NUR 326: hormonal regulation - hyperthyroid & thyroid storm 💯

what are risk factors for hormonal imbalances

- hormonal supplement therapy
- advanced age
- obesity
- sedentary lifestyle
- genetics
- chromosomal deficiencies/abnormalities
- family history, esp autoimmune repsonses/conditions
- stress, trauma
- chronic medical conditions
- cancer treatment

what are assessment examination for hormonal imbalances

- because of their location, most glands except thyroid and testes are inaccessible to direct examination
- vital signs, height, weight
- inspection: many clues about hormonal balance or imbalance may be noted with general inspection → skin color/texture, hair texture, body posture, facial characteristics, affect
- palpation: thyroid gland, testes, ovaries
- auscultation: enlarged thyroid, auscultated for bruits

what are clinical management regarding screening for hormonal imbalances

- primary laboratory tests: thyroid, diabetic lab work
- screening recommendations for: infants = routine newborn uniform congenital and thyroid screening for 31 core conditions; adults = pertinent to screen for thyroid and diabetes in at-risk adults

what is the continuum of thyroid dysfunction

(hyper) thyrotoxicosis ← hyperthyroidism ← euthyroid → hypothyroidism → myxedema coma (hypo)

what is one of the most common endocrine issues (alongside diabetes)

- disorders of the thyroid is one of the most common endocrine issues
- issues with the thyroid include: goiter, nodules (both benign and malignant), hyper and hypothryoidism, thyrotoxicosis

what is hyperthyroidism

- a form of thyrotoxicosis where excess amounts of thyroid hormones (T3 and T4) are secreted from the thyroid gland
- causes an increase in body metabolism
- causes a person to be very energetic

what are risk factors for hyperthyroidism

- demographics: adult females age 30-50 (highest risk group → women more affected than men)
- autoimmune/genetic: graves disease (most common cause 60-80%), genetic markers (HLA B8, HLA DR3), family history, increased incidence in 2nd and 3rd decades of life
- environmental triggers: infections (include COVID 19), vitamin D deficiency, stress and changes in microbiome, smoking
- thyroid conditions: toxic multinodular goiter, toxic adenoma, thyroid inflammation

what is graves disease

- autoimmune disease: diffuse thyroid enlargement, excessive thyroid hormone secretion
- accounts for 80% of hyperthyroid cases
- precipitating factors interact with genetic factors
- women 5x more likely than men
- people with Graves disease often have other autoimmune disorders (RA, Addison’s, systemic lupus erythmatosus)
(*TSH is low)

what are nursing assessments for hyperthyroidism

- health history
- subjective
- objective
(everything is elevated)

what should you know regarding hyperthyroidism clinical manifestations

these manifestations are related to increased metabolism and increased thyroid hormones

with clinical manifestations of hyperthyroidism, describe metabolic changes

- weight loss despite good appetite (earliest symptom), heat intolerance and excessive perspiration, increase thirst, urination, and diarrhea

with clinical manifestations of hyperthyroidism, describe cardiovascular

- tachycardia (+160 bpm and +80 at rest), palpitations, widened pulse pressure (increased systolic but low diastolic bp), A-fib, +HR risk

with clinical manifestations of hyperthyroidism, describe neurological/psychological

- nervousness and irritability (earliest sx), insomnia, restlessness, fine hand tremors, difficulty concentrating, emotional lability (crying, depression ←→ euphoria), hyperactive DTR

with clinical manifestations of hyperthyroidism, describe musculoskeletal

- muscle weakness and fatigue, tremulousness

with clinical manifestations of hyperthyroidism, describe integumentary

- warm, moist, velvety skin; fine, soft, silky hair; scalp hair thinning

with clinical manifestations of hyperthyroidism, describe reproductive

- scanty menstruation or amenorrhea, decreased libido (sexual drive), infertility

with clinical manifestations of hyperthyroidism, describe thyroid specific findings

- goiter - thyroid enlargement, visible
- bruits on auscultation (d/t increased blood supply)

with clinical manifestations of hyperthyroidism, describe graves disease specific: ophthalmopathy

- exophthalmos (20-50% with graves): bilateral or unilateral eye protrusion
- diplopia, photophobia, excessive tearing, bloodshot appearance

with clinical manifestations of hyperthyroidism, describe special populations: older adults

- apathetic thyrotoxicosis: slowed movements, depressed affect (not hyperactivity), A-fib

what are cardinal signs clinical manifestations of a thyroid storm, relating to hyperthermia

- profound fever: 105-106 F (40.7-41.1 C) or higher, disproportionate to other findings

what are cardinal signs clinical manifestations of a thyroid storm, relating to cardiovascular

- severe tachycardia, heart rate up to 200 bpm
- atrial dysrhythmias (a-fib most common), frequent premature atrial contractions or atrial flutter
- widened pulse pressure, high-output heart failure → cardiovascular collpase
- palpitations
- prominent S3 heart sound, systolic murmurs over pulmonic/aortic areas, occasionally pericardial rub
- hypotension and shock (late), worsening angina (in patients with underlying heart disease

what are cardinal signs clinical manifestations of a thyroid storm, relating to neurological

- marked apprehension and restlessness, agitation, anxiety, tremors
- confusion → delirium seizures → progression to coma

what are cardinal signs clinical manifestations of a thyroid storm, relating to gastrointestinal

- abdominal pain, nausea, vomiting, diarrhea (contributes to fluid volume depletion)

what are cardinal signs clinical manifestations of a thyroid storm, relating to metabolic

- dramatically increased metabolic rate
- profound dehydration (from increased metabolic demands), increased oxygenation and nutrient demands

what should you know regarding clinical manifestations of a thyroid storm

rare, life-threatening emergency, death within 48 hours without treatment

what are diagnostic studies for hyperthyroidism

- decreased or undetectable TSH
- increased total T3 and T4
- radioactive iodine uptake (RAIU)

what are collaborative care goals for hyperthyroidism

1. block adverse effects of thyroid hormones
2. suppress hormone oversecretion
3. prevent complications

what is the first line of therapy for hyperthyroidism collaborative care

- antithyroid medications: works best for mild hyperthryoidism
- methimazole (Tapazole) preferred
- propylthiouracil (PTU) - 2nd line d/t hepatotoxicity
→ blocks thyroid hormone synthesis
→ improvement begins in 1-2 weeks, optimal results in 4-8 weeks
→ therapy continues 6 months to 2 years
→ only 20-30% achieve permanent remission

what is the second primary treatment option for hyperthyroidism

- radioactive iodine therapy (RAI)
→ preferred treatment for most nonpregnant adults (contraindicated in prengnacy/breastfeeding)
→ destroys thyroid tissue, limiting hormone secretion
→ effects delayed 2-3 months
→ high risk of post-treatment hypothyroidism requiring lifelong replacement

what is the third primary treatment option for hyperthyroidism

- surgery: thyroidectomy
→ indicated for large goiter with tracheal compression, cancer, or failed medical therapy
→ subtotal thyroidectomy removes 90% of gland
- provides rapid T3/T4 reduction

what are adjunct treatment options for hyperthyroidism collaborative care

1. beta blockers: goal is symptom management, controls tachycardia, tremor, restlessness
2. iodine preparations: decreases hormone secretion, reduces gland vascularity pre-surgery (10-14 days)
(these prevent complications)

what are nursing interventions for hyperthyroidism

- promote rest: physical/emotional stress stimulates thyroid activity
- high-calorie diet: meet increased metabolic demands, ongoing monitoring required
- patient education: medication adherence, scheduled dosing, ongoing monitoring required
- family support: help cope with emotional outbursts and mood changes (resolves when euthryoid)
- monitor for complications: thyroid crisis, hypothryopidism

what is collaborative care for a thyroid storm

- necessitates agressive treatment
- give medications that block thyroid hormone production
- monitor for dysrhythmias
- ensure adequate oxygenation
- fluid and electrolyte replacement

what is nutritional therapy for hyperthyroidism

- high calorie diet (4000-5000 cal/day): 6 full meals/day with snacks in between, protein intake 1-2 g/kg ideal body weight, increased carbohydrate intake
- avoid highly seasoned and high-fiber foods, alcohol, caffeine
- dietitian referral

treatment comparison for high thyroid disorder