INTRODUCTION

The thyroid gland is a small, butterfly-shaped organ located in the neck below and in front of the Adam's apple.

Thyroid hormone is a chemical substance produced by the thyroid gland and released into the bloodstream. It interacts with almost all body cells, causing them to increase their metabolic activity.

Hyperthyroidism is a condition In which there is overproduction of thyroid hormone by the thyroid gland, causing the levels of thyroid hormone in the blood to be too high. People who have it are often said to have an "overactive thyroid".

Hyperthyroidism is also known as thyrotoxicosis from the prefix "thyro-" meaning thyroid, the term "toxic" meaning poisonous, and the suffix "-osis" meaning condition.

GRAVE'S DISEASE

The most common type of hyperthyroidism, results from aexcessive output of thyroid hormones caused by abnormal stimulation of the thyroid gland by irculating immunoglobinsn

Clinical Manifestations

Nervousness

Emotionally hyperexcitable, irritable and apprehensive

They cannot sit quietly

Suffers from palpitations

Tolerate heat poorly and perspire unusually freely

With salmon color skin that is warm, soft and moist

Exophthalmos

Increase appetite and dietary intake

Progressive weight lossabnormal muscular fatigability and weakness

Amenorrhea

Changes in the bowel function

General Objectives:

Within 4 hours of case presentation, the participants will be able to gain knowledge, skills and attitude regarding the topic diffuse toxic goiter.

Specific Objectives

After 4 hours if case presentation we will be able to:

Knowledge:

1. Discuss briefly and completely the health history of the client.2. Define diffuse toxic goiter comprehensively .3. Discuss the disease process, its participating and predisposing factor contributing to it.4. Enumerate possible and actual nursing interventions to manage the clients condition.5. Discuss nursing care plan appropriate in providing care to alleviate client symptoms.6. List down medications used to treat diffuse toxic goiter.7. Discuss the pathophysiology of diffuse goiter in a schematic diagram.

Skills:

1. Use collected data as the basis of case presentation.2. Organize data and topics systematically for easy analysis.3. Assemble and arrange all materials for presentation to save time.4. List down the corrections given by clinical instructors and participants.5. Work assigned task properly to ensure attainment of goal clearly.6. Deliver the data clearly upon presentation with self-confidence.7. Analyze the questions asked by the clinical instructors and participants and answer it comprehensively.

Attitude:

1. Accept compliments and criticism positively from clinical instructors and participants.2. Answer the questions ask by clinical instructors and participants.3. Display cooperation and unity within the group.4. Show courtesy and respect in conversing with participants and clinical instructors during open forum.5. Share some helpful information with the participants to the level of their understanding.6. Treat all gathered information confidentially.7. Display Augustinian values at all times.

PHYSICAL ASSESSMENT

Vital Information:

Name : H.L.

Age : 43 years old

Sex : Female

Address : Brgy. Jibolo, Janiuay, Iloilo

Chief Complaint: Difficulty of breathing (DOB)

Admitting Diagnosis: Community Acquired Pneumonia- Moderate Risk, Diffuse Toxic Goiter (CAP-MR, DTG storm)

General Survey:

Awake, conscious and conversant, lying on bed in a moderate high back rest with IVF of PNSS 1L x 40 cc/hr. inserted at left metacarpal vein at the level of 590 cc, drops regulated at 13-14 gtts/min., patent and infusing well. With O2 at 2-3 L/min. via nasal cannula. Vital signs taken and revealed BP of 130/80 mmHg, body temperature of 37.1 0C, pulse rate of 96 beats/min. and respiratory rate of 30 breaths/min. Weakness noted, dress appropriately. Complaints of difficulty of breathing.

SKIN and NAILS

Skin brown in color on exposed areas and lighter on unexposed areas such as chest, abdomen and axilla. Hyperhydrosis noted due to excessive sweating. Mole approximately cm, brown, oval, smooth, flat and have well-defined borders noted on the upper right cheek. Uniform skin temperature of 37.1 0C on exposed areas, cooler than unexposed areas. Axilla are more moist than exposed areas. Skin becomes more fine-textured. Has good skin turgor that springs back within 2-3 seconds after pinching. Vascular lesion noted, ecchymosis on the right dorsal area of the hand due to IV insertion, presence of pain when touched, does not blanch.

Nails slightly pinkish, angle of nail attachment 1600, convex curvature, smooth texture and intact epidermis. Beau’s line on nails noted, may result from severe illness (horizontal depression). Good capillary refill upon performing blanch test about 2-3 seconds.

HAIR

Hair black and with gray coloring that occurs with aging. Hair loss on scalp and axilla noted thins due to age, fine silky in texture, presence of redness mostly on the nape area due to presence of lice. Presence of very fine body hairs noted over the body. Scalp intact. Absence of masses or lumps noted.

HEAD, FACE AND NECK

Normocephalic, oval contour and symmetrical facial appearance. Presence of wrinkles on forehead. No tenderness or lesions, relatively smooth with no unexpected contours or bulges. TMJ smooth, symmetrical motion, with no pain upon palpation.

No periorbital edema around the frontal and maxillary sinuses. Absence of tenderness noted.

EYES

Eyes clear and bright, in parallel alignment. Eyelashes equally distributed and curved slightly outward. No crusting or infestation noted. Visible sclera between iris and upper lid (exophthalmia) present. Eyelids in contact with eyeball. No lesions.

Protrusion of eyeballs noted due to hyperthyroidism. Absence of swelling, redness, or drainage of the lacrimal glands and nasolacrimal ducts. Bulbar conjunctiva is clear, pinkish in color, with few underlying blood vessels and white sclera visible. Palpebral conjunctiva is smooth, glistening, pinkish in color and with minimal blood vessels present. Sclera smooth, white and glistening. Cornea and lens clear, smooth and glistening. Corneal reflex

and blinking reflex positive (CN V intact). Iris brown and circular. Pupils are equally round and reactive to light and accommodation. Constrict when focus to a near object and dilate when looking at a far object.

Eyeball is firm and nontender. Lacrimal glands and nasolacrimal ducts are nontender, nonpalpable and absence of tearing.

Able to read letters without correction on the chart 20 ft. away corresponding with 20/20 in vision. Correctly identifies colored bars on the chart. Smooth, conjugate movement of eyes in all directions, and extraocular muscle intact (CN III, IV and VI).

EARS

Symmetrical in size, consistent with skin color, intact and no lesions noted. Helix of ear is level with the inner and outer canthus of the eyes. Minimal cerumen noted on both ears. Soft and pliable, nontender auricle. Pinna recoils within 2 seconds after it is folded. No foreign objects. Canal patent. Free of redness or drainage.

Able to repeat most words whispered in each ear at a distance of 1 ft. (CN VIII intact). Patient able to hear tick of a watch in each ear at a distance of 5 inches. (CN VIII intact).

NOSE

Shape symmetrical, placed at midline, no nasal flaring and no drainage. Pink nasal mucosa, moist, with only scant mucus present. Intact with no lesions or perforations. No crusting or polyps noted. Septum located at midline and no deviation. Cartilaginous portion is slightly mobile, nontender, and no masses upon palpation. Nares patent, air flows freely.

MOUTH

Red-brown upper lip and pinkish lower lip, midline, symmetrical, skin intact and dry. 26 teeth present, white, not loose and with good occlusion. Dental caries noted, 2 premolars and 1 molar on the lower left portion of the mouth. Pink, moist, intact mucosa and absence of lesions or swelling noted. Gums consistent in color with other mucosa and intact, with no bleeding. Light pink, smooth, soft palate and lighter pink hard palate, more irregular texture. Both palate are intact. Uvula at midline of soft palate, pink, moist and without lesions. Symmetrical rise of the uvula (CN IX, GLOSSOPHARYNGEAL and CN X, VAGUS intact). Presence of gag reflex noted.

Tongue pink and moist. Mucosa intact with no lesions or discolorations. Papillae intact. Tongue is freely and symmetrically mobile (CN XII intact). Able to identify varying flavors like sweet candy.

Mucosa of oropharynx is pink, moist and intact. No lesions, erythema, swellings or lumps noted. Tonsils symmetrical, pink, and moist. Absence of lesions or swelling.

Lips soft, nontender and no masses upon palpation. Parotid glands are nonpalpable and nontender as well as the submandibular and sublingual glands.

NECK

Neck erect, midline and enlarged, visible thyroid present due to goiter. Thyroid masses felt upon palpation. Thyroid gland moves up with the cartilage as the patient swallows. Has limited range of motion of the neck. Thyroid gland palpable, bruit sound detected because of increased vascularity of hyperthyroidism.

CHEST (ANTERIOR and POSTERIOR)

Anterior chest light brown in color, absence of hairs noted, skin intact and no scars. Symmetrical in appearance with symmetrical in rise and fall when breathing. Respiratory rate of 30 breaths/min. tachypnea noted.

Posterior chest same color with the anterior chest, skin intact, chest expansion equal and spine straight without lateral curves or deformities.

Tracheal deviation due to thyroid enlargement. Absence of tenderness, deformities and lumps. Symmetrical chest excursion without lag. Equal bilateral tactile fremitus and diminished midthorax.

Resonance to second intercostals space on left, slightly dull on the third through fifth intercostals space over heart. Posterior thorax resonance to T10-T12 with deep inspiration. Adventitious sound noted, rhonchi heard upon auscultation. No abnormal voice sounds.

HEART

Positive pulsation at apex. No cardiac murmurs noted upon auscultation. Cardiac rate is 96 beats/min.

ABDOMEN

Abdominal contour flat, light brown skin color. Normoactive bowel sounds heard 4 cycles/min. No lesions, lumps or masses noted.

BREAST

Breast conical and symmetrical. Skin color lighter than in exposed areas. No lesions, redness or edema, texture even. Presence of stretch marks both around the breasts. Areola and nipple darker in color than breast. Nipples everted, pointing in same direction, no discharge. Axilla skin intact, no rashes or lesions.

Breasts soft, nontender, less firm and elastic in postmenopausal women. Nipples elastic, nontender. No discharge or white, sebaceous secretion. Nonpalpable axilla and clavicular nodes.

UPPER EXTREMITIES

Uniform skin color, fingernails of equal thickness, positive brisk capillary refill less than 2-3 seconds and no edema, erythema or skin masses noted. With IV insertion at the left metacarpal vein, IV insertion made: 3 on the right hand and 2 on the left. In full range of motion, able to extend and flex both arms and able to rotate wrists. Brachial, radial and ulnar pulses are easily palpated and equal in strength and amplitude. Skin temperature is warm bilaterally.

LOWER EXTREMITIES

Leg hair distributed evenly, thinner and moist skin. No varicosities, swelling, or lesions. Popliteal, posterior tibial and dorsalis pedis pulses are easily palpated and bilaterally equal in strength and amplitude. Negative Homans’ sign noted. Skin warm to touch.

GENITALIA

Consistent with skin color, with normal pattern of urination and defecation. Able to urinate at least 10 times per day with approximately 360 cc/voiding and defecate once a day. Has a regular menstrual cycle and consumes 3 pads/day in 3 consecutive days. No masses, lumps or lesions as stated by the client.

DRUG STUDY

Paracetamol300mg/amp IVTT q6H PRN for temp≥ 37.8ºC

*Classification: Nonopioid analgesics and antipyretics*Indications: Mild pain or fever*Action: Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation. The drug may relieve fever through central action in the hypothalamic heat regulating center.*Adverse reaction:

Hematologic: Hemolytic anemia, leukopenia, neutropenia, pancytopenia Hepatic: Jaundice Metabolic: Hypoglycemia Skin: Rash, urticaria

*Effects on Lab test results: May decrease glucose and haemoglobin levels and hematocrit May decrease neutrophil, WBC, RBC, and platelet count May cause false-positive test result for urinary 5-hydroxyindoleacetic acid. May

falsely decrease glucose level in home monitoring systems.*Contraindications and cautions:

Contraindicated in patients hypersensitive to drug. Use cautiously in patients with long term alcohol use because therapeutic doses

cause hepatotoxicity in these patients. *Nursing Considerations:

PTU (propylthiouracil)50mg 1tab 12 tabs now and then, 4 tabs q6H

*Classification: Thyroid hormone antagonist*Indications: Hyperthyroidism, Thyrotoxic crisis*Action: Inhibits oxidation of iodine in thyroid gland, blocking activity of iodine to combine with tyrosine to form t4 and may prevent coupling of monoiodotyrosine and diiodotyrosine to form t4 and t3.* Adverse Reaction:

CNS: Headache, drowsiness, vertigo, paresthesia, neuritis, neuropathies, CNS stimulation, depression, fever.

CV: Vasculitis EENT: Visual Disturbances, loss of taste GI: Diarrhea, nausea, vomiting, epigastric distress, salivary gland enlargement GU: Nephritis Hematologic: Agranulocytosis, leukopenia, thrombocytopenia, aplastic anemia Hepatic: Jaundice, hepatotoxicity Metabolic: dose-related hypothyroidism Musculoskeletal: arthralgia, myalgia

Skin: rash, urticaria, skin discoloration, pruritus, erythema nodosum, exfoliative dermatitis, lupus like syndrome

Other: lymphadenopathy*Effects on lab test results:

May decrease haemoglobin level May decrease granulocyte, WBC and platelet counts and liotyronine uptake.

*contraindications: Contraindicated to patients hypersensitive to drug.* Nursing Considerations:

Patients older than 40 may have an increased risk of Agranulocytosis Give drugs with meals to reduce adverse GI reactions. Watch for hypothyroidism (mental depression, cold intolerance, and hard, nonpitting

edema) Monitor hepatic function. Stop drug if transaminase levels are greater than three

times the upper limit of normal.*Patient teaching:

Instruct patient to take drugs with meals Warn patients to report fever, sore throat, mouth sores, and skin eruptions Tell patient to report unusual bleeding and bruising. Tell patient to ask prescriber about using iodized salt and eating shellfish. These

foods contain iodine and may alter effectiveness of the drug Teach patient to watch for signs and symptoms of hypothyroidism and to notify

prescriber.

Ambroxol78mg/cap 1cap OD

*Classification: *Action:*Indication: Secretolytic therapy in acute and chronic bronchopulmonary diseases associated with abnormal mucus secretions and impaired mucus transport.*Contraindications: Should not be used in patients known to be hypersensitive to Ambroxol or other components of the formulation*Special Precautions:

Tablets (30 mg) contain 684mg lactose per maximum recommended daily dose (120 mg). Patients with rare hereditary galactose intolerance, the Lapp lactase deficiency or glucose-galactose Malabsorption should not take this medication.

Syrup (15/5ml) contains 10.5 g sorbitol per maximum recommended daily dose (30 ml). Patients with rare hereditary fructose intolerance should not take this medicine. It may also have mild laxative effect.

* Nursing Considerations:*Patient Teaching:

Propranolol hydrochloride40mg/tab 1tab BID

*Classification: Beta-adrenergic blocker (non selective)*Indications: adjunctive management of thyrotoxicosis and Thyrotoxic crisis.

*Action: competitively blocks beta-adrenergic receptors in the heart and juxtaglumerular apparatus, decreasing the influence of the sympathetic nervous system on these tissues, the excitability of the heart, cardiac workload, and oxygen consumption, and the release of rennin and lowering BP.*Contraindication: Contraindicated with allergy to beta-blocking-agents, sinus bradycardia, second or third degree heart block, carcinogenic shock, Chronic heart failure, bronchial asthma, bronchospasm, COPD, pregnancy (neonatal bradycardia, hypoglycaemia, apnea and low birth weight with long term use during pregnancy), lactation.*Special Precaution: Propranolol (inderal) must be used with caution in patients with decompensated cirrhosis. Use cautiously with patients with significant hepatic or renal impairment. Care should be taken when starting treatment and selecting the initial dose.*Nursing responsibilities:

Assess history allergy to beta-blocking agents, sinus bradycardia, second or third degree heart block, cardiogenic shock, chronic heart failure, bronchial asthma, bronchospasm, COPD, hypoglycaemia and diabetes, hepatic dysfunction, pregnancy and lactation.

Do not discontinue drug abruptly after long term therapy because hypersensitivity to catecholamines may have developed.

Give oral drug with food to facilitate absorption. Advise client that she may experience these side effects: dizziness, drowsiness, light-

headedness, blurred vision, nausea, loss of appetite, nightmares, depression, sexual impotence

Tell client to report difficulty of breathing, night cough, swelling of the extremities, slow pulse, confusion, depression, rash, fever, and sore throat.

Ranitidine hydrochloride 50mg IVTT q12H

*Classification: Antiulcer drugs*Indication:

Active duodenal and gastric ulcer Maintenance therapy for duodenal or gastric ulcer Pathologic hypersecretory conditions, such as Zollinger-Ellison syndrome (ZES) Gastroesophageal reflux disease Erosive esophagitis Heartburn

*Action: Competitively inhibits action of histamine on the H2 at receptor sites of parietal cells, decreasing gastric acid secretion.*Adverse reaction:

CNS: headache, malaise, vertigo EENT: blurred vision Hepatic: Jaundice Others: anaphylaxis, angioedema, burning and itching at injection site

*Effects on lab test results: May increase Creatinine and ALT levels May cause false-positive results in urine protein test using Multistix

*Contraindications and Cautions: Contraindicated to patients Hypersensitive to drug and those with porphyria. Use

cautiously in patients with impaired renal function.*Nursing Considerations:

Assess patient for abdominal pain. Note for presence of blood in emesis, stool or gastric aspirate. Drug may be added to total parenteral nutrition solutions.

*Patient Teaching: Instruct patient on proper use of OTC preparation, as indicated. Remind patient to take once-daily prescription drug at bedtime for best results. Instruct client to take without regard to meal because absorption is not affected by

food. Urge patient to avoid cigarette smoking because gastric acid secretions worsen the

disease. Advise the patient to report abdominal pain and blood in stool or emesis.

Piperacillin sodium + Tazobactam sodium (20 syn)4.5 IVTT q8H ANST via soluset to run q2H

*Classification: Anti-infectives (Extended spectrum penicillin, beta-lactamase inhibitor)*Indication: Moderate to severe infections from pireracillin and Tazobactam-susceptible, beta –lactamase-producing strains of microorganisms in appendicitis *Action: Inhibits cell wall synthesis during bacterial multiplication*Contraindication: Contraindicated to patients hypersensitive to drug or other penicillin.* Special Precaution: Use cautiously in patients with bleeding tendencies, uremia, hypokalemia, and allergies to other drugs especially cephalosporins, because of possible cross sensitivity.*Adverse Reaction:

CNS: headache, insomnia, fever, seizures, agitation, dizziness, anxiety CV: hypertension, tachycardia, chest pain, edema EENT: rhinitis GI: diarrhea, nausea, vomiting, pseudomembranous colitis, vomiting, dyspepsia,

stool changes, abdominal pain GU: intestinal nephritis and candidiasis Hematologic: Leukopenia, neutropenia, thrombocytopenia, anemia, eosinophilia, Respiratory: Dyspnea Skin: Pruritus, rash Other Anaphylaxis, pain, inflammation, phlebitis at IV site, hypersensitivity

reactions*Effects on lab test results:

May decrease haemoglobin level May increase eosinophil count. May decrease neutrophil, platelet, and WBC

counts. May cause false-positive result for urine glucose test using copper reduction

method, such as clinitest.*Contraindications and cautions:

Contraindicated to patients hypersensitive to drug or other penicillins Use cautiously in patients with bleeding tendencies, uremia, hypokalemia, and

allergies to other drugs, especially cephalosporins, because of possibility of cross-sensitivity.

*Nursing Considerations: obtain specimen for culture and sensitivity tests before giving the first dose. Therapy

may begin pending results if large doses are given or if therapy is prolonged, superinfections may occur

especially in elderly, debilitated, or immunosuppressed patients drug contains 2.35 mEq sodium/g of Piperacillin. Monitor patient’s sodium intake. Monitor hematologic and coagulation parameters Patients with cystic fibrosis may have a higher rate of fever and rash. Monitor these

patients closely.*Patient Teaching:

Tell patient to report adverse reactions promptly.

Tell patient to alert a health care provider about discomfort at the IV site.

Ipatropium bromide 1 neb 28H

*Classification: Bronchodilators*Indications:

Bronchospasm in chronic bronchitis and emphysema. Rhinorrhea caused by allergic and non allergic perennial rhinitis Rhinorrhea caused by the common cold Rhinorrhea caused by seasonal allergic rhinitis

*Action: Inhibits vagally mediated reflexes by antagonizing acetylcholine at muscarinic receptors on bronchial smooth muscle.*Adverse reaction:

CNS: dizziness, pain, headache, nervousness CV: palpitations, hypertension, chest pain EENT: blurred vision, rhinitis, pharyngitis, sinusitis, epistaxis GI: nausea, GI distress, dry mouth Musculoskeletal: back pain Respiratory: upper respiratory tract infection, bronchitis, bronchospasm, cough ,

Dyspnea, increased sputum. Skin: rash Other: flulike symptoms, hypersensitivity reactions.

*Contraindications and cautions: Contraindicated to patient s hypersensitive to drug, atropine, or its derivatives and in

those hypersensitive to soy lecithin or related foodProducts, such as soybeans and peanuts

Use cautiously in patients with angle closure glaucoma, prostatic hyperplasia, or bladder neck obstruction

*Nursing Considerations: If patient uses a mask for nebulizer, take care to prevent leakage around the mask

because eye pain or temporary blurring of vision may occur.*Patient teaching:

Warn patient that drug isn’t effective for treating acute episodes of bronchospasms when rapid response is needed.

Teach the patient to perform oral inhalation correctly. Inform patient that use of a spacer device with MDI may improve drug delivery to

lungs Warn patient to avoid accidentally spraying drug in the eyes. Temporary blurring of

vision may result. If more than one inhalation is prescribed, tell patient to wait at least 2 minutes before

repeating procedure. Instruct patient to remove canister and wash inhaler in warm, soapy water at least

once weekly. If patient is also using corticosteroid inhaler, instruct him to use ipatropium first and

then wait about 5 minutes before using the corticosteroid. This lets the bronchodilator open air passages for maximal effectiveness of the corticosteroid.

MEDICAL-SURGICAL INTERVENTIONS

DIAGNOSTIC TESTS

FUNCTION TESTS PROCEDURE AND PREPARATION INTERPRETATION

Tests related to serum levels of thyroid hormone

Serum T4 ConcentrationBlood Sample; test determines ability of T4 extracted from serum to displace radioactive T4 from T4 – binding proteins; not affected by a iodides and dyes that elevate PBI and depress RAIU.

Measures circulating thyroxine that is bound to TBG and free t4; normal, 3 to 7 mcg/100ml; increase TBG such as occurs in pregnancy, and estrogen therapy causes increased T4 values; decreased TBG as seen with glococortioid therapy and hypoproteinemia caused decreased T4 values.

Serum T3 concentration Radioassay of blood sample; no special preparation

Measures circulating T3 that is bound to TBG and free T3; normal values 100 to 170 mcg/100ml and are elevated in T3 thyrotoxicosis; variations in thyroxine – binding globulin (TBG) can influence test results as they do for serum T4.

Triodothyronine (T3) resin uptake Blood sample drawn; in laboratory resin and radioactive T3 are added to sample of blood; radioactive T3 will bind to unoccupied sites of thyroxine – binding globulin (TBG);

Normally 25 to 30 of radioactive T3

will bind to resin; in hyperthyroidism, where there are increased amounts of endogenous thyroid hormone, value will be

radioactive counts are done on blood and resins to determine amount of T3 (radioactive) bound to resin.

increased; in hypothyroidism T3 resin uptake will be low; this is not a measure of patient’s endogenous T3 level; test is affected by total amount of TBG; in wasting diseases where amount of TBG may be decreased, reading maybe falsely elevated; phenytoin (Dilantin) and salicylates compete with thyroxine for TBG sites and may give false – negative T3 resin uptake.

Free T4 and free T3 Blood sample, special laboratory procedures

Measures unbound metabolically active T4 and T3; is a difficult test and is not used frequently; instead FT4I is calculated; FT4I varies direct with FT4

Free T4 index (FT4I) Serum T4 and T3U measured Free T4I is product of T4 and T3U; changes in TBG causes reciprocal alterations in serum T4 and T3U, so that FT4I stays normal

Thyroid antibody tests Blood sample; in laboratory RBCs are latex coated with thyroid globulin and mixed with blood.

Test may differentiate cause of thyroid enlargement; if antibodies is present, agglutination occurs.

Tests related to peripheral effects of thyroid hormone

Function Test Procedure and Preparation Interpretation

Basal metabolism rate (BMR) Patient at rest; amount of oxygen used while at rest is calculated; patient’s oxygen use is compared with established norms for people of same sex, age and size; results expressed in percentage above or below normal; patient received nothing by mouth (NPO) the night before, should have 8 hours of sleep, and should stay in bed morning of test; no food or smoking is allowed; anxiety will increased BMR so patient needs explanation of what to expect

Normal range is –15% to +15%; in hyperthyroidism patient’s BMR will be greater than +15%; in hypothyroidism patient’s BMR will be less than -15%; BMR is less accurate than other tests describe about but maybe used to observe patients on thyroid therapy

Serum cholesterol level Blood sample; Patient placed on NPO list night before

Normals vary from laboratory; high levels found in hypothyroidism and low levels found in hyperthyroidism; data augment other test

Achilles tendon reflex recording Electrodes from recording drum attached to patient’s ankle; while ankle tendon is tapped, recording is done.

Slow, sluggish jerk indicates hypothyroidism; rapid jerk indicates hyperthyroidism

Thyroid function test

Function test Procedures and preparation Interpretation

Hypothalamus level test

TRH stimulation test TRH is given IV and then serum TSH levels are repeatedly measured

Normal serum TSH begins to rise at 10 min and peaks at 45 min, subnormal tests reflect diminished TSH reserve; supranormal response occurs in patients with hypothyroidism of thyroid origin; no response in most patients with thyrotoxicosis except when it is caused by excess TSH.

Pituitary level test

TSH radioimmunoassay Blood sample, no special interpretation

Directly measures TSH level, measurement aids in differentiating primary and secondary hypothyroidism; values are elevated in primary hypothyroidism because of loss negative feddback.

Thyroid stimulating hormone(TSH) stimulation test

Baseline levels of radioactive iodine uptake(RAIU) and protein- bound iodine(PBI) are taken, TSH injection is given and repeat RAIU and PBI levels are taken

Assists in differentiating between primary and secondary hypothyroidism; in primary hypothyroidism repeat levels of RAIU and PBI stays the same; if they become normal, this indicates hypothyroidism caused by two little TSH( secondary).

Thyroid level test

Radioactive iodine uptake(RAIU)

A tracer dose of radioactive iodine(131I) is given by mouth. At 2, 6, and 24 hr following administration, scintillation in a detector is place over neck in region of thyroid and amount of accumulated radioactive iodine is measured; excess iodine in any foods, cough medicines, X- ray media, other medications and enriched iodine foods affect test by giving low readings; diarrhea, causing decrease absorption tracer dose, gives low readings, renal failure, causing decrease excretion, can cause elevated readings; no radiation precautions are necessary.

Normal thyroid will take up 5% to 35% of tracer dose; increase uptake occurs in hyperthyroidism; excess tracer dose is excreted in urine and can be measured; urine is collected in 24 hr; decrease amounts of urine indicate hyperthyroid state

Thyroid scan Dose of 131I is given, and scintillation scan is done: scanner is move over thyroid and a picture of distribution of radioactivity is recorded; no radiation precaution necessary

Size, shape, and anatomic function of gland assessed; areas of increased or decreased uptake noted

Thyroid suppression test RAIU test and serum t4 levels are done, patient given thyroid hormone for 7- 10 days, RAIU and serum t4 repeated

If euthyroid(normal), repeated RAIU and serum t4 will be low; failure of hormone therapy to suppress RAIU and serum T4 indicates hyperthyroidism.

Adjunctive Therapy

Compound such as potassium iodide, lugol’s solution and saturated solution of potassium iodide may be used in combination with antithyroid agents or beta-adrenergic blockers to prepare the patient with hyper thyroidism for surgery. These agents reduce the activity of the thyroid hormone and vascularity of the thyroid gland, making the surgical procedure safer.

Nursing Intervention

Give with milk or fruit juice to make it acceptable to the taste. Administer through straw to avoid staining of teeth.

Antithyroid medications

Antithyroid agents block the utilization of iodine by interfering with the iodination of thyrosine and the coupling of iodothyrosines in the synthesis of thyroid hormones. The most commonly used medications are prophylthiouracil (propacil, PTU) or methimazole (Tapazole) until the patient is euthyroid. These medications block extrathyroidal conversion of T4 to T3.

Radioactive Iodine Therapy

The goal of radioactive iodine therapy 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 on reduction of the hyperthyroid state and inevitability hypothyroidism.

Nursing Intervention

Instruct client what to expect with the tasteless, colorless radioiodine which may be administered by radiologist.

Closely monitor client after treatment with radioactive iodine until euthyroid state is reached.

Surgery

Thyroidectomy is an operative procedure done most commonly by a general surgeon, or occasionally by an otolaryngologist, in the operating room of a hospital. The operation begins when an anesthesiologist puts the patient to sleep. The anesthesiologist injects drugs into the patient's veins and then places an airway tube in the windpipe to ventilate (provide air for) the patient. The surgeon makes an incision in the front of the neck where a tight-fitting necklace would rest. He locates and takes care not to injure the parathyroid glands and the recurrent

laryngeal nerves, while freeing the thyroid gland from these surrounding structures. The blood supply to the portion of the thyroid gland that is to be removed is clamped off. Then all or part of the gland is removed. If cancer is present, all, or almost all, of the gland is removed. If other diseases or a nodule is present, the surgeon may remove only part of the gland. The total amount of thyroid gland removed depends upon the thyroid disease being treated. A drain (a soft plastic tube that drains fluid out of the area) may be placed before the incision is closed. The incision is closed either with sutures (stitches) or metal clips. A dressing is placed over the incision and the drain, if one is used.

Total Thyroidectomy is the total surgical removal of the thyroid gland. Both sections (lobes) of the thyroid gland are usually removed. Additional treatments with thyroid-stimulating hormone (TSH) suppression and radioactive iodine work best when as much of the thyroid is removed as possible.

Subtotal Thyroidectomy is the removal of one complete lobe, the isthmus, and part of the other lobe. This is used for hyperthyroidism caused by Graves' disease.

Biopsy is the process of taking a sample of living tissue for examination. Many different types of tissue can be biopsied, including skin, bone, organs and other soft tissues. It may be done to examine the tissues of the thyroid, the parathyroid and, in rare cases, nearby lymph nodes. This is done to make sure that the portion of the thyroid that is left, if any, is not diseased. In some cases, the tissue is examined by a pathologist immediately, so that a second surgery to remove a diseased portion of the thyroid is not necessary.

Nursing Interventions

Preoperative Care

Assess the client for typical manifestations of Grave’s disease. A hyper state may be obvious from apparent weight loss, and exopthalmos may be obvious as well. Also question the client for visual difficulties, fatigue, weakness,

tremors, and insomnia.

Promote Preoperative Euthyroid State. The client must be carefully prepared for a thyroidectomy to avoid complications (e.g., thyroid storm and hemorrhage).

Postoperative

Monitor for Postoperative Complications.

Monitor and treat HypoCalcemia.