HYPERTHYROIDISM

by
saida sadiq
• Hyperthyroidism is the second most prevalent
endocrine disorder, after diabetes mellitus. Graves’
disease, the most common type of hyperthyroidism,
results from an excessive output of thyroid hormones
caused by abnormal stimulation of the thyroid gland
by circulating immunoglobulins. The disorder may
appear after an emotional shock, stress, or an
infection, but the exact significance of these
relationships is not understood. Other common
causes of hyperthyroidism include thyroiditis and
excessive ingestion of thyroid hormone
Clinical Manifestations
Patients with well-developed hyperthyroidism exhibit a characteristic group of signs
and symptoms (sometimes referred to as thyrotoxicosis).
• The presenting symptom is often nervousness. These patients are often emotionally
hyper excitable, irritable, and apprehensive; they cannot sit quietly; they suffer from
palpitations; and their pulse is abnormally rapid at rest as well as on exertion.
• They tolerate heat poorly and perspire unusually freely.
• The skin is flushed continuously, with a characteristic salmon color, and is likely to be
warm, soft, and moist.
• However, patients may report dry skin and diffuse pruritus. A fine tremor of the
hands may be observed.
• Patients may exhibit ophthalmopathy, such as exophthalmos (bulging eyes), which
produces a startled facial expression. Despite treatment, these ocular changes are not
always reversible. Patients should be informed that smoking has been shown to
aggravate ocular changes
• Other manifestations include
• an increased appetite and dietary intake,
• progressive weight loss,
• abnormal muscular fatigability and weakness (difficulty in climbing stairs and rising
from a chair), a
• menorrhea, and changes in bowel function. The pulse rate ranges constantly
between 90 and 160 bpm; the systolic, but characteristically not the diastolic, blood
pressure is elevated; atrial fibrillation may occur; and cardiac decompensation in the
form of heart failure is common, especially in elderly patients. Osteoporosis and
fracture are also associated with hyperthyroidism.
• Cardiac effects may include sinus tachycardia or dysrhythmias, increased pulse
pressure, and palpitations; these changes may be related to increased sensitivity to
catecholamines or to changes in neurotransmitter turnover. Myocardial hypertrophy
and heart failure may occur if the hyperthyroidism is severe and untreated
 Medical Management
Appropriate treatment of hyperthyroidism depends on the
underlying cause and often consists of a combination of
therapies,
• Including antithyroid agents
• radioactive iodine,
• and surgery.
Treatment of hyperthyroidism is directed toward reducing
thyroid hyperactivity to relieve symptoms and preventing
complications. Surgical removal of most of the thyroid gland is
a nonpharmacologic alternative.
• No treatment for thyrotoxicosis is without side effects, and all
three treatments (radioactive iodine therapy, antithyroid
medications, and surgery) share the same complications:
relapse or recurrent hyperthyroidism and permanent
hypothyroidism.

• The rate of relapse increases in patients who have had very

severe disease, a long history of dysfunction, ocular and
cardiac symptoms, large goiter, or relapse after previous
 Pharmacologic Therapy
• Two forms of pharmacotherapy are available for
treating hyperthyroidism and controlling excessive
thyroid activity:
• use of irradiation by administration of the
radioisotope iodine 131 (131I) for destructive effects
on the thyroid gland
• antithyroid medications that interfere with the
synthesis of thyroid hormones and other agents that
control manifestations of hyperthyroidism.
Radioactive Iodine Therapy
The goal of radioactive iodine therapy (131I) is to destroy the
overactive thyroid cells. Almost all the iodine that enters and
is retained in the body becomes concentrated in the thyroid
gland. Therefore, the radioactive isotope of iodine is
concentrated in the thyroid gland, where it destroys thyroid
cells without jeopardizing other radiosensitive tissues. Over a
period of several weeks, thyroid cells exposed to the
radioactive iodine are destroyed, resulting in reduction of the
hyperthyroid state and inevitably hypothyroidism
• The patient is instructed about what to expect with this
tasteless, colorless radioiodine, which may be administered
by the radiologist. Typically, a single dose is needed. About
95% of patients are cured by one dose of radioactive iodine.
The additional 5% require two doses; rarely is a third dose
necessary. Use of an ablative dose of radioactive iodine
initially causes an acute release of thyroid hormone from the
thyroid gland and may cause increased symptoms. The
patient is observed for signs of thyroid storm ,a life-
threatening condition manifested by cardiac dysrhythmias,
fever, and neurologic impairment (Harris, 2007). Propranolol
(Inderal) is useful in controlling these symptoms
 Antithyroid Medications
• The objective of pharmacotherapy is to inhibit one or more
stages in thyroid hormone synthesis or hormone release.
Antithyroid agents block the utilization of iodine by
interfering with the iodination of tyrosine and the coupling
of iodotyrosines in the synthesis of thyroid hormones. This
prevents the synthesis of thyroid hormone. Most
commonly, propylthiouracil (PTU) or methimazole
(Tapazole) is used until the patient is euthyroid (ie, neither
hyperthyroid nor hypothyroid).
Surgical Management
• Surgery to remove thyroid tissue was once the
primary method of treating hyperthyroidism. Today,
surgery is reserved for special circumstances—for
example, in pregnant women who are allergic to
antithyroid medications, in patients with large goiters,
or in patients who are unable to take antithyroid
agents. Surgery for treatment of hyperthyroidism is
performed soon after the thyroid function has
returned to normal
THYROIDITIS
 THYROIDITIS
• Thyroiditis, inflammation of the thyroid gland, can be acute,
subacute, or chronic. Each type of thyroiditis is characterized by
inflammation, fibrosis, or lymphocytic infiltration of the thyroid
gland.
• Acute thyroiditis is a rare disorder caused by infection of the
thyroid gland by bacteria, fungi, mycobacteria, or parasites.
Staphylococcus aureus and other staphylococci are the most
common causes. Infection typically causes anterior neck pain and
swelling, fever, dysphagia, and dysphonia. Pharyngitis or pharyngeal
pain is often present. Examination may reveal warmth, erythema
(redness), and tenderness of the thyroid gland.
• Subacute thyroiditis may be subacute granulomatous thyroiditis
(deQuervain’s thyroiditis) or painless thyroiditis (silent thyroiditis
or subacute lymphocytic thyroiditis). Subacute granulomatous
thyroiditis is an inflammatory disorder of the thyroid gland that
predominantly affects women between 40 and 50 years old
The condition presents as a painful swelling in the anterior neck
that lasts 1 to 2 months and then disappears spontaneously
without residual effect. It often follows a respiratory infection.
The thyroid enlarges symmetrically and may be painful. The
overlying skin is often reddened and warm. Swallowing may be
difficult and uncomfortable. Irritability, nervousness, insomnia,
and weight loss—manifestations of hyperthyroidism—are
common, and many patients experience chills and fever as well.
• Treatment aims to control the inflammation. In general, nonsteroidal anti-
inflammatory drugs (NSAIDs) are used to relieve neck pain. Acetylsalicylic
acid (aspirin) is avoided if symptoms of hyperthyroidism occur because
aspirin displaces thyroid hormone from its binding sites and increases the
amount of circulating hormone.
• Beta-blocking agents (eg, propranolol [Inderal]) may be used to control
symptoms of hyperthyroidism. Antithyroid agents, which block the synthesis
of T3 and T4, are not effective in thyroiditis because the associated
thyrotoxicosis results from the release of stored thyroid hormones rather
than from their increased synthesis. In more severe cases, oral
corticosteroids may be prescribed to reduce swelling and relieve pain;
however, they do not usually affect the underlying cause.
• Painless thyroiditis (subacute lymphocytic thyroiditis) often occurs in the
postpartum period and is thought to be an autoimmune process. Symptoms
of hyperthyroidism or hypothyroidism are possible.
 CHRONIC THYROIDITIS (HASHIMOTO’S
DISEASE)
• Chronic thyroiditis, which occurs most frequently in women between 30 and
50 years old, has been termed Hashimoto’s disease, or chronic lymphocytic
thyroiditis; its diagnosis is based on the histologic appearance of the inflamed
gland. In contrast to acute thyroiditis, the chronic forms are usually not
accompanied by pain, pressure symptoms, or fever, and thyroid activity is
usually normal or low rather than increased. Cell-mediated immunity may
play a significant role in the pathogenesis of chronic thyroiditis, and there
may be a genetic predisposition to it. If untreated, the disease runs a slow,
progressive course, leading eventually to hypothyroidism.
• The objective of treatment is to reduce the size of the thyroid gland and
prevent hypothyroidism. Thyroid hormone therapy is prescribed to reduce
thyroid activity and the production of thyroglobulin. If hypothyroid symptoms
are present, thyroid hormone therapy is prescribed. Surgery may be required
if pressure symptoms persist.
 THYROID TUMORS
• Tumors of the thyroid gland are classified on the basis of being benign or
malignant, the presence or absence of associated thyrotoxicosis, and the
diffuse or irregular quality of the glandular enlargement. If the enlargement is
sufficient to cause a visible swelling in the neck, the tumor is referred to as a
goiter.
• All grades of goiter are encountered, from those that are barely visible to those
producing disfigurement. Some are symmetric and diffuse; others are nodular.
Some are accompanied by hyperthyroidism, in which case they are described as
toxic; others are associated with a euthyroid state and are called nontoxic
goiters
1. ENDEMIC (IODINE-DEFICIENT) GOITER
• The most common type of goiter, encountered chiefly in geographic
regions where the natural supply of iodine is deficient (eg, the Great
Lakes areas of the United States), is the so-called simple or colloid goiter.
• In addition to being caused by an iodine deficiency, simple goiter may be
caused by an intake of large quantities of goitrogenic substances in
patients with unusually susceptible glands. These substances include
excessive amounts of iodine or lithium, which is used in treating bipolar
disorders
2. NODULAR GOITER
Some thyroid glands are nodular because of areas of
hyperplasia (overgrowth). No symptoms may arise as a
result of this condition, but not uncommonly these nodules
slowly increase in size, with some descending into the
thorax, where they cause local pressure symptoms. Some
nodules become malignant, and some are associated with a
hyperthyroid state. Thus, the patient with many thyroid
nodules may eventually require surgery .
Thyroidectomy Pre-Operative Nursing Care
The goal in the thyroidectomy pre-operative phase is to identify any
risk factors that might complicate the surgery or the recovery and
then implement strategies to reduce them. You need to perform
five main tasks during the pre-operative nursing assessment. These
include:
• Obtaining the patient’s medical history
• Performing a physical examination of the Thyroid Gland
• Evaluating the patient’s psychosocial factors
• Get all the required medical tests and imaging for Thyroidectomy
• Ensure all pre-operative documentation is in order