4th edition).Jaypee Brothers Medical Publishers (P)Ltd.page
no. 897-899
• Sharma M.Poudel K. Gautam R.(2015).Essential textbook of Medical
Surgical Nursing, (1st edition),Samiksha books Pvt Ltd.Page no.
396-399
• Robbins and Cotran.(2015)Pathologic Basis of Disease,South Asian
Edition. Vol II,Reed Elsevier India Private Limited.page no.1083-1085

85. Reference
• Retrived from https://en.wikipedia.org/wiki/Hyperthyroidism on jun
09, 2021.
• Retrived from https://www.thyroid.org/hyperthyroidism/
• Retrived from https://www.webmd.com/a-to-z-guides/overactive-
thyroid-hyperthyroidism