01.06 Hyperthyroidism

Overview

  1. Excess secretion of thyroid hormone (TH) from thyroid gland
  2. Results in Increased Metabolic Rate

Nursing Points

General

  1. Causes
    1. Graves Disease (autoimmune)
    2. Excess secretion of TSH from Pituitary
    3. Thyroid, Pituitary, or Hypothalamic Tumor
    4. Medication Reaction
  2. Thyroid Storm (Thyroid Crisis)
    1. Acute Exacerbation due to infection, stress, trauma

Assessment

  1. ↑ T3, T4, Free T4 hormones
  2. ↓ TSH
  3. Positive radioactive iodine uptake scan
  4. Goiter
  5. Cardiac
    1. Tachycardia, HTN, palpitations
  6. Neurological
    1. Hyperactive reflexes, hand tremor
    2. Emotional instability, agitation
  7. Sensory
    1. Exophthalmos (bulging eyes)
    2. Blurred vision
  8. Integumentary
    1. Fine, thin hair
  9. Reproductive
    1. Amenorrhea
    2. Change in Libido
      1. Some patients experience increased libido, while others report decreased libido
  10. Metabolic
    1. Hypermetabolic
    2. ↑ Temperature
    3. Heat intolerance
    4. Weight Loss
    5. Hypocalcemia
      1. Due to excess Calcitonin
  11. Thyroid Storm (Thyroid Crisis)
    1. Febrile state
    2. Tachycardia, HTN
    3. Tremors
    4. Seizures

Therapeutic Management

  1. Provide rest in a cool, quiet environment
  2. Cardiac Monitoring
  3. Maintain Patent Airway
  4. Provide eye protection for exophthalmos
    1. Regular eye exams
    2. Eye drops for moisture
  5. Medications
    1. Antithyroid medications → propylthiouracil or methimazole
    2. Radioactive Iodine 131 → taken up by thyroid gland
      1. Destroys some thyroid cells over 6-8 weeks
      2. Avoid in pregnancy
      3. Monitor for hypothyroidism
  6. Surgical Removal of Thyroid (Thyroidectomy)
    1. Monitor airway (swelling)
      1. Assess for obstruction, stridor, dysphagia
      2. Have tracheotomy equipment available
    2. Maintain in upright position
    3. Assess for bleeding
    4. Monitor for hypocalcemia
      1. Due to a decrease in hormone parathormone
        1. Due to removal of parathyroid glands
        2. **Note: incorrectly stated in video**
      2. Have calcium gluconate available PRN
    5. Minimal talking after surgery

Nursing Concepts

  1. Hormone Regulation
    1. Administer medications (PTU or methimazole)
    2. Monitor hormone levels (T3, T4, Free T4, TSH)
    3. Monitor for s/s Thyroid Storm
  2. Thermoregulation
    1. Keep in a cool environment
    2. Monitor temperature for fever
  3. Nutrition
    1. Ensure adequate nutritional intake
    2. Increased caloric needs

Patient Education

  1. Avoid caffeine and reduce stress
  2. Smoking Cessation
  3. S/s to report to provider (Thyroid Storm)
  4. Medication Instructions

Reference Links

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Video Transcript

In this lesson we’re going to talk about hyperthyroidism. You can already start to guess what this is by the name. Hyper always means high or excess, and obviously we’re referring to the thyroid gland.

So, hyperthyroidism is a condition of excess secretion of thyroid hormones, we’ll see increased levels of T3, T4, and Free T4 in the blood. We’ll also see decreased levels of TSH, or Thyroid Stimulating Hormone. Why is that? Well, let’s review how these hormones get secreted. The hypothalamus in the brain releases Thyrotropin Releasing Hormone, which goes to the pituitary gland and tells it to release Thyroid Stimulating Hormone. TSH goes to the Thyroid gland to tell it to secrete more thyroid hormones. Then, when the levels are high enough, the body sends a signal back to the hypothalamus to tell it to stop. That’s called a negative feedback loop. So, when something happens that causes these levels to be elevated, that means TSH secretion will decrease significantly. Now, the most common cause is Grave Disease, but also a tumor on any of those three glands could cause over secretion of TSH or these thyroid hormones. It could also simply be due to an overdose of thyroid medication. So, what does this do? Well…it’s excessive thyroid hormone action. The thyroid hormones are responsible for increased metabolism, growth & development, and increased effect of catecholamines like epinephrine. So, the biggest thing we see is an increased metabolic rate.

So…any time you think hyperthyroid, I want you to think hypermetabolic. Think about how you’d feel if you went and ran 10 miles right now. You’ll be hot, Your heart rate and blood pressure will go up. You may have palpitations and be shaky. And, if you’re anything like me, this 10-mile run will also make you emotional unstable and super agitated! And, of course if you do this 10 mile run repeatedly, you’ll lose weight, right? It’s all due to this hypermetabolic state. We’ll also see patients develop goiter, which is an enlarged bulge in the neck due to the overactive thyroid.

The other thing we see in hyperthyroidism, especially Graves’ Disease, is exophthalmos or these bulging eyes and blurry vision. This is like the look on my face when someone tells me I have to run 10 miles! It also causes heat intolerance. I mean, if you just ran 10 miles and you’re hot and sweaty, the last thing you want is a hot shower or a hot bath. You want to cool off and stay cool, right? Now, the other problem we see is that with this crazy high metabolism, the body starts to ignore some more non-vital functions. Their hair begins to thin, their libido decreases, and women will stop having periods. Think about young gymnasts who work out so much and they’re so hypermetabolic that they never have periods.
Then, as with most diseases, there’s a possibility for acute exacerbation, in this case known as Thyroid Storm or Crisis. They’ll be febrile, tachycardic, and hypertensive and can possible have tremors and seizures as well.

So how do we manage these patients? Well we want to provide rest and a cool, quiet environment and cardiac monitoring. We also want to make sure the patient has a patent airway, especially with the possibility of goiter and that neck swelling. We’ll provide eye protection for exophthalmos like eye drops. As far as medications, we can give antithyroid meds like propylthiouracil or methimazole or we can give radioactive iodine 131. In a functioning thyroid gland, we’ll see uptake of radioactive iodine so we can see it on a scan. With radioactive iodine 131, specifically, it will be taken up by the thyroid and it will actually destroy some of those thyroid cells so that will help decrease the overall levels of thyroid hormones. We do need to make sure this doesn’t shift them all the way into hypothyroidism. We’ll talk more about hypothyroidism in the next lesson.

The patient also has the option for surgical removal or a thyroidectomy. Post-op we want to monitor their airway because they could have swelling or obstruction. Listen for stridor or possibly dysphagia. We usually have tracheotomy equipment ready at the bedside. We want to keep them upright, assess for bleeding, and have them avoid talking for a while to protect the surgical site. We also want to monitor for hypocalcemia. You see, the thyroid hormone normally secretes calcitonin to increase calcium levels. Without it, our calcium levels can drop, so we make sure to have calcium gluconate available in case we need it.

Our priority nursing concepts for patients with hyperthyroidism are going to be hormone regulation, thermoregulation, and nutrition. With that hypermetabolic state we really need to make sure they’re getting enough calories in and we’re monitoring for and preventing thyroid storm. Make sure you check out the care plan attached to this lesson for more detailed nursing interventions and rationales.
Included

So, let’s recap. Hyperthyroidism is a state of excessive secretion of thyroid hormones, so we see excess T3, T4, and free T4 levels and decreased TSH levels. It could be caused by Graves Disease or tumors of the hypothalamus, pituitary, or thyroid, or by overdose of thyroid medications. Remember when you think hyperthyroid, I want you to think hypermetabolic. Their blood pressure, heart rate, and temperature all go up and they might even be shaky or agitated. We want to give antithyroid meds and possibly radioactive iodine, but if those don’t work, the patient may require a thyroidectomy. That will make them hypothyroid, so make sure you check out that lesson as well!

So those are the basics of hyperthyroidism, make sure you check out all the resources attached to this lesson to learn more. Now, go out and be your best self today. And, as always, happy nursing!

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  • Question 1 of 10

A 40-year-old female client with recent thyroid surgery has been admitted to the hospital with a fever, tremors, profuse sweating and anxiety. Based on this client’s symptoms, which drug class would be a priority to give to this client?

  • Question 2 of 10

The nurse is reviewing the shift assignments and notes one of the clients has Grave’s disease. The nurse knows the client with Grave’s disease could potentially exhibit which of the following?

  • Question 3 of 10

A 36-year-old client must undergo a total thyroidectomy for treatment of thyroid cancer. Which of the following has been shown as a complication of this type of surgery?

  • Question 4 of 10

A patient has just been admitted to the surgical nursing unit after a thyroidectomy. What position would be best for this particular patient?

  • Question 5 of 10

Which of the following medications are for thyroid regulation?

  • Question 6 of 10

Which range best describes normal levels of thyroid-stimulating hormone?

  • Question 7 of 10

A nurse is caring for a client is undergoing a parathyroidectomy. Which potential risks must the nurse consider when caring for this client following surgery?

  • Question 8 of 10

A client is being tested for Graves’ disease. The nurse knows that which one of the following lab panels would be used to rule out this condition?

  • Question 9 of 10

A client has been brought to the emergency department suffering from thyroid storm. Which of the following signs or symptoms would the nurse expect to see in this situation?

  • Question 10 of 10

A nurse is caring for a client who has had thyroid surgery. The client’s calcium result has returned at 7.5 mg/dL. Which nursing interventions are the most appropriate based on this calcium level? Select all that apply.