Page 35 Complete Your CE Test Online - Click Here The following tests are used to confirm a diagnosis of hyperthyroidism [5,6,11] : ● ● Radioimmunoassay shows elevated serum T4 and T3. ● ● TSH levels are decreased. ● ● Thyroid scan shows an increased uptake of radioactive iodine. Diagnostic alert! Thyroid scan is contraindicated if the patient is pregnant [5] . ● ● Ultrasound confirms the presence of subclinical ophthalmopathy. ● ● In Graves’ disease the thyroid stimulating immunoglobulin is positive. Treatment and nursing considerations Treatment initiatives depend on any underlying causes, the size of the goiter, patient age, severity of the disease, and any complications that are present[6] . Anti-thyroid medications Anti-thyroid medications are used for children, young adults, pregnant women, and for those patients who are unable to tolerate or who refuse other types of treatment[5,6,11,16] . Examples of such medications include propylthiouracil (PTU) and methimazoke (Tapazole). They act by depressing the synthesis of thyroid hormone by inhibiting thyroid peroxidase. PTU is given in daily divided doses. Tapazole is given in a single daily dose[6] . Anti-thyroid medications may also be used before or after radioiodine therapy as a supplemental treatment[16] . Side effects of both PTU and Tapazole include rash, joint pain, liver failure, or a decreased white blood cell (WBC) count. Use of Tapazole is associated with a slight risk of birth defects, thus PTU is the preferred drug for use in pregnant women[16] . Treatment continues until the patient becomes clinically euthyroid (having normal thyroid function). This can take from 3 months to 2 years. If normal thyroid function cannot be maintained without therapy, radiation or surgical intervention is recommended[6] . Medications are discontinued gradually to prevent exacerbation[6] . Beta blockers Beta blockers do not prevent or inhibit thyroid hormone production. However, they do limit the effects of excessive amounts of thyroid hormone on the body. Beta blockers can provide fairly quick relief of some signs and symptoms such as arrhythmias, tremors, anxiety, irritability, diaphoresis, diarrhea, muscle weakness, and heat intolerance [6,16] . Radioactive iodine therapy Radioactive iodine (radioiodine) acts by limiting secretion of thyroid hormone by destroying thyroid tissue. Given by mouth, dosage of the drug is controlled so that hypothyroidism does not occur. As the thyroid gland shrinks, signs and symptoms decrease gradually over a period of several weeks to several months. Radioactive therapy may increase Graves’ ophthalmopathy. This is usually temporary and mild. However, if the patient is already affected with moderate to severe eye problems, this type of therapy may be contraindicated[6,16] . Radioactive iodine therapy alert! The primary advantage of radioactive iodine therapy is that it can result in a lasting remission of hyperthyroidism. However, use of radioactive iodine therapy can cause the patient to become permanently hypothyroid[6] . While patients are receiving iodine therapy they must be observed for signs and symptoms of iodine toxicity such as swelling of the buccal mucosa, excessive salivation, skin eruptions, and/or coryza (inflammation of the nasal mucous membranes). If side effects occur the use of iodides is discontinued[6] . Surgery If other therapeutic interventions are not effective surgery (subtotal thyroidectomy) may be necessary. Surgery is also used for patients who have large goiters. Most of the thyroid gland is removed, necessitating life-long thyroid hormone replacement. Risks associated with subtotal thyroidectomy include damage to vocal cords and the parathyroid glands[16] . Treatment of Graves’ ophthalmopathy Mild cases of Graves’ ophthalmopathy are managed by using OTC artificial tears during the day and lubricating gels at night[16] . For severe cases the following interventions may be prescribed[16] . ● ● Administration of corticosteroids: Corticosteroids such as prednisone are given to reduce swelling behind the eyes. ● ● Eye muscle surgery: Inflammation may shorten the muscles of the eyes, making them too short for the eyes to properly align. During surgery, the surgeon cuts the eye muscles and reattaches them further back in the eye to facilitate alignment. More than one surgical procedure may be needed. ● ● Orbital decompression surgery: The surgeon removes the bone between the eye socket and the sinuses. This allows the eyes to move back to their normal position. This procedure is indicated if vision loss is possible due to pressure on the optic nerve. ● ● Orbital radiotherapy: Targeted x-rays, administered over a period of several days, are used to destroy some of the tissue behind the patients’ eyes. This procedure was once quite common. Recent studies, however, suggest that this procedure provides no benefit for patients with mild to moderately severe Graves’ ophthalmopathy. ● ● Prisms: Prisms in eyeglasses are used to correct double vision because of Graves’ disease. Prisms work for some, but not all, patients affected with double vision. Emergency treatment of thyroid storm Thyroid storm is a medical emergency requiring prompt treatment. Treatment initiatives include[5,6] : ● ● Prevention of new thyroid hormone synthesis with thioamides such as PTU. ● ● Prevention of thyroid hormone release using iodine (Lugol’s solution). ● ● Inhibition or control of the side effects of thyroid hormones with corticosteroids and beta blockers such as Inderal. ● ● Initiatives targeted at the systemic effects of thyroid hormones include the use of a cooling blanket and acetaminophen (Tylenol) for excessive body heat, administration of intravenous fluids and electrolytes to correct dehydration and electrolyte imbalance, and treatment of the trigger event (e.g., heart attack and other physical and emotional stressors). Nursing actions focus on actions that help patients and families deal with the effects of the disease, compliance with treatment, and knowledge acquisition to help them lead normal lives.