HYPERTHYROIDISM
- 1. MRS.ROJARANI.K, RNM,M.SC(N), MEDICAL SURGICAL NURSING ASSISTANT PROFESSOR GANGA COLLEGE OF NURSING COIMBATORE
- 3. OBJECTIVES At the end of the class the students will be able to, • Review of anatomy and physiology of thyroid gland • define Hyperthyroidism • list the etiology &risk factors of hyperthyroidism • describe the pathophysiology • list the clinical manifestation • enumerate the assessment and diagnostic findings • list the complications • explain the medical management • describe the surgical management • describe the nursing management • explain the dietary management
- 4. INTRODUCTION Hyperthyroidism is hyperactivity of the thyroid gland with sustained increase in synthesis and release of thyroid hormones. The secretion of thyroid hormone is no longer under the regulatory control of the hypothalamic–pituitary center. There are a number of pathologic causes of hyperthyroidism in children and adults. These include Grave’s disease, toxic adenoma, toxic multinodular, goiter, approximately 95% of cases of hyperthyroidism.
- 5. REVIEW OF ANATOMY AND PHYSIOLOGY • The thyroid gland is a butterfly-shaped gland located in the front of the neck. The thyroid gland itself is regulated by the pituitary gland in the brain, and the pituitary gland is regulated by the hypothalamus, another gland in the brain. • It consists of two lateral lobes connected by an isthmus. The gland is about 5 cm long, 3 cm wide and weight about 30 g. • The thyroid gland produces three hormones (T4),triiodithyroxine (T3),and calcitonin
- 6. REVIEW OF ANATOMY AND PHYSIOLOGY
- 7. INTRODUCTION Hyperthyroidism is hyperactivity of the thyroid gland with sustained increase in synthesis and release of thyroid hormones. The secretion of thyroid hormone is no longer under the regulatory control of the hypothalamic–pituitary center. There are a number of pathologic causes of hyperthyroidism in children and adults. These include Grave’s disease, toxic adenoma, toxic multinodular, goiter, approximately 95% of cases of hyperthyroidism.
- 8. INTRODUCTION Graves disease is the most common cause of hyperthyroidism (60% - 80%) of all cases. Females are affected more frequently than men 10:15 Monozygotic twins show 50% concordance rates
- 9. DEFINITION Hyperthyroidism is the term for overactive tissue within the thyroid gland, resulting in overproduction and thus an excess of circulating free thyroid hormones: thyroxin (T4), triiodothyronine (T3), or both. Hyperthyroidism is hyperactivity of the thyroid gland with sustain increase in synthesis and release of hormones.
- 10. INCIDENCE • Hyperthyroidism is a common condition. • It has been estimated that there are 4.7/1000 women with active disease. • When previously treated cases were included, the population prevalence rose to 20/1000 in women. • As for hypothyroidism, it is much less common in men who have a lifetime prevalence of around 2/1000
- 11. CAUSES OF HYPERTHYROIDISM CIRCULATING THYROID STIMULATORS: • Graves disease • Neonatal Graves disease • Thyrotropin-secreting tumor (Pituitary adenoma) • Choriocarcinoma THYROIDALAUTONOMY: • Toxic multinodular goiter • Toxic solitary adenoma • Congenital hyperthyroidism • Iodine-induced hyperthyroidism(Jod-Basedow)
- 12. CAUSES OF HYPERTHYROIDISM CONT’ DESTRUCTION OF THYROID FOLLICLES (THYROIDITIS) • Sub acute thyroiditis • Painless or postpartum thyroiditis • Amiodarone-induced thyroiditis • Acute (infectious) thyroiditis EXOGENOUS THYROID HORMONE • Iatrogenic Excess ingestion of thyroid hormone • Factitious Excess ingestion of thyroid hormone • Hamburger thyrotoxicosis
- 13. CAUSES OF HYPERTHYROIDISM CONT’ ECTOPIC THYROID TISSUE: • Stroma ovary - Ovarian teratoma containing thyroid tissue • Metastatic follicular thyroid cancer • Pituitary resistance to thyroid hormone
- 14. RISK FACTORS • A previous thyroid problem, such as goiter • A previous history of thyroids surgery • Type 1diabetes • Primary adrenalin sufficiency • A family history of thyroid disease • Pernicious anaemia. • Over 60years
- 15. PATHOPHYSIOLOGY Hyperthyroidism characterized by loss normal regulatory control of thyroid hormone secretion The action of thyroid hormone on the body is stimulatory, hyper metabolism result Increase sympathetic nervous system activity Alteration secretion and metabolism of hypothalamic pituitary and gonadal hormone.
- 16. PATHOPHYSIOLOGY CONT’ Excessive amount of thyroid hormone stimulate the cardiac system and increase the adrenergic receptors Tachycardia and increase cardiac output, stroke volume and peripheral blood flow Negative nitrogenous balance, lipid depletion and the resultant state of nutritional deficiency HYPERTHYROIDISM
- 18. CLINICAL MANIFESTATION Symptoms and their severity depend on duration and extent of thyroid hormone excess, and the age of the individual. Individuals may experience: Nervousness and irritability Palpitations and tachycardia Heat intolerance or increased sweating Tremor Weight loss or gain Increase in appetite The skin is flushed continiously,with a characteristic salmon colour in Caucasians and is likely to be warm, soft and moist
- 20. CLINICAL MANIFESTATION CONT’ Frequent bowel movements or diarrhea Lower leg swelling Sudden paralysis Shortness of breath with exertion Decreased menstrual flow Impaired fertility Sleep disturbances (including insomnia)
- 21. CLINICAL MANIFESTATION CONT’ Changes in vision Photophobia, or light sensitivity Eye irritation with excess tears Diplopia, or double vision Exophthalmos, or forward protrusion of the eyeball Fatigue and muscle weakness Thyroid enlargement Pretibial myxedema (fluid buildup in the tissues about the shin bone; may be seen with Grave's disease)
- 22. INVESTIGATION History and physical examination Ophthalmic examination ECG- atrial tachycardia Thyroid function test: T3 andT4 Thyroid releasing hormone stimulation test Radioactive iodine uptake(RAIU) Thyroid ultrasound Thyroid scinti scan Cholesterol test Glucose test
- 23. INVESTIGATION
- 24. INVESTIGATION
- 25. LABORATORY ASSESSMENT TEST NORMAL VALUE HYPERTHYROIDISM Serum T3 70-205 ng/dl Increased Serum T4 4-12 ng/dl Increased Free T4 index 0.8-2.4 ng/dl Increased T3 renin uptake 24-34% increased TRH stimulation test Double the value Little or no TSH response Thyroid suppressiontest N / A Fails to suppress RAIU or levels.
- 26. LABORATORY ASSESSMENT CONT’ TSH stimulation test >10% in RAIU Fails to suppress RAIU Thyroid antibodies Titre < 1:100 High titre Thyrotrophine receptor antibodies Titre < 130% of basal activity . High titre indicate grave’s disease TSH 2-10 Μu /ml Low in grave’s disease ; high in secondary or tertiary hyperthyroidism . Thyroid-stimulating immunoglobulin (TSI) test. This test, also called a thyroid-stimulating antibody test, measures the level of TSI in your blood. Most people with Graves' disease have this antibody, but people whose hyperthyroidism is caused by something else do not.
- 27. COMPLICATION • Heart problems - These include a rapid heart rate , atrial fibrillation, congestive heart failure, • Brittle bones - Untreated hyperthyroidism can also lead to weak, brittle bones(osteoporosis). • Eye problems - People with Graves' ophthalmopathy develop eye problems, including bulging, red or swollen eyes, sensitivity to light, and blurring or double vision. Untreated, severe eye problems can lead to vision loss.
- 28. COMPLICATION • Red, swollen skin - In rare cases, people with Graves' disease develop Graves' dermopathy. This affects the skin, causing redness and swelling, often on the shins and feet. • Thyroid crisis • Hypothyroidism
- 29. MANAGEMENT Anti thyroid drugs Beta blockers Radio active therapy Surgical management-Sub total thyroidectomy
- 30. MEDICAL & NUTRITIONAL MANAGEMENT Anti-thyroid medications These –medications gradually reduce symptoms of hyperthyroidism by preventing your thyroid gland from producing excess amounts of hormones. They include propylthiouracil and methimazole(Tapazole). • Symptoms usually begin to improve in 6 to 12 weeks, but treatment with anti-thyroid medications typically continues at least a year and often longer.
- 31. MEDICAL & NUTRITIONAL MANAGEMENT CONT’Propylthiouracil (PTU) One of the advantages of PTU is that it has a lower risk of birth defects and therefore it is the first line treatment for pregnant women. A disadvantage is that PTU is only available in 50-milligram units Methimazole (Tapazole) The main benefit of Tapazole is that it can be taken one, two, or three times a day (depending on your dosage). Pills are available in 5 or 10 milligrams. It also has fewer side effects and often reverses hyperthyroidism quickly.
- 32. MEDICAL & NUTRITIONAL MANAGEMENT CONT’ • Inhibitor of hormone synthesis – Carbimazole – Methimazole – Propylthiouracil • Inhibitor of hormone release – Iodine – Iodides of Na,k – Organic iodides • Radioactive iodine – 131 I (Radioactive iodine) • Ionic inhibitors – Thiocynate(-SCN) – Perchlorates(-ClO4) – Nitrates(NO3) CLASSIFICATION OF ANTITHYROID DRUGS
- 33. MEDICAL & NUTRITIONAL MANAGEMENT CONT’ Beta blockers • These drugs are commonly used to treat high blood pressure. • They are used to reduce a rapid heart rate and help prevent palpitations. • Side effects may include fatigue, headache, upset stomach, constipation, Diarrhea or dizziness.
- 34. MEDICAL & NUTRITIONAL MANAGEMENT CONT’ Radio active iodine: • Taken by mouth, radioactive iodine is absorbed by your thyroid gland, where it causes the gland to shrink and symptoms to subside, usually within three to six months.
- 35. MEDICAL & NUTRITIONAL MANAGEMENT CONT’ Radio active iodine cont’: It is used to treat toxic adenoma, toxic multi nodular goitre . It is contraindicated during pregnancy because it crosses the placenta. They should also be instructed to not conceive for at least 6 months following treatment. Radioactive iodine should not be given until at least 6 weeks after lactation stops. Over a period of several weeks, thyroid cells exposed to the radioactive iodine are destroyed, resulting in reduction of the hyper thyroid state and inevitably hypothyroidism.
- 36. MEDICAL & NUTRITIONAL MANAGEMENT CONT’ Eat a heart-healthy diet. This diet should include foods such as: Fruits, vegetables, grains, and fat-free or low- fat milk and milk products, Lean meats, poultry, fish, beans, eggs, and nuts. Limit foods with saturated fats, trans fats, cholesterol, sodium (salt), and added sugars. Get regular physical activity for at least 30 minutes a day on most days of the week. Limit your intake of alcohol.
- 37. MEDICAL & NUTRITIONAL MANAGEMENT CONT’
- 38. SURGICAL MANAGEMENT Surgical Treatment of Thyroid Disease General 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.
- 40. NURSING MANAGEMENT • Improving nutritional status • Enhancing coping measures • Improve self esteem • Maintaining body temperature
- 41. NURSING MANAGEMENT Imbalanced nutrition less than body requirement related to anorexia and increase metabolic demand is inappropriate. Intervention: • High calorie diet (4000-5000kcal/day) • High protein diet (1-2 g/kg of ideal bodyweight) • Frequent meals
- 42. NURSING MANAGEMENT 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 Intervention: • Assist with regular physical activity. • Assist in activities of daily living
- 43. NURSING MANAGEMENT Ineffective coping related to irritability, hyper excitability, apprehension, and emotional instability Low self esteem related to changes in appearance, excessive appetite, and weight loss Risk for injury: corneal ulceration, infection and not possible blindness related inability to close the eye lids secondary to exophthalmos.
- 44. NURSING MANAGEMENT Hyperthermia related to accelerated metabolic rate resulting in fever, diaphoresis and reported heat intolerance. Impaired social interaction related to extreme agitation, hyperactivity, and mood swings resulting in inability to relate effectively with others
- 45. PREVENTION • Hyperthyroidism is not preventable. You may avoid the symptoms of hyperthyroidism by being diagnosed and treated early. • Lifestyle changes may help reduce your symptoms. • Avoiding caffeine and reducing stress may help relieve symptoms of anxiety, nervousness, poor concentration, and fast heartbeat. • Quitting smoking can reduce your risk of developing Grave’s Ophthalmopathy • Attend all of your doctor appointments. • Advice to take anti thyroid medication at the same time each day. • Continue to monitor dose of medicine to make sure receive the correct amount.
- 46. REFERENCE Smeltzer.Suzanne co et al, “Text book of Medical Surgical Nursing” Published by Elsevier,12th Edition Black, J.M., et.al., 1997.MedicalSurgicalNursing.5thedi. Philadelphia: Saunders publication. Bliley, D.M., 1987.Medical Surgical Nursing. ST Louis: Mosby Company. Brunner and Suddarth, 1995. Text Book of Medical Surgical Nursing. Philadelphia: Mosby Company.
- 47. REFERENCE Lewis, “Medical Surgical Nursing” Published by Elsevier, 11th Edition: Year-1996 Pamela .L. Swearingen, Malavizhi.S, “Nursing care Planning Resources”2017, Published by Elsevier, First south Asia Edition: Page no-287.Volume-1. WEB SOURCES www.wikipedia.com www.mayoclinic.org/diseases- conditions/hyperthyroidism/