Hyperthyroidism
Ms. Geetha is a case of hyperthyroidism. She is admitted in the ward for subtotal thyroidectomy for goitre :
a) List down the clinical manifestations of hyperthyroidism.
b) Explain the pre-operative preparations of Mrs.Geetha for the surgery
c) Describe the post operative complications and their management
d) Plan the immediate and late post operative nursing care for Mrs. Geetha applying the nursing process
Synonym : thyrotoxicosis :
Clinical Manifestations : -
Some of the most typical symptoms of Graves' Disease may include the following:-
Presenting symptom : nervousness
Apprehension (anxiety, nervousness, fear)
Tremors in the hands
Emotional hyperexcitability
Irritability
Mental impairment,
memory lapses,
diminished attention span
Decreased concentration
Erratic behavior
Emotional lability
Insomnia (inability to get enough sleep)
Abnormally rapid pulse both at rest and during exertion
Palpitations
Arrhythmia (irregular heart beat)
Atrial fibrillation may occur
Raised blood pressure (Hypertension)
Systolic but not the diastolic blood pressure is elevated
Congestive Cardiac Failure may occur in the elderly
Cannot sit quietly
Exophthalmos - startled appearance
Double vision
Eye pain, irritation, tingling sensation behind the eyes or the feeling of grit or sand in the eyes
Swelling or redness of eyes or eyelids/eyelid retraction
Sensitivity to light
Intolerance to heat
Profuse sweating
Flushed skin
Elderly patients : dry skin, hives Itchy skin,
Brittle nails
Hair loss
Increased appetite and dietary intake
Changes in bowel function usually diarrhoea
Progressive weight loss
Abnormal muscular fatigability (difficulty in climbing stairs and rising from a chair)
Diminished/changed sex drive
Decrease in menstrual periods (oligomenorrhea), Irregular and scant menstrual flow (Amenorrhea)
Difficulty conceiving/infertility/recurrent miscarriage
Abnormal breast enlargement (men)
Osteoporosis, fracture
Goiter
Shortness of breath
Chronic sinus infections
Lumpy, reddish skin of the lower legs (pretibial myxedema)
Sometimes dizziness occurs
Preoperative preparations for subtotal thyroidectomy
Control hyperthyroidism with drugs like carbimazole (takes months to control)
If anaemia is present it corrected by iron supplements
Investigations done to evaluate the fitness of the patient to undergo surgery:
Hb, TC, DC, ESR; Blood Sugar, Blood Urea, Serum Creatinine, tests for HIV, HbSAg
An assessment of the cardiac status by ECG, Echocardiogram
Estimation of T3 T4 TSH
Post operative complications and their management
Bleeding
Injury to the Recurrent Laryngeal Nerve
Hypoparathyroidism
Thyrotoxic Storm
Injury to the Superior Laryngeal Nerve
Infection
Hypothyroidism
Bleeding : - If a neck hematoma is compromising the patient's airway, open the surgical incision at the bedside to release the collection of blood, and immediately transfer the patient to the operating room.
In the case of a hematoma without impending airway obstruction, transfer the patient to the operating room as soon as is practical. Remain with the patient and be prepared to assist with intubation or tracheostomy.
In the operating room, open the surgical incision, explore the wound, irrigate it, control all bleeding sites, and close the wound
Injury to the recurrent laryngeal nerve : -
In bilateral vocal-cord paralysis - obtain an adequate airway - endotracheal intubation
Emergency tracheotomy may be required
wait for six months for any temporary injury to recover
Medialization operation - most commonly performed
Reinnervation
Hypoparathyroidism - IV calcium slowly over 10 mts
(The condition may be due to direct trauma to the parathyroid glands, devascularization of the glands, or removal of the glands during surgery.
intravenous calcium gluconate. Ten milliliters of 10% solution (1 g) may be administered over 10 minutes. A calcium infusion may be started at a rate of 1-2 mg/kg/h if symptoms do not resolve. Titrate the infusion to the patient's symptoms and calcium levels. Start oral calcium when the patient is able to tolerate it. One to two grams of elemental oral calcium should be supplied each day. Calcium carbonate 1250 mg provides 500 mg of elemental calcium; therefore, the patient should take 2500-5000 mg/day. The patient needs concomitant replacement of vitamin D with calcitriol (Rocaltrol) 0.25-1 mcg/d.)
Hypothyroidism - thyroxine - eltroxine
Thyrotoxic storm -
Stop the procedure.
Intravenous beta-blockers
steroids
Cooling blankets and cooled intravenous fluids
Oxygenation
Infection
Appropriate antibiotics
Injury to the Superior Laryngeal Nerve
Speech therapy
Immediate and late post operative nursing care
