Pathophysiology of Graves' disease

Answer

Pathophysiology of Graves' disease

Graves' disease refers to an autoimmune disorder that occurs when the body produces antibodies to the thyroid-stimulating hormone receptors. These antibodies bind to the thyroid-stimulating hormone receptors (TSHr) and chronically stimulate it thereby causing hyperthyroidism (Bahn, 2003). The thyroid-stimulating hormone receptor is expressed on the cells that produce thyroid hormone, that is, the follicular cells of the thyroid gland. Besides, the chronic stimulation results in an abnormally high production of T3 and T4 cells that lead to the clinical symptoms of hyperthyroidism, and the visible enlargement of the thyroid gland referred to as a goiter. Notably, the thyroid gland is under constant stimulation by the autoantibodies against the thyrotropin receptor, and the increased production of thyroid hormones suppresses the secretion of pituitary thyrotropin (Falgarone, Heshmati, Cohen, Reach, 2013). These thyroid-stimulating antibodies induce the secretion of thyroid hormone and thyroglobulin under the influence of 3,'5'-cyclic adenosine monophosphate besides stimulating protein synthesis, iodine uptake, and thyroid gland growth that results in the enlargement of the thyroid glands hence goiter.

Current surgical treatment options for a patient with Graves' disease

The surgical treatment of Graves’ disease involves the removal of all of the thyroid gland or a portion of the thyroid gland in a surgical procedure referred to as thyroidectomy. There are two surgical treatment options namely; total thyroidectomy and subtotal thyroidectomy (Wilhelm, McHenry, 2010). The total thyroidectomy is sometimes called near-total and involves the removal of all the thyroid gland of the patient. The subtotal thyroidectomy, on the other hand, involves removal of the thyroid gland of the patient in part leaving behind some thyroid tissue to prevent the lifelong need for thyroid hormone medication for the patient. Besides, the subtotal thyroidectomy is critical in minimizing the risks of injuring all four parathyroid glands as well as recurrent laryngeal nerves. However, the total thyroidectomy is most preferred as it posits no risk of still having hyperthyroidism after surgery a situation that would worsen the patient’s condition (Liu, Bargren, Schaefer, Chen, Sippel, 2011).

• Assessment of ventilation

Airway problems like the retrosternal extension of the gland may complicate an anaesthesia for thyroidectomy. Consequently, preoperative assessment of the airway is critical to enable the anaesthetist to deal with acute airway complications during the perioperative phase. This can be done by assessing the patient’s history of respiratory difficulties such as positional dyspnoea that is associated with a degree of dysphagia or breathlessness on assuming the supine position. Notably, large-sized goiter presenting for a prolong duration may result in the development of tracheomalacia by the patient. This is because a rapid increase in goiter size may result from either hemorrhage or rapidly enlarging malignancy that can lead to difficulty in airway management. The hemorrhage or enlarging malignancy may cause obstructions in the airways hence, leading to the hoarse voice and difficulty in breathing. Before discharge from the Post Anaesthesia Recovery Unit, the vocal cords of this patient were checked using a fibreoptic endoscope to view the vocal cords atraumatically (Chi, Wu, Hsieh, Sheen-Chen, Chou, 2011). Notably, the patient was extubated when adequate laryngeal reflexes and spontaneous respiration returned. Coughing was avoided at all cost although the history of the patent of cigarette smoking made it difficult to control the coughs. Notably, the respiratory obstruction posited by hoarse voice and difficulty in breathing led to the sixty minutes stay of the patient in the Post Anaesthesia Recovery Unit before being transferred to the recovery ward. During this time, the patient was carefully assessed for cervical haematoma development. Also, the vocal cord function was examined by indirect laryngoscopy and video laryngostroboscopy to diagnose the cause of the hoarse voice. Notably, vocal abnormalities after thyroidectomy were discovered and the patient committed to treatment before discharge. Moreover, signs of vocal cords palsy and tracheal compression were assessed through the examination of the following aspects of goiter; the size, duration, consistency and extent of enlargement. Besides, fixed and hardness of the gland was an indicator of malignancy. On the other hand, the inability to sense, by touch, the lower border of thyroid gland pointed to retrosternal extension that caused superior venocaval obstruction syndrome, Horner's syndrome and pleural and pericardial effusion as a result of the compression effect on the surrounding vital structures leading to difficulty in breathing and hoarse voice (Chi, Wu, Hsieh, Sheen-Chen, Chou, 2011). Also, assessment of neck movements in all planes, namely; atlantoaxial flexion and extension, was critical in airway evaluation. This helped in determining the necessity of placing the patient in a high Fowler’s position.

• Assessment of circulation

 Surgical procedures-preparations coupled with anesthesia have a significant effect on the splanchnic and hepatic circulation. Notably, general anaesthesia decreases cardiac output and peripheral resistance thereby affecting the circulation proportionately to the concentration of the anaesthesia in the blood. Use of an aesthesia on a patient during the thyroidectomy lowers the speed of blood circulation in the body leading to decreased portal blood flow triggered by the decrease in cardiac output characterized by reduced rate of the heartbeat (Kim, Park, Son, Kim, Kim, Woo, 2013). Consequently, the rate of supply of both oxygen and nutrients to the brain is reduced leading to inactivity of the brain that results in the drowsiness witnessed after the surgery of the patient. However, as the effect of the anaesthesia gradually subsided from the blood stream, the patient became much easier to arouse. This aspect was assessed by examining the effects of the general anesthetics on left ventricular function as well as the distribution of cardiac output besides assessing the extent to which responses to pharmacological and physiological stimuli are modified by the general anesthesia. Besides, postoperative bleeding caused compression and rapid airway obstruction in the patient resulting in the difficulty in breathing. This was assessed by examining the signs of swelling or haematoma formation and decompressing such swellings that compromised the patient’s airway by removing the surgical clips (Kim, Park, Son, Kim, Kim, Woo, 2013).

• Assessment of consciousness

The general anaesthesia induces unresponsiveness and amnesia that results in unconsciousness of the patient by blocking the brain’s ability to integrate information (Chi, Wu, Hsieh, Sheen-Chen, Chou, 2011). Notably, anesthesia produces functional disconnection in the posterior parietal area of the brain that interrupts the cortical communication leading to a loss of integration. The consciousness of the patient after surgery can be assessed using brain function monitors. For example, bispectral index monitor is a critical tool for consciousness assessment after anesthetic surgery. It records the electroencephalogram (EEG) signal over the forehead besides reducing the complex signal into a single number. As such, the electroencephalogram tracks the patient’s depth of anesthesia thereby assessing the consciousness of the patient (Shih, Duh, Hsieh, Liu, Lu, Wong, Yeh, 2010). Moreover, consciousness assessment after surgery can be conducted on the patient by asking the patient simple questions and evaluation how sober the patient responds to these questions.

Discharge Plan

Name: ____Louise___________________ Age: _32___ Sex:  Female____  

Diagnosis:   grave’s disease_____________ Surgery Undergone: __ total thyroidectomy __ 

Hospital: _____________________ Rm. /Ward-Bed No. ___________Physician:______________

Objectives:

1. Provide psychological support.
2. Prevent complications.
3. Reduce metabolic demands and support cardiovascular function
4. Provide information about the disease process and therapy needs.

Medications:

Exercise / Activity

Slight exercise like walking and normal routines are allowed to continue. However, the patient should avoid vigorous activity and heavy lifting for two weeks. The rationale behind the activity restriction is that the airways are still obstructed, and the high demand of oxygen by the body during strenuous activities may not be met hence the individual may collapse.

Treatment to be continued at home;

Health teachings

Follow the medication prescriptions as provided and consult your physician when side effects identified above persists. Observe any bleeding and swellings on at the site of surgery and report to your physician immediately.

Psychological support needs

Spiritual counselling, supportive counselling, and family therapy are recommended for the psychological support of the patient.

 Discharge Details

1. Date and Time of Discharge: _2/3/2016 at 1400HRS________________
2. Accompanied by: _None______________________________________
3. Mode of Transportation: _Personal car___________________________
4. General Condition upon Discharge: _In stable condition but drowsy with a hoarse voice. __________________________________________________________________________

THESE DISCHARGE INSTRUCTIONS WERE EXPLAINED TO THE PATIENT

Read and Understood: _________________________________

PATIENT (Signature over printed name)

Validated: _________________________________

STUDENT NURSE (Signature over printed name)

_________________________________

CLINICAL INSTRUCTOR (Signature over printed name)