INTRODUCTION

The thyroid gland is a small, butterfly-shaped organ located in the neck below and in front
of the Adam's apple.

Thyroid hormone is a chemical substance produced by the thyroid gland and released into
the bloodstream. It interacts with almost all body cells, causing them to increase their
metabolic activity.

Hyperthyroidism is a condition In which there is overproduction of thyroid hormone by the

thyroid gland, causing the levels of thyroid hormone in the blood to be too high. People who
have it are often said to have an "overactive thyroid".

Hyperthyroidism is also known as thyrotoxicosis from the prefix "thyro-" meaning

thyroid, the term "toxic" meaning poisonous, and the suffix "-osis" meaning condition.

GRAVE'S DISEASE

The most common type of hyperthyroidism, results from aexcessive output of thyroid
hormones caused by abnormal stimulation of the thyroid gland by irculating
immunoglobinsn

Clinical Manifestations

 Nervousness

 Emotionally hyperexcitable, irritable and apprehensive

 They cannot sit quietly

 Suffers from palpitations

 Tolerate heat poorly and perspire unusually freely

 With salmon color skin that is warm, soft and moist

 Exophthalmos

 Increase appetite and dietary intake

 Progressive weight lossabnormal muscular fatigability and weakness

 Amenorrhea

 Changes in the bowel function

General Objectives:

Within 4 hours of case presentation, the participants will be able to gain knowledge,
skills and attitude regarding the topic diffuse toxic goiter.
Specific Objectives

After 4 hours if case presentation we will be able to:

Knowledge:

1. Discuss briefly and completely the health history of the client.

2. Define diffuse toxic goiter comprehensively .
3. Discuss the disease process, its participating and predisposing factor contributing to
it.
4. Enumerate possible and actual nursing interventions to manage the clients condition.
5. Discuss nursing care plan appropriate in providing care to alleviate client symptoms.
6. List down medications used to treat diffuse toxic goiter.
7. Discuss the pathophysiology of diffuse goiter in a schematic diagram.

Skills:

1. Use collected data as the basis of case presentation.

2. Organize data and topics systematically for easy analysis.
3. Assemble and arrange all materials for presentation to save time.
4. List down the corrections given by clinical instructors and participants.
5. Work assigned task properly to ensure attainment of goal clearly.
6. Deliver the data clearly upon presentation with self-confidence.
7. Analyze the questions asked by the clinical instructors and participants and answer
it comprehensively.

Attitude:

1. Accept compliments and criticism positively from clinical instructors and participants.
2. Answer the questions ask by clinical instructors and participants.
3. Display cooperation and unity within the group.
4. Show courtesy and respect in conversing with participants and clinical instructors
during open forum.
5. Share some helpful information with the participants to the level of their
understanding.
6. Treat all gathered information confidentially.
7. Display Augustinian values at all times.

PHYSICAL ASSESSMENT

Vital Information:

Name : H.L.

Age : 43 years old

Sex : Female

Address : Brgy. Jibolo, Janiuay, Iloilo

Chief Complaint: Difficulty of breathing (DOB)

Admitting Diagnosis: Community Acquired Pneumonia- Moderate Risk, Diffuse Toxic Goiter
(CAP-MR, DTG storm)

General Survey:

Awake, conscious and conversant, lying on bed in a moderate high back rest with IVF
of PNSS 1L x 40 cc/hr. inserted at left metacarpal vein at the level of 590 cc, drops regulated
at 13-14 gtts/min., patent and infusing well. With O2 at 2-3 L/min. via nasal cannula. Vital
signs taken and revealed BP of 130/80 mmHg, body temperature of 37.1 0C, pulse rate of 96
beats/min. and respiratory rate of 30 breaths/min. Weakness noted, dress appropriately.
Complaints of difficulty of breathing.

SKIN and NAILS

Skin brown in color on exposed areas and lighter on unexposed areas such as chest,
abdomen and axilla. Hyperhydrosis noted due to excessive sweating. Mole approximately
cm, brown, oval, smooth, flat and have well-defined borders noted on the upper right cheek.
Uniform skin temperature of 37.1 0C on exposed areas, cooler than unexposed areas. Axilla
are more moist than exposed areas. Skin becomes more fine-textured. Has good skin turgor
that springs back within 2-3 seconds after pinching. Vascular lesion noted, ecchymosis on
the right dorsal area of the hand due to IV insertion, presence of pain when touched, does
not blanch.

Nails slightly pinkish, angle of nail attachment 1600, convex curvature, smooth
texture and intact epidermis. Beau’s line on nails noted, may result from severe illness
(horizontal depression). Good capillary refill upon performing blanch test about 2-3 seconds.

HAIR

Hair black and with gray coloring that occurs with aging. Hair loss on scalp and axilla
noted thins due to age, fine silky in texture, presence of redness mostly on the nape area
due to presence of lice. Presence of very fine body hairs noted over the body. Scalp intact.
Absence of masses or lumps noted.

HEAD, FACE AND NECK

Normocephalic, oval contour and symmetrical facial appearance. Presence of

wrinkles on forehead. No tenderness or lesions, relatively smooth with no unexpected
contours or bulges. TMJ smooth, symmetrical motion, with no pain upon palpation.

No periorbital edema around the frontal and maxillary sinuses. Absence of

tenderness noted.

EYES

Eyes clear and bright, in parallel alignment. Eyelashes equally distributed and curved
slightly outward. No crusting or infestation noted. Visible sclera between iris and upper lid
(exophthalmia) present. Eyelids in contact with eyeball. No lesions.
 Protrusion of eyeballs noted due to hyperthyroidism. Absence of swelling, redness, or
drainage of the lacrimal glands and nasolacrimal ducts. Bulbar conjunctiva is clear, pinkish
in color, with few underlying blood vessels and white sclera visible. Palpebral conjunctiva is
smooth, glistening, pinkish in color and with minimal blood vessels present. Sclera smooth,
white and glistening. Cornea and lens clear, smooth and glistening. Corneal reflex and
blinking reflex positive (CN V intact). Iris brown and circular. Pupils are equally round and
reactive to light and accommodation. Constrict when focus to a near object and dilate when
looking at a far object.

Eyeball is firm and nontender. Lacrimal glands and nasolacrimal ducts are nontender,
nonpalpable and absence of tearing.

Able to read letters without correction on the chart 20 ft. away corresponding with
20/20 in vision. Correctly identifies colored bars on the chart. Smooth, conjugate movement
of eyes in all directions, and extraocular muscle intact (CN III, IV and VI).

EARS

Symmetrical in size, consistent with skin color, intact and no lesions noted. Helix of
ear is level with the inner and outer canthus of the eyes. Minimal cerumen noted on both
ears. Soft and pliable, nontender auricle. Pinna recoils within 2 seconds after it is folded. No
foreign objects. Canal patent. Free of redness or drainage.

Able to repeat most words whispered in each ear at a distance of 1 ft. (CN VIII intact).
Patient able to hear tick of a watch in each ear at a distance of 5 inches. (CN VIII intact).

NOSE

Shape symmetrical, placed at midline, no nasal flaring and no drainage. Pink nasal
mucosa, moist, with only scant mucus present. Intact with no lesions or perforations. No
crusting or polyps noted. Septum located at midline and no deviation. Cartilaginous portion
is slightly mobile, nontender, and no masses upon palpation. Nares patent, air flows freely.

MOUTH

Red-brown upper lip and pinkish lower lip, midline, symmetrical, skin intact and dry.
26 teeth present, white, not loose and with good occlusion. Dental caries noted, 2 premolars
and 1 molar on the lower left portion of the mouth. Pink, moist, intact mucosa and absence
of lesions or swelling noted. Gums consistent in color with other mucosa and intact, with no
bleeding. Light pink, smooth, soft palate and lighter pink hard palate, more irregular texture.
Both palate are intact. Uvula at midline of soft palate, pink, moist and without lesions.
Symmetrical rise of the uvula (CN IX, GLOSSOPHARYNGEAL and CN X, VAGUS intact).
Presence of gag reflex noted.

Tongue pink and moist. Mucosa intact with no lesions or discolorations. Papillae
intact. Tongue is freely and symmetrically mobile (CN XII intact). Able to identify varying
flavors like sweet candy.

Mucosa of oropharynx is pink, moist and intact. No lesions, erythema, swellings or

lumps noted. Tonsils symmetrical, pink, and moist. Absence of lesions or swelling.
 Lips soft, nontender and no masses upon palpation. Parotid glands are nonpalpable
and nontender as well as the submandibular and sublingual glands.

NECK

Neck erect, midline and enlarged, visible thyroid present due to goiter. Thyroid
masses felt upon palpation. Thyroid gland moves up with the cartilage as the patient
swallows. Has limited range of motion of the neck. Thyroid gland palpable, bruit sound
detected because of increased vascularity of hyperthyroidism.

CHEST (ANTERIOR and POSTERIOR)

Anterior chest light brown in color, absence of hairs noted, skin intact and no scars.
Symmetrical in appearance with symmetrical in rise and fall when breathing. Respiratory
rate of 30 breaths/min. tachypnea noted.

Posterior chest same color with the anterior chest, skin intact, chest expansion equal
and spine straight without lateral curves or deformities.

Tracheal deviation due to thyroid enlargement. Absence of tenderness, deformities

and lumps. Symmetrical chest excursion without lag. Equal bilateral tactile fremitus and
diminished midthorax.

Resonance to second intercostals space on left, slightly dull on the third through fifth
intercostals space over heart. Posterior thorax resonance to T10-T12 with deep inspiration.
Adventitious sound noted, rhonchi heard upon auscultation. No abnormal voice sounds.

HEART

Positive pulsation at apex. No cardiac murmurs noted upon auscultation. Cardiac rate
is 96 beats/min.

ABDOMEN

Abdominal contour flat, light brown skin color. Normoactive bowel sounds heard 4
cycles/min. No lesions, lumps or masses noted.

BREAST

Breast conical and symmetrical. Skin color lighter than in exposed areas. No lesions,
redness or edema, texture even. Presence of stretch marks both around the breasts. Areola
and nipple darker in color than breast. Nipples everted, pointing in same direction, no
discharge. Axilla skin intact, no rashes or lesions.

Breasts soft, nontender, less firm and elastic in postmenopausal women. Nipples
elastic, nontender. No discharge or white, sebaceous secretion. Nonpalpable axilla and
clavicular nodes.

UPPER EXTREMITIES
 Uniform skin color, fingernails of equal thickness, positive brisk capillary refill less
than 2-3 seconds and no edema, erythema or skin masses noted. With IV insertion at the left
metacarpal vein, IV insertion made: 3 on the right hand and 2 on the left. In full range of
motion, able to extend and flex both arms and able to rotate wrists. Brachial, radial and
ulnar pulses are easily palpated and equal in strength and amplitude. Skin temperature is
warm bilaterally.

LOWER EXTREMITIES

Leg hair distributed evenly, thinner and moist skin. No varicosities, swelling, or
lesions. Popliteal, posterior tibial and dorsalis pedis pulses are easily palpated and bilaterally
equal in strength and amplitude. Negative Homans’ sign noted. Skin warm to touch.

GENITALIA

Consistent with skin color, with normal pattern of urination and defecation. Able to
urinate at least 10 times per day with approximately 360 cc/voiding and defecate once a
day. Has a regular menstrual cycle and consumes 3 pads/day in 3 consecutive days. No
masses, lumps or lesions as stated by the client.

DRUG STUDY

Paracetamol
300mg/amp IVTT q6H PRN for temp≥ 37.8ºC

*Classification: Nonopioid analgesics and antipyretics

*Indications: Mild pain or fever
*Action: Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of
prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation.
The drug may relieve fever through central action in the hypothalamic heat regulating
center.
*Adverse reaction:
 Hematologic: Hemolytic anemia, leukopenia, neutropenia, pancytopenia
 Hepatic: Jaundice
 Metabolic: Hypoglycemia
 Skin: Rash, urticaria
*Effects on Lab test results:
 May decrease glucose and haemoglobin levels and hematocrit
 May decrease neutrophil, WBC, RBC, and platelet count
 May cause false-positive test result for urinary 5-hydroxyindoleacetic acid. May
falsely decrease glucose level in home monitoring systems.
*Contraindications and cautions:
 Contraindicated in patients hypersensitive to drug.
 Use cautiously in patients with long term alcohol use because therapeutic doses
cause hepatotoxicity in these patients.
*Nursing Considerations:

PTU (propylthiouracil)
50mg 1tab 12 tabs now and then, 4 tabs q6H
*Classification: Thyroid hormone antagonist
*Indications: Hyperthyroidism, Thyrotoxic crisis
*Action: Inhibits oxidation of iodine in thyroid gland, blocking activity of iodine to combine
with tyrosine to form t4 and may prevent coupling of monoiodotyrosine and diiodotyrosine
to form t4 and t3.
* Adverse Reaction:
 CNS: Headache, drowsiness, vertigo, paresthesia, neuritis, neuropathies, CNS
stimulation, depression, fever.
 CV: Vasculitis
 EENT: Visual Disturbances, loss of taste
 GI: Diarrhea, nausea, vomiting, epigastric distress, salivary gland enlargement
 GU: Nephritis
 Hematologic: Agranulocytosis, leukopenia, thrombocytopenia, aplastic anemia
 Hepatic: Jaundice, hepatotoxicity
 Metabolic: dose-related hypothyroidism
 Musculoskeletal: arthralgia, myalgia
 Skin: rash, urticaria, skin discoloration, pruritus, erythema nodosum, exfoliative
dermatitis, lupus like syndrome
 Other: lymphadenopathy
*Effects on lab test results:
 May decrease haemoglobin level
 May decrease granulocyte, WBC and platelet counts and liotyronine uptake.
*contraindications: Contraindicated to patients hypersensitive to drug.
* Nursing Considerations:
 Patients older than 40 may have an increased risk of Agranulocytosis
 Give drugs with meals to reduce adverse GI reactions.
 Watch for hypothyroidism (mental depression, cold intolerance, and hard, nonpitting
edema)
 Monitor hepatic function. Stop drug if transaminase levels are greater than three
times the upper limit of normal.
*Patient teaching:
 Instruct patient to take drugs with meals
 Warn patients to report fever, sore throat, mouth sores, and skin eruptions
 Tell patient to report unusual bleeding and bruising.
 Tell patient to ask prescriber about using iodized salt and eating shellfish. These
foods contain iodine and may alter effectiveness of the drug
 Teach patient to watch for signs and symptoms of hypothyroidism and to notify
prescriber.

Ambroxol
78mg/cap 1cap OD

*Classification:
*Action:
*Indication: Secretolytic therapy in acute and chronic bronchopulmonary diseases
associated with abnormal mucus secretions and impaired mucus transport.
*Contraindications: Should not be used in patients known to be hypersensitive to
Ambroxol or other components of the formulation
*Special Precautions:
 Tablets (30 mg) contain 684mg lactose per maximum recommended daily dose (120
mg). Patients with rare hereditary galactose intolerance, the Lapp lactase deficiency
or glucose-galactose Malabsorption should not take this medication.
 Syrup (15/5ml) contains 10.5 g sorbitol per maximum recommended daily dose (30
ml). Patients with rare hereditary fructose intolerance should not take this medicine.
It may also have mild laxative effect.
* Nursing Considerations:
*Patient Teaching:

Propranolol hydrochloride
40mg/tab 1tab BID

*Classification: Beta-adrenergic blocker (non selective)

*Indications: adjunctive management of thyrotoxicosis and Thyrotoxic crisis.
*Action: competitively blocks beta-adrenergic receptors in the heart and juxtaglumerular
apparatus, decreasing the influence of the sympathetic nervous system on these tissues,
the excitability of the heart, cardiac workload, and oxygen consumption, and the release of
rennin and lowering BP.
*Contraindication: Contraindicated with allergy to beta-blocking-agents, sinus
bradycardia, second or third degree heart block, carcinogenic shock, Chronic heart failure,
bronchial asthma, bronchospasm, COPD, pregnancy (neonatal bradycardia, hypoglycaemia,
apnea and low birth weight with long term use during pregnancy), lactation.
*Special Precaution: Propranolol (inderal) must be used with caution in patients with
decompensated cirrhosis. Use cautiously with patients with significant hepatic or renal
impairment. Care should be taken when starting treatment and selecting the initial dose.
*Nursing responsibilities:
 Assess history allergy to beta-blocking agents, sinus bradycardia, second or third
degree heart block, cardiogenic shock, chronic heart failure, bronchial asthma,
bronchospasm, COPD, hypoglycaemia and diabetes, hepatic dysfunction, pregnancy
and lactation.
 Do not discontinue drug abruptly after long term therapy because hypersensitivity to
catecholamines may have developed.
 Give oral drug with food to facilitate absorption.
 Advise client that she may experience these side effects: dizziness, drowsiness,
light-headedness, blurred vision, nausea, loss of appetite, nightmares, depression,
sexual impotence
 Tell client to report difficulty of breathing, night cough, swelling of the extremities,
slow pulse, confusion, depression, rash, fever, and sore throat.

Ranitidine hydrochloride
50mg IVTT q12H

*Classification: Antiulcer drugs

*Indication:
 Active duodenal and gastric ulcer
 Maintenance therapy for duodenal or gastric ulcer
  Pathologic hypersecretory conditions, such as Zollinger-Ellison syndrome (ZES)
 Gastroesophageal reflux disease
 Erosive esophagitis
 Heartburn
*Action: Competitively inhibits action of histamine on the H2 at receptor sites of parietal
cells, decreasing gastric acid secretion.
*Adverse reaction:
 CNS: headache, malaise, vertigo
 EENT: blurred vision
 Hepatic: Jaundice
 Others: anaphylaxis, angioedema, burning and itching at injection site
*Effects on lab test results:
 May increase Creatinine and ALT levels
 May cause false-positive results in urine protein test using Multistix
*Contraindications and Cautions:
 Contraindicated to patients Hypersensitive to drug and those with porphyria. Use
cautiously in patients with impaired renal function.
*Nursing Considerations:
 Assess patient for abdominal pain.
 Note for presence of blood in emesis, stool or gastric aspirate.
 Drug may be added to total parenteral nutrition solutions.
*Patient Teaching:
 Instruct patient on proper use of OTC preparation, as indicated.
 Remind patient to take once-daily prescription drug at bedtime for best results.
 Instruct client to take without regard to meal because absorption is not affected by
food.
 Urge patient to avoid cigarette smoking because gastric acid secretions worsen the
disease.
 Advise the patient to report abdominal pain and blood in stool or emesis.

Piperacillin sodium + Tazobactam sodium (20 syn)

4.5 IVTT q8H ANST via soluset to run q2H

*Classification: Anti-infectives (Extended spectrum penicillin, beta-lactamase inhibitor)

*Indication: Moderate to severe infections from pireracillin and Tazobactam-susceptible,
beta –lactamase-producing strains of microorganisms in appendicitis
*Action: Inhibits cell wall synthesis during bacterial multiplication
*Contraindication: Contraindicated to patients hypersensitive to drug or other penicillin.
* Special Precaution: Use cautiously in patients with bleeding tendencies, uremia,
hypokalemia, and allergies to other drugs especially cephalosporins, because of possible
cross sensitivity.
*Adverse Reaction:
 CNS: headache, insomnia, fever, seizures, agitation, dizziness, anxiety
 CV: hypertension, tachycardia, chest pain, edema
 EENT: rhinitis
 GI: diarrhea, nausea, vomiting, pseudomembranous colitis, vomiting, dyspepsia,
stool changes, abdominal pain
 GU: intestinal nephritis and candidiasis
 Hematologic: Leukopenia, neutropenia, thrombocytopenia, anemia, eosinophilia,
 Respiratory: Dyspnea
 Skin: Pruritus, rash
  Other Anaphylaxis, pain, inflammation, phlebitis at IV site, hypersensitivity
reactions
*Effects on lab test results:
 May decrease haemoglobin level
 May increase eosinophil count. May decrease neutrophil, platelet, and WBC
counts.
 May cause false-positive result for urine glucose test using copper reduction
method, such as clinitest.
*Contraindications and cautions:
 Contraindicated to patients hypersensitive to drug or other penicillins
 Use cautiously in patients with bleeding tendencies, uremia, hypokalemia, and
allergies to other drugs, especially cephalosporins, because of possibility of cross-
sensitivity.
*Nursing Considerations:
 obtain specimen for culture and sensitivity tests before giving the first dose. Therapy
may begin pending results
 if large doses are given or if therapy is prolonged, superinfections may occur
especially in elderly, debilitated, or immunosuppressed patients
 drug contains 2.35 mEq sodium/g of Piperacillin. Monitor patient’s sodium intake.
 Monitor hematologic and coagulation parameters
 Patients with cystic fibrosis may have a higher rate of fever and rash. Monitor these
patients closely.
*Patient Teaching:
 Tell patient to report adverse reactions promptly.
 Tell patient to alert a health care provider about discomfort at the IV site.

Ipatropium bromide
1 neb 28H

*Classification: Bronchodilators
*Indications:
 Bronchospasm in chronic bronchitis and emphysema.
 Rhinorrhea caused by allergic and non allergic perennial rhinitis
 Rhinorrhea caused by the common cold
 Rhinorrhea caused by seasonal allergic rhinitis
*Action: Inhibits vagally mediated reflexes by antagonizing acetylcholine at muscarinic
receptors on bronchial smooth muscle.
*Adverse reaction:
 CNS: dizziness, pain, headache, nervousness
 CV: palpitations, hypertension, chest pain
 EENT: blurred vision, rhinitis, pharyngitis, sinusitis, epistaxis
 GI: nausea, GI distress, dry mouth
 Musculoskeletal: back pain
 Respiratory: upper respiratory tract infection, bronchitis, bronchospasm, cough ,
Dyspnea, increased sputum.
 Skin: rash
  Other: flulike symptoms, hypersensitivity reactions.
*Contraindications and cautions:
 Contraindicated to patient s hypersensitive to drug, atropine, or its derivatives and in
those hypersensitive to soy lecithin or related food
Products, such as soybeans and peanuts
 Use cautiously in patients with angle closure glaucoma, prostatic hyperplasia, or
bladder neck obstruction
*Nursing Considerations:
 If patient uses a mask for nebulizer, take care to prevent leakage around the mask
because eye pain or temporary blurring of vision may occur.
*Patient teaching:
 Warn patient that drug isn’t effective for treating acute episodes of bronchospasms
when rapid response is needed.
 Teach the patient to perform oral inhalation correctly.
 Inform patient that use of a spacer device with MDI may improve drug delivery to
lungs
 Warn patient to avoid accidentally spraying drug in the eyes. Temporary blurring of
vision may result.
 If more than one inhalation is prescribed, tell patient to wait at least 2 minutes
before repeating procedure.
 Instruct patient to remove canister and wash inhaler in warm, soapy water at least
once weekly.
 If patient is also using corticosteroid inhaler, instruct him to use ipatropium first and
then wait about 5 minutes before using the corticosteroid. This lets the
bronchodilator open air passages for maximal effectiveness of the corticosteroid.

MEDICAL-SURGICAL INTERVENTIONS

DIAGNOSTIC TESTS
FUNCTION TESTS
Tests related to serum levels
of thyroid hormone
Serum T4 Concentration
Serum T3 concentration
Triodothyronine (T3) resin
uptake
PROCEDURE AND
PREPARATION
Blood Sample; test
determines ability of T4
extracted from serum to
displace radioactive T4 from
T4 – binding proteins; not
affected by a iodides and
dyes that elevate PBI and
depress RAIU.
Radioassay of blood sample;
no special preparation
Blood sample drawn; in
laboratory resin and
radioactive T3 are added to
sample of blood; radioactive
T3 will bind to unoccupied
sites of thyroxine – binding
globulin (TBG); radioactive
counts are done on blood
and resins to determine
amount of T3 (radioactive)
bound to resin.
INTERPRETATION
Measures circulating
thyroxine that is bound to
TBG and free t4; normal, 3 to
7 mcg/100ml; increase TBG
such as occurs in pregnancy,
and estrogen therapy causes
increased T4 values;
decreased TBG as seen with
glococortioid therapy and
hypoproteinemia caused
decreased T4 values.
Measures circulating T3 that
is bound to TBG and free T3;
normal values 100 to 170
mcg/100ml and are elevated
in T3 thyrotoxicosis;
variations in thyroxine –
binding globulin (TBG) can
influence test results as they
do for serum T4.
Normally 25 to 30 of
radioactive T3 will bind to
resin; in hyperthyroidism,
where there are increased
amounts of endogenous
thyroid hormone, value will
be increased; in
hypothyroidism T3 resin
uptake will be low; this is not
a measure of patient’s
endogenous T3 level; test is
affected by total amount of
TBG; in wasting diseases
where amount of TBG may
be decreased, reading
maybe falsely elevated;
phenytoin (Dilantin) and
salicylates compete with
thyroxine for TBG sites and
may give false – negative T3
resin uptake.
Tests related to peripheral effects of thyroid hormone
Function Test
Basal metabolism rate (BMR)
Serum cholesterol level
Achilles tendon reflex
recording
Thyroid function test
Function test
Hypothalamus level test
TRH stimulation test
Procedure and Preparation
Patient at rest; amount of
oxygen used while at rest is
calculated; patient’s oxygen
use is compared with
established norms for people
of same sex, age and size;
results expressed in
percentage above or below
normal; patient received
nothing by mouth (NPO) the
night before, should have 8
hours of sleep, and should
stay in bed morning of test;
no food or smoking is
allowed; anxiety will
increased BMR so patient
needs explanation of what to
expect
Blood sample; Patient placed
on NPO list night before
Electrodes from recording
drum attached to patient’s
ankle; while ankle tendon is
tapped, recording is done.
Procedures and preparation
TRH is given IV and then
serum TSH levels are
repeatedly measured
Interpretation
Normal range is –15% to
+15%; in hyperthyroidism
patient’s BMR will be greater
than +15%; in
hypothyroidism patient’s
BMR will be less than -15%;
BMR is less accurate than
other tests describe about
but maybe used to observe
patients on thyroid therapy
Normals vary from
laboratory; high levels found
in hypothyroidism and low
levels found in
hyperthyroidism; data
augment other test
Slow, sluggish jerk indicates
hypothyroidism; rapid jerk
indicates hyperthyroidism
Interpretation
Normal serum TSH begins to
rise at 10 min and peaks at
45 min, subnormal tests
reflect diminished TSH
reserve; supranormal
response occurs in patients

Pituitary level test
TSH radioimmunoassay Blood sample, no special
interpretation
Thyroid stimulating Baseline levels of radioactive
hormone(TSH) stimulation iodine uptake(RAIU) and
test protein- bound iodine(PBI)
are taken, TSH injection is
given and repeat RAIU and
PBI levels are taken
Thyroid level test
Radioactive iodine A tracer dose of radioactive
uptake(RAIU) iodine(131I) is given by mouth.
At 2, 6, and 24 hr following
administration, scintillation in
a detector is place over neck
in region of thyroid and
amount of accumulated
radioactive iodine is
measured; excess iodine in
any foods, cough medicines,
X- ray media, other
medications and enriched
iodine foods affect test by
giving low readings;
diarrhea, causing decrease
absorption tracer dose, gives
low readings, renal failure,
causing decrease excretion,
can cause elevated readings;
no radiation precautions are
with hypothyroidism of
thyroid origin; no response in
most patients with
thyrotoxicosis except when it
is caused by excess TSH.
Directly measures TSH level,
measurement aids in
differentiating primary and
secondary hypothyroidism;
values are elevated in
primary hypothyroidism
because of loss negative
feddback.
Assists in differentiating
between primary and
secondary hypothyroidism; in
primary hypothyroidism
repeat levels of RAIU and PBI
stays the same; if they
become normal, this
indicates hypothyroidism
caused by two little
TSH( secondary).
Normal thyroid will take up
5% to 35% of tracer dose;
increase uptake occurs in
hyperthyroidism; excess
tracer dose is excreted in
urine and can be measured;
urine is collected in 24 hr;
decrease amounts of urine
indicate hyperthyroid state
 necessary.

Thyroid scan Dose of 131I is given, and Size, shape, and anatomic
scintillation scan is done: function of gland assessed;
scanner is move over thyroid areas of increased or
and a picture of distribution decreased uptake noted
of radioactivity is recorded;
no radiation precaution
necessary

Thyroid suppression test RAIU test and serum t4 levels If euthyroid(normal),

are done, patient given
thyroid hormone for 7- 10
days, RAIU and serum t4
repeated
repeated RAIU and serum t4
will be low; failure of
hormone therapy to suppress
RAIU and serum T4 indicates
hyperthyroidism.

Adjunctive Therapy

Compound such as potassium iodide, lugol’s solution and saturated solution of

potassium iodide may be used in combination with antithyroid agents or beta-adrenergic
blockers to prepare the patient with hyper thyroidism for surgery. These agents reduce the
activity of the thyroid hormone and vascularity of the thyroid gland, making the surgical
procedure safer.

Nursing Intervention

➢ Give with milk or fruit juice to make it acceptable to the taste.

➢ Administer through straw to avoid staining of teeth.

Antithyroid medications

Antithyroid agents block the utilization of iodine by interfering with the iodination of
thyrosine and the coupling of iodothyrosines in the synthesis of thyroid hormones. The most
commonly used medications are prophylthiouracil (propacil, PTU) or methimazole (Tapazole)
until the patient is euthyroid. These medications block extrathyroidal conversion of T4 to T3.

Radioactive Iodine Therapy

The goal of radioactive iodine therapy is to destroy the overactive thyroid cells.
Almost all the iodine that enters and is retained in the body becomes concentrated in the
thyroid gland. Therefore, the radioactive isotope of iodine is concentrated in the thyroid
gland, where it destroys thyroid cells without jeopardizing other radiosensitive tissues. Over
a period of several weeks, thyroid cells exposed to the radioactive iodine are destroyed,
resulting on reduction of the hyperthyroid state and inevitability hypothyroidism.

Nursing Intervention

➢ Instruct client what to expect with the tasteless, colorless radioiodine which may be
administered by radiologist.
➢ Closely monitor client after treatment with radioactive iodine until euthyroid state is
reached.

Surgery

Thyroidectomy is an operative procedure done most commonly by a general surgeon, or

occasionally by an otolaryngologist, in the operating room of a hospital. The operation
begins when an anesthesiologist puts the patient to sleep. The anesthesiologist injects drugs
into the patient's veins and then places an airway tube in the windpipe to ventilate (provide
air for) the patient. The surgeon makes an incision in the front of the neck where a tight-
fitting necklace would rest. He locates and takes care not to injure the parathyroid glands
and the recurrent laryngeal nerves, while freeing the thyroid gland from these surrounding
structures. The blood supply to the portion of the thyroid gland that is to be removed is
clamped off. Then all or part of the gland is removed. If cancer is present, all, or almost all,
of the gland is removed. If other diseases or a nodule is present, the surgeon may remove
only part of the gland. The total amount of thyroid gland removed depends upon the thyroid
disease being treated. A drain (a soft plastic tube that drains fluid out of the area) may be
placed before the incision is closed. The incision is closed either with sutures (stitches) or
metal clips. A dressing is placed over the incision and the drain, if one is used.

Total Thyroidectomy is the total surgical removal of the thyroid gland. Both
sections (lobes) of the thyroid gland are usually removed. Additional treatments with
thyroid-stimulating hormone (TSH) suppression and radioactive iodine work best when as
much of the thyroid is removed as possible.

Subtotal Thyroidectomy is the removal of one complete lobe, the isthmus, and
part of the other lobe. This is used for hyperthyroidism caused by Graves' disease.

Biopsy is the process of taking a sample of living tissue for examination. Many
different types of tissue can be biopsied, including skin, bone, organs and other soft tissues.
It may be done to examine the tissues of the thyroid, the parathyroid and, in rare cases,
nearby lymph nodes. This is done to make sure that the portion of the thyroid that is left, if
any, is not diseased. In some cases, the tissue is examined by a pathologist immediately, so
that a second surgery to remove a diseased portion of the thyroid is not necessary.

Nursing Interventions

Preoperative Care

Assess the client for typical manifestations of Grave’s disease. A hyper state may be obvious
from apparent weight loss, and exopthalmos may be obvious as well. Also question the
client for visual difficulties, fatigue, weakness, tremors, and insomnia.

Promote Preoperative Euthyroid State. The client must be carefully prepared for a
thyroidectomy to avoid complications (e.g., thyroid storm and hemorrhage).

Postoperative

Monitor for Postoperative Complications.

Monitor and treat HypoCalcemia.