PATHOPHYSIOLOGY OF HYPERTHYROIDISM

Thyroid Gland

Predisposing factors: Precipitating factors:

• Age • Stress
• Sex • Smoking
↓

↑ Thyroid Hormone (T3, T4) due to

Immune Reactivity to TSH Receptor
(Graves Disease)

Specific Immune Response/ Autoimmune

Infiltration of Lymphocytic, Mucopolysaccharides,

Fluid, Glycosaminoglycans

Fluid retention in Retrobulbar Soft Tissue, Extra-ocular Muscle

↙ ↓ ↘
Pressure to
Optic Nerve Bulging of Eyes Diplopia

↓ ↓

Blindness Proptosis/ Exophtalmus → Lid Retraction

↓ ↓

Lid Lag Corneal Exposure

↓
Dryness of Corneal
Irritation of Eyes
HYPOTHYROIDISM

NURSING MANAGEMENT

• The client should not take sedatives unless absolutely necessary.

• If a sedative or opioid must be given, administer no more than one third to one half of the
usual dose.

• Assess the client for respiratory depression or s decreased level of consciousness.

• Warm, comfortable environment

• Prevent skin breakdown
• Avoid sedatives
• Prevent constipation
• Assess energy level and mental alertness
• Monitor VS-Wt-I&O-visible edema
• Cardiac assessment

MEDICAL MANAGEMENT

• Lyvothyroxine sodium is the principal form of replacement therapy.

• Clients who respond to TH therapy receive a maintenance dose of T4 daily for life.

• Lyvothyroxine sodium- drug of choice for thyroid replacement therapy, which is

converted to both t4 and t3.

HYPERTHYROIDISM

NURSING MANAGEMENT

• Obtain a complete history and asking questions concerning weight, appetite, activity, heat
tolerance, and bowel activity

• Provide the client with a well-balanced diet high in calories, protein, carbohydrates, and
minerals.

• Discourage the ingestion of foods that increase peristalsis and thus result in diarrhea, such
as highly seasoned, bulky and fibrous foods.

For exophthalmus:
 • Instruct the client to wear dark eye glasses.

• Warn the client to avoid getting dust or dirt in the eyes.

• If the eyelids cannot be closed easily or at all, have the client wear a sleeping mask or
lightly tape the eyes shut with non-allergic tape.

• Elevate the head of the bed at night, and have the client restrict salt intake to relieve
edema.

MEDICAL MANAGEMENT

• Curtail the excessive secretion of TH and prevent and treat complications.

• Choice of intervention is based on age, goiter size, and whether the client has other health
problems.

• The three major forms of therapy are antithyroid medication, radio-iodine therapy, and
surgery.

• Iodide, propylthiouracil, and methimazole- major medications used to control

hyperthyroidism.

• Adrenergic blocking agents may be administered as adjunctive therapy.

For exophthalmus:

• Diuretics- may alleviate some periorbital edema.

• Methyl-cellulose eye drops help reduce eye irritation.

Surgical Management:

Thyroidectomy

- Thyroidectomy is an operation that involves

the surgical removal of all or part of the
thyroid gland.

-Thyroidectomy is a surgical procedure in

which all or part of the thyroid gland is
removed. The thyroid gland is located in the forward (anterior) part of the neck
 just under the skin and in front of the Adam's apple. The thyroid is one of the
body's endocrine glands, which means that it secretes its products inside the body,
into the blood or lymph. The thyroid produces several hormones that have two
primary functions: they increase the synthesis of proteins in most of the body's
tissues, and they raise the level of the body's oxygen consumption.

To remove the thyroid gland, an incision is

made at the front of the neck (A). Muscles and
connecting tissue, or fascia, are divided (B). The veins
and arteries above and below the thyroid are severed
(C), and the gland is removed in two parts (D). The
tissues and muscles are repaired before the skin incision
is closed (E). (Illustration by GGS Inc.)

Purpose

All or part of the thyroid gland may be removed to correct a variety of abnormalities. If a
person has a goiter, which is an enlargement of the thyroid gland that causes swelling in the front
of the neck, the swollen gland may cause difficulties with swallowing or breathing.
Hyperthyroidism (overactivity of the thyroid gland) produces hypermetabolism, a condition in
which the body uses abnormal amounts of oxygen, nutrients, and other materials. A
thyroidectomy may be performed if the hypermetabolism cannot be adequately controlled by
medication, or if the condition occurs in a child or pregnant woman. Both cancerous and
noncancerous tumors (frequently called nodules) may develop in the thyroid gland. These
growths must be removed, in addition to some or the entire gland itself.

Demographics

Screening tests indicate that about 6% of the United States population has some
disturbance of thyroid function, but many people with mildly abnormal levels of thyroid
hormone do not have any disease symptoms. It is estimated that between 12 and 15 million
people in the United States and Canada are receiving treatment for thyroid disorders as of 2002.
In 2001, there were approximately 34,500 thyroidectomies performed in the United States.
Females are somewhat more likely than males to require a thyroidectomy.

Description

A thyroidectomy begins with general anesthesia administered by an anesthesiologist. The

anesthesiologist injects drugs into the patient's veins and then places an airway tube in the
windpipe to ventilate (provide air for) the person during the operation. After the patient has been
anesthetized, the surgeon makes an incision in the front of the neck at the level where a tight-
fitting necklace would rest. The surgeon 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 next step is clamping off the blood supply to the portion of the thyroid gland that
is to be removed. Next, the surgeon removes all or part of the gland. If cancer has been
diagnosed, all or most of the gland is removed. If other diseases or nodules are present, the
surgeon may remove only part of the gland. The total amount of glandular tissue removed
depends on the condition being treated. The surgeon may place a drain, which is a soft plastic
tube that allows tissue fluids to flow out of an area, before closing the incision. The incision is
closed with either sutures (stitches) or metal clips. A dressing is placed over the incision and the
drain, if one has been placed.

People generally stay in the hospital one to four days after a thyroidectomy.

Diagnosis/Preparation

Thyroid disorders do not always develop rapidly; in some cases, the patient's symptoms
may be subtle or difficult to distinguish from the symptoms of other disorders. Patients suffering
from hypothyroidism are sometimes misdiagnosed as having a psychiatric depression. Before a
thyroidectomy is performed, a variety of tests and studies are usually required to determine the
nature of the thyroid disease. Laboratory analysis of blood determines the levels of active thyroid
hormones circulating in the body. The most common test is a blood test that measures the level
of thyroid-stimulating hormone (TSH) in the bloodstream. Sonograms and computed
tomography scans ( CT scans ) help to determine the size of the thyroid gland and location of
abnormalities. A nuclear medicine scan may be used to assess thyroid function or to evaluate the
condition of a thyroid nodule, but it is not considered a routine test. A needle biopsy of an
abnormality or aspiration (removal by suction) of fluid from the thyroid gland may also be
performed to help determine the diagnosis.

If the diagnosis is hyperthyroidism, a person may be asked to take antithyroid medication

or iodides before the operation. Continued treatment with antithyroid drugs may be the treatment
of choice. Otherwise, no other special procedure must be followed prior to the operation.

Aftercare

A thyroidectomy incision requires little to no care after the dressing is removed. The area
may be bathed gently with a mild soap. The sutures or the metal clips are removed three to seven
days after the operation.

Risks

There are definite risks associated with the procedure. The thyroid gland should be
removed only if there is a pressing reason or medical condition that requires it.
 As with all operations, people who are obese, smoke, or have poor nutrition are at greater
risk for developing complications related to the general anesthetic itself.

Hoarseness or voice loss may develop if the recurrent laryngeal nerve is injured or
destroyed during the operation. Nerve damage is more apt to occur in people who have large
goiters or cancerous tumors.

Hypoparathyroidism (underfunctioning of the parathyroid glands) can occur if the

parathyroid glands are injured or removed at the time of the thyroidectomy. Hypoparathyroidism
is characterized by a drop in blood calcium levels resulting in muscle cramps and twitching.

Hypothyroidism (underfunctioning of the thyroid gland) can occur if all or nearly all of
the thyroid gland is removed. Complete removal, however, may be intentional when the patient
is diagnosed with cancer. If a person's thyroid levels remain low, thyroid replacement
medications may be required for the rest of his or her life.

A hematoma is a collection of blood in an organ or tissue, caused by a break in the wall

of a blood vessel. The neck and the area surrounding the thyroid gland have a rich supply of
blood vessels. Bleeding in the area of the operation may occur and be difficult to control or stop.
If a hematoma occurs in this part of the body, it may be life-threatening. As the hematoma
enlarges, it may obstruct the airway and cause a person to stop breathing. If a hematoma does
develop in the neck, the surgeon may need to perform drainage to clear the airway.

Wound infections can occur. If they do, the incision is drained, and there are usually no
serious consequences.

PROCEDURE:

- A thyroid surgery begins with the administration of general anesthesia. Once the
anesthesia takes effect, the procedure begins with an incision 2 inches to 4 inches
long that stretches horizontally over the thyroid. Based on the tests performed
before the procedure and the appearance of the thyroid, the final determination of
how much of the thyroid should be removed is made.

- At this point, the portion or portions of the thyroid are removed using a scalpel.
Special care is taken not to harm or disturb the parathyroid glands and the vocal
cords, both of which rest in the neck near the thyroid.

- A biopsy may also 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.
- Once the thyroid has been removed and any necessary samples have been taken,
the area is examined for bleeding. Once the surgeon is confident that there is no
bleeding present, the incision is closed. It may be closed with staples or sutures,
and in some cases, a surgical drain may be placed to remove fluid from the area in
the days after surgery.

- Once a sterile bandage is applied to the incision, the surgery is completed.

Anesthesia is discontinued and medication is given to wake the patient. The
patient is then taken to the recovery room to be closely monitored while the
remaining anesthetic wears off.

FAR EASTERN UNIVERSITY

INSTITUTE OF NURSING

THYROID DISEASES
(Hypothyroidism and Hyperthyroidism)

Submitted by:
Olano, Gazelle O.

Oliveros, Anna May P.

 Omaña, Ophelia Ross D.

Ong- Juco, Kresta Janine A.

Submitted to: