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Nursing Care Plan | NCP Graves Disease

Graves disease is an autoimmune disorder of the thyroid gland, which means that an abnormal immune response causes the person’s thyroid gland to produce too much of thyroid hormone known as thyroxine. It is named for Robert James Graves (1797–1853), an Irish physician who first described a patient with goiter and exophthalmos in 1835.

In Graves disease, the patient’s thyroid gland, which is located at the base of the throat, is stimulated by an autoimmune response to increase its production of thyroxine. Doctors do not know what triggers the body’s immune system to target the thyroid gland, although some think that genetic factors may be involved. Other researchers think that bacterial or viral infections may trigger the onset of the disorder, as it often appears suddenly, particularly in middle-aged adults. Overproduction of the hormone then causes such characteristic symptoms of the disease as anxiety, general restlessness, sleep problems, bulging eyes, heat sensitivity, and weight loss.

Graves disease is the most common cause of hyperthyroidism in the United States, accounting for 70–80 percent of cases and affecting about thirty people in every 100,000. It appears to run in some families, with patients often having relatives diagnosed with either Graves disease itself or Hashimoto disease, another thyroid disorder. As of 2008, however, no specific gene had yet been identified as the sole cause of Graves disease. The disorder is most common in adults over the age of twenty but may affect children as well. It is seven times as common in women than in men. Most affected women are between the ages of thirty and sixty. Graves disease is found in all races and ethnic groups, but the genetic markers that have been linked to the disorder appear to vary with race and ethnicity.
Nursing Care Plan | NCP Graves Disease
Nursing Care Plan Signs and Symptoms
In Graves disease, a person’s immune system mistakenly produces antibodies that target the thyroid gland; however, instead of destroying the gland, the antibodies stimulate it to make too much thyroxine. Some researchers believe that age and stress may combine with genetic factors to trigger the onset of the disease. In a few cases, Graves disease appears to be triggered by traumatic injury to the thyroid gland.

The most common symptoms of Graves disease are:
• Anxiety, irritable mood, and difficulty sleeping.
• Losing weight in spite of normal or even increased food intake.
• Exophthalmos. This is a symptom in which the eyeballs bulge outward from the eye socket. This symptom develops because the tissues and muscles behind the eye swell and push the eyeball forward. It is more likely to develop in patients who smoke.
• Goiter. This symptom is an enlargement of the thyroid gland that causes a bulge at the base of the neck.
• Muscle weakness and tremor.
• Brittle hair.
• Increased sensitivity to heat and heavy sweating.
• Speeded-up or irregular heartbeat.
• In women, lighter than normal menstrual periods.
• Frequent bowel movements.
• Double vision and eye irritation.

Undiagnosed and untreated Graves disease can lead to a condition known as thyroid storm, in which the patient’s body temperature rises as high as 105°F (40.5°C). Thyroid storm is a medical emergency and can end in death if not treated. The symptoms of thyroid storm include chest pain, heavy sweating, shortness of breath, disorientation, and very rapid heartbeat as well as a rise in body temperature. The patient should be taken to a hospital for emergency treatment. Other complications that can result from untreated Graves disease include osteoporosis (brittle bones) and weakened heart muscle leading to congestive heart failure.

Nursing Care Plan Diagnosis
People should visit their doctor for a checkup if they notice such outward signs of Graves disease as goiter, weight loss, or increased sensitivity to heat. The doctor will begin by taking a history, including a family history of thyroid disorders. He or she will then check the patient’s eyes for exophthalmos and feel the thyroid gland for swelling. The patient’s blood pressure and pulse will also be checked.

The doctor will then order blood tests to check the levels of thyroxine in the patient’s blood and another hormone known as thyroid-stimulating hormone or TSH. In Graves disease, the thyroid gland is stimulated by an abnormal antibody rather than by TSH, so a blood test that indicates high levels of thyroxine and low levels of TSH points to Graves disease as the cause.

Another test that is used to diagnoseGraves disease consists of injecting the patient with radioactive iodine and measuring the amount that is taken up by the thyroid gland. The thyroid gland needs iodine to produce thyroxine, so that if the test shows that the gland is taking up the radioactive iodine in higher amounts, it indicates that the patient has an overactive gland.

Nursing Care Plan Treatment
There are three major forms of treatment for Graves disease: antithyroid drugs that lower the amount of thyroid hormone produced; radioactive iodine, which destroys all or part of the thyroid gland; and surgical removal of all or part of the thyroid gland. Antithyroid drugs are about 30–50 percent effective in relieving the symptoms of Graves disease and are generally not recommended for younger patients. Radioactive iodine and surgery are 90–95 percent effective, but patients must take replacement thyroid hormone for the remainder of their lives. Radioactive iodine is not recommended, however, for patients with severe eye problems associated with Graves disease.

Prognosis
The prognosis for recovery from Graves disease depends partly on the patient’s overall health and partly on how quickly the disorder is diagnosed. Most patients have good results provided they take replacement thyroid as prescribed and see their doctors for regular follow-up visits. Patients are usually advised to watch for signs of fever, sore throat, and throat ulcers, and see their doctor at once if they develop those symptoms. In most cases of Graves disease, nomatter which therapy is used, eventually the patient will wind up with an underactive gland and require replacement thyroid hormone.

Prevention
There is no known way to prevent Graves disease.

The Future
Graves disease is not likely to become more common in the future. It is likely, however, that researchers will discover more information about the genetic factors involved in the disease and the specific conditions that trigger its onset.
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