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Copy of Graves Disease case study

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Barbara Rhine

on 24 March 2014

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Transcript of Copy of Graves Disease case study

Jackie Blake

Graves Disease
*Most common cause of hyperthyroidism
Steve, Natasha, Mark Y.
Adult Endocrine Case Study (HYPERTHYROIDISM)
July 17, 2013
Is caused by inflammation byproducts accumulating in the retro-orbital tissues
Occurs in about 1/3 cases
Is usually bilateral but can be unilateral
Is accompanied by other disturbances such as blurred vision, diplopia, pain, tearing, and photophobia
The resulting inability to close the eyes completely increases risk of corneal dryness, irritation, infection, and ulceration
Ocular muscle involvement can lead to paralysis of eyes
Is usually not reversible!
Nonsurgical Management
Nonsurgical Management
Reducing stimulation
decrease noise
decrease stress
promote rest
limit visitors
keep door to room closed
Promote Comfort
lower room temperature
keep pitcher of ice water full
suggest frequent cool showers (or cool sponge bath)
change linen if diaphoretic
Hyperthyroidism
Excessive delivery of thyroid hormone (TH) to tissues
Results in increased metabolic rate in ALL tissues and increases sympathetic nervous system stimulation systemically
CAUSED BY: Graves disease, excess TSH, thyroiditis, neoplasms, drug side effects, excessive thyroid meds.

MANIFESTATIONS
Tachycardia
Increased blood flow
Caloric and nutritional deficiencies/excesses
Increased appetite
Diaphoresis
Hyperactive bowels/diarrhea
Emotional lability
Heat intolerance
Insomnia
Smooth, warm skin
Hair loss
GRAVES is an autoimmune disorder, often presenting with these common comorbidities: myasthenia gravis, DM, celiac disease, and pernicious anemia
Chief complaint:
generalized weakness, the “shakes,” feelings of “burning up,” palpitations, intermittent chest pains, shortness of breath, and swelling in the feet
30 year old female
*NOTE: Common symptoms of a thyroid storm are LIGHT-HEADEDNESS, DELIRIUM, VERTIGO, PSYCHOSIS...
History of Present Illness
PATHOPHYSIOLOGY
Antibodies bind to TSH and cause thyroid gland to overproduce TH. The result is thyroid gland enlargement (goiter). However, goiter can be exhibited with hypothyroidism as well.
RISK
Graves is hereditary and is seen 8x more often in women, usually between 20 and 40 yrs. of age.
Graves Disease
*Most common cause of hyperthyroidism
EXOPHTHALMOS (forward protrusion of the eyes)
Family History: Grandmother with Graves’ disease, otherwise negative.

Her history: Nonsmoker; drinks 2-4 beers intermittently when anxious; lives with fiancé - their wedding, which has been an on-again off-again affair for 2 years, is planned in 6 months.
More History....

Fatigue
Difficulty sleeping
Hand tremors
Pretibial myxedema (hyaluronic acid deposits)

Reduced/absent menstruation
Atrial fibrillation
Angina
CHF
OTHER PARTICULAR MANIFESTATIONS (s/s of hyperthyroid, plus...)
THYROID STORM
Rare now due to prompt diagnosis and treatment, but is MOST COMMON WITH Graves disease
Triggers are stressors such as infection, trauma, DKA, or pressure on the gland during surgery


Hyperthermia (102-106 degrees F)
Tachycardia
Systolic hypertension
Dyspnea
Nausea/ vomiting/ diarrhea
Abdominal pain
Restlessness
Tremors
Confusion/ psychosis/ delirium/ seizures
*** IF UNTREATED, MORTALITY IS LIKELY! ***
TREATMENT
Cooling without aspirin (increases free TH!) or shivering
Replacing fluids, glucose, and electrolytes
O2 for resp. distress
Stabilize cardiovasc. function
Reduce TH synthesis and secretion by iodine administration (Lugol's, SSKI, Thyro-Block)
SIGNS/ SYMPTOMS
Nonsurgical Management
Drug therapy
Iodine preparations: short-term therapy, decrease blood flow through thyroid gland, inhibiting the release of thyroid hormone
take drug 1 hour after thionamide administration to prevent an increase in thyroid hormone production
improvement happens within 2 weeks
should help with cardiac effects and other manifestations of hyperthyroidism
too much can cause hypothyroidism, monitor levels
Lithium: used when patient cannot tolerate other anti-thyroid drugs, inhibits release of thyroid hormones
side effects can include depression, tremors, diabetes insipidus, N & V
drink plenty of fluids (drug increases urine output)
watch for weight gain, slow heart rate, cold intolerance (signs of hypothyroidism, may need to lower dosage)
Nonsurgical Management
Drug therapy
Anti-thyroid drugs (thionamides): initial treatment of hyperthyroidism, prevent new formation of thyroid hormones by inhibiting thyroid binding of iodine
propylthiouracil (PTU), methimazole (Tapazole)
take every 8 hr
avoid crowds, people who are ill, report fevers, sore throat (some of these drugs reduce blood cell counts and immune response, agranulocytosis is a serious side effect and any signs of infection should be monitored)
report dark urine or jaundice (liver toxicity/failure)
report pregnancy status (some of these drugs cause birth defects and should not be used during pregnancy)
Beta-adrenergic blocking drugs (propranol hydrochlorides): supportive therapy, relieve palpitations, tachycardia, anxiety, diaphoresis
Monitor HR and BP (decreased is expected).
Assess for SOB, fatigue, dizziness (most common side effects).
Nonsurgical management
Radioactive iodine therapy (RAI)
thyroid gland picks up the local radiation, which destroys some of the cells that produce thyroid hormone
not used in pregnant women (crosses placenta)
radiation dose is very low, radiation precautions are not needed, elimination from body is quick
encourage fluids, RAI is excreted through kidneys
performed outpatient, 1-3 doses as needed, may take 6-8 weeks for full symptom relief
drug treatment still used during and after treatment
regular monitoring needed to prevent hypothyroidism, which is a major side effect
patient will then require lifelong thyroid hormone replacement
Surgical Management
If a large goiter is causing tracheal or esophageal compression, or if patient is not responding to anti-thyroid drugs, the surgical plan of care may include removal of part of thyroid gland (subtotal thyroidectomy), or all (total thyroidectomy). After a total thyroidectomy, patient must take lifelong thyroid hormone replacement.

Pre-operative Care
Try to attain euthyroid state before surgery by taking anti-thyroid drugs to decrease thyroid hormone secretion.
Give iodine preparations to decrease thyroid size and vascularity (to reduce risk of thyroid storm or hemorrhage during surgery)
Control any dysrhythmias, HTN, or tachycardia before surgery.
Follow a high carbohydrate and high protein diet before surgery.
Explain surgery to patient/family and answer any questions.
Explain the drain and dressing that will be in place after surgery.
Symptoms have worsened lately.
Anxious, forgetful, and confused;
frequent diarrhea; numbness and tingling in feet and hands;
no period in 4 months; has lost 15.5 pounds over the past few months despite a “ravenous” appetite;
feels that eyes are protruding and frequently has tearing, pain, double vision, and light sensitivity;
takes propylthiouracil only 1-2 x a day because she forgets to take it and thinks it causes diarrhea and an itchy rash all over;
denies sore throat or joint pain
Monitoring
check apical pulse
check BP
check temperature
even a one degree Fahrenheit increase should be immediately reported
could be beginning of thyroid storm
patient should be on tele
check cardiac status for dysrythmias
ask patient to report palpitations, vertigo, chest pain, or dyspnea
ABNORMAL LAB VALUES
Na: 130 (135-145)
TT4: 20 (4.5-12.5)
TT3: 830 ( >20 y/o 80-200)
TSH: <0.05 (0.4-4.40)
K: 3.2 (3.5-5.0)
HCT: 23% (36-46%)
HGB: 8.0 (12-15.5)
Total Bili: 3.5 (0.3-1.0)
AST: 150 (5-40)
ALT: 145 (7-56)
WBC: 14,300 (3,500-10,500)
BUN: 35 (7-20)
Vitamin B12: 80 (200-900)
Cultural Implications
There are no evident cultural implications.

Surgical Management
Operative Procedures
Under general anesthesia
endotracheal tube placement during surgery
will cause few days of hoarseness
Neck is extended, surgeon makes a collar incision above clavicle
Surgeon attempts to avoid the parathyroid glands and laryngeal nerves to avoid injury and complications
In a subtotal thyroidectomy, the remaining thyroid tissues are sutured to the trachea
In a total thyroidectomy, the parathyroid glands are left with an intact blood supply to prevent causing hypo-parathyroidism (and hypocalcemia).
***Rapid intervention is critical because Jackie Black is exhibiting signs/symptoms suggestive of an approaching THYROID STORM!
Surgical Management
Post-operative Care
Monitor patient for complications: Check every 15 min until stable, then every 30 min
Hemorrhage: inspect dressing and behind neck. If they have a drain, it will be serosanguineous
Respiratory distress: from swelling, laryngeal nerve damage, or tetany. Make sure emergency tracheostomy equipment, suctioning equipment, and oxygen are in the room.
Parathyroid gland damage: causing hypocalcemia and tetany. Ask patient about any tingling in extremities or mouth. Monitor for any muscle twitching. (can give calcium gluconate/chloride)
Laryngeal nerve damage: results in hoarseness and weak voice. Usually lasts for only 1-2 days.
Thyroid storm: can be FATAL. Manifestations develop quickly! Major signs: tachycardia, fever, or systolic hypertension. Also: abdominal pain, N&V, diarrhea, anxiety, tremors, confusion, psychosis, coma!
Health Teaching
Eye and vision care
Elevate head of bed at night
Use eyedrops (artificial tears)
Dark glasses to treat photophobia
If severe: possible steroid therapy to reduce swelling, diuretics to decrease edema, or surgery (orbital decompression).
Teach patient & family
Signs of hyper- AND hypothyroidism
Need for thyroid hormone replacement if hypo-
Regular follow-ups
Sutures come out 3-4 days after surgery
Report any swelling, major drainage, redness, severe pain
Mood swings occur with hyperthyroidism. Will decrease with continued treatment.
Nursing Diagnoses
Risk for decreased cardiac output d/t ventricular hypertrophy
(possible cardiac failure)

Disturbed sensory perception: Visual
(exophthalmos)

Imbalanced Nutrition: Less than Body Requirements
(increased metabolism)

Disturbed body image and anxiety
(goiter / exophthalmos and mood swings)
Questions to answer...
Jackie's Relationship:
Bruises (back, trunk, wrists), rib fractures, on/off again relationship with upcoming wedding.
Is she safe? Is there abuse? Does she have support network?

Missing Data:
Mg and Ca lab values (remember PTH can also be affected in thyroid disease).
When did she last take meds?
Why is she taking pseudoephedrine? Does she have an Advanced Directive?

Resources:
Family and friends? Hubbard House?
Support group for abuse victims and one for graves disease.
Information about possible future surgery.
Diagnosis
HYPERTHYROIDISM
Labs
Increased TH (T3 and T4) and increased radioactive iodine (RAI) uptake are diagnostic for hyperthyroidism
TSH, thyroid antibodies, and T3 resin uptake (T3RU) may be ordered.
Manifestations of the disease that is causing excess free TH
Thyroid scan or MRI to identify tumors.
Delegation?
A new/floating nurse is not likely prepared to care for this patient; but as charge nurse, you could assign Jackie to an experienced nurse.
Ethical Considerations
- Remember to look out for any red flags
- Report abuse (with patient's permission) when encountering a patient who has experienced this kind of injury

LOOK FOR
*Patterned injuries (belt buckle, cigarette burns)
*Multiple injuries in various stages of healing
*Unexplained injuries
*Injuries in hidden areas
*Extreme bruising on buttocks, shoulders, genitalia
Your role as a nurse is essential!
Nurse's legal obligations
Ethical Considerations
Must report abuse!

Federal and state laws require healthcare professionals to report suspected abuse.
The federal Violence Against Women Act in 1994 (amended in 1996) establishes domestic violence as a national crime.
Anxious, forgetful, confused
Numbness/tingling in feet and hands
Full transcript