1. SUBMITTED TO, SUBMITTED BY,
MRS SHREEMINI PILLAI MS SHRADDHA MIRE
READER MSC NURSING 1ST YR
MEDICAL SURGICAL NSG. PG COLLEGE OF NURSING

2. INTRODUCTION
Hyperthyroidism and thyrotoxicosis are terms
often used interchangeably, however each refers to slightly
different conditions. Hyperthyroidism refers to over activity
of the thyroid gland, with resultant excessive secretion of
thyroid hormones and accelerated metabolism in the
periphery. Thyrotoxicosis refers to the clinical effects of an
unbound thyroid hormone, regardless of whether or not the
thyroid is the primary source.
There are a number of pathologic causes of
hyperthyroidism in children and adults. These include
Grave's disease, toxic adenoma, toxic multinodular, goiter,
and thyroiditis. Of these, Grave's disease accounts for
approximately 95% of cases of hyperthyroidism. To
understand the pathophysiology of hyperthyroidism, it is
necessary to understand the normal physiology of the thyroid
gland.

3. Prevalence
Women 2%
Men 0.2%
15% of cases occur in patients older than 60
years of age

4. What is the thyroid gland?
The thyroid gland is a butterfly-shaped
endocrine gland that is normally located in the
lower front of the neck. The thyroid’s job is to
make thyroid hormones, which are secreted into
the blood and then carried to every tissue in the
body. Thyroid hormone helps the body use
energy, stay warm and keep the
brain, heart, muscles, and other organs working
as they should.

5. Definition
Hyperthyrodism is due to increased level of
thyroid hormone. Diffuse toxic goiter (graves
disease) toxic multinodular goiter (plummer’s
disease) toxic adema.
According to ”Sanjay Azad”
Hyperthyroidism is hyperactivity of the thyroid
gland with sustain increase in synthesis and release
of hormones.
According to ”watson’s”

6. Hyperthyroidism implies an excessive secretions of
thyroid hormones and may called as thyrotoxicosis, but
toxic goiter, exopthalmic goiter or grave’s disease. The
term exopthalmic goiter or grave’s disease are reversal
for hyperthyroidism that is accompanied by
exopthalmus and extreme nervesness.
•
According to ”lewis heifkemper”
Hyperthyroidism is defined as excessive secretion of
thyroid hormone. Thyrotoxicosis is an acute
exacerbation of all thyroid symptoms.
According to “Luckmann’s”

7. Anatomy Of The Thyroid
• It is butter fly shaped located just inferior to the
larynx.
• It is composed of right and left lateral lobes, one
on either side of trachea, that are connected by
isthmus anterior to the trachea.
• Microscopic spherical sac called thyroid follicles
make up most of the thyroid gland.
• The walls of each follicles consist primarily of
cells called follicular cells.

8. • The thyroid gland is a highly vascularized organ
located anteriorly in the neck, deep to the
platysma, sternothyroid and sternohyoid
muscles, and extending from the 5th cervical (C5) to
the 1st thoracic (T1) vertebrae.
• The gland consists of two lobes (left and right)
connected by a thin, median isthmus overlying the
2nd to 4th tracheal rings, typically forming an "H"
or "U" shape.
• Beneath the visceral layer of the pretracheal, deep
cervical fascia, the thyroid gland is surrounded by a
true inner capsule, which is thin and adheres closely
to the gland.

9. • The capsule sends projections into the thyroid
forming septae and dividing it into lobes and
lobules.
• Dense connective tissue attachments secure the
capsule of the thyroid to both the cricoid cartilage
and the superior tracheal rings.

10. Action of thyroid hormones
 Thyroid hormone increases the basal metabolic rate
the rate of oxygen consumption understand or basal
condition by stimulating the use of cellular oxygen
to produce ATP.
It stimulate synthesis of additional sodium-
potassium pump.
In the regulation of metabolism, the thyroid
hormone stimulate protein synthesis and increase
the use of glucose and fattyacid for ATP production
The thyroid hormone enhance some action of the
catecholamine's because they up-regulate beat
receptors.

11. Etiology
• Grave’s disease:- autoimmune; genetic component.
• Toxic multinodular goiter:- autonomus function of thyroid; multinodular.
• Toxic solitary adenoma:- single adenoma of follicular cells that secrets and
functions independently of thyroid secreting hormone may selectively hyper
secrets T3 resulting in T3 toxicosis.
• Hyperthyroidism:- rare;thyroid cancer cell do not usually concentrate
iodine efficiently; may occur with the large follicular carcinoma.
• TSH secreting pituitary adenoma chorionic hyperthyroidism:- chorionic
gonadotropin has week thyrotropin activity. Tumors such as
choriocarcinoma, embryonal cell carcinoma, and hydatiform molecules
have high concentration of chorionic gonadotropic that can stimulate T3
and T4 secretion; hyperthyroidism resolves after the treatment of tumor.

12. • Struma ovary:- ovarian dermoid made up partly of thyroid tissues
that secretes thyroid hormones.
• There are several causes of hyperthyroidism. Most often, the entire
gland is overproducing thyroid hormone. Less commonly, a single
nodule is responsible for the excess hormone secretion, called a
"hot" nodule. Thyroiditis (inflammation of the thyroid) can also
cause hyperthyroidism. Functional thyroid tissue producing an
excess of thyroid hormone occurs in a number of clinical conditions.
• Oral consumption of excess thyroid hormone tablets is possible
(surreptitious use of thyroid hormone), as is the rare event of
consumption of ground beef contaminated with thyroid tissue, and
thus thyroid hormone (termed "hamburger hyperthyroidism").
• Amiodarone, an anti-arrhythmic drug, is structurally similar to
thyroxine and may cause either under- or overactivity of the thyroid

13. Pathophysiology
Hyperthyrodism is charaterised by loss of the normal regulatory control of thyriod
hormone secretion
The action of thyroid hormone on the body is stimulatory, hypermetabolism result
Increase in sympathetic nervous system activity
Alteration of secretion and metabolism of hypothalamic pitutiary and gonadal
hormones.
Excessive amount of thyroid hormone stimulate the cardiac system and increases the of-
adrenergic receptors
Trachycardia and increased cardiac out put, stroke volume, adernergic responciveness and
peripherial blood flow.
Leads to a negative nitrogenous balance, lipid depletion and the resultant state of
nutritional deficiency.
Hyperthyrodism result

14. Clinical manifestation:-
• Older patient presents with lack of clinical signs
and symptoms, which makes diagnosis more
difficult
• Thyroid storm is a rare presentation, occurs
after stressful illness in under treated or
untreated patient.
Characteristics
-Delirium -Dehydration
-Severe tachycardia -Vomiting
-Fever
-Diarrhea

15. • Skin
-Warm
-May be erythematous (due to
increased blood flow)
-Smooth- due to decrease in keratin
-Sweaty and heat intolerance
-Onycholysis –softening of nails and loosening
of nail beds
• Hyperpigmentation
-Due the patient increase ACTH secretion
• Pruritis
-mainly in graves disease
• Thinning of hair
• Vitilago and alopecia areata
-mainly due to autoimmune disease
• Infilterative dermopathy
-Graves disease, most common on shins

16. • Eyes
Stare
Lid lag
*Due to sympathetic over activity
*Only Grave’s disease has ophthalmopathy
-Inflammation of extraocular muscles, orbital fat
and connective tissue.
-This results in exopthalmos
-More common in smokers

17. Cardiovascular System
• Increased cardiac output (due to increased
oxygen demand and increased cardiac
contractibility.
• Tachycardia
• Widened pulse pressure
• High output – heart failure

18. Serum lipid
• Low total cholesterol
• Low HDL
• Low total cholesterol/HDL ratio
Respiratory system
• Dyspnea on rest and with exertion
• Oxygen consumpation and CO2 production increases.
• Hypoxemia and hypercapnea, which stimulates ventilation
• Respiratory muscle weakness
• Decreased exercise capacity
• Tracheal obstruction
• Increased pulmonary arterial pressure

19. GI System
-Weight loss due to increased calorigenesis
-Hyperdefecation
-Malabsorption
-Steatorrhea
-Celiac Disease (in Grave’s Disease)
-Hyperphagia (weight gain in younger patient)
-Anorexia- weight loss in elderly
-Dysphagia
-Abnormal LFT especially phosphate
GU System
• Urinary frequency and nocturia
• Enuresis is common in childrenReduce mid-cycle LH
surge

20. In Femails
• Oligomenorrhea and amenorrhea
• Anovulatory infertility
In mail
• High total testosterone
• Low free testosterone
• Gynecomastia
• Decreased libido
• Erectile dysfunction
• Decreased or abnormal sperm

21. Skeletal System
Grave’s disease is associated with thyroid
acropathy
-Clubbing of nails
-Periosteal bone formation in metacarpal bone
or phalanges
Neuromuscular System
• Tremors-outstretched hand and tongue
• Hyperactive tendon reflexes

22. Psychiatric
• Hyperactivity
• Emotional lability
• Anxiety
• Decreased concentration
• Insomnia

23. Endocrine
• Increased sensitivity of pancreatic beta cells to
glucose
• Increased insulin secretion
• Antagonism to peripheral action of insulin
• Latter effects usually predominate leading to
intolerance.

24. Diagnostic Test
TSH
 Serum TSH is suppressed in hyperthyroidism (<
0.05 mU/L), except in cases secondary to TSH
hypersecretion.
 Raised free T4 or T3; T4 is almost always raised but T3
is more sensitive as there are occasional cases of
isolated 'T3 toxicosis'.
 TSH receptor antibodies are not measured routinely,
but are commonly present: thyroid-stimulating
immunoglobin (TSI) 80% positive, TSH-binding
inhibitory immunoglobin (TBII) 60-90% in Graves'
disease .

25. • T3
The T3 (or Triiodothyronine) assay is
another assay which is used in the diagnosis of
thyroid disorders. In developing
hyperthyroidism, the Free T3 concentration is a
more sensitive indicator of developing disease than
is T4 (free T4), and the former is therefore preferred
for confirming hyperthyroidism that has already
been suggested by a suppressed TSH result.
The T3 assay is also useful for diagnosing a
variant of hyperthyroidism known as T3
thyrotoxicosis.

26. Other Tests
• Auto antibodies of clinical interest in thyroid disease
include thyroid-stimulating antibodies (TSAb),
• TSH receptor-binding inhibitory immunoglobulins
(TBII),
• Antithyroglobulin antibodies (Anti-Tg Ab) and the
anti thyroid peroxidase antibody (Anti-TPO Ab). Of
these, anti-TPO Ab has emerged as the most
generally useful marker for the diagnosis and
management of autoimmune thyroid disease.

27. Ultrasound
Similar in its use for evaluating a breast
mass, ultrasound can be used to assess a thyroid
nodule. Its advantage over physical exam alone lies
in its ability to distinguish solid from cystic
nodules, whether more than one nodule exists, and
the exact size and extent of a nodule. In
fact, ultrasound can be used to assess the size and
shape of the thyroid gland itself. Because of the
recent advances in this form of imaging
technology, ultrasound has become quite sensitive a
modality, particularly when assessing size and
numbers of nodules.

28. Ultrasound characteristics which
suggest a benign nodule include:
• Nodule filled with fluid (likely
a cyst)
• Multiple nodules throughout
the gland (likely a
multinodular goiter)
• No blood flowing through
nodule (again, likely a cyst)
• Sharp edges seen around
nodule

29. FINE NEEDLE ASPIRATION
• Provided adequate sample is removed on
biopsy, FNA of thyroid nodules can be used
to categorize tissue into the following
categories: malignant, benign, thyroiditis,
follicular neoplasm, suspicious, or non-
diagnostic.
• The technique has decreased unnecessary
operative procedures in patients with benign
nodules and increased the probability that
surgery will be performed on those with
malignant disease.
• The one drawback lies with hypocellular
samples and aspirates with high follicular
cellularity.
• Hypocellular aspirates may be encountered
in cystic nodules.
• Aspirates with a high follicular cellularity
suggest follicular neoplasm, however, FNA
cannot reliably distinguish a benign follicular
neoplasm from a malignant one, and thus
surgical resection remains the necessary
recourse to obtain a definitive diagnosis.

30. Thyroid Scan
• The tissue that makes up the thyroid gland
is unique in that it is able to take up and
trap iodine and certain other molecules of
similar size.
• When radioactive isotopes of these
substances (tracers) are swallowed or
injected into the bloodstream, they are
taken up by the thyroid gland.
• As they decay, a special camera can detect
the energy that is released, creating a
picture of the thyroid gland.
• The radioactive isotopes that are most
commonly used as tracers to perform
thyroid scans are called 123-Iodine, 99m-
Technetium pertechnetate and 131-Iodine.

31. MEDICAL MANAGEMENT
Antithyroid drugs:-
Radio active iodone
Surgery

32. Antithyroid drugs:-
• Commonly used drugs are propylthiomacil (PTU)
100-300 mg three times a day and methimazole
(tapazole) is given in a dose of 10-15 mg three times
a day till the patient is euthyroid and there after in a
dose of 5 mg three times aday for upto 12 to 18
months these drugs interferes with the binding of
organic iodine and the coupling of the iodotyrosines
initial response is seen antithyroid drugs as it
prevents an increase in the size of the gland and
thyroid insufficiency.
• Assessment During Treatment:-
• Clinical examination, pulse rate, and the thyroid
hormone levels.

33. Iodides:-
• Iodides are useful because iodine inhibits the synthesis
of thyroid hormone. They are used often a use of most
often a course of propylthiouracil to suppress hormone
secretion before thyroidectomy. The iodides may be used
to treat thyrotoxicosis.
• Lugol’s solution’s (5% iodide and 10% potassium iodide)
and saturated solution of potassium iodide.
Side effects
• Iodine solution can cause discolouration of the teeth and
gastric upset. The effects are minimize if the iodine
solution is diluted with milk and fruit jucies or some
other beverages and sipped with straw.
• Signs of iodine toxicity include swelling and irritation of
mucus membrane and increased salivation.

34. Radio iodide:-
• It is widely used modality of treatment I 131 is
preferred and the dose for diffuse toxic goiter is 7 to
9millicurie and for toxic goiter is 12-15 mc. Many
patient will require more than one dose. It can be
used in most of the patient except in new born and
pregnant women and lactating women. Beta
adrenergic blocker can be given to control cardiac
symptoms. The radiation doses used to treat
hyperthyroidism does not pose a threat to others.
• Side effects :- its side effects are minimal.
Inflammation of thyroid gland (thyrioditis) and the
parotid gland (parotiditis) may occur.
Hypothyroidism may occur or develop years of the
treatment.

35. Surgical Treatment of Thyroid
Disease
General
Several surgical options exist for treating thyroid
disease and the choice of procedure depends on two
main factors.
• The first is the type and extent of thyroid disease
present.
• The second is the anatomy of the thyroid gland
itself.
The most commonly performed procedures
include:
lobectomy, lobectomy with isthmectomy, subtotal
thyroidectomy, and total thyroidectomy.

36. Thyroid Lobectomy and Isthmectomy
• As its name implies, thyroid lobectomy involves removal
of only one lobe of the thyroid gland. This may involve
crossing the midline to include the isthmus
(isthmectomy) or it may involve the affected lobe alone.
• Indications for thyroid lobectomy include biopsy for a
solitary thyroid nodule suspicious of
malignancy, compressive or cosmetic symptoms from a
multinodular goiter, or removal of a well-differentiated
malignancy in a low-risk patient (although this is
controversial). Thyroid lobectomy ± isthmectomy is a
surgical option for well-differentiated papillary
carcinomas, although many surgeons may have option
for a total thyroidectomy instead with removal of
affected cervical nodes if necessary.

37. ADVANTAGE AND DISADVANTAGE
• The advantage of this procedure is that normal
thyroid tissue is left behind to provide
endogenous hormone. In addition, there is less
chance of disrupting the parathyroid glands or
recurrent laryngeal nerves on the unaffected
side.
• The disadvantage to lobectomy is that with a
remnant lobe left in place, the use of radioiodine
as ablative therapy is compromised.

38. Subtotal Thyroidectomy
• In a subtotal thyroidectomy, the affected side
(lobe) of the gland is removed, along with the
isthmus and a substantial portion of the
opposite lobe. Typically reserved for small, non-
aggressive thyroid cancers, this is also a viable
option for goiters which cause compressive or
cosmetic problems in the neck.

39. Total Thyroidectomy
• Total thyroidectomy involves complete removal
of the thyroid gland and is the operation of
choice for practically all thyroid cancers. Even
obstructive goiter is occasionally treated with
total thyroidectomy as opposed to subtotal
thyroidectomy. In fact, certain situations are
absolute indications for complete gland removal
including medullary thyroid carcinoma, sarcoma
of the thyroid gland, and stage IE thyroid
lymphoma.

40. NURSING MANAGEMENT

41. Nursing management :-
• Nursing Diagnosis:- imbalanced nutrition
less than body requirement related to anorexia
and increase metabolic demand is inappropriate.
• Expected Out comes:- The client’s weight loss
will end as evidenced by an ability to consume
sufficient calories to return to ideal body weight.

42. • Nursing diagnosis:- Activity intolerance related to
exhaustion secondary to accelerated metabolic rate
resulting in inability to perform activity without
shortness of breath and significant increased in heart
rate.
• Expected Out comes:- the client will engage in a
normal level of activity by ability to maintain a proper
balance of rest and activity to prevent exhaustion.

43. • Nursing Diagnosis :- risk for injury: corenal
ulceration, infection and not possible blindness
related inability to close the eye lids secondary to
exophthalmos.
• Expected Outcomes :- the client should not
experience coreneal ulceration infection or blindness
as evidenced by the lack of further development of
expothalmus.

44. • Nursing diagnosis :- Hyperthyremia related to
accelerated metabolic rate resulting in
fever, diaphoresis and reported heat intolerance.
• Expected outcomes :- the client will not exhibit
hyperthermia as evidenced by return to normal body
temperature.

45. • Nursing diagnosis :- Impaired social interaction
related to extreme agitation, hyperactivity, and mood
swings resulting in inability to relate effectively with
others.
• Expected out comes:- the client will not suffer
from impaired social interact without
difficulty, without agitation, hyperactivity or mood
swings.

46. Complication:-
• The major complications of grave’s disease are :
• Exopathalom
• Heart disease
• Thyroid storm (thyroid crisis)
• Thyrotoxicosis

47. Exophthalmo’s :-
The client with exopthalmos should wear dark
glasses and warm them to avoid getting dust or dirt
in there eyes when they can not close their eyelids
easily at all they should were a sleeping mask
(available in drug store) or lightly tape the eye shunt
with non-allergic tape. They can elevate the head of
the bed at night and have the client restrict salt in
take to relive edema.

48. Heart disease:-
Heart disease the second complication of
graves disease poses a serious there at tachycardia
almost always accompanies thyrotoxicosis, and
atrial fibrillation may also appears. Congestive
cardiac failure found in old client with long stand
thyrotoxicosis.
Thyroid strom:-
Thyroid strom is sometimes fatal acute
episode of thyroid activity is characterised by high
fevear, delirium dehydration and extreme
irritability. It was once a common occurring crisis
but seldom develops.

49. Thyroid strom:-
Thyroid strom is sometimes fatal acute
episode of thyroid activity is characterised by
high fevear, delirium dehydration and extreme
irritability. It was once a common occurring
crisis but seldom develops.
Thyroid strom require heroic
intervention farcentral. The high fevear is
treated with hypothermic blancket dehydration
is reversed by intravenous fluid.