Medical Management of Hyperthyroidism

Antithyroid Medications:

• Propylthiouracil (PTU):

  • Typical adult dosage: 100-150 mg, administered three times daily.

  • Potential side effects: Risk of liver damage, skin rash, joint discomfort, and a rare but serious blood disorder called agranulocytosis (marked by a significant decrease in white blood cells).

• Methimazole (Tapazole):

  • Standard adult dosage: 10-30 mg, given once daily or divided into two doses across the day.

  • Possible side effects: Skin reactions like rash and itching, nausea, and the potential for agranulocytosis.

Beta-Blockers:

• These medications are used to manage symptoms associated with hyperthyroidism, such as elevated heart rate, tremors, and anxiety.

• Common examples include propranolol and atenolol.

• Adult dosages are variable depending on individual needs.

• Possible side effects: May include tiredness, lightheadedness, and reduced blood pressure.

Radioactive Iodine (RAI) Therapy:

• Administered orally as a capsule or liquid.

• The purpose is to reduce the activity or destroy overactive thyroid tissue.

• Potential short-term side effects: Possible temporary increase in hyperthyroidism symptoms, neck discomfort, and symptoms resembling radiation sickness (nausea, fatigue).

Management of Thyrotoxicosis

Treatment Goals:

• Reduce Thyroid Gland Activity: Aim to decrease the excessive hormone production by the thyroid.

• Control Heart Rate: Manage rapid heart rate (tachycardia) and elevated blood pressure (hypertension) often associated with thyrotoxicosis.

• Partial Thyroidectomy (Surgical Removal): In some cases, surgical intervention to remove a portion of the thyroid gland may be necessary.

Pre-operative Management:

• Hospital Admission: Typically, patients are admitted to the surgical unit approximately 3-2 days before the scheduled surgery.

• Patient Positioning: Ensure the patient is in a comfortable position, accommodating their preference.

• Comprehensive History Collection: Detailed patient history is taken to gather crucial information, including:

  • Demographic Information: Basic personal details.

  • Prior Health Issues: Past medical conditions.

  • Current Medical Status: Presence of conditions like diabetes or liver disease.

  • Family Health Background: History of conditions such as hypertension within the family.

  • Current Health Complaint: Detailed history to identify the underlying cause of the thyrotoxicosis.

• Clinical Observations:

  • Vital Signs Assessment: Regular monitoring of temperature, pulse, respiration (TPR), and blood pressure (BP) to detect any vital sign abnormalities.

  • General Physical Examination: A thorough head-to-toe examination to identify any general abnormalities (using a systematic approach like JACCOLD – Jaundice, Anemia, Cyanosis, Clubbing, Oedema, Lymphadenopathy, Dehydration).

  • Specific Thyroid Examination: Palpation of the thyroid gland to assess for enlargement or any unusual characteristics.

• Physician Consultation: Inform the physician about the patient’s condition and initial findings.

• Pre-Doctor’s Visit Actions: While waiting for the physician, orient the patient to the ward environment and routine.

• Medical Investigations: Upon arrival, the doctor will order necessary diagnostic tests, which may include:

  • Chest X-ray: To assess the lungs and mediastinum.

  • Thyroid Function Tests (TFTs): Blood tests to measure thyroid hormone levels.

  • Thyroid Biopsy: Tissue sample taken for cytological and histological examination to rule out malignancy and assess thyroid tissue.

  • Indirect Laryngoscopy: Examination of the larynx using a mirror to assess vocal cord function, especially important before thyroid surgery to evaluate recurrent laryngeal nerve function.

Preoperative Medications:

Based on lab results, particularly thyroid function tests, the physician will prescribe preoperative medications, which may include:

• Carbimazole: 10-15 mg once daily for 12 weeks, then reduced to 5 mg every 8 hours. The last dose is given shortly before surgery. Carbimazole helps to reduce thyroid hormone levels before surgery.

• Lugol’s Iodine: 0.3-0.9ml three times a day in milk, given for 10 days leading up to surgery, including the day of surgery. Lugol’s iodine helps to reduce the vascularity of the thyroid gland, minimizing bleeding during surgery.

• Propranolol: 40-80 mg every 12 hours if blood pressure is elevated. Propranolol is a beta-blocker used to control heart rate and blood pressure.

• Diazepam: 5mg twice daily to help calm and sedate the patient before surgery, reducing anxiety.

• Digoxin: 0.25mg once daily if atrial fibrillation (irregular heart rhythm) is detected. Digoxin is used to control heart rate in atrial fibrillation.

Pre-Surgical Nursing Care:

• Procedure Explanation and Consent: Explain the surgical procedure, its benefits, and expected outcomes to the patient. Obtain informed consent by ensuring the consent form is signed after the patient understands the information.

• Reassurance: Provide emotional support and reassurance to alleviate patient anxiety.

• Consent Form Handling: Ensure the informed consent form is properly signed and documented.

• Patient Preparation: Prepare the patient for surgery:

  • Clean the patient as needed.

  • Dress the patient in a surgical gown.

• Blood Sample Collection: Obtain a blood sample for hemoglobin estimation and blood group determination in case transfusion is needed.

• Surgical Site Preparation: Inspect and clean the surgical site (neck area) if specifically instructed by the surgeon.

• Theater Notification: Inform the operating theater staff about the patient’s readiness for surgery.

• Patient Transfer to Theater: Transfer the patient to the operating theater for the procedure.

• Surgical Procedure: In the operating theater, a partial thyroidectomy (removal of part of the thyroid gland) is performed.

• Recovery Room Transfer: After surgery, the patient is transferred to the recovery room for immediate post-operative monitoring.

• Ward Staff Notification: Ward nurses are notified to prepare for the patient’s return to the ward from the recovery room.

MANAGEMENT: POST-THYROIDECTOMY (In Case of Surgery)

Post-Operative Patient Reception:

• Nurse Team Mobilization: Upon notification from the operating theater nurse, two nurses should go to the recovery room to receive the patient.

• Initial Vital Signs Assessment: Immediately upon receiving the patient, assess vital signs, particularly respiratory rate and pulse, to confirm patient stability.

• Ward Transfer and Bed Preparation: Transfer the patient back to the ward and place them in a prepared post-operative bed. Obtain and follow any specific post-operative instructions from the theater staff.

• Positioning: Position the patient in the recovery position (usually lateral or semi-prone) to maintain airway and prevent aspiration.

• Frequent Observations: Monitor vital signs frequently: every 15 minutes for the first hour, then every 30 minutes for the next hour, followed by hourly checks until the patient is fully recovered and stable.

Post-Operative Medications:

• The physician will prescribe post-operative medications as needed. Common examples include:

  • Analgesics for Pain Relief:

    • Pethidine: 50mg-100mg via intramuscular injection (IM) up to 3 doses for initial pain management, followed by…

    • Tramadol: 100mg intravenously (IV) three times a day for 7 days for ongoing pain relief.

  • Sedatives:

    • Diazepam: 10-15mg as needed for sedation and anxiety relief.

Specific Post-Thyroidectomy Nursing Care:

• Drainage Tube Management:

  • Tube Removal: Drainage tubes are typically removed within 48 hours post-operation, based on the volume and nature of drainage, and as per doctor’s orders.

• Wound Care:

  • Dressing Changes: Change wound dressings whenever they become soiled to maintain wound cleanliness and prevent infection.

• Suture Removal:

  • Timing: Sutures are usually removed on the 3rd or 4th post-operative day, only upon the doctor’s instruction and assessment of wound healing.

  • Drainage Management: Ensure continuous drainage into a drainage bottle or maintain a sterile dressing if drainage is minimal.

• Respiratory Monitoring and Intervention:

  • Intubation Readiness: Be prepared for potential intubation if respiratory distress due to laryngeal edema (swelling) occurs.

• Hemorrhage Monitoring:

  • Close Observation: Vigilantly monitor for signs of hemorrhage at the surgical site and systemically (vital signs, patient condition).

• Environmental Comfort and Rest:

  • Calm Environment: Create a quiet and peaceful environment to promote rest.

  • Sleep Aids: Administer prescribed sedatives or sleep-promoting medications if needed to encourage sleep.

• Drain and Suture Care:

  • Drain Management: Change drainage collection systems every 24 hours or as per protocol.

  • Suture Care: As mentioned, sutures are removed around the 3rd or 4th day upon doctor’s order.

• Neck Movement Restriction:

  • Minimize Movement: Encourage the patient to minimize neck movements to reduce pain and strain on the surgical site.

• Pain Management:

  • Analgesic Administration: Regularly administer prescribed analgesics to effectively manage post-operative pain.

• Vital Signs Monitoring for Complications:

  • Frequency: Monitor vital signs every 2 hours to promptly detect potential complications such as thyroid storm or surgical site infections.

• Antibiotic Administration:

  • Ceftriaxone: Administer prescribed antibiotics like ceftriaxone 2g every 24 hours to prevent or treat infections.

• Dietary Management:

  • High-Calorie Diet: Order a high-calorie diet to meet increased metabolic needs, satisfy hunger, and prevent tissue breakdown.

  • Nutrient-Rich Foods: Encourage milk intake initially, followed by a diet rich in carbohydrates, and snacks high in protein, minerals, and vitamins, particularly vitamins A, B6, and C, to support healing.

• Daily Nursing Care:

  • Hygiene: Provide daily oral care and skin care to maintain patient hygiene and comfort.

  • Elimination: Monitor and manage bowel and bladder function.

• Physiotherapy:

  • Throat and Respiratory Exercises: Encourage gentle throat exercises and deep breathing and coughing exercises to prevent respiratory complications and stiffness.

• Psychological Support (Psychotherapy):

  • Offer emotional and psychological support to address anxiety and promote mental well-being during recovery.

• Fluid Balance Monitoring:

  • Intake and Output Tracking: Strictly monitor, maintain, and record fluid intake and output on patient fluid balance charts to ensure adequate hydration and detect any fluid imbalances.