The document discusses hyperthyroidism, also known as thyrotoxicosis, which is a condition caused by an overactive thyroid gland producing excessive thyroid hormones. The main causes of hyperthyroidism are Graves' disease, toxic nodular goiter, thyroiditis, and pituitary tumors. The document outlines the signs and symptoms of hyperthyroidism, diagnostic tests, and treatment options including antithyroid medications, radioactive iodine therapy, surgery, and management of complications.

1. Mrs Dipali Dumbre
MSc Nursing
Medical Surgical Nursing
SCON

3. “Hyperthyroidism is hyperactivity of the thyroid gland
with sustained increase in synthesis and release of thyroid
hormones.”
Hyperthyroidism is sometimes called thyrotoxicosis, the
technical term for too much thyroid hormone in the
blood.

4.  Graves’ disease. (In Graves’ disease, immune system creates antibodies
known as thyroid-stimulating immunoglobulins. These antibodies attach to
healthy thyroid cells can cause thyroid to create too much thyroid hormone.)
 Toxic nodular goiter,
 Thyroiditis,
 Exogenous iodine excess,
 Pituitary tumors
 Thyroid cancer

5.  Graves’ disease is an autoimmune disease of unknown etiology
marked by diffuse thyroid enlargement and excessive thyroid
hormone secretion.
 Precipitating factors such as infection, and stressful life events
may interact with genetic factors to cause Graves’ disease.
 Graves’ disease accounts for 75% of the cases of
hyperthyroidism.
 The patient develops antibodies to the TSH receptor.

6.  These antibodies attach to the receptors and stimulate the
thyroid gland to release T3, T4, or both.
 The excessive release of thyroid hormones leads to the
clinical manifestations associated with thyrotoxicosis.
 The disease is characterized by remissions and
exacerbations, with or without treatment.
 It may progress to destruction of the thyroid tissue, causing
hypothyroidism.

7.  Nodular goiters are thyroid hormone–secreting nodules
that function independent of TSH stimulation.
 If these nodules are associated with hyperthyroidism, they
are termed toxic.
 The nodules are usually benign follicular adenomas.

8.  Increases metabolism.
 It also increases tissue sensitivity to stimulation by the
sympathetic nervous system.
 Palpation of the thyroid gland may reveal a goiter.
 Auscultation of the thyroid gland may reveal bruits, a reflection
of increased blood supply.
 Ophthalmopathy, a term used to describe abnormal eye
appearance or function.
 A classic finding in Graves’ disease is exophthalmos, a
protrusion of the eyeballs from the orbits.

9.  Exophthalmos is a type of infiltrative ophthalmopathy that
is due to impaired venous drainage from the orbit, which
causes increased fat deposits and fluid (edema) in the
retroorbital tissues.


10.  Acropachy: Acropachy refers to a dermopathy associated with
Graves' disease. It is characterized by soft-tissue swelling of the
hands and clubbing of the fingers.

11.  Cardiovascular Manifestation:
• Systolic hypertension
• Increased rate and force of cardiac contractions
• Bounding, rapid pulse
• Increased cardiac output
• Cardiac hypertrophy
• Systolic murmurs
• Dysrhythmias
• Palpitations
• Atrial fibrillation (more common in the older adult)

12.  Respiratory System:
• Increased respiratory rate
• Dyspnea on mild exertion
Gastrointestinal:
• Increased appetite, thirst
• Weight loss
• Increased peristalsis
• Diarrhea, frequent defecation
• Increased bowel sounds

13.  Nervous System
• Difficulty in focusing eyes
• Nervousness
• Fine tremor (of fingers and tongue)
• Insomnia
• Lability of mood, delirium
• Restlessness
• Personality changes of irritability, agitation
• Exhaustion
• Hyperreflexia of tendon reflexes
• Depression, fatigue, apathy (in the older adult)
• Lack of ability to concentrate
• Stupor, coma

14.  Thyrotoxic crisis (also called thyroid storm) is an acute,
rare condition in which all hyperthyroid manifestations are
heightened.
 Although it is considered a life-threatening emergency,
death is rare when treatment is vigorous and initiated early.
 Causes: It is thought to be stressors (e.g., infection,
trauma, surgery) in a patient with preexisting
hyperthyroidism, either diagnosed or undiagnosed.

15.  Clinical Manifestations:
• Severe tachycardia,
• Heart failure,
• Shock,
• Hyperthermia (up to 105.3° F [40.7° C]),
• Restlessness,
• Agitation : A state of anxiety or nervous excitement
• Seizures,
• Abdominal pain,
• Nausea, vomiting,
• Diarrhea,
• Delirium, and coma.

16. Treatment:
• It is aimed at reducing circulating thyroid hormone levels
by appropriate drug therapy.
• Supportive therapy is directed at managing respiratory
distress, fever reduction, fluid replacement, and elimination
or management of the initiating stressor(s).

17.  History and physical examination
 Ophthalmologic examination
 ECG
 Laboratory tests :
• Decreased TSH levels
• Elevated free thyroxine (free T4) levels
 Radioactive iodine uptake (RAIU):
The RAIU test is used to differentiate Graves’ disease from
other forms of thyroiditis. The patient with Graves’ disease
will show a diffuse, homogeneous uptake of 35% to 95%,
whereas the patient with thyroiditis will show an uptake of
less than 2%.

18.  Antithyroid Drugs.
The first-line antithyroid drugs are
Propylthiouracil (PTU) and methimazole (Tapazole).
These drugs inhibit the synthesis of thyroid hormones. PTU
also blocks peripheral conversion of T4 to T3.

19. Iodine.
 Iodine is used with other antithyroid drugs to prepare the
patient for thyroidectomy or for treatment of thyrotoxic
crisis.
 The administration of iodine in large doses rapidly inhibits
synthesis of T3 and T4 and blocks the release of these
hormones into circulation.
 It also decreases the vascularity of the thyroid gland,
making surgery safer and easier.

20.  β-Adrenergic Blockers.
 β-Adrenergic blockers are used for symptomatic relief of
thyrotoxicosis that results from increased β-adrenergic
receptor stimulation caused by excess thyroid hormones.
 Propranolol (Inderal) is usually administered with other
antithyroid agents and rapidly provides symptomatic relief.
 Atenolol (Tenormin) is the preferred β-adrenergic blocker
for use in the hyperthyroid patient with asthma or heart
disease

21. Radioactive Iodine Therapy
 Radioactive iodine (RAI) therapy is the treatment of choice for
most nonpregnant adults.
 RAI damages or destroys thyroid tissue, thus limiting thyroid
hormone secretion.
 RAI has a delayed response, and the maximum effect may not
be seen for 2 to 3 months.
 For this reason, the patient is usually treated with antithyroid
drugs and propranolol before and during the first 3 months after
the initiation of RAI until the effects of radiation become
apparent.

22. Surgical Therapy
 Thyroidectomy is indicated for individuals who have been
unresponsive to antithyroid therapy, for individuals with very
large goiters causing tracheal compression, and for individuals
with a possible malignancy.
 Additionally, this surgery may be done when an individual is
not a good candidate for RAI.
 One advantage thyroidectomy has over RAI is a more rapid
reduction in T3 and T4 levels.
 A Subtotal thyroidectomy is the preferred surgical procedure
and involves the removal of a significant portion of the thyroid
gland.

23.  Endoscopic thyroidectomy is a minimally invasive
procedure.
 It is an appropriate procedure for patients with small
nodules (less than 3 cm) where there is no evidence of
malignancy.
 Advantages of endoscopic thyroidectomy over open
thyroidectomy include less scarring, less pain, and a faster
return to normal activity.

24.  When subtotal thyroidectomy is the treatment of choice, the
patient must be adequately prepared to avoid postoperative
complications.
Preoperative
 Preoperative teaching should include comfort and safety
measures in which the patient can participate.
 Coughing, deep breathing, and leg exercises should be
practiced and their importance explained.
 The patient should be taught how to support the head
manually while turning in bed, because this maneuver
minimizes stress on the suture line after surgery.
 Range-of-motion exercises of the neck should be practiced.

25. Post Operative
 Oxygen, suction equipment, and a tracheostomy tray should
be readily available.
 A tracheostomy tray is required in case airway obstruction
occurs.
 Recurrent laryngeal nerve damage leads to vocal cord
paralysis. If there is paralysis of both cords, airway
obstruction will occur, requiring an immediate tracheostomy.
 Respiration may also become difficult because of excess
swelling of the neck tissues, hemorrhage, hematoma
formation, and laryngeal stridor. Laryngeal stridor (harsh,
vibratory sound) may occur during inspiration and expiration
as a result of edema of the laryngeal nerve.
 Laryngeal stridor may also be related to tetany, which occurs
if the parathyroid glands are removed or damaged during
surgery leading to hypocalcemia. To treat tetany, IV calcium
salts such as calcium gluconate should be available.

26. After a thyroidectomy the nurse should do the following:
 Assess the patient every 2 hours for 24 hours for signs of
hemorrhage or tracheal compression such as irregular
breathing, neck swelling, frequent swallowing, sensations of
fullness at the incision site, choking, and blood on the
anterior or posterior dressings.
 Place the patient in a semi-Fowler position and support the
patient's head with pillows, and avoid flexion of the neck and
any tension on the suture lines.
 Monitor vital signs.
 Complete the initial assessment by checking for signs of
tetany secondary to hypoparathyroidism (e.g., tingling in
toes, fingers, or around the mouth; muscular twitching) and
by evaluating difficulty in speaking and hoarseness.

27.  Trousseau's sign and Chvostek's sign should be
monitored for 72 hours.
 Trousseau's sign: Inflating the BP cuff for several mintues causes
muscular contraction,including flexion of the wrist and
metacapophalangeal joints

28.  Chvostek's sign: Tapping on the facial nerve causes twitching of
facial muscles.
 Some hoarseness is to be expected for 3 to 4 days after surgery
because of edema.
 Control postoperative pain by giving medication.