Hyperthyroidism

- Pts. w/ well-developed hyperthyroidism

exhibits characteristic group of signs
and symp. referred to thyrotoxicosis
NCM 116 Lec
- Thyrotoxicosis is the clinical
Mrs. Ma Jesseca P. Monsanto
manifestation of excess thyroid
Thyroid Disorders
hormone action at the tissue level due
- Conditions that affects the thyroid to inappropriately high circulating
glands, a butterfly-shaped gland in the thyroid hormone conc. while
front of the neck hyperthyroidism is a subset of
- The thyroid has imp. roles to regulate thyrotoxicosis and refers specifically to
numerous metabolic process excess thyroid hormone synthesis and
throughout the body. secretion by the thyroid gland.
- Different types of thyroid disorders
Types of hyperthyroidism:
affect either its structure or fxn.
1. Primary thyrotoxicosis
Considering thyroid disorders, we have 2
most common conditions:  Diffuse toxic goiters/graves’ disease
 Hyperthyroidism 2. Secondary thyrotoxicosis
 Hypothyroidism
 Toxic nodular goiter
Hyperthyroidism  Toxic nodule
 Hyperactivity of the thyroid gland w/  Hyperthyroidism due to rare cause
sustained increase in synthesis and Primary hyperthyroidism
release of thyroid hormones.
 2nd most prevalent endocrine disorder - Term used to in the pathology is w/n
after DM the thyroid gland
 A set of disorders that involve excess Secondary hyperthyroidism
synthesis and secretion of thyroid
hormones (T3 and T4) by the thyroid - Used when the thyroid gland is
gland, w/c leads to the hypermetabolic stimulated by excessive TSH in the
condition of thyrotoxicosis circulation

Thyrotoxicosis vs. Hyperthyroidism Diffuse Toxic Goiter (Graves Disease)

Thyrotoxicosis  Most common cause of

 A symptom complex due to hyperthyroidism
raised levels of thyroid  Autoimmune disorder that causes
hormones hyperthyroidism/overactive thyroid. W/
 Refers to the biochemical and this disease, the immune system attacks
physiological manifestations of the thyroid and causes it to make more
excessive thyroid hormones thyroid hormone than the body needs.
 Can also occur due to causes  Irish physician: Dr. Robert Graves who
other than hyperthyroidism described a case of goiter w/
exophthalmos in 1835
Hyperthyroidism  Grave’s disease has also been called
 Term used for excessive exophthalmic goiter
production of hormones by the  Common: young females (20-40)
thyroid gland  Whole gland involved
 Pathology is in the thyroid  50% family h/o autoimmune endocrine
gland itself disease

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  Hypertrophy and hyperplasia-abnormal  If the increased hormone production is
TSH-R Ab bind to TSH receptor coming from a single nodule in the
disproportionate and prolonged effect gland this is called toxic adenoma
 Genetic susceptibility  Middle aged/ elderly
 Most common cause (50-60%)  Eye signs-rare
 An autoimmune disorder in w/c  Secondary thyrotoxicosis (TT)
antibodies produced by immune system  Nodules-inactive
stimulate thyroid to produce too much  Internodular tissue- overactive
thyroid hormone.  Toxic adenoma- autonomous

Other manifestation of Graves’ Toxic multinodular goiter

 Approx. 50% of pts. w/ Grave’s disease  Also called plummer disease

also develop clinically evident  Thyroid condition charac. by marked
ophthalmopathy, and dermopathy enlargement of the thyroid gland or
occurs in 1 to 2% of pts. goiter.
 Eye signs- lid lag (von Graefe’s sign),  There is firm, thyroid nodules and
spasm of the upper eyelid revealing the overproduction of thyroid hormone or
sclera above the corneoscleral limbus hyperthyroidism
(Dalrymple’s sign), and a prominent  15-20% of cases
stare, due to catecholamine excess.  Occurs more commonly in elderly, esp.
 True infiltrative eye disease results in w/ long standing goiter
periorbital edema, conjunctival swelling  unknown etiology
and congestion (chemosis), proptosis,
limitation of upward and lateral gaze Toxic nodule
(from involvement of the inferior and  Solitary overactive nodule
medial rectus muscles, respectively),  Part of generalized nodularity or two
keratitis and even blindness due to toxic adenoma
optic nerve involvement.  Autonomous
 Infiltrative exophthalmos frequently  TSH- suppressed by high T3 and T4
encountered has been explained by  Normal surrounding thyroid tissue-
postulating that the thyroid gland and suppressed and inactive
the extraocular muscle share a common
antigen w/c is recognized by the Thyroiditis
antibodies  Described as a cause of
 Antibodies binding the extraocular hyperthyroidism
muscle would cause swelling behind the  15-20% cases
eyeball.
 A destructive release of preformed
Toxic nodular goiter thyroid hormone
 Swelling or inflammation of thyroid
 Involves an enlarged thyroid gland that gland and can lead to over or
contains a small round mass or masses underproduction of thyroid hormone
called nodules w/c produce too much
 Caused by an attack on the thyroid
thyroid hormone
gland causing inflammation and
 A toxic thyroid nodule causes damage to the thyroid cells
hyperthyroidism. This occurs when a
 Antibodies that attack the thyroid cause
single nodule or lump grows in the
most types of thyroiditis as such
thyroid gland causing it to become
thyroiditis is often an autoimmune
enlarged and produce excess thyroid
disease like juvenile or type 1 diabetes
hormones.
and rheumatoid arthritis

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  The chronic thyroiditis or Hashimoto’s  History and physical examination
disease occurs most frequently in  Ophthalmologic examination
women w/n 30-50 y.o has been termed considering exophthalmos
chronic lymphocytic thyroiditis  ECG-may reveal atrial tachycardia
 Chronic thyroiditis dx is based on the  Lab tests: TSH test (N:approx..0.5-5
histologic appearance of the inflamed mIU/L)
glands and in contrast to acute  TFT (thyroid fxn test)- look at the levels
thyroiditis, the chronic forms are usu. of the TSH and thyroxine or T4 in the
not accompanied by pain, pressure blood
symptoms or fever, and thyroid act. is  T3
usu. normal or low rather than  T4
increased and that cell mediated  TRH (thyroid releasing hormone)
immunity may play a significant role in stimulation test- measure the amount
the pathogenesis of chronic thyroiditis of TSH in the blood and the result
and there may be genetic conveys how well the thyroid is fxning
predisposition to it. and the doc can use the TSH test results
to diagnose thyroid disorders: hypo-and
Chronic Thyroiditis
hyper-thyroidism
 Hashimoto’s disease  Radioactive iodine uptake (RAIU)- to
 Enlarged, inflamed underactive thyroid confirm hyperthyroidism, test uses a
(goiter) radioactive tracer and a special probe
to measure how much tracer the
Clinical Manifestations of Hyperthyroidism thyroid gland absorbs from
the blood. A test of thyroid
fxn and measures the amount
of radioactive iodine taken by
mouth that accumulates in
the thyroid gland

Management of Hyperthyroidism

 Overall goal in tx: block

the adverse effects of
thyroid hormones and
stop their oversecretion
This involves:
 Pts. may experience exophthalmos or  Drug therapy and antithyroid drugs
bulging of the eyes w/c produces a  The 2 forms of pharmacotherapy
startled facial expression are available for treating
 Cardiac effects: tachycardia or hyperthyroidism and controlling
dysrhythmias, increased PP and excessive thyroid act. is w/ the use
palpitation of irradiation by administration of
 It has been suggested that these the radioisotope for destructive
changes may be related to increased effects on the thyroid gland and
sensitivity to catecholamine or to antithyroid meds that interferes w/
changes in neurotransmitter turnover the synthesis of thyroid hormones
 Client may also be having myocardial and other agents that controls the
hypertrophy and heart failure may manifestations of hyperthyroidism.
occur if the hyperthyroidism is severe  The antithyroid drugs or agents
and untreated blocks the utilization of iodine by
Diagnostic Test for Hyperthyroidism interfering w/ the iodination of
tyrosine and decoupling of

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 iodotyrosine in the synthesis of destroys the thyroid tissue and high
thyroid hormones. This prevents cure rates w/ single dose tx. (80%)
the synthesis of thyroid hormone - Tx. of choice for:
and the most commonly used meds o Grave’s disease
are: Propylthiouracil/PTU, o Multinodular goiter, toxic
methimazole/tapazole nodules in pts. older than 40 y.o
 These meds blocks the and in recurrent thyrotoxicosis
extrathyroidal conversion of T4 to
Surgical Tx
T3 because antithyroid meds do not
interfere w/ the release or act. of  Could also be instituted for clients w/
previously formed thyroid hyperthyroidism and is recommended
hormones thus it may take several when radioactive iodine (RAI) therapy is
weeks for relief of the symp. contraindicated
 The antithyroid drugs inhibits the a. have confirmed cancer or
synthesis of thyroid hormones and suspicious thyroid nodules
blocks conversion of T4 to T3 b. young
c. pregnant or desire to
Another drug therapy is the admin. of:
conceive soon after tx.
 B adrenergic blockers d. severe rxns. to antithyroid
(propranolol)- inhibits adrenergic meds.
effects, imp. in controlling the e. large goiters causing
sympathetic nervous system effects compressive symp.
of hyperthyroidism ex. Propranolol f. reluctant to undergo RAI
or inderal is used to control therapy
nervousness, tachycardia, tremor,  Thyroidectomy
anxiety and heat intolerance. The - Surgery is don to remove thyroid tissue
pt. continues taking propranolol and is the primary method for treating
until the FT4 and TSH level is w/n hyperthyroidism
normal - Pregnant women allergic to antithyroid
meds, pts. w/ large goiters, or unable to
Indications:
take antithyroid agents
o Prompt control of symp. - Surgery for tx. of hyperthyroidism is
o Tx. of choice for thyroiditis performed soon after the thyroid fxn
o First-line therapy before has returned to normal w/c is approx.
surgery, radioactive iodine, 4-6 wks
and antithyroid drug
1. Total or near thyroidectomy

 Radioactive iodine therapy  For pts. w/ coexistent thyroid

- goal is to destroy the overactive thyroid cancer, severe
cells and use of radioactive iodine is the ophthalmopathy, life treating
most common tx. in the elderly pt. rxns to antithyroid drugs
- almost all the iodine that enters and is
2.Subtotal thyroidectomy is
retained in the body becomes conc. In
recommended for the rest of pts. w/
the thyroid gland therefore the
cancer
radioactive isotope of iodine is conc. In
the thyroid gland where it destroys the 3. Bilateral subtotal thyroidectomy in
thyroid cells w/o jeopardizing other w/c 1-2 grams of thyroid tissue is left on
radiosensitive tissues. both sides
- W/ radioactive iodine therapy that
Nursing Mgmnt
concentrates in the thyroid glands and

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 *look into the textbook for specific  Neonatal hyperthyroidism
interventions r/t nsg dx that I will be  Apathetic hyperthyroidism
presenting o The only presenting features:
unexplained weight loss or cardiac
1. Fatigue r/t hypermetabolic state w/
symp. Such a serial fibrillation and
increased energy requirements
CHF
2. Imbalanced Nutrition: Less than body  Cardiac hypertrophy
rqmnts r/t increased metabolism  Acropachy; ophthalmopathy
(increased appetite/intake w/ loss of o Acropachy is disabling and can lead
weight), N/V, diarrhea to total loss of hand fxn. And clients
may also have clubbing of fingers
3. Risk for impaired tissue integrity r/t
w/ osteoarthropathy including
alterations of protective mechanisms of
periosteal new bone formation and
eye: impaired closure of
these may occur among clients w/
eyelid/exophthalmos
hyperthyroidism
- proper eye care is imp. to avoid o Ophthalmopathy is compromised
infection, irritation and blindness to our vision and blindness due to corneal
pt. lesion or optic nerve compression
w/c can be seen w/ clients w/
Clinical Outcomes of Inadequately
exophthalmia brought about by
Treated Hyperthyroidism
hyperthyroidism
 Thyrotoxicosis o Cardiovascular fxn can also be
o Clinical manifestation of excess affected leading to cardiac
thyroid hormone action at the hypertrophy
tissue level due to inappropriately
high circulating thyroid hormone
conc.
o Hyperthyroidism is a subset of
thyrotoxicosis and refers
specifically to excess thyroid
hormone synthesis and secretion
by the thyroid gland
 Thyroid storm
o Also referred to as thyrotoxic crisis
is an acute, life-threatening
hypermetabolic state induced by
excessive release of thyroid
hormones in ind. w/ thyrotoxicosis
 Severe weight loss w/ catabolism of
bones and muscles
 Cardiac and psychogenic
complications
 Osteoporosis (men and women)
o Effect can be particularly
devastating in women in whom the
disease may compound the bone
loss secondary to chronic
anovulation or menopause
o Bone loss is accelerated in pts. w/
hyperthyroidism
 Sarcopenia and myopathy

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 - Acropachy is described as clubbing of
fingers for clients w/ hyperthyroidism

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