nursing care of patient with hyperthyrodism
TRANSCRIPT
Nursing care of patient with hyperthyrodism
Objectives :1. explain the pathophysiology ,etiologies, signs, and
symptoms of hyperthyrodism in order to take care of pt 2. Identify therapeutic treatment of hyperthyrodism in order to
take care of pt 3. Identify data would you collect when caring for patients
with hyperthyrodismin order to take care of pt 4. Identify nursing care will you provide for patients with 4. Identify nursing care will you provide for patients with
hyperthyrodismin order to take care of pt5. Use the nursing process as a framework for care of patients
with hyperthyrodismin order to take care of pt6. Identify the nursing care for pt underwent thyedectomy
Hyperthyroidism
Hyperthyroidism is the second most prevalent endocrine disorder, after diabetes mellitus.
Graves’ disease, the most common type of Graves’ disease, the most common type of hyperthyroidism, results from an excessive output of thyroid hormones.
It affects women eight times more frequently than men
Pathophysiology
Hyperthyroidism results in excessive amounts of circulating thyroid hormone (thyrotoxicosis).
Primary hyperthyroidismPrimary hyperthyroidism
occurs when a problem within the thyroid gland causes excess hormone release.
Secondary hyperthyroidism
Occurs because of excess TSH release from the pituitary, causing overstimulation of the thyroid gland; thyroid gland;
Tertiary hyperthyroidism is caused by excess TRH from the hypothalamus.
A high level of thyroid hormone increases the metabolic rate and increase the number of beta-adrenergic receptor sites in the body, which enhances the activity of norepinephrine. which enhances the activity of norepinephrine.
The resulting fight-or-flight response is the
cause of many of the symptoms of hyperthyroidism.
Etiology
A variety of disorders can cause hyperthyroidism.
Graves’ disease
Multinodular goiter, in which thyroid nodules secrete excess TH
A pituitary tumor .A pituitary tumor .
A thyroid tumor.
Patients taking thyroid hormone for hypothyroidism may take too much.
Heredity may also play a role in autoimmune hyperthyroidism.
Signs and Symptoms
Many signs and symptoms are related to the hypermetabolic state, such as
heat intolerance, increased appetite with
weight loss, and increased frequency of weight loss, and increased frequency of bowel movements. Nervousness, tremor, tachycardia, and palpitations.
Heart failure may occur because of tachycardia and the resulting inefficient pumping of the heart.
If treatment is not begun, the patient may If treatment is not begun, the patient may become manic or psychotic.
Additional signs that occur only with Graves’ disease include thickening of the skin on the anterior legs and exophthalmos (bulging of )the eyesexophthalmos (bulging of )the eyes
Complication
Thyrotoxic crisis also called thyroid storm is sever hyperthroid state that occur in hyperthyroid pt who are untreated or who are experiencing stresser or may occur are experiencing stresser or may occur following thyredectomy
Symptoms include tachycardia, high fever, hypertension (with eventual heart failure and hypotension), dehydration, restlessness, and delirium or coma.and delirium or coma.
If thyrotoxic crisis occurs, treatment is first directed toward relieving the life-threatening symptoms.
Acetaminophen is given for the fever.
Intravenous fluids and a cooling blanket may be ordered to cool the patient
A beta-adrenergic blocker, such as A beta-adrenergic blocker, such as propranolol, is given for tachycardia.
Oxygen is administered and the head of the bed is elevated
Once symptoms are controlled and the patient is safe, the underlying thyroid problem is treated
HYPOTHYROIDISM.
This can occur as a result of treatment. Patients with a history of hyperthyroidism should be monitored for the onset of should be monitored for the onset of hypothyroidism.
Diagnostic Tests
Serum levels of T 3 and T 4 are elevated.
TSH is low in primary hyperthyroidism or high if the cause is pituitary.
A thyroid scan can be done to locate a A thyroid scan can be done to locate a tumor.
The thyroid gland may be enlarged
Therapeutic Interventions
Several medications can be used to treat hyperthyroidism.
Propylthiouracil (PTU) and methimazole(Tapazole) inhibit the synthesis of TH.(Tapazole) inhibit the synthesis of TH.
Propranolol (Inderal) is a beta-blocking medication that relieves the sympathetic nervous system symptoms.
Oral iodine suppresses the release of thyroid hormone.
Radioactive iodine ( RAI) may be used to destroy a portion of the thyroid gland.destroy a portion of the thyroid gland.
Nursing Process for the Patient with hyperthyroidismAssessment/data collection
Monitor the patient with hyperthyroidism closely until normal thyroid activity is restored. restored.
Monitor vital signs and report any increases in pulse and blood pressure to the registered nurse or physician.
Monitor lung sounds because crackles may indicate heart failure.
Assess level of anxiety and ability to cope with symptoms.
Monitor weight and bowel function.
Assess eyes for risk for injury caused by Assess eyes for risk for injury caused by exophthalmos, and note degree of muscle weakness.
Never palpate the thyroid gland of a patient with hyperthyroidism because palpation may stimulate release of thyroid hormone and precipitate a thyrotoxichormone and precipitate a thyrotoxiccrisis.
Nursing diagnosis
Hyperthermia related to hypermetabolicstate
Expected outcomes:
Body temperature will be within normal Body temperature will be within normal limits.
Intervention
Monitor temperature.
aminister acetaminophen as ordered to reduce temperature.
Apply cooling blanket as ordered. Apply cooling blanket as ordered.
External cooling may be necessary if acetaminophen is not effective.
Nursing diagnosis
Diarrhea related to increase in peristalsis
Expected outcomes:
Patient will maintain fluid and electrolyte Patient will maintain fluid and electrolyte balance.
Intervention
Provide a low-fiber diet.
Provide small frequent meals of bland foods (bananas, rice, apple sauce) that are less likely to worsen diarrhea.
Monitor electrolytes, especially sodium Monitor electrolytes, especially sodium and potassium.
Monitor for dehydration.
Keep skin clean and dry; apply barrier cream to protect skin from injury from stool.
Nursing diagnosis
Imbalanced nutrition, less than requirements, related to increased metabolism
Expected outcomes: Expected outcomes:
The patient will maintain weight in proportion to height.
Intervention
• Determine healthy weight for height, so the expected outcome is realistic for the patient.
• Monitor weight weekly to make sure • Monitor weight weekly to make sure interventions are working.
• Consult dietician for high-calorie diet with six meals to meet caloric requirements
Nursing diagnosis
Disturbed sleep pattern related to sympathetic stimulation
Expected outcomes:Expected outcomes:
The patient will state feeling rested upon awakening.
Intervention
• Provide a quiet, restful environment to assist the patient to fall a sleep.
• Ask the patient if music or earplugs are desired to mask environmental noise.desired to mask environmental noise.
• Administer propranolol or sedative as ordered to reduce sympathetic stimulation and calm patient.
Nursing diagnosis
Anxiety related to sympathetic stimulation
Expected outcomes:
Patient will state anxiety is controlled.
Intervention
• Provide the patient with accurate information about the disorder and treatment, and that proper treatment will correct symptoms. correct symptoms.
• Administer propranolol or antianxiety agent as ordered to reduce sympathetic stimulation and calm patient.
• Offer massage, music, or other relaxation techniques preferred by the patient.
Nursing diagnosis
Risk for injury related to hyper metabolic state and eye involvement
Expected outcomes:
Patient will remain safe and without injury.Patient will remain safe and without injury.
• Report changes in vital signs to the physician. Prompt treatment can reduce complications.
• Administer lubricating saline eye drops as • Administer lubricating saline eye drops as ordered to protect eyes from drying.
• Advise use of dark, tight fitting glasses to protect eyes from light and injury.
• Elevate the head of the bed to reduce edema behind the eyes.
• Provide a low-sodium diet.
• Teach patient to notify physician • Teach patient to notify physician immediately if eye pain or vision changes occur.
Patient education.
Teach the patient about the disease and symptoms of hyperthyroidism to report.
Also teach the patient how to take medications and the importance of routine medications and the importance of routine follow-up laboratory testing.
Evaluation
If the plan of care is effective, the patient will remain free from complications or injury.
Eyes will be comfortable and free from injury. injury.
Body temperature will be kept within normal limits
Diarrhea will be controlled, and complications of diarrhea such as skin breakdown and dehydration avoided.
The patient’s weight should remain stable. The patient’s weight should remain stable.
The patient should report that he or she is rested on awakening and that anxiety is controlled.
Nursing care for the Patient Nursing care for the Patient UndergoingUndergoing
ThyroidectomyThyroidectomy
Patients may undergo thyroidectomyfor cancer of the thyroid,
hyperthyroidism, or a goiter that is causing dyspnea or dysphagia.
A total thyroidectomy is usually performed if cancer is present.
After a total thyroidectomy, lifelong replacement hormone must be taken. replacement hormone must be taken.
A subtotal (partial) thyroidectomy
might be done for hyperthyroidism, leaving a portion of the thyroid gland to continue to secrete TH.
Preoperative Care
Before undergoing a thyroidectomy, the patient should be in a euthyroid state to avoid complications during and after surgery.
This is accomplished with the use of antithyroid medication such as methimazoleantithyroid medication such as methimazole(Tapazole).
A saturated solution of potassium iodide may also be administered to decrease the size and vascularity of the gland, reducing the risk of bleeding during surgery.
Perform a baseline assessment of vital signs and voice quality, so you can compare findings postoperatively.
Explain what the patient can expect before, Explain what the patient can expect before, during, and after surgery.
Preoperative teaching should include how to perform gentle range-of-motion exercises of the neck, how to support the neck during position changes, and how to neck during position changes, and how to use an incentive spirometer after surgery.
Postoperative Care
Data collection. Monitor vital signs, oxygen saturation,
drain (if present), and dressing every 15 minutes initially, progressing to every 4 hours, as ordered. hours, as ordered.
Decreased blood pressure with increased pulse should alert you to the possibility of shock related to blood loss.
Tachycardia and fever, along with mental status changes, can indicate thyrotoxic crisis.
Check the back of the neck for pooling of blood. Because of the location of the surgery,
observe for signs of respiratory distress, observe for signs of respiratory distress, including an increase in respiratory rate, dyspnea, or stridor.
Ask the patient to speak to detect
hoarseness of the voice, which can indicate
trauma to the recurrent laryngeal nerve.
Monitor the patient’s serum calcium levels and Monitor the patient’s serum calcium levels and
watch for evidence of tetany .
Report abnormal findings to the RN or physician
immediately.
Nursing diagnoses
Risk for Ineffective Airway Clearance
related to edema at surgical site
Expected outcome:
The patient will maintain a clear airway
as evidenced by easy breathing without
stridor.
Intervention
Notify physician about respiratory distress
immediately; keep a tracheostomy set at
the bedside.
Maintain patient in semi-Fowler’s position Maintain patient in semi-Fowler’s position
to help reduce edema and promote
comfort.
Monitor neck dressing. If the dressing
seems to get tighter, it may be a sign that
the patient’s neck is swelling, which could
impair the airway.impair the airway.
Use room humidifier or humidified
oxygen to keep airways and secretions
moist.
Remind the patient to do coughing and
deep-breathing exercises every hour.
Have suction equipment available in case
patient is unable to cough up secretions patient is unable to cough up secretions
effectively.
Encourage the patient to use the incentive
spirometer to assist with deep breathing
Assess the patient’s swallowing and gag
reflexes before offering clear liquids to
guard against aspiration.
Nursing diagnoses:
Risk for Injury (tetany, thyrotoxic crisis
related to surgical procedure
Expected outcome
Complications will be recognized and
treated quickly.
Intervention
Monitor patient for muscle spasms or
numbness or tingling around the mouth, and
report immediately if theyoccur.
These are symptoms of tetany that must be
treated immediately.
Tetany is most likely to occur 24 to 72 hours
postoperatively.
Monitor vital signs often, and report
changes immediately.
Elevated vital signs may be signs of Elevated vital signs may be signs of
thyrotoxic crisis, which is most likely
to occur up to 18 hours
postoperatively.
Nursing diagnoses
Acute Pain related to surgical procedure
Expected outcome: Expected outcome:
The patient’s pain will be controlled
as evidenced by patient stating pain rating is
acceptable.
Intervention
Administer acetaminophen or opioids as
ordered. Avoid aspirin products. (Aspirin
binds to the same protein as thyroid hormone binds to the same protein as thyroid hormone
and can precipitate a thyrotoxic crisis).
Use pillows or sandbags to support the
patient’s head.
Nursing diagnoses
Risk for Ineffective Self Health Management related
to knowledge deficit
Expected outcome: Expected outcome:
The patient will be able to effectively manage self-care
needs as evidenced by (1) verbalizing understanding
of follow-up care, (2) weight stabilizes at appropriate
weight for height, and (3) TH levels are within normal
limits.
Intervention
Teach the patient to do gentle range-of-motion exercises,
avoiding hyperextension of the neck, which can cause
strain on the incision line. Avoidance of neck movement
due to pain can result in contracture. due to pain can result in contracture.
Consult dietitian to assist the patient with potential
dietary changes needed following surgery.
Teach the patient the importance of follow-up care to avoid
complications:
How to administer replacement hormone if ordered.
How to change the dressing and to report bleeding or signs
of infection at the site.
Importance of immediately reporting unusual irritability,
fever, palpitations, or signs of tetany.
Importance of follow-up lab work for thyroid function and
medication adjustment.
Evaluation
If the plan has been effective, complications
caused by surgery will not occur or will be
recognized and reported early. recognized and reported early.
Pain will be prevented or controlled,
and the patient will demonstrate
understanding of postoperative self-care
Complications
Thyrotoxic crisis.
Thyrotoxic crisis can result from manipulation of the
thyroid gland during surgery, with the subsequent thyroid gland during surgery, with the subsequent
release of large amounts of TH.
This is a rare complication because the use of antithyroid
drugs before surgery has become routine.
Tetany.
Tetany is caused by low calcium levels and is
characterized by tingling in the fingers and characterized by tingling in the fingers and
perioral area (around the mouth), muscle
spasms, twitching, and cardiac dysrhythmias.
Muscle spasms in the larynx can lead to
respiratory obstruction.
Watch carefully for symptoms of tetany and report
them immediately if they occur because if the
problem is not recognized quickly, death can
result.
Tetany can occur if the parathyroid glands are accidentally removed during thyroid surgery.
Because of the proximity of the parathyroid Because of the proximity of the parathyroid glands to the thyroid, it is sometimes difficult for the surgeon to avoid them.
In the absence of parathyroid hormone (PTH), serum calcium levels drop and tetany results. IV calcium gluconate is given to treat acute tetany.given to treat acute tetany.
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