Shannon Galey University of South Florida Med Surg 1

Hormones of the thyroid gland T3 and T4 produce and regulate adrenaline, epinephrine, dopamine T3 and T4 are crucial for brain development Also regulates metabolism Works hand in hand with pituitary gland to produce TSH ( pituitary gland controls the amount of TSH released to the body) Thyroid can be considered the “manager” of the body Regulates all body organs and functions THYROID FUNCTIONS

PATHOPHYSIOLOGY Hyperthyroidism is a disorder that involves the excess secretions of thyroid hormones by the thyroid gland, this can lead to a hyper metabolic condition called thyrotoxicosis. The most common forms of hyperthyroidism are graves disease, Plummer disease, (Toxic multinodular goiter) and toxic adenoma.

Diffuse enlargement of both thyroid lobes, with uniform uptake of isotope and elevated radioactive iodine uptake 60-80% of all cases of Hyperthyroidism in the US Peak occurrence in people aged years old GRAVES DISEASE

Irregular areas of relatively diminished and occasionally increased uptake; overall radioactive iodine uptake is mildly to moderately increased 15-20% of all hyperthyroidism cases Occurs more commonly in places with iodine deficiencies US adds Iodine to foods so we have less “Plummer disease” then other countries TOXIC MULTI NODULAR GOITER “PLUMMER DISEASE”

3-5% of all hyperthyroidism cases growth of a thyroid nodule that produces and secretes excess amounts of thyroid Many times this nodule may be benign TOXIC ADENOMA

While seen in both men and women, it is more common in women A persons chance increases with age presents typically from ages years old. Reoccurring pregnancies can lead to thyroiditis which puts younger women at risk for Hyperthyroidism. Hyperthyroidism is one of the most frequently encountered condition in endocrinology Out of three forms of hyperthyroidism, Graves disease is the most common. 25 million people Caucasians and Hispanics are more at risk then African Americans WHO GETS HYPERTHYROID

Preterm labor Pregnancy induced hypertension Eclampsia (one or more convulsions in women during pregnancy whom suffer from high blood pressure. Thyroid storm (is a life-threatening health condition that is associated with untreated or undertreated hyperthyroidism. During thyroid storm, an individual’s heart rate, blood pressure, and body temperature can soar to dangerously high levels. Without prompt, aggressive treatment, thyroid storm is often FATAL Heart Failure DANGERS OF HYPERTHYROIDISM

Medications Propylthiouracil Methimazole Anti thyroid drugs, they work by blocking thyroids ability to produce thyroid hormone Radioactive Iodine (RIA) Pts whom have been on medication for at least 6 months who have seen no improvement 550 MBq does of radio active iodine is administered Majority of the time kills thyroid and pt becomes hypothyroid, or the thyroid will return to normal TREATMENTS FOR HYPERTHYROIDSIM

Broccoli Brussel sprouts Cabbage Cauliflower Kale Mustard greens Peaches Pears Rutabagas Soybeans Spinach Turnips All of these foods help suppress thyroid function Can be used with daily medications DIETARY MODIFICATIONS

Nervousness Anxiety Increased Perspiration Heat Intolerance Hyperactivity Heart Palpitations SYMPTOMS

Tachycardia and atrial arrhythmia Cardiac Output can be % higher in hyperthyroid pt. Systolic hypertension Warm, moist and smooth skin Lid lag Fixed stare Hand tremors Muscle weakness Weight loss despite increased appetite Reduction in menstrual flow or oligomenorrhea Diarrhea SIGNS

Younger patients exhibit sympathetic activation (anxiety, hyper activity and tremors) Older patients exhibit cardiovascular symptoms (dyspnea, atrial fibrillation) and weight loss Patients with Graves disease often have more “marked” symptoms then patients with other forms Opthalmopathy (periorbital edema, diplopia or proptosis) may indicate Graves disease CLINICAL PRESENTATION CAN VARY

Thyroid Stimulating Hormone (TSH) Free Thyroxine (FT4) Total Triodothyronine (T3) Thyrotoxicosis is marked by suppressed TSH levels and elevated T 3 and T 4 levels Patients with milder thyrotoxicosis may have elevation of T 3 levels only Subclinical hyperthyroidism features decreased TSH and normal T 3 and T 4 levels Thyroid Function TestThyroid Function Studies DIAGNOSTIC TESTS AND LABS

Anti ̶ thyroid peroxidase (anti-TPO) antibody Thyroid-stimulating immunoglobulin (TSI) Graves disease – Significantly elevated anti-TPO, elevated TSI Toxic multinodular goiter- Low or absent anti-TPO Toxic adenoma – Low or absent anti-TPO Patients without active thyroid disease may have mildly positive anti-TPO Autoantibody tests for hyperthyroidism Autoantibody titers in hyperthyroidism DIAGNOSTIC TEST AND LABS CONTINUED

Stabilization of thyroid function (with meds) Radio active Iodine is recommended(hypo is much safer!) If thyroid ablation totally kills thyroid patient receives thyroid replacement drugs (Synthroid) Thyroid Hormone causes excess left ventricle thickening (heart failure or death) Hyperthyroidism has also been linked to dilated cardiomyopathy and pulmonary hypertension. Graves Disease patients should be concerned with eye disorders and should be checked regularly All Hyperthyroid patients should be monitored regularly and have blood work every 3-6 months PROGNOSIS

Activity intolerance r/t increased oxygen need due to increased metabolic rate Anxiety r/t increased stimulation, loss of control Diarrhea r/t gastric mobility Ineffective health maintenance r/t deficient knowledge regarding medications, and coping with stress Insomnia r/t anxiety, excessive sympathetic discharge Imbalanced nutrition r/t less then body requirements r/t increased metabolic rate and increased gastrointestinal activity Risk for injury r/t eye disorders or injuries NURSING DIAGNOSIS

Energy Management Exercise therapy Nutritional Management Medication Management Stress Reduction Assessment of Vital Signs Education on disorder and Medications Reporting any changes in signs or symptoms to doctor NURSING INTERVENTIONS

A) Hoarseness and laryngeal stridor B) Bulging eyeballs and arrhythmias C) Elevated temperature and heart failure D) Lethargy progressing suddenly to impairment of consciousness A PATIENT IS ADMITTED TO THE HOSPITAL IN THYROTOXIC CRISIS (THYROID STORM). ON PHYSICAL ASSESSMENT OF THE PATIENT THE NURSE WOULD EXPECT TO FIND?

The Answer is C : Elevated temperature and signs of heart failure A hyperthyroid crisis results in marked manifestations of hyperthyroidism, with fever tachycardia, heart failure, shock, hyperthermia, agitation, delirium, and coma. Although exophthalmos (abnormal bulging of eyeballs) may be present in the patient with Graves' disease, it is not a significant factor in hyperthyroid crisis. Hoarseness and laryngeal stridor are characteristic of hypoparathyroidism, and lethargy progressing to coma is characteristic of myxedema coma, a complication of hypothyroidism. RATIONALE

A)Adrenal Gland B) Pituitary Gland C) Parathyroid Gland D) Thyroid Gland SECRETION OF THYROID STIMULATING HORMONE (TSH) BY WHICH OF THE FOLLOWING GLANDS CONTROLS THE RATE AT WHICH THE THYROID HORMONE IS RELEASED?

The Answer is B : The Pituitary Gland By secretion of TSH the pituitary gland controls the amount of thyroid hormone released. The adrenal gland is not involved with the thyroid gland. The parathyroid gland only secretes parathyroid hormones and influences calcium, depending on the amount of calcium and phosphorus in the blood. The thyroid gland secretes thyroid hormone but does not control the mount released. RATIONALE

A)Weight loss, Dyspnea and atrial fibrillation B) palpitations, heat intolerance and irritability C) Cold intolerance and weight gain D) Numbness, cramping and tingling of extremities WHICH OF THE FOLLOWING GROUP OF SYMPTOMS WOULD YOU EXPECT TO FIND IN AN ELDERLY PATIENT WITH HYPERTHYROIDISM?

The Answer is A : Weight loss, dyspnea and A fib Most elderly people present with weight loss, A fib and dyspnea. While heat intolerance, palpations and irritability can be seen in younger patients with hyperthyroidism. Cold intolerance, weight gain, numbness and tingling of extremities are typically associated with Hypothyroidism. RATIONALE

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