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Hyperthyroidism is a metabolic imbalance that results from overproduction of thyroid hormone. The most common form of this condition is Grave’s disease, which common manifestations are increase of thyroxine (T4) production and enlargement of the thyroid gland known as goiter.

The incidence of Grave’s disease affects women eight times more frequently than men especially on ages 30-60. (Tierney, et al., 2005) A family history of thyroid abnormalities is also one contributing factor to this condition.

Signs and Symptoms

  • Palpitations
  • Dysrhythmias: atrial fibrillation
  • Systolic hypertension, tachycardia, full bounding pulse, wide pulse pressure
  • Urinating in large amounts
  • Diarrhea or frequent bowel movements
  • Sudden weight loss
  • Anxiety
  • Increased appetite and thirst
  • Enlarged thyroid (goiter)
  • Exophthalmos
  • Rapid and hoarse speech
  • Heat intolerance and excessive sweating
  • Difficulty of breathing
  • Weakness, fatigues, and muscle atrophy
  • Elevated temperature, excessive sweating
  • Nervousness
  • Fine tremors: purposeless, quick, and jerky movements of body parts
  • Hyperactive Deep Tendon reflex
  • Oligomenorrhea or amenorrhea

Medical Management

There are several treatments used for managing hyperthyroidism. The treatment mainly depends on the underlying cause, severity of the condition, the age, and the parity.  Hyperthyroidism management is composed with different therapies. The main goal for these therapies is to decrease the hyperactivity of the thyroid gland in secreting thyroid hormones.

Antithyroid therapy

Propylthiouracil (PTU) and methimazole (Tapazole) are antithyroid agents that inhibit the synthesis of thyroid hormones.

Propranolol (Inderal), or beta-adrenergic blocking agents, are used as an adjunct therapy for symptomatic relief of tachycardia and other peripheral effects until antithyroid hormones reach their full effect.

Radioactive Iodine therapy

The goal of this therapy is to destroy the overactive thyroid cells. Radioactive isotope of iodine is concentrated in the thyroid gland, where it destroys thyroid cells without jeopardizing other radiosenstive tissues. (Smeltzer, Bare, Hinkle, & Cheever, 2010)

Surgical Management

Thyroidectomy is a surgical removal of the thyroid gland. It is performed to patients with hyperthyroidism who doesn’t respond to antithyroid medications and iodine therapy. There are two kinds of thyroidectomy. Total thyroidectomy is a surgical procedure where all the thyroid gland is removed. On the other hand, subtotal thyroidectomy is a surgical procedure in which only a portion of the thyroid gland is removed to prevent the need for lifelong thyroid hormone medication.

Thyroidectomy Nursing Care Plan

Nursing Problem with cuesNursing Diagnosis With RationaleObjectives (SMART)Nursing InterventionsRationale for Interventions
No subjective and objective cues. Presence of signs and symptoms establishes an actual diagnosis.Risk for Ineffective Airway Clearance related to bleeding, swelling or laryngeal spasm

Rationale:

The incidence of bleeding after thyroid surgery is low (0.3-1%), but an unrecognized or rapidly expanding hematoma can cause airway compromise and asphyxiation.

Long-term goal:

Within the 8-hour shift of nursing care, patient will maintain a patent airway as evidenced by absence of neck swelling, and signs & symptoms of airway obstruction such as dyspnea, stridor, and cyanosis.

Assessment:

1. Monitor respiratory rate, depth, and work of breathing.
2.Auscultate breath sounds, noting presence of rhonchi.
3.  Assess for dyspnea, stridor, “crowing”, and cyanosis. Note quality of voice.
Independent: 

4. Keep head of bed elevated 30-45 degrees. Caution client to avoid neck bending; support head with pillows in the immediate postoperative period.

5. Assist with repositioning, deep breathing exercises, or coughing.

6.Suction mouth and trachea as indicated, noting color and characteristics of sputum.
7. Check dressing frequently, especially posterior portion.

8. Investigate reports of difficulty swallowing, drooling of oral secretions.

9. Keep tracheostomy tray at bedside.

Collaborative:

10. Provide steam inhalation.

1. Respirations may remain somewhat rapid because of hyperthyroid state, but development of respiratory distress is indicative of tracheal compression from edema or hemorrhage.

2. Rhonchi may indicate airway obstruction or accumulation of copious thick secretions.

3. Indicators of tracheal obstruction or laryngeal spasm, requiring prompt evaluation and intervention.

4. Enhances breathing and reduces likelihood of tension on surgical wound.

5. Maintains clear airway ventilation. Although “routine” coughing is not encouraged and may be painful, it may be necessary to clear secretions.

6. Edema or pain may impair client’s ability to clear own airway.

7. If bleeding occurs, anterior dressing may appear dry because blood pools dependently.

8. May indicate edema or sequestered bleeding in tissues surrounding operative site.

9. Compromised airway may create a life-threatening situation requiring emergency procedure.

10 Reduces sore throat and tissue edema.Promotes expectoration of secretions.

References: 

  • Doenges, M., Moorhouse, M., Murr, A. (2006) Nursing Care Plans: Guidelines for individualizing client care across the lifespan. F. A Davis Company, Philadelphia. 7th edition.
  • Mosby. 2006. Mosby’s Pocket Dictionary of Medicine, Nursing, and Health Professions. Elsevier Singapore. 5th edition.
  • Sharma, P. & Meyers, A. (2013). Complications of Thyroid Surgery. Retrieved at http://emedicine.medscape.com/article/852184-overview
  • Smeltzer, S., Bare, B., Hinkle, J., Cheever, K. 2010. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. Lippincott Williams & Wilkins. 12th edition
  •  Tierney, L. M., McPhee, S. J. & Papadakis. M. A. (2005). Current medical diagnosis and treatment. New York: Lange Medical Books/McGraw Hill.
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Rina Malones is currently working as a critical care/acute stroke nurse. Besides from blogging, she's also studying International Health at University of the Philippines Open University.