HYPERTHYROIDISM

 HYPERTHYROIDISM

1. Mrs. Kamilioni Nyanga, aged 35 years, a business woman, married with 2 children was admitted to your ward with complaints of insomnia, heat intolerance and fine tremors. A diagnosis of hyperthyroidism was arrived at after thorough investigations.

a. Define hyperthyroidism.

b. State the three types of hyperthyroidism.

c. You decide to carry out a physical examination/assessment on Mrs. Nyanga. State the four techniques that you are going to use when performing a physical assessment.

d. Write down the management of Mrs. Nyanga while in hospital up to discharge

ANSWERS

a. Definition of Hyperthyroidism: This is a disorder of the endocrine system caused by excessive thyroid hormones, thyroxin and triiodothyroxine in the blood, characterized by increased body metabolic rate.

b. Three types of Hyperthyroidism:

Graves’s disease: The most common form of hyperthyroidism. It is an autoimmune disorder, associated with a diffuse enlargement of the gland, in which antibodies behave like TSH, stimulating thyroid hormone production.

Toxic adenoma (Solitary nodule): This type of tumor constitutes about 5% of thyroid disease. In these cases a thyroid nodule may act autonomously and produce excess levels of thyroid hormones, leading to suppression of the normal thyroid.

Toxic Multi-nodular goiter: This type of goiter is characterized by an asymmetrical nodular thyroid enlargement.

c. TECHNIQUES THAT CAN BE USED TO PERFORM A PHYSICAL ASSESSMENT

PALPATION: This is the examination of body organs by touch or pressure of the hand over the body part. Palpation on the anterior part of the neck to feel for the thyroid gland which will be enlarged. Visual and touch senses are predominantly used.

AUSCULTATION: This is the use of a stethoscope to examine the internal organs by listening to the sounds they give out. Listen to the heart sound for any abnormalities such as arrhythmias and also over the thyroid gland for bruit.

INSPECTION: This is the use of sight/visual senses to observe the patient’s gait, facial expressions and any unusual lumps on the body. Inspect the neck, the skin and the eyes. Enlarged gland may be revealed, heat on the skin and exophthalmia may also be revealed.

PERCUSSION: This is the method of diagnosis by tapping with the fingers or with a light hummer (patella hummer) upon any body part. This will give the condition of the underlying organ.

d. MANAGEMENT OF MRS. NALUNTAMBWE

I. MEDICAL MANAGEMENT:

INVESTIGATION

• History taking of symptoms such as tremors, hunger, sweating, heat intolerance.

• Physical assessment: Inspection, palpation, Auscultation and Percussion

• Thyroid function test (T3, T4 and TSH levels) are carried out and are followed by radiological examination of the neck.

• Needle biopsy and aspiration may be used to give a firm diagnosis and differentiate between the types.

MEDICATION

• Iodine if there is failure of ant thyroid drugs or in toxic multinodular goiter. Iodine usually reserved for; failure to respond to ant thyroid drugs, relapse after 1-2 years of therapy, toxic multinodular goiter solitary toxic nodule. Dose is 4-10mci(millicuries), it inhibits thyroid hormone secretion.

Radioactive Iodine (131I) is the most common used agent. Its use usually results in hypothyroidism

• Anxiolytic drugs: e.g. Diazepum 5-10mg orally.

• Ant thyroid drugs: Carbimazole 30-40mg daily or Propylthiouracil 300-600mg daily to inhibit synthesis of thyroid hormones. The most severe side effect of these drugs is leucopenia. Patient should be discontinued the drug at the first sign of infection.

• Beta-adrenergic blocking agents: Propanolol (Inderal) to relieve tachycardia, anxiety, heat intolerance and tremors.

• Diet: If significant weight loss has occurred a diet high in calories, protein, carbohydrates and vitamins is recommended to restore a normal nutritional state.

• May require surgery (Thyroidectomy) at some stage.

NURSING MANAGEMENT

Some of the Nursing diagnosis is as follows:

• Altered nutrition; less than body requirement related to hyper metabolism or inadequate nutrient absorption.

• Sleep pattern disturbance related to accelerated metabolism

• Anxiety related to SNS stimulation

• Body image disturbance related to exophthalmia

• Hyperthermia related to accelerated metabolism.

ENVIRONMENT

The environment should be conducive to provide frequent periods of rest. The room should be quiet, cool with none stimulating. Provide nonexertional activities such as reading, watching television, working cross word puzzle or listening to soothing music. The environment should also be calm to minimize emotional stress. Limit the number of visitors and the amount of time they spend with the patient. Use only light-weight sheet for the top cover and give the patient light loose pajamas. Assist patient walking upstairs or other exertion activities. Administer short acting sedatives as prescribed to promote rest. After administering these agents, raise side rails and caution patient not to smoke in bed.

OBSERVATIONS

Measure and report temperature, temperature >38.3 degrees Celsius should be reported because this often is the first sign of impending thyroid storm.

If thyroid storm is suspected, monitor vital signs hourly for evidence of hypotension and increasing tachycardia and fever. Monitor patient for signs of heart failure, which occurs as a result of thyroid storm. Assess for signs of anxiety and administer short-acting sedatives as prescribed. Observe for corneal ulceration by doing eye examination if exophthalmia is present. Observe also for the input and output especially that the patient has diaphoresis.

NUTRITION AND FLUIDS

Provide food high in calories, protein, carbohydrates and vitamins. Provide between-meals snacks to maximize patient’s consumption. Administer vitamin supplements as prescribed. Administer prescribed ant diarrheal drugs, which increase absorption of nutrients from the GIT.

Weigh patient daily and report significant losses to physician. Discourage eating of foods that increase peristalsis and thus result in diarrhea (highly seasoned, bulky or fibrous food). Give fluids as tolerated

COMFORT MEASURES/HYGIENIC MEASURES

As prescribed, administer acetaminophen to decrease temperature. ASA is contra-indicated because it releases thyroxin from protein-binding sites and free thyroxin levels. Provide cool sponge bath. Change patients linen as often as possible in case of excessive sweating. Administer PTU as prescribed to prevent further synthesis and release of thyroid hormone. Administer propranolol as prescribed to block sympathetic nervous system effects. Administer IV fluids as prescribed to provide adequate hydration and prevent vascular collapse.

Administer sodium iodine as prescribed, one hour after administering PTU. Small amounts of insulin may be administered to control hyperglycemia. Adjust care activities to patient’s tolerance. Administer lubricating eye drops as prescribed to supplement lubrication and decrease SNS stimulation, which can cause lid retraction. If appropriate, apply eye shield or tape the eyes shut at bed-time.

PSYCHOLOGICAL CARE

Encourage the patient to communicate feelings of frustration so as to deflate her stress. Advise significant others to avoid discussing stressful topics and refrain from arguing with the patient. Reassure patient that anxiety symptoms are relate to the disease process and that treatment decreases their severity. Inform significant others that the patient behavior is physiologic and should not be taken personally. Explain that the protrusion of the eyes is physiological and with treatment it will disappear.

HEALTH EDUCATION

• Inform her possibility of surgery.

• Explain the importance of taking ant thyroid medications daily, in divided doses and at regular interval as prescribed.

• Teach her the indicators of hypothyroidism

• Teach patient the side effects of thioamide and the symptoms that necessitate medical attention.

• Explain to her the importance of taking a diet rich in proteins, calories, carbohydrates and vitamins to meet the body demand.

• Emphasis the importance of medical follow-up.

• If she is receiving radioactive iodine, she should not hold children to her chest for 72hrs following therapy because of effects of radiation