Graves' Disease: Recognition and Treatment Across the Lifespan

marina.todeasaRN, ASN, EMT-P

Graves' disease is an autoimmune disorder and is the most common cause of hyperthyroidism. Immunoglobulins stimulate the thyroid tissue and cause it to secrete too much of the thyroid hormones, which help to regulate metabolism in the body¹. This disease affects women more often than men, and onset is most commonly between ages 30-50. Graves' disease presents with all of the classic symptoms of hyperthyroidism, such as irritability, agitation, palpitations, heat intolerance, diaphoresis, tremors, increased appetite, weight loss, and weakness; but is unique in that it may also cause eye and vision problems².

Graves' disease often affects the pediatric population after being sick with a virus or experiencing extreme stress. It may be insidious in children and so sometimes is not diagnosed until the disease is more advanced.

Geriatric patients often have an atypical presentation of signs and symptoms with hyperthyroidism, similar to the population's atypical complaints or symptoms with CAD or infection. These may include atrial fibrillation, weakness, confusion, and depression¹.

Assessment & Diagnostic Testing

Assessment should include questions about the onset, severity, and duration of symptoms, as well as how they are affecting the patient's daily life, activities, relationships, and responsibilities. Assessment should also include any other medical conditions; medications, vitamins, and supplements they take on a daily basis; and any recent illnesses or stressors in their lives.

Blood tests will be done, and the expected results will be that T3 and T4 are elevated, but TSH levels are low¹. If more testing is needed to determine if the hyperthyroidism is due to Graves' disease or another condition, a blood test for antibodies to the TSH receptor will be done, as well as an iodine uptake study².

Care Measures/Treatment/Medication

Nursing care will focus on keeping the patient cool and calm as much as possible, as well as ensuring they have proper hydration and nutrition since hyperthyroidism causes the metabolic rate to increase.

The most common treatment with medication includes radioactive iodine therapy, thionamide drugs, which prevent thyroid hormones from being made, and beta blockers. Surgical removal of part or all of the thyroid itself is another possible treatment.

"Radioiodine therapy is the most common therapy used for adults with Graves' disease in the United States.²" However, it is never used during pregnancy or breastfeeding, so any patients of childbearing age will need a negative pregnancy test before administration³. Radioactive iodine is not a first-line treatment for pediatrics, because they are more at risk for delayed hypothyroidism and cancer as they get older³.

PTU (propylthiouracil) is a medication avoided in the pediatric and geriatric populations due to its side effect of liver injury. PTU is used in pregnancy and breastfeeding because methimazole crosses the placenta and enters breast milk³.

With radioactive iodine and medication therapy, the nurse will also need to anticipate and manage any potential complications, including hypothyroidism due to treatment, and leukopenia or thrombocytopenia, which are side effects of thionamides.

Beta blockers are used primarily for symptom relief from tachycardia and hypertension.

Thyroidectomy, or removal of the thyroid gland, works quickly but causes hypothyroidism for the rest of the patient's life. They will need to take thyroid hormone replacement drugs². Post-op, the nurse will need to monitor the patient for thyroid storm, which occurs from manipulation of the thyroid during the procedure. The nurse will also monitor for symptoms of hypocalcemia, which can occur if the parathyroid glands were damaged or removed with the thyroid. These symptoms include muscle spasms or cramps, tetany, and even severe laryngospasm.

Patient Education

Teaching will include explaining the pathophysiology of Graves' disease at a level appropriate for the patient's age and comprehension levels. They and their families or caregivers should also be instructed in signs and symptoms associated with hyperthyroidism and thyroid storm, which is a medical emergency. All patients will need instruction about self-management, especially if they will be on a long-term course of medication. They will need frequent follow-up care and lab work to assess if the medication is working or needs to be adjusted.

References/Resources

1 Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's Textbook of Medical-Surgical Nursing (14th ED.). Wolters Kluwer.

2 Thyrotoxicosis: StatPearls Publishing

3 Burchum, J. R., & Rosenthal, L. D. (2016). Lehne's Pharmacology for Nursing Care (9th ED.). Elsevier.

Graves' Disease: Recognition and Treatment Across the Lifespan

Assessment & Diagnostic Testing

Care Measures/Treatment/Medication

Patient Education

About marina.todeasaRN, ASN, EMT-P

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