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Marian T. Gadugdug

What is Graves Disease?

A multisystem autoimmune disorder
characterized by pronounced
hyperthyroidism usually associated
with an enlarged thyroid gland and
exophthalmos (abnormal protrusion
of the eyeball).
Usually associated with thyroid
stimulating antibodies that bind to
TSH receptors, and stimulate
thyroid secretion.

Pathophysiology of
Graves Disease
Hyperthyroidism is a clinical
syndrome in which there is a
sustained increase in synthesis
and release of thyroid hormones
by the thyroid gland
Graves disease indicates that
normal regulatory mechanisms
are overridden by abnormal
immunologic mechanism
Negative Feed Back

The most common form of

An autoimmune disease that increases T4
production, enlarges the thyroid gland and
causes multisystem changes.
In Graves disease, a thyroid-stimulating
hormone receptor autoantibody stimulates
the thyroid gland to produce high
concentrations of T3 and T4.

Clinical Manifestations
Heat intolerance
Increased bowel movements
Light or absent menstrual
Fast heart rate
Trembling hands

Muscle weakness
Warm, moist skin
Hair loss
Starring gaze
Clinical Manifestations of Graves
Fine tremor of the hands
Weight loss

Atrial arrythmias
Enlarged thyroid gland
Increased heat tolerance
Increased metabolic rate

Thyroid gland is enlarged; it is soft
and may pulsate; a thrill may be felt
and a bruit heard over thyroid
Obtain a health history, including
family history of hyperthyroidism,
and note reports of irritability or
increased emotional reaction and the
impact of these changes on patients
interaction with family, friends, and

Assess stressors and patients ability to

cope with stress.
Evaluate nutritional status and presence
of symptoms; note excessive
nervousness and changes in vision and
appearance of eyes.
Assess and monitor cardiac status
periodically (heart rate, blood pressure,
heart sounds, and peripheral pulses).
Assess emotional state and psychological

Diagnostic Tests
1) Thyroid Uptake Scan:
Evaluates size, position, and function
of thyroid gland
Performed with radioactive iodine
(usually in conjunction with RAI)
Iodide I 123 is the most commonly
used because of short half-life and
low radiation exposure
Scans are taken 20 minutes 2-4hours
after oral dose of radioactive iodine

Used to differentiate between Graves

disease and other thyroid conditions and
evaluate thyroid function
Client is placed in supine position on scan
table and scanning is performed over the
Additional scan can be taken for oral
doses can be performed in 24 hours
Hyperthyroidism & Graves Disease:
Indicated by area of diffuse increased

2) Radioactive iodine uptake (RAIU)

Measures ability of gland to concentrate and
retain iron
When radioactive iodine administered is
rapidly absorbed into bloodstream
Measures rate of accumulation, incorporation,
and release of iodine by the thyroid
Rate of absorption of radioactive
iodine(determined by increase in radioactivity
of thyroid gland) measures ability of thyroid to
concentrate iodine from blood plasma

Uptake measured in % by dividing

amount of uptake over dosage
Useful in diagnosis of
hyperthyroidism and
Uptake by thyroid gland should be:
1-13% after 2h
5-2-% after 6 h
15-40% after 24h

3) Blood tests:
Radioactive iodine uptake
of the gland may be

Lab Values
Lab Value


(Free Thyroxine)



260-480 pg/dL

(Thyroid Stimulating

0.4-4.2 nU/mL

1) Beta-Blockers
Mechanism of action- Inhibit adrenergic effects
Indications- Prompt control of symptoms;
treatment of choice for thyroiditis; first-line
therapy before surgery, radioactive iodine, and
antithyroid drugs; short-term therapy in
Contraindications and complications- Use with
caution in older patients and in patients with
pre-existing heart disease, chronic obstructive
pulmonary disease, or asthma

2) Iodides
Mechanism of action: Black the conversion of T4
to T3 and inhibit hormone release
Indications: Rapid decrease in thyroid hormone
levels; preoperatively when other medications are
ineffective or contraindicated; during preg-nancy
when antithyroid drugs are not tolerated; with
antithyroid drugs to treat amiodarone(Cordarone-) induced hyperthyroidism
Contraindications/Complications: Paradoxical
increases in hormone release with prolonged use;
common side effects of sialadenitis, conjunctivitis,
or acneform rash; interferes with the response to
radioactive iodine; prolongs the time to achieve
euthyroidism with antithyroid drugs

3) Antithyroid Drugs
Mechanism of Action: Interferes with the
organification of iodine; PTU can block
peripheral conversion of T4 to T3 in large doses
Indications: Long-term treatment of Graves'
disease (preferred first-line treatment in
Europe, Japan, and Australia); PTU is treatment
of choice in patients who are pregnant and
those with severe Graves' disease; preferred
treatment by many endocrinologists for children
and for adults who refuse radioactive iodine;
pretreatment of older and cardiac patients
before radioactive iodine or surgery; both
medications considered safe for use while

Contraindications/Complications: High
relapse rate; relapse more likely in smokers,
patients with large goiters, and patients with
positive thyroid-stimulating antibody levels at
end of therapy; major side effects include
polyarthritis (1 to 2 percent), agranulocytosis
(0.1 to 0.5 percent); PTU can cause elevated
liver enzymes (30 percent), and
immunoallergic hepatitis (0.1 to 0.2 percent);
methimazole can cause rare cholestasis and
rare congenital abnormalities; minor side
effects (less than 5 percent) include rash,
fever, gastrointestinal effects, and arthralgia

4) Radioactive Iodine Treatment

Mechanism of Action: Concentrates
in the thyroid gland and destroys
thyroid tissue
Indications: High cure rates with
single-dose treatment (80 percent);
treatment of choice for Graves'
disease in the United States,
multinodular goiter, toxic nodules in
patients older than 40 years, and
relapses from antithyroid drugs

Contraindications/Complications: Delayed
control of symptoms; posttreatment
hypothyroidism in majority of patients with
Graves' disease regardless of dosage (82
percent after 25 years); contraindicated in
patients who are pregnant or breastfeeding; can
cause transient neck soreness, flushing, and
decreased taste; radiation thyroiditis in 1
percent of patients; may exacerbate Graves'
ophthalmopathy; may require pretreatment with
antithyroid drugs in older or cardiac patients

5) Surgical Removal of the Gland

Mechanism of Action: Reduces Thyroid Mass
Indications: Treatment of choice for patients
who are pregnant and children who have
had major adverse reactions to antithyroid
drugs, toxic nodules in patients younger
than 40 years, and large goiters with
compressive symptoms; can be used for
patients who are noncompliant, refuse
radioactive iodine, or fail antithyroid drugs,
and in patients with severe disease who
could not tolerate recurrence; may be done
for cosmetic reasons

Contraindication/Complications: Risk
of hypothyroidism (25 percent) or
hyperthyroid relapse (8 percent);
temporary or permanent
hypoparathyroidism or laryngeal
paralysis (less than 1 percent);
higher morbidity and cost than
radioactive iodine; requires patient
to be euthyroid preoperatively with
antithyroid drugs or iodides to avoid
thyrotoxic crisis

Nursing Responsibilities
Educate patient regarding importance of a wellbalanced, high-calorie diet, and discourage food
that increase peristalsis and thus results in
Provide several small, well-balanced meals (up to
six meals a day) to satisfy patients increased
Provide quiet atmosphere during mealtime to aid
Monitor patients weight
Advise patient to notify the health care provider
when a weight loss of more than 2 kg occurs

Teach the patient to stay in a cool

environment, primarily because heat
intolerance is common.
Reassure the patient that the emotional
reactions being experienced are a result of
the disorder and that with effective
treatment those symptoms will be
Provide eye protection if patient experiences
eye changes secondary to hyperthyroidism;
instruct regarding correct instillation of
eyedrops or ointment to soothe the eyes.

Give cool baths and provide cool fluids; monitor body temperature.
Monitor closely for signs and symptoms indicative of thyroid
Administer medications as ordered (PTU, hydrocoritcosteroids,
Stress long-term follow-up care.
Remind the patient and family about the importance of health
promotion activities and recommended health screening.

Nursing Diagnoses: Hyperthyroidism


Nursing Diagnoses
o Imbalanced Nutrition, less than body requirements
r/t exaggerated metabolic rate, excessive
appetite, and increased gastrointestinal activity
o Ineffective coping r/t irritability, hyperexcitability,
apprehension, and emotional instability
o Low self-esteem r/t changes in appearance,
excessive appetite, and weight loss
o Altered body temperature
o Activity intolerance
o Sleep pattern disturbance

Post-op Care if Surgical Removal

of the gland is done:

Monitor VS including pain control

Monitor and assess drains
Provide a fluid diet
Monitor blood calcium levels, to ensure
parathyroid glands are intact and functioning
Administer IV antibiotics as ordered
Assess for hemorrhage
Monitor for signs of low blood calcium
- Numbness of fingers or lips, muscle cramps,
facial twitching
Position in Semi-Fowlers

Monitor for damage to vocal cords

Discharge Orders
- Acetaminophen 325 mg prn
- Erythromycin
Thyroid Hormone Replacement
- Synthroid 0.125 mg QD
No driving until 1 week after surgery
Follow-up appointment 7-10 days after

Health Teaching
1) Medicine
Antithyroid Drugs
2) Exercise
Exercises that strengthen your heart and improve
circulation and muscle tone are needed to keep your
cardiovascular system functioning well and keep you
physically fit. Walking continues to be the most overall
beneficial physical activity, and it is available to everyone.

3) Treatment
Radioactive Iodine
4) Home care
Teach patient how the medication regimen fits
in with the boarder therapeutic plan.
Instruct patient and family about the
importance of continuing therapy indefinitely
after discharge and about the consequences of
failing to take medication.

5) Out-patient follow-up check-up

Follow-up appointment is depending on the
physicians order.

6) Diet
Focus on fresh fruits and vegetables. These will
give you the most vitamins and minerals for
your efforts and offer the balance you need.
Fish and chicken will be better for you rather
than excessive amounts of pork and beef. Limit
rich sauces and cheeses.

7) Spiritual care
Provide therapeutic
Pastoral care
Include patient to our personal