14. Hyperthyroidism (also called thyrotoxicosis; Graves’ disease): spectrum of symptoms of accelerated metabolism caused by excessive amounts of circulating thyroid hormon Graves’ disease is most common cause of hyperthyroidism. The three components of Graves’ disease are hyperthyroidism, ophthalmopathy (protrusion of the eyes), and skin lesions (dermopathy). Graves’ disease is triggered by: stress, smoking, radiation of the neck, some medications (interleukin-2), and infections. Treatment of hyperthyroidism is accomplished by antithyroid medications, radioactive iodine administration (capsule given once), or surgery. Patients may need to take supplemental thyroid hormone (levothyroxine) after treatment.
    1. Pathophysiology: diffuse hyperplasia of thyroid gland—> overproduction of thyroid hormone and increased blood serum levels. Hormone stimulates mitochondria to increase energy for cellular activities and heat production. As metabolic rate increases, fat reserves are utilized, despite increased appetite and food intak Cardiac output is increased to meet increased tissue metabolic needs, and peripheral vasodilation occurs in response to increased heat production. Neuromuscular hyperactivity —» accentuation of reflexes, anxiety, and increased alimentary tract mobility. Graves’ disease is caused by stimulation of the gland by immunoglobulins of the IgG class.
    2. Risk factors:
       1. Possible autoimmune response resulting in increase of a gamma globulin called longacting thyroid stimulator (LATS).
       2. Occurs in third and fourth decade.
       3. Affects women more than men.
       4. Emotional trauma, infection, increased stress.
       5. Overdose of medications used to treat hypothyroidism.
       6. Use of certain weight-loss products.
    3. Assessment:
       1. Subjective data:
          1. Nervousness, mood swings.
          2. Palpitations.
          3. Heat intolerance.
          4. Dyspnea.
          5. Weakness.
       2. Objective data:
          1. Eyes: exophthalmos, characteristic stare, lid lag.
          2. Skin:
             1. Warm, moist, velvety.
             2. Increased sweating; increased melanin pigmentation.
             3. Prétibial edema with thickened skin and hyperpigmentation.
          3. Weight loss despite increased appetite.
          4. Muscle: weakness, tremors, hyperkinesia.
          5. Vital signs: BP—increased systolic pressure, widened pulse pressure; tachycardia.
          6. Goiter: thyroid gland noticeable and palpable.
          7. Gynecological: abnormal menstruation.
          8. GI: frequent bowel movements.
          9. Activity pattern: overactivity leads to fatigue, which leads to depression, which stimulates patient into overactivity, and pattern continues. Danger: total exhaustion.
          10. Lab data:
              1. Elevated: serum T< (>11 p.g/100 mL), free T, or free T ₄ index, T ₃ level (>35%) and free T ₃ level.
              2. Elevated: thyroid uptake of radioiodine (RAIU).
              3. Elevated: metabolic rate (BMR).
              4. Decreased: WBC caused by decreased granulocytosis (<4500).
    4. Analysis/nursing diagnosis:
       1. Altered nutrition, less than body requirements, related to elevated basal metabolic rate.
       2. Risk for injury related to exophthalmos and tremors.
       3. Activity intolerance related to fatigue from overactivity.
       4. Fatigue related to overactivity.
       5. Anxiety related to tachycardia.
       6. Sleep pattern disturbance related to excessive amounts of circulating thyroid hormone.
    5. Nursing care plan/implementation:
    1. Goal: protect from stress: private room, restrict visitors, quiet environment.
    2. Goal: promote physical and emotional equilibrium.
    1. Environment: quiet, cool, well ventilate.
    2. Eyecare:
       1. Sunglasses to protect from photophobia, dust, win
       2. Protective drops (methylcellulose) to soothe exposed corne
    3. Diet
       1. High: calorie, protein, vitamin
       2. 6 meals/day, as neede
       3. Weigh daily.
       4. Avoid stimulants (coffee, tea, colas, tobacco).
    3. Goal: prevent complications.
       1. Medications as ordered:
          1. Propylthiouracil to block thyroid synthesis; hyperthyroidism returns when therapy is stoppe
          2. Methimazole (Tapazole) to inhibit synthesis of thyroid hormon
          3. Iodine preparations: used in combination with other medications when hyperthyroidism not well controlled; saturated solution of potassium iodide (SSKI) or Lugol’s solution; more palatable if diluted with water, milk, or juice; give through a straw to prevent staining teet Takes 2-4 wk before results are evident.
          4. Propranolol (Inderal), atenolol (Tenormin), metoprolol (Lopressor) given to counteract the increased metabolic effect of thyroid hormones, but do not alter their levels. Relieve the symptoms of tachycardia, tremors, and anxiety.
       2. Monitor for thyroid storm (crisis)— medical emergency: acute episode of thyroid overactivity caused when increased amounts of thyroid hormone are released into the bloodstream and metabolism is markedly increase
          1. Risk factors for thyroid storm: patient with uncontrolled hyperthyroidism (usually Graves’ disease) who undergoes severe sudden stress, such as:
             1. Infection.
             2. Surgery.
             3. Beginning labor to give birt
             4. Taking inadequate antithyroid medications before thyroidectomy.
          2. Assessment:
             1. Subjective data— thyroid storm:
                1. Apprehension.
                2. Restlessness.
             2. Objective data— thyroid storm:
                1. Vital signs: elevated temperature (106°F), hypotension, extreme tachycardi
                2. Marked respiratory distress, pulmonary edem
                3. Weakness and delirium.
                4. If untreated, patient could die of heart failur
          3. Medications—thyroid storm:
             1. Propylthiouracil or methimazole (Tapazole) to decrease synthesis of thyroid hormon
             2. Sodium iodide IV; Lugol’s solution orally to facilitate thyroid hormone synthesis.
             3. Propranolol (Inderal) to slow heart rat
             4. Aspirin to decrease temperatur
             5. Steroids to combat crisis.
             6. Diuretics, digitalis to treat heart failur
    4. Goal: health teaching.
       1. Stress-reduction techniques.
       2. Importance of medications, their desired effects and side effects.
       3. Methods to protect eyes from environmental damage.
       4. Signs and symptoms of thyroid storm.
    5. Goal: prepare for additional treatment as needed.
       1. Radioactive iodine therapy: I, a radioactive isotope of iodine to decrease thyroid activity.
          1. I dissolved in water and given by mouth.
          2. Hospitalization necessary only when large dose is administered.
          3. Minimal precautions needed for usual dose.
             1. Sleep alone for several nights.
             2. Flush toilet several times after use.
          4. Effectiveness of therapy seen in 2-3 wk; single dose controls 90% of patients.
          5. Monitor for signs of hypothyroidism.
    6. Evaluation/outcome criteria:
    1. Complications avoided.
    2. Compliance with medical regimen.
    3. No further weight loss.
    4. Able to obtain adequate sleep.