Page 34 nursing.elitecme.com Complete Your CE Test Online - Click Here Complications There are a number of complications associated with hyperthyroidism. These include[5] : ● ● Corneal ulcers. ● ● Decreased libido. ● ● Fertility problems. ● ● Gynecomastia. ● ● Hyperpigmentation. ● ● Muscle atrophy. ● ● Muscle weakness. ● ● Myasthenia gravis. ● ● Osteoporosis. ● ● Paralysis. Cardiovascular complications such as arrhythmias, cardiac insufficiency, and cardiac decompression may occur. Cardiovascular complications are most common in elderly patients[5] . Nursing consideration: Thyroid storm is the most serious complication of hyperthyroidism. Also referred to as thyrotoxic crisis, thyroid storm usually occurs in patients with preexisting, though often undiagnosed, thyrotoxicosis. Untreated, it is usually fatal[5,11] . When excessive amounts of T3 and T4 are produced systemic adrenergic activity increases, which leads to overproduction of epinephrine. Excessive amounts of epinephrine cause significant hypermetabolism that, in turn, leads to rapid cardiac, GI, and sympathetic nervous system decompensation. Hypertension, tachycardia, vomiting, extreme irritability, and temperature up to 106 °F can occur. Thyroid storm can progress to delirium, coma, and death. The onset of thyroid storm is abrupt and triggered by stressors such as trauma, surgery, infection, or serious events such as stroke, myocardial infarction, preeclampsia, or pulmonary embolism[11] . Clinical presentation The characteristic signs and symptoms of hyperthyroidism are [5,6,11] : ● ● Enlarged thyroid gland (also referred to as goiter). ● ● Exophthalmos (abnormally protruding eyes and a characteristic staring gaze). ● ● Heat intolerance. ● ● Nervousness. ● ● Inability to sit still. ● ● Weight loss even though appetite is increased. ● ● Diaphoresis. ● ● Diarrhea. ● ● Tremors. ● ● Palpitations. Hyperthyroidism alert! Although exophthalmos is considered by many HCPs to be the most characteristic sign of hyperthyroidism, it is actually absent in many patients with the disease[5] . Hyperthyroidism alert! Most of the signs and symptoms of hyperthyroidism are due to an increased metabolic rate, excessive heat production, increased cardiovascular and neuromuscular activity, and sympathetic nervous system hyperactivity[6] . Hyperthyroidism affects every system of the body. Therefore, a multitude of signs and symptoms may be apparent. The following is a review of additional signs and symptoms according to body systems. ● ● Cardiovascular system: Cardiovascular system effects are seen most often in elderly patients. Cardiac effects include arrhythmias (usually atrial fibrillation), tachycardia with a full, bounding pulse, cardiac insufficiency, visible point of maximal impulse, cardiac decompensation, and resistance to the prescribed therapeutic dose of digoxin in patients who are taking the drug[5,6,11] . ● ● CNS: CNS signs and symptoms are most commonly seen in younger patients. For example, patients may complain of having difficulty concentrating. This is because an increased production of T4 accelerates cerebral functioning. An increase in basal metabolic rate can lead to anxiety, nervousness, mood swings, and emotional instability. Some patients may even develop overt psychosis. Increased activity in the area of the spinal cord that controls muscle tone can lead to tremors, shaky handwriting, and clumsiness[5,11] . ● ● GI system: Anorexia may develop. Patients may complain of nausea and vomiting because of increased GI motility and peristalsis. Patients may notice an increase in the number of stools, soft stools, and/or diarrhea. The liver may become enlarged. ● ● Integumentary system: Skin is warm, smooth, moist, thick, flushed, and has a velvet-like texture. There is evidence of hyperpigmentation and loss of skin color in blotches (vitiligo). Plaque-like or nodular skin lesions may be noted. The hair is fine and soft and begins to gray prematurely. Hair loss is evident in both men and women. Nails are fragile and there is separation of the distal portion of the nail from the nail bed[11] . ● ● Musculoskeletal system: There is muscle weakness accompanied by muscle atrophy. Osteoporosis and acropachy are also possibilities[11] . ● ● Reproductive system: Women may experience menstrual abnormalities such as oligomenorrhea (abnormally light or infrequent menstrual periods) and amenorrhea (absence of menstruation), impaired fertility, decreased libido, and a higher incidence of spontaneous abortions. Men may develop gynecomastia (abnormal development of mammary glands) due to an increase in estrogen levels. They may also experience a decrease in libido[5,11] . ● ● Senses: Patients blink infrequently as a result of exophthalmos. This leads to dry eyes, reddened conjunctiva and cornea, and corneal ulcers. Patients have difficulty looking upward and strabismus (the eyes do not “line up” at the same time and therefore cannot look at the same object at the same time)[5,11] . Diagnosis Diagnosis is made based on the presenting clinical picture, a thorough history and physical examination, and evaluation of blood hormone levels[5,6] . Diagnostic alert! Although many of the signs and symptoms of hyperthyroidism are deemed to be “characteristic” of the disease, it is important for nurses and other HCPs to be alert to their development. Early recognition and prompt treatment are important. In hyperthyroidism palpation of the thyroid gland may reveal that the gland is asymmetrical and lobular. It may actually be enlarged to as much as 3 to 4 times its normal size. Enlargement of the liver may also be noted[5,11] . A full, bounding pulse may be palpated along with a heart rate indicative of tachycardia[11] . Evaluation of reflexes may show hyperreflexia[11] . When auscultating the heart, the examiner may detect a rapidly accelerating heart beat that may be confirmed on ECG as paroxysmal supraventricular tachycardia or atrial fibrillation. Other findings may include[11] : ● ● Systolic murmur. ● ● Wide pulse pressure. ● ● Audible bruit over the thyroid gland (may indicate toxicity). EBP alert! Research shows that that cardiovascular signs and complications are especially likely in elderly patients. Monitor elderly patients for such signs and complications very carefully[5,11] .