SUBMITTED TO, SUBMITTED BY,MRS SHREEMINI PILLAI MS SHRADDHA MIREREADER MSC NURSING 1ST YRMEDICAL SURGICAL NSG. PG COLLEGE OF NURSING
INTRODUCTION Hyperthyroidism and thyrotoxicosis are termsoften used interchangeably, however each refers to slightlydifferent conditions. Hyperthyroidism refers to over activityof the thyroid gland, with resultant excessive secretion ofthyroid hormones and accelerated metabolism in theperiphery. Thyrotoxicosis refers to the clinical effects of anunbound thyroid hormone, regardless of whether or not thethyroid is the primary source. There are a number of pathologic causes ofhyperthyroidism in children and adults. These includeGraves disease, toxic adenoma, toxic multinodular, goiter,and thyroiditis. Of these, Graves disease accounts forapproximately 95% of cases of hyperthyroidism. Tounderstand the pathophysiology of hyperthyroidism, it isnecessary to understand the normal physiology of the thyroidgland.
Prevalence Women 2% Men 0.2% 15% of cases occur in patients older than 60 years of age
What is the thyroid gland? The thyroid gland is a butterfly-shaped endocrine gland that is normally located in the lower front of the neck. The thyroid’s job is to make thyroid hormones, which are secreted into the blood and then carried to every tissue in the body. Thyroid hormone helps the body use energy, stay warm and keep the brain, heart, muscles, and other organs working as they should.
Definition Hyperthyrodism is due to increased level of thyroid hormone. Diffuse toxic goiter (graves disease) toxic multinodular goiter (plummer’s disease) toxic adema. According to ”Sanjay Azad” Hyperthyroidism is hyperactivity of the thyroid gland with sustain increase in synthesis and release of hormones. According to ”watson’s”
Hyperthyroidism implies an excessive secretions ofthyroid hormones and may called as thyrotoxicosis, buttoxic goiter, exopthalmic goiter or grave’s disease. Theterm exopthalmic goiter or grave’s disease are reversalfor hyperthyroidism that is accompanied byexopthalmus and extreme nervesness. • According to ”lewis heifkemper” Hyperthyroidism is defined as excessive secretion ofthyroid hormone. Thyrotoxicosis is an acuteexacerbation of all thyroid symptoms. According to “Luckmann’s”
Anatomy Of The Thyroid• It is butter fly shaped located just inferior to the larynx.• It is composed of right and left lateral lobes, one on either side of trachea, that are connected by isthmus anterior to the trachea.• Microscopic spherical sac called thyroid follicles make up most of the thyroid gland.• The walls of each follicles consist primarily of cells called follicular cells.
• The thyroid gland is a highly vascularized organ located anteriorly in the neck, deep to the platysma, sternothyroid and sternohyoid muscles, and extending from the 5th cervical (C5) to the 1st thoracic (T1) vertebrae.• The gland consists of two lobes (left and right) connected by a thin, median isthmus overlying the 2nd to 4th tracheal rings, typically forming an "H" or "U" shape.• Beneath the visceral layer of the pretracheal, deep cervical fascia, the thyroid gland is surrounded by a true inner capsule, which is thin and adheres closely to the gland.
• The capsule sends projections into the thyroid forming septae and dividing it into lobes and lobules.• Dense connective tissue attachments secure the capsule of the thyroid to both the cricoid cartilage and the superior tracheal rings.
Action of thyroid hormones Thyroid hormone increases the basal metabolic rate the rate of oxygen consumption understand or basal condition by stimulating the use of cellular oxygen to produce ATP.It stimulate synthesis of additional sodium- potassium pump.In the regulation of metabolism, the thyroid hormone stimulate protein synthesis and increase the use of glucose and fattyacid for ATP productionThe thyroid hormone enhance some action of the catecholamines because they up-regulate beat receptors.
Etiology• Grave’s disease:- autoimmune; genetic component.• Toxic multinodular goiter:- autonomus function of thyroid; multinodular.• Toxic solitary adenoma:- single adenoma of follicular cells that secrets and functions independently of thyroid secreting hormone may selectively hyper secrets T3 resulting in T3 toxicosis.• Hyperthyroidism:- rare;thyroid cancer cell do not usually concentrate iodine efficiently; may occur with the large follicular carcinoma.• TSH secreting pituitary adenoma chorionic hyperthyroidism:- chorionic gonadotropin has week thyrotropin activity. Tumors such as choriocarcinoma, embryonal cell carcinoma, and hydatiform molecules have high concentration of chorionic gonadotropic that can stimulate T3 and T4 secretion; hyperthyroidism resolves after the treatment of tumor.
• Struma ovary:- ovarian dermoid made up partly of thyroid tissues that secretes thyroid hormones.• There are several causes of hyperthyroidism. Most often, the entire gland is overproducing thyroid hormone. Less commonly, a single nodule is responsible for the excess hormone secretion, called a "hot" nodule. Thyroiditis (inflammation of the thyroid) can also cause hyperthyroidism. Functional thyroid tissue producing an excess of thyroid hormone occurs in a number of clinical conditions.• Oral consumption of excess thyroid hormone tablets is possible (surreptitious use of thyroid hormone), as is the rare event of consumption of ground beef contaminated with thyroid tissue, and thus thyroid hormone (termed "hamburger hyperthyroidism").• Amiodarone, an anti-arrhythmic drug, is structurally similar to thyroxine and may cause either under- or overactivity of the thyroid
Pathophysiology Hyperthyrodism is charaterised by loss of the normal regulatory control of thyriod hormone secretion The action of thyroid hormone on the body is stimulatory, hypermetabolism result Increase in sympathetic nervous system activity Alteration of secretion and metabolism of hypothalamic pitutiary and gonadal hormones. Excessive amount of thyroid hormone stimulate the cardiac system and increases the of- adrenergic receptors Trachycardia and increased cardiac out put, stroke volume, adernergic responciveness and peripherial blood flow. Leads to a negative nitrogenous balance, lipid depletion and the resultant state of nutritional deficiency. Hyperthyrodism result
Clinical manifestation:-• Older patient presents with lack of clinical signs and symptoms, which makes diagnosis more difficult• Thyroid storm is a rare presentation, occurs after stressful illness in under treated or untreated patient. Characteristics -Delirium -Dehydration -Severe tachycardia -Vomiting -Fever -Diarrhea
• Skin -Warm -May be erythematous (due to increased blood flow) -Smooth- due to decrease in keratin -Sweaty and heat intolerance -Onycholysis –softening of nails and loosening of nail beds• Hyperpigmentation -Due the patient increase ACTH secretion• Pruritis -mainly in graves disease• Thinning of hair• Vitilago and alopecia areata -mainly due to autoimmune disease• Infilterative dermopathy -Graves disease, most common on shins
• Eyes Stare Lid lag *Due to sympathetic over activity *Only Grave’s disease has ophthalmopathy -Inflammation of extraocular muscles, orbital fat and connective tissue. -This results in exopthalmos -More common in smokers
Cardiovascular System• Increased cardiac output (due to increased oxygen demand and increased cardiac contractibility.• Tachycardia• Widened pulse pressure• High output – heart failure
Serum lipid• Low total cholesterol• Low HDL• Low total cholesterol/HDL ratioRespiratory system• Dyspnea on rest and with exertion• Oxygen consumpation and CO2 production increases.• Hypoxemia and hypercapnea, which stimulates ventilation• Respiratory muscle weakness• Decreased exercise capacity• Tracheal obstruction• Increased pulmonary arterial pressure
GI System -Weight loss due to increased calorigenesis -Hyperdefecation -Malabsorption -Steatorrhea -Celiac Disease (in Grave’s Disease) -Hyperphagia (weight gain in younger patient) -Anorexia- weight loss in elderly -Dysphagia -Abnormal LFT especially phosphateGU System• Urinary frequency and nocturia• Enuresis is common in childrenReduce mid-cycle LH surge
In Femails• Oligomenorrhea and amenorrhea• Anovulatory infertilityIn mail• High total testosterone• Low free testosterone• Gynecomastia• Decreased libido• Erectile dysfunction• Decreased or abnormal sperm
Skeletal SystemGrave’s disease is associated with thyroid acropathy -Clubbing of nails -Periosteal bone formation in metacarpal bone or phalangesNeuromuscular System• Tremors-outstretched hand and tongue• Hyperactive tendon reflexes
Endocrine• Increased sensitivity of pancreatic beta cells to glucose• Increased insulin secretion• Antagonism to peripheral action of insulin• Latter effects usually predominate leading to intolerance.
Diagnostic TestTSH Serum TSH is suppressed in hyperthyroidism (< 0.05 mU/L), except in cases secondary to TSH hypersecretion. Raised free T4 or T3; T4 is almost always raised but T3 is more sensitive as there are occasional cases of isolated T3 toxicosis. TSH receptor antibodies are not measured routinely, but are commonly present: thyroid-stimulating immunoglobin (TSI) 80% positive, TSH-binding inhibitory immunoglobin (TBII) 60-90% in Graves disease .
• T3 The T3 (or Triiodothyronine) assay is another assay which is used in the diagnosis of thyroid disorders. In developing hyperthyroidism, the Free T3 concentration is a more sensitive indicator of developing disease than is T4 (free T4), and the former is therefore preferred for confirming hyperthyroidism that has already been suggested by a suppressed TSH result. The T3 assay is also useful for diagnosing a variant of hyperthyroidism known as T3 thyrotoxicosis.
Other Tests• Auto antibodies of clinical interest in thyroid disease include thyroid-stimulating antibodies (TSAb),• TSH receptor-binding inhibitory immunoglobulins (TBII),• Antithyroglobulin antibodies (Anti-Tg Ab) and the anti thyroid peroxidase antibody (Anti-TPO Ab). Of these, anti-TPO Ab has emerged as the most generally useful marker for the diagnosis and management of autoimmune thyroid disease.
Ultrasound Similar in its use for evaluating a breast mass, ultrasound can be used to assess a thyroid nodule. Its advantage over physical exam alone lies in its ability to distinguish solid from cystic nodules, whether more than one nodule exists, and the exact size and extent of a nodule. In fact, ultrasound can be used to assess the size and shape of the thyroid gland itself. Because of the recent advances in this form of imaging technology, ultrasound has become quite sensitive a modality, particularly when assessing size and numbers of nodules.
Ultrasound characteristics whichsuggest a benign nodule include:• Nodule filled with fluid (likely a cyst)• Multiple nodules throughout the gland (likely a multinodular goiter)• No blood flowing through nodule (again, likely a cyst)• Sharp edges seen around nodule
FINE NEEDLE ASPIRATION• Provided adequate sample is removed on biopsy, FNA of thyroid nodules can be used to categorize tissue into the following categories: malignant, benign, thyroiditis, follicular neoplasm, suspicious, or non- diagnostic.• The technique has decreased unnecessary operative procedures in patients with benign nodules and increased the probability that surgery will be performed on those with malignant disease.• The one drawback lies with hypocellular samples and aspirates with high follicular cellularity.• Hypocellular aspirates may be encountered in cystic nodules.• Aspirates with a high follicular cellularity suggest follicular neoplasm, however, FNA cannot reliably distinguish a benign follicular neoplasm from a malignant one, and thus surgical resection remains the necessary recourse to obtain a definitive diagnosis.
Thyroid Scan• The tissue that makes up the thyroid gland is unique in that it is able to take up and trap iodine and certain other molecules of similar size.• When radioactive isotopes of these substances (tracers) are swallowed or injected into the bloodstream, they are taken up by the thyroid gland.• As they decay, a special camera can detect the energy that is released, creating a picture of the thyroid gland.• The radioactive isotopes that are most commonly used as tracers to perform thyroid scans are called 123-Iodine, 99m- Technetium pertechnetate and 131-Iodine.
MEDICAL MANAGEMENTAntithyroid drugs:- Radio active iodone Surgery
Antithyroid drugs:-• Commonly used drugs are propylthiomacil (PTU) 100-300 mg three times a day and methimazole (tapazole) is given in a dose of 10-15 mg three times a day till the patient is euthyroid and there after in a dose of 5 mg three times aday for upto 12 to 18 months these drugs interferes with the binding of organic iodine and the coupling of the iodotyrosines initial response is seen antithyroid drugs as it prevents an increase in the size of the gland and thyroid insufficiency.• Assessment During Treatment:-• Clinical examination, pulse rate, and the thyroid hormone levels.
Iodides:-• Iodides are useful because iodine inhibits the synthesis of thyroid hormone. They are used often a use of most often a course of propylthiouracil to suppress hormone secretion before thyroidectomy. The iodides may be used to treat thyrotoxicosis.• Lugol’s solution’s (5% iodide and 10% potassium iodide) and saturated solution of potassium iodide.Side effects• Iodine solution can cause discolouration of the teeth and gastric upset. The effects are minimize if the iodine solution is diluted with milk and fruit jucies or some other beverages and sipped with straw.• Signs of iodine toxicity include swelling and irritation of mucus membrane and increased salivation.
Radio iodide:-• It is widely used modality of treatment I 131 is preferred and the dose for diffuse toxic goiter is 7 to 9millicurie and for toxic goiter is 12-15 mc. Many patient will require more than one dose. It can be used in most of the patient except in new born and pregnant women and lactating women. Beta adrenergic blocker can be given to control cardiac symptoms. The radiation doses used to treat hyperthyroidism does not pose a threat to others.• Side effects :- its side effects are minimal. Inflammation of thyroid gland (thyrioditis) and the parotid gland (parotiditis) may occur. Hypothyroidism may occur or develop years of the treatment.
Surgical Treatment of ThyroidDiseaseGeneral Several surgical options exist for treating thyroid disease and the choice of procedure depends on two main factors.• The first is the type and extent of thyroid disease present.• The second is the anatomy of the thyroid gland itself. The most commonly performed procedures include: lobectomy, lobectomy with isthmectomy, subtotal thyroidectomy, and total thyroidectomy.
Thyroid Lobectomy and Isthmectomy• As its name implies, thyroid lobectomy involves removal of only one lobe of the thyroid gland. This may involve crossing the midline to include the isthmus (isthmectomy) or it may involve the affected lobe alone.• Indications for thyroid lobectomy include biopsy for a solitary thyroid nodule suspicious of malignancy, compressive or cosmetic symptoms from a multinodular goiter, or removal of a well-differentiated malignancy in a low-risk patient (although this is controversial). Thyroid lobectomy ± isthmectomy is a surgical option for well-differentiated papillary carcinomas, although many surgeons may have option for a total thyroidectomy instead with removal of affected cervical nodes if necessary.
ADVANTAGE AND DISADVANTAGE• The advantage of this procedure is that normal thyroid tissue is left behind to provide endogenous hormone. In addition, there is less chance of disrupting the parathyroid glands or recurrent laryngeal nerves on the unaffected side.• The disadvantage to lobectomy is that with a remnant lobe left in place, the use of radioiodine as ablative therapy is compromised.
Subtotal Thyroidectomy• In a subtotal thyroidectomy, the affected side (lobe) of the gland is removed, along with the isthmus and a substantial portion of the opposite lobe. Typically reserved for small, non- aggressive thyroid cancers, this is also a viable option for goiters which cause compressive or cosmetic problems in the neck.
Total Thyroidectomy• Total thyroidectomy involves complete removal of the thyroid gland and is the operation of choice for practically all thyroid cancers. Even obstructive goiter is occasionally treated with total thyroidectomy as opposed to subtotal thyroidectomy. In fact, certain situations are absolute indications for complete gland removal including medullary thyroid carcinoma, sarcoma of the thyroid gland, and stage IE thyroid lymphoma.
Nursing management :-• Nursing Diagnosis:- imbalanced nutrition less than body requirement related to anorexia and increase metabolic demand is inappropriate.• Expected Out comes:- The client’s weight loss will end as evidenced by an ability to consume sufficient calories to return to ideal body weight.
• Nursing diagnosis:- Activity intolerance related to exhaustion secondary to accelerated metabolic rate resulting in inability to perform activity without shortness of breath and significant increased in heart rate.• Expected Out comes:- the client will engage in a normal level of activity by ability to maintain a proper balance of rest and activity to prevent exhaustion.
• Nursing Diagnosis :- risk for injury: corenal ulceration, infection and not possible blindness related inability to close the eye lids secondary to exophthalmos.• Expected Outcomes :- the client should not experience coreneal ulceration infection or blindness as evidenced by the lack of further development of expothalmus.
• Nursing diagnosis :- Hyperthyremia related to accelerated metabolic rate resulting in fever, diaphoresis and reported heat intolerance.• Expected outcomes :- the client will not exhibit hyperthermia as evidenced by return to normal body temperature.
• Nursing diagnosis :- Impaired social interaction related to extreme agitation, hyperactivity, and mood swings resulting in inability to relate effectively with others.• Expected out comes:- the client will not suffer from impaired social interact without difficulty, without agitation, hyperactivity or mood swings.
Complication:-• The major complications of grave’s disease are :• Exopathalom• Heart disease• Thyroid storm (thyroid crisis)• Thyrotoxicosis
Exophthalmo’s :- The client with exopthalmos should wear dark glasses and warm them to avoid getting dust or dirt in there eyes when they can not close their eyelids easily at all they should were a sleeping mask (available in drug store) or lightly tape the eye shunt with non-allergic tape. They can elevate the head of the bed at night and have the client restrict salt in take to relive edema.
Heart disease:- Heart disease the second complication of graves disease poses a serious there at tachycardia almost always accompanies thyrotoxicosis, and atrial fibrillation may also appears. Congestive cardiac failure found in old client with long stand thyrotoxicosis.Thyroid strom:- Thyroid strom is sometimes fatal acute episode of thyroid activity is characterised by high fevear, delirium dehydration and extreme irritability. It was once a common occurring crisis but seldom develops.
Thyroid strom:- Thyroid strom is sometimes fatal acute episode of thyroid activity is characterised by high fevear, delirium dehydration and extreme irritability. It was once a common occurring crisis but seldom develops. Thyroid strom require heroic intervention farcentral. The high fevear is treated with hypothermic blancket dehydration is reversed by intravenous fluid.