Professional Documents
Culture Documents
DISEASE
Marian T. Gadugdug
BSN-3A
Pathophysiology of
Graves Disease
Hyperthyroidism is a clinical
syndrome in which there is a
sustained increase in synthesis
and release of thyroid hormones
by the thyroid gland
Graves disease indicates that
normal regulatory mechanisms
are overridden by abnormal
immunologic mechanism
Negative Feed Back
Clinical Manifestations
Palpitations
Heat intolerance
Nervousness
Insomnia
Breathlessness
Increased bowel movements
Light or absent menstrual
periods
Fast heart rate
Trembling hands
Muscle weakness
Warm, moist skin
Hair loss
Starring gaze
Fatigue
Clinical Manifestations of Graves
Disease
Nervousness
Fine tremor of the hands
Weight loss
Fatigue
Dyspnea
Palpitations
Atrial arrythmias
Exophthalmos
Enlarged thyroid gland
Increased heat tolerance
Increased metabolic rate
Assessment
Thyroid gland is enlarged; it is soft
and may pulsate; a thrill may be felt
and a bruit heard over thyroid
arteries.
Obtain a health history, including
family history of hyperthyroidism,
and note reports of irritability or
increased emotional reaction and the
impact of these changes on patients
interaction with family, friends, and
co-workers.
Diagnostic Tests
1) Thyroid Uptake Scan:
Evaluates size, position, and function
of thyroid gland
Performed with radioactive iodine
(usually in conjunction with RAI)
Iodide I 123 is the most commonly
used because of short half-life and
low radiation exposure
Scans are taken 20 minutes 2-4hours
after oral dose of radioactive iodine
3) Blood tests:
TSH
T4
T3
Radioactive iodine uptake
of the gland may be
tested
Lab Values
Lab Value
Normal
T4
(Free Thyroxine)
0.7-2.0ng/dL
T3
(Free
Triiodothyronine)
260-480 pg/dL
TSH
(Thyroid Stimulating
Hormone)
0.4-4.2 nU/mL
Treatment
1) Beta-Blockers
Mechanism of action- Inhibit adrenergic effects
Indications- Prompt control of symptoms;
treatment of choice for thyroiditis; first-line
therapy before surgery, radioactive iodine, and
antithyroid drugs; short-term therapy in
pregnancy
Contraindications and complications- Use with
caution in older patients and in patients with
pre-existing heart disease, chronic obstructive
pulmonary disease, or asthma
2) Iodides
Mechanism of action: Black the conversion of T4
to T3 and inhibit hormone release
Indications: Rapid decrease in thyroid hormone
levels; preoperatively when other medications are
ineffective or contraindicated; during preg-nancy
when antithyroid drugs are not tolerated; with
antithyroid drugs to treat amiodarone(Cordarone-) induced hyperthyroidism
Contraindications/Complications: Paradoxical
increases in hormone release with prolonged use;
common side effects of sialadenitis, conjunctivitis,
or acneform rash; interferes with the response to
radioactive iodine; prolongs the time to achieve
euthyroidism with antithyroid drugs
3) Antithyroid Drugs
Mechanism of Action: Interferes with the
organification of iodine; PTU can block
peripheral conversion of T4 to T3 in large doses
Indications: Long-term treatment of Graves'
disease (preferred first-line treatment in
Europe, Japan, and Australia); PTU is treatment
of choice in patients who are pregnant and
those with severe Graves' disease; preferred
treatment by many endocrinologists for children
and for adults who refuse radioactive iodine;
pretreatment of older and cardiac patients
before radioactive iodine or surgery; both
medications considered safe for use while
breastfeeding
Contraindications/Complications: High
relapse rate; relapse more likely in smokers,
patients with large goiters, and patients with
positive thyroid-stimulating antibody levels at
end of therapy; major side effects include
polyarthritis (1 to 2 percent), agranulocytosis
(0.1 to 0.5 percent); PTU can cause elevated
liver enzymes (30 percent), and
immunoallergic hepatitis (0.1 to 0.2 percent);
methimazole can cause rare cholestasis and
rare congenital abnormalities; minor side
effects (less than 5 percent) include rash,
fever, gastrointestinal effects, and arthralgia
Contraindications/Complications: Delayed
control of symptoms; posttreatment
hypothyroidism in majority of patients with
Graves' disease regardless of dosage (82
percent after 25 years); contraindicated in
patients who are pregnant or breastfeeding; can
cause transient neck soreness, flushing, and
decreased taste; radiation thyroiditis in 1
percent of patients; may exacerbate Graves'
ophthalmopathy; may require pretreatment with
antithyroid drugs in older or cardiac patients
Contraindication/Complications: Risk
of hypothyroidism (25 percent) or
hyperthyroid relapse (8 percent);
temporary or permanent
hypoparathyroidism or laryngeal
paralysis (less than 1 percent);
higher morbidity and cost than
radioactive iodine; requires patient
to be euthyroid preoperatively with
antithyroid drugs or iodides to avoid
thyrotoxic crisis
http://www.surgeryencyclopedia.com/images/gesu_03_img0203.jpg
Nursing Responsibilities
Educate patient regarding importance of a wellbalanced, high-calorie diet, and discourage food
that increase peristalsis and thus results in
diarrhea.
Provide several small, well-balanced meals (up to
six meals a day) to satisfy patients increased
appetite.
Provide quiet atmosphere during mealtime to aid
digestion.
Monitor patients weight
Advise patient to notify the health care provider
when a weight loss of more than 2 kg occurs
Give cool baths and provide cool fluids; monitor body temperature.
Monitor closely for signs and symptoms indicative of thyroid
storm.
Administer medications as ordered (PTU, hydrocoritcosteroids,
methimazole)
Stress long-term follow-up care.
Remind the patient and family about the importance of health
promotion activities and recommended health screening.
Nursing Diagnoses
o Imbalanced Nutrition, less than body requirements
r/t exaggerated metabolic rate, excessive
appetite, and increased gastrointestinal activity
o Ineffective coping r/t irritability, hyperexcitability,
apprehension, and emotional instability
o Low self-esteem r/t changes in appearance,
excessive appetite, and weight loss
o Altered body temperature
o Activity intolerance
o Sleep pattern disturbance
Health Teaching
1) Medicine
Beta-blockers
Iodides
Antithyroid Drugs
2) Exercise
Exercises that strengthen your heart and improve
circulation and muscle tone are needed to keep your
cardiovascular system functioning well and keep you
physically fit. Walking continues to be the most overall
beneficial physical activity, and it is available to everyone.
3) Treatment
Radioactive Iodine
Surgery
4) Home care
Teach patient how the medication regimen fits
in with the boarder therapeutic plan.
Instruct patient and family about the
importance of continuing therapy indefinitely
after discharge and about the consequences of
failing to take medication.
6) Diet
Focus on fresh fruits and vegetables. These will
give you the most vitamins and minerals for
your efforts and offer the balance you need.
Fish and chicken will be better for you rather
than excessive amounts of pork and beef. Limit
rich sauces and cheeses.
7) Spiritual care
Provide therapeutic
communication
Pastoral care
Include patient to our personal
prayer