POLYTECHNIC COLLEGE OF DAVAO DEL SUR. INC.

McArthur Highway, Brgy.Kiagot , Digos City

A CASE PRESENTATION ON

HYPERTHYROIDISM

Presented to:

Jethro Leo F. Donaire, RN, EMT

GROUP 12 BSN 3B

Flores, Marie Joy

Racman, Ella Maica

Razonable, Clendon

Relacion, Eden Claire

Rubellano, Dhana Angela

Senajon, Rei Louie

Silvano, Janeene Fe Nicole

Somosot, Jessa

Tubac, Sheila Mae

Waling, Eric Crizza Mae

 INTRODUCTION

Hyperthyroidism is the most prevalent endocrine disorder after diabetes mellitus.

- Graves' disease is the most common type of hyperthyroidism that results from an excessive
output of thyroid hormones caused by abnormal stimulation of the thyroid gland by
circulating immunoglobulins.
- It affects women eight times more frequently, below 40 years of age than men, and peaks
between the second and fourth decades of life.
- It is primarily associated with severe emotional stress, secondarily with autoimmune
disorders.

Two major hormones that affect how your body works are made in your thyroid. These are called
thyroxine (T-4) and triiodothyronine (T-3).

Your thyroid controls things like how fast your heart beats and how quickly you burn calories. It
releases hormones to control your metabolism (all the things your body does to turn food into
energy and keep you going).
 DESCRIPTION OF THE DISEASE

Hyperthyroidism, a common endocrine disorder, is a form of thyrotoxicosis resulting from

an excessive synthesis and secretion of endogenous or exogenous thyroid hormones by the thyroid
(Norris, 2019). The most common causes are Graves disease, toxic multinodular goiter, and toxic
adenoma. Other causes include thyroiditis (inflammation of the thyroid gland) and excessive
ingestion of thyroid hormone. Hyperthyroidism is hyperactivity of the thyroid gland with a
sustained increase in synthesis and release of thyroid hormones. Hyperthyroidism occurs in women
more than men, with the highest frequency in persons 20 to 40 years old.

Graves disease is an autoimmune disorder that results from an excessive output of thyroid
hormones caused by abnormal stimulation of the thyroid gland by circulating immunoglobulins.
This disease affects women eight times more frequently than men, with onset usually between the
second and fourth decades. The disorder may appear after an emotional shock, stress, or infection,
but the exact significance of these relationships is not understood (Norris, 2019). Clinical
manifestations are related to the increase in metabolic rate and increased oxygen consumption. The
patient may appear anxious, restless and irritable, and exhibit fine tremors of the hands. The patient
will be tachycardic and complain of palpitations.

The course of the disease may be mild, characterized by remissions and exacerbations, and
terminate with spontaneous recovery in a few months or years. Conversely, it may progress
relentlessly, with the untreated person becoming emaciated, intensely nervous, delirious, and even
disoriented; eventually, the heart fails. The goal management of hyperthyroidism is to block the
adverse effects of excessive thyroid hormone, suppress oversecreting thyroid hormone, and prevent
complications. There are several treatment options, including antithyroid medications, radioactive
iodine therapy, and surgical intervention. The choice of treatment is influenced by the patient’s age
and preferences, the coexistence of other diseases, and pregnancy status.

DEFINITION OF TERMS

Thyroid storm.
- also known as thyrotoxic crisis, is an acute, life-threatening complication of
hyperthyroidism that presents with multi-system involvement
- The mortality associated with thyroid storm is estimated to be 8 to 25% despite modern
advancements in its treatment and supportive measures.

Community-acquired pneumonia.
- Pneumonia that is acquired outside the hospital.
- The most commonly identified pathogens are streptococcus pneumoniae, haemophiles
influenzae, atypical bacteria and viruses

Primary (essential) hypertension

- is high blood pressure that is multi-factorial and doesn’t have one distinct cause. It’s also
known as idiopathic or essential hypertension. Above-normal blood pressure is typically
anything over 120/80 mmHg. This means that the pressure inside your arteries is higher than
it should be.

Congestive heart failure, or heart failure

- is a complex clinical syndrome characterized by inefficient myocardial performance,
resulting in compromised blood supply to the body.

Atrial fibrillation (AFib)

- is an irregular and often very rapid heart rhythm. An irregular heart rhythm is called an
arrhythmia. AFib can lead to blood clots in the heart. The condition also increases the risk of
stroke, heart failure and other heart-related complications.

Hypothyroidism
- is a common endocrine disorder resulting from deficiency of thyroid hormones
- also called underactive thyroid disease, is a common disorder. With hypothyroidism, your
thyroid gland does not make enough thyroid hormone.
Hyperthyroidism
- A condition that occurs when the thyroid gland makes more thyroid hormones than the body
needs. Thyroid hormones control the way the body uses energy and affect the body’s
metabolism. Hyperthyroidism may be caused by an autoimmune disorder called Graves’
disease, benign lumps in the thyroid gland, and inflammation of the thyroid gland. It may
also be caused by consuming too much iodine in the diet or by taking too much thyroid
hormone medicine.
Seizure
- Is a condition where brain cells malfunction and send electrical signals uncontrollably. The
causes symptoms affecting other parts of your brain and your body. Seizure are often
treatable depending on the underlying cause.
Hypertension
- High blood pressure is a common condition that affects the body's arteries. It's also called
hypertension. If you have high blood pressure, the force of the blood pushing against the
artery walls is consistently too high. The heart has to work harder to pump blood.

TSH (Thyroid stimulating hormone)

- The test measure how much of this hormone is in your blood. TSH is produced by the
pituitary gland in your brain, which tells your thyroid to make and release other key
hormones that your body needs to function
- The test can also detect a thyroid disorder before you have any symptoms.

. Thyroxine, also known as T4

- is a type of thyroid hormone. A T4 test measures the level of T4 in your blood. Too much or
too little T4 can be a sign of thyroid disease.

X-ray Result test:

Cardiomegaly with mild congestion
- Refer to the enlargement of the heart and is usually indicative of an underlying heart
condition.
- Congestion that the heart muscle has become less able to contract over time or has a
mechanical problem that limits its ability to fill with blood. As a result, it can’t keep up with
the body’s demand, and blood returns to the heart faster than it can be pumped out-it
becomes congested or backed up.

Lingular pneumonia
- is a respiratory infection that affects the left lung’s upper lobe, known as the lingula.

CT-scan of cranial result.

 Encephalomacia, right superior frontal gyrus.
 Petechial hyperdensity, pons. R/O bleed

Encephalomalacia
 - refers to softening of the brain’s tissue due to hemorrhage or inflammation. It is one of the
most serious types of brain injury. It can affect specific parts of the brain, or can be more
widespread, and encephalomalacia can lead to complete dysfunction of the part of the brain
that is affected.

Petechial hyperdensity
- The friction between the wall of the vessel and the surrounding cerebral tissue,
neurovascular friction, at the moment of impact would cause petechial hemorrhages in the
brain following injury.

ETIOLOGY

Graves’ disease is an autoimmune disease of unknown etiology characterized by diffuse

thyroid enlargement and excessive thyroid hormone secretion. Graves’ disease accounts for up to
80% of the cases of hyperthyroidism. Women are five times more likely than men to develop
Graves’ disease. Precipitating factors such as insufficient iodine supply, infection, and stressful life
events may interact with genetic factors to cause Graves’ disease. Cigarette smoking increases the
risk of Graves’ disease and the development of eye problems associated with the disease.11 In
Graves’ disease the patient develops antibodies to the TSH receptor. These antibodies attach to the
receptors and stimulate the thyroid gland to release T3, T4, or both. The excessive release of thyroid
hormones leads to the clinical manifestations associated with thyrotoxicosis. The disease is
characterized by remissions and exacerbations, with or without treatment. It may progress to
destruction of the thyroid tissue, causing hypothyroidism.

Graves' disease is the most common cause of hyperthyroidism, this is an autoimmune

disorder where the immune system which is supposed to protect the body instead attacks the thyroid
gland and causes it to produce too much thyroid hormones. Other common causes of
hyperthyroidism include thyroid nodules which are lumps in the thyroid gland that are typically not
cancerous but can become overactive as well as thyroiditis which is inflammation of the thyroid
gland in addition for individuals. Taking a thyroid hormone medication for hypothyroidism which is
under active thyroid if the dose is too high this can lead to hyperthyroidism.
 SIGNS AND SYMPTOMS

There are many symptoms of hyperthyroidism, and they can impact your entire body. You
may experience some of these symptoms and not others, or many of them at the same time.
Symptoms of hyperthyroidism can include:

 Rapid heartbeat (palpitations).

 Feeling shaky and/or nervous.

 Weight loss.

 Increased appetite.

 Diarrhea and more frequent bowel movements.

 Vision changes.

 Thin, warm and moist skin.

 Menstrual changes.

 Intolerance to heat and excessive sweating.

 Sleep issues.

 Swelling and enlargement of the neck from an enlarged thyroid gland (goiter).

 Hair loss and change in hair texture (brittle).

 Bulging of the eyes (seen with Graves’ disease).

  Muscle weakness

DIAGNOSIS & TESTS

Your healthcare provider can diagnose hyperthyroidism in several ways, including:

 A physical exam of your neck to see if your thyroid is larger than normal.

 Blood tests to look for high levels of thyroid hormone in your body.

 Imaging tests to look at your thyroid.

 Physical exam for diagnosing hyperthyroidism

If you’re experiencing symptoms of hyperthyroidism, your healthcare provider’s may check the

following during a physical exam in their office:

 Your thyroid: Your provider may gently feel your thyroid through the outside of your neck

to check if it’s enlarged, bumpy or tender.

 Your eyes: Your provider may check your eyes for swelling, redness, bulging and other signs

of Graves’ eye disease.

 Your heart: Your provider may use a stethoscope to listen to your heart for a rapid and/or

irregular heartbeat.
  Your hands: Your provider may have you outstretch your hands to see if you have a tremor.

They may also look for changes in your fingernails.

 Your skin: Your provider may feel your skin to see if it’s warm and moist.

Blood tests for diagnosing hyperthyroidism

Your healthcare provider may take a blood sample to look for high levels of thyroid hormone. This

is called thyroid function testing. When you have hyperthyroidism, levels of the thyroid hormones

T3 and T4 are above normal and thyroid-stimulating hormone (TSH) is lower than normal.

Imaging Tests for diagnosing hyperthyroidism

Taking a closer look at your thyroid can help your provider diagnose hyperthyroidism and the

possible cause of it. Imaging tests your provider could use to examine your thyroid include:

Radioactive iodine uptake (RAIU) test:

For this test, you’ll take a small, safe dose of radioactive iodine (also called a radiotracer) by mouth

to see how much of it your thyroid absorbs. After a certain amount of time — usually at six and 24

hours later — your healthcare provider will scan your neck with a device called a gamma probe to

see how much of the radioactive iodine your thyroid has absorbed. If your thyroid has absorbed a

lot of the radioactive iodine, it means that your thyroid gland is producing too much thyroxine (T4).

If this is the case, you most likely have Graves' disease or thyroid nodules.

Thyroid scan: This procedure is an extension of the RAIU, where in addition to measuring the

absorbed amount of radioactivity by your thyroid, you’ll lie on a table with your head tilted back

while a special camera (gamma camera) takes several images of your thyroid. The radioactive
material makes all or certain parts of your thyroid appear “bright” on the screen. Your provider may

use a thyroid scan to look for lumps or nodules on your thyroid, inflammation, swelling, goiter or

thyroid cancer.

Thyroid ultrasound: An ultrasound uses high-frequency sound waves to create images of your

thyroid. It’s a non-invasive procedure that allows your provider to look at your thyroid on a screen.

Your provider may use this test to look for nodules on your thyroid

ANATOMY & PHYSIOLOGY

 The thyroid gland is an endocrine organ consisting of two connected lobes that are found
situated on the trachea, just inferior to the thyroid cartilage (Adam’s apple). The principle thyroid
hormones that regulate functions in the body are thyroxine (T4) and triiodothyronine (T3). T4 is
mainly inactive, and is converted peripherally in the body to make the more active T3. T3 and T4
are synthesized from iodine and tyrosine.
Hormonal output from the thyroid is regulated by negative feedback. Beginning from the
hypothalamus, thyrotropin-releasing hormone (TRH) is released, which results in the production of
thyroid-stimulating hormone (TSH) by the anterior pituitary that in turn stimulates production of T3
and T4. Excess amounts of T3 and T4 provides negative feedback at both the level of the anterior
pituitary and hypothalamus. Calcitonin is also produced by the thyroid, and plays a role in calcium
homeostasis.

Parathyroid glands - The main function of the parathyroid glands is to make the parathyroid
hormone (PTH). This chemical regulates the amounts of calcium, phosphorus and magnesium in the
bones and blood.
Thyroid Cartilage - It supports and protects the vocal cords and helps create the sound of a
person's voice.
Cricoid cartilage - serves to maintain airway patency
Paramydal Lobe of thyroid - normal anatomic variant representing a superior sliver of thyroid
tissue arising from the thyroid isthmus
Thyroid Isthmus - the thyroid gland has two lobes, which are flat and oval, one on each side of the
trachea, joined by an isthmus across the front of the trachea. The thyroid isthmus lies about halfway
between the thyroid cartilage (the Adam's apple) and the sternal notch.
Trachea - the main airway to the lungs and often called as windpipe.
 MEDICAL MANAGEMENT
NUTRITION AND DIET
Hyperthyroidism is a condition where the thyroid gland produces excessive thyroid hormones,
leading to an increased metabolic rate. Managing nutrition and diet plays a crucial role in managing
this condition. Here are some key points to consider:
• Balanced diet: Aim for a balanced diet that includes a variety of nutrient-rich foods from
all food groups. This ensures you're getting essential vitamins, minerals, and macronutrients
(carbohydrates, proteins, and fats) necessary for overall health.
• Lean protein sources: Incorporate lean proteins such as chicken, turkey, fish, legumes,
and low-fat dairy products. These foods help maintain muscle mass and support a healthy
metabolism.
• Complex carbohydrates: Choose complex carbohydrates like whole grains, fruits, and
vegetables, which provide sustained energy and help manage blood sugar levels.
• Healthy fats: Include healthy fats in your diet, such as those found in nuts, seeds,
avocados, and olive oil. These fats help support overall health and may have a positive impact on
thyroid function.
• Fiber-rich foods: Consume plenty of fiber-rich foods like vegetables, fruits, whole grains,
and legumes. Fiber helps regulate digestion and may also help stabilize blood sugar levels.
• Avoid goitrogens: Some foods, known as goitrogens, can interfere with thyroid function.
These include cruciferous vegetables like broccoli, cauliflower, and Brussels sprouts. However,
cooking these vegetables can significantly reduce their goitrogenic effects, so it's not necessary to
avoid them completely.
• Limit caffeine and alcohol: Excessive caffeine and alcohol intake can exacerbate the
symptoms of hyperthyroidism. Limit your caffeine consumption and avoid excessive alcohol intake.
• Stay hydrated: Drink plenty of water throughout the day to support overall health and
proper thyroid function.
• Consult a healthcare professional or a registered dietitian: They can provide personalized
dietary recommendations based on your specific needs and the severity of your hyperthyroidism.
Remember that managing hyperthyroidism may also require medication or other treatments
prescribed by your healthcare provider. Always follow their advice and maintain open
communication about your symptoms and any changes in your condition.

SURGICAL MANAGEMENT
Surgical management of hyperthyroidism primarily involves the removal of the overactive thyroid
gland, known as a thyroidectomy. There are two main types of thyroidectomy:

• Near-Total Thyroidectomy: This procedure involves the removal of most of the thyroid
gland, leaving behind a small portion to minimize the risk of hypothyroidism (underactive thyroid).
This method is often preferred when the patient has a single, large, autonomously functioning
thyroid nodule or toxic multinodular goiter.
• Total Thyroidectomy: In this procedure, the entire thyroid gland is removed. This option
is usually considered when the patient has Graves' disease, a severe form of hyperthyroidism, or
when there is a high risk of malignancy or recurrent hyperthyroidism.
Before the surgery, patients may be given medications to help control their hyperthyroidism, reduce
the size of the thyroid gland, and minimize blood loss during the procedure. During the surgery, the
surgeon makes an incision in the neck and carefully removes the thyroid gland. The procedure is
usually performed under general anesthesia, and the patient will typically stay in the hospital for
one to two days for observation.
After the surgery, patients will need to take thyroid hormone replacement medication for the rest of
their lives, as the thyroid gland no longer produces the necessary hormones. Regular follow-up
appointments with an endocrinologist will be required to monitor thyroid function and adjust
medication dosages as needed.

PHARMACOTHERAPY
Pharmacologic management of hyperthyroidism aims to reduce the production of thyroid hormones
and alleviate symptoms. The primary medications used include:
• Antithyroid drugs: These medications, such as methimazole and propylthiouracil, work
by inhibiting the synthesis of thyroid hormones. They are usually the first-line treatment for
hyperthyroidism and are taken orally.
• Beta-blockers: Although they don't directly affect thyroid hormone production, beta-
blockers like propranolol can help manage symptoms like rapid heartbeat, anxiety, and tremors.
They work by blocking the effects of excess thyroid hormones on the body.
• Iodine: In some cases, an iodine solution or potassium iodide may be prescribed, which
temporarily blocks thyroid hormone production. This is typically used before thyroid surgery or in
certain cases of thyroid storm, a life-threatening complication of hyperthyroidism.
• Radioactive iodine: Another treatment option is the administration of radioactive iodine
(I-131), which selectively targets and destroys overactive thyroid cells, reducing hormone
production. This treatment is usually reserved for patients who don't respond well to antithyroid
drugs or those who require a more permanent solution.
It is crucial to consult with a healthcare professional to determine the most appropriate treatment
plan for an individual case of hyperthyroidism.

NURSING MANAGEMENT
NURSING DIAGNOSES
Based on the assessment data, major priority nursing diagnoses may include the following:
• Risk for impaired cardiac function associated with alteration in heart
• rate and rhythm.
• Impaired nutritional status associated with exaggerated metabolic
• rate, excessive appetite, and increased GI activity
• Difficulty coping associated with irritability, hyperexcitability,
• apprehension, and emotional instability
• Situational low self-esteem associated with changes in appearance,
• excessive appetite, and weight loss
• Risk for impaired thermoregulation

PLANNING AND GOALS

The major goals for the patient may include maintenance of adequate cardiac function, maintenance
of adequate nutritional status, improved coping ability, improved self-esteem, maintenance of
normal body temperature, and absence of complications.

NURSING INTERVENTIONS
 Maintaining adequate cardiac output/ Monitoring and Managing Potentioal Complication
• Monitor vital signs, especially heart rate and blood pressure (both increase in
hyperthyroidism)
• Ask if the patient has chest pain (Due to increased heart work)
• Listen to the heart for murmurs
• Obtain ECG (atrial arrhythmias may occur in hyperthyroidism)
• Teach the patient to relax
• Administer medications as prescribed (beta-blockers)
• Provide oxygen if the saturation is less than 94%
• Check thyroid function labs

 Improving Nutritional Status

• Check intake and output (diarrhea is a common feature in hyperthyroidism)
• Weigh patient daily
• Administer antithyroid medications as prescribed
 Maintaining Normal Body Temperature
• If the patient has a fever, provide a cooling blanket
• Provide a comfortable environment for the patient
 Health teaching
• Educate the patient about thyroid surgery
• Educate the patient on radioactive iodine and how it can destroy the thyroid gland
 DISCHARGE PLANNING
Medicine
 Discuss with the patient and watcher the need to comply with home medications.
 Explain to them the advantages and disadvantages of strict compliance with the treatment
regimen.
 Instruct the patient and watcher the right time, right medications, right dosage, and right
route as ordered by the physician.
 Instruct the patient not to skip taking medications and complete the whole course of
medication.
 Remind the patient and watcher of the importance of taking into consideration the foods
or other drugs that are contraindicated while taking the medications.
 Instruct and warn patients and significant others about the possible effects and adverse
reactions that may occur brought about by taking the medications.
 Remind them to take the drugs properly and take note of the expiration date before taking
the medication.
 Encourage the patient not to take medications not prescribed by the physician.
 Instruct the patient not to stop the medication abruptly or adjust the dosage without a
prescription from the physician.
 Instruct the family to properly store and handle the medications so as not to let children
accidentally get hold of it.

Treatment
 Explain the purpose of the treatment and why it is continued at home.
 Explain to the family the condition of the patient and give them information.
 Direct and instruct the watcher to give the medication or assist the patient according to
the medication regimen.
 Emphasize the importance of recognizing any sign of unusualities.

Nutrition and Diet

- Instruct patients to avoid foods that can inhibit thyroid secretion such as strawberries,
peaches, pears, cabbage, turnips, spinach, Brussels sprouts, cauliflower, radishes, and peas.
- Limit Iodine Intake- Avoid or limit iodine-rich foods such as iodized salt, seaweed,
seafood, and dairy products.
- Avoid Stimulants- Reduce or eliminate caffeine-containing beverages like coffee, tea, and
energy drinks.
- Eat Small, Frequent Meals- Eating smaller, more frequent meals throughout the day can
help manage weight loss and stabilize blood sugar levels, which may fluctuate due to
hyperthyroidism.
- Include Calcium and Vitamin D- Good sources of calcium include dairy products, leafy
greens, tofu, and fortified foods. Vitamin D can be obtained from sunlight exposure and fortified
foods like fatty fish and fortified dairy alternatives.
- Limit Goitrogenic Foods- While cooking typically inactivates these compounds, it may
be beneficial to limit the raw consumption of goitrogenic foods such as cabbage, broccoli, Brussels
sprouts, kale, and cauliflower.
- Increase Protein Intake- Include lean sources of protein such as poultry, fish, tofu,
legumes, and nuts.
 - Maintain Adequate Hydration- Drinking plenty of water is important for overall health
and can help alleviate symptoms such as sweating, and heat intolerance associated with
hyperthyroidism.

Education
• Educate the patient's family members about hyperthyroidism, its management, and how
they can support the patient during their recovery process.
• Ensure that the patient understands the roles of different healthcare providers involved in
their care and how to contact them if needed.
• Instruct the patient on when to seek emergency medical care, such as if they experience
severe symptoms like chest pain, extreme weakness, or difficulty breathing.
• Schedule a follow-up appointment with an endocrinologist or primary care provider to
monitor the patient's thyroid hormone levels, symptoms, and response to treatment. Regular blood
tests may be necessary to adjust medication dosage as needed.
• Before discharge, review the entire discharge plan with the patient and their family
members to ensure they understand and can follow the recommendations effectively.

EVIDENCE-BASED PRACTICE

PRACTICE GUIDELINES EVIDENCE IMPLEMENTATION

 Diagnosis  Thyroid function tests,  Follow established

including measurement guidelines, such as those
of serum levels of from the American Thyroid
thyroid-stimulating Association or the Endocrine
hormone (TSH), free Society, for interpreting
thyroxine (FT4), and thyroid function tests and
free triiodothyronine diagnosing hyperthyroidism.
(FT3), are crucial for
diagnosing
hyperthyroidism.

 Regular monitoring of  Regular testing of  Schedule follow-up

thyroid function. thyroid function (TSH, appointments to monitor
Free T4) ensures thyroid function,
optimal dosing and adjusting medication as
early detection of over- necessary.
or undermedication.

 Treatment options  Antithyroid drugs  Consider patient

(ATDs), radioactive preferences, the
iodine therapy, and underlying cause of
surgery are common hyperthyroidism, and
treatment options. The potential side effects
choice depends on when deciding on the
factors such as the most appropriate
cause of treatment. Engage in
hyperthyroidism, shared decision-making
patient preference, and with the patient.
 Radioactive Iodine Therapy  Radioactive iodine is  Educate patients about
effective in reducing the procedure, potential
thyroid function. It is side effects, and the need
often considered a for long-term monitoring.
definitive treatment for Follow recommended
hyperthyroidism. guidelines for patient
selection and dose
calculation.

 Surgery (Thyroidectomy)  Thyroidectomy may be  Discuss the risks and

recommended in certain benefits of surgery with
cases, such as large the patient. Ensure proper
goiters or when other preoperative and
treatments are postoperative care,
contraindicated. including thyroid
hormone replacement
therapy.

 Patient Education.  Educating patients  Provide clear, evidence-

about hyperthyroidism, based information on the
its management, and the condition, medications,
importance of and lifestyle
medication adherence modifications. Address
improves self- patient questions and
management. concerns.
 Regular Follow-up and  Regular monitoring of  Establish a structured
continuity of care. thyroid function and follow-up schedule,
clinical status is including thyroid
essential for assessing function tests and clinical
treatment efficacy and assessments. Adjust
detecting complications. treatment plans as needed
based on monitoring
results.