Hypothyroidism and Hyperthyroidism

1. Description
Hypothyroidism
- Hypothyroidism, or underproduction of the thyroid hormone, is a rare condition in
late adolescents and especially rare in pregnancy because women with symptoms of
untreated hypothyroidism are often anovulatory and unable to conceive. A woman who
does conceive can then face another obstacle in that she can have difficulty increasing
thyroid functioning to a necessary pregnancy level, which can then lead to early
spontaneous miscarriage.

Hyperthyroidism
- Hyperthyroidism, or overproduction of thyroid hormone, causes symptoms such
as a rapid heart rate, exophthalmos (i.e., protruding eyeballs), heat intolerance, heart
palpitations, and weight loss. Sometimes called Graves disease, it is more apt to be
seen in pregnancy than is hypothyroidism.
MATERNAL AND CHILD HEALTH NURSING (8th Edition).pdf

2. Pathophysiology or Concept Map

 PREDISPOSING PRECIPITATING
FACTORS: FACTORS:
history of chronic illness Toxic nodular goiter
female autoimmune disease
65 yrs old TSH level is Grave's Disease

low
Elevation of Blood test
iodine
Weight gain Elevation of Radioactive iodine
uptake test and
Increased BP and HR
T3 and T4 thyroid scan

HYPERTHYROIDIS
Surgery:: M
Thyroidectomy
MEDICATIONS:
Propylthiouracil
carbimazole
methiamazole
Radioactive Iodine
Beta blockers

PREDISPOSING FACTORS:
Hereditary PRECIPITATING FACTORS:
Female TSH level is Pregnancy
Autoimmune disease
65 yrs above high Hashimoto’s disease

Iodine is low

Low T3 and T4

HYPOTHYROIDISM

3. Laboratory Test
Hyperthyroidism
• Medical history and physical exam. During the exam your doctor may try to
detect a slight tremor in your fingers when they're extended, overactive reflexes, eye
changes and warm, moist skin. Your doctor will also examine your thyroid gland as you
swallow to see if it's enlarged, bumpy or tender and check your pulse to see if it's rapid
or irregular.
• Blood tests. Blood tests that measure thyroxine and thyroid-stimulating hormone
(TSH) can confirm the diagnosis. High levels of thyroxine and low or nonexistent
amounts of TSH indicate an overactive thyroid. The amount of TSH is important
because it's the hormone that signals your thyroid gland to produce more thyroxine.
• Radioiodine uptake test. For this test, you take a small, oral dose of radioactive
iodine (radioiodine) to see how much will collect in your thyroid gland. You'll be checked
after four, six or 24 hours — and sometimes after all three time periods — to see how
much iodine your thyroid has absorbed.
• Thyroid scan. During this test, you'll have a radioactive isotope injected into the
vein on the inside of your elbow or sometimes into a vein in your hand. You then lie on a
table with your head stretched backward while a special camera produces an image of
your thyroid gland on a computer screen. This test shows how iodine collects in your
thyroid.
• Thyroid ultrasound. This test uses high-frequency sound waves to produce
images of the thyroid. Ultrasound may be better at detecting thyroid nodules than other
tests, and there's no exposure to any radiation.

Hypothyroidism
• FREE T3 Lab Test
Free T3 is the workhorse of all thyroid hormones, measuring the free, unbound levels of
triiodothyronine in the bloodstream. It’s important to remember that Free T3 is
considered more accurate than Total T3. In hyperthyroidism Free T3 is typically
elevated. In hypothyroidism, Free T3 is typically low.
• FREE T4 Lab Test
Free T4 measures the available and unbound T4 hormone. For patients on natural
desiccated thyroid medicine with healthy adrenals, a normal lab test will show Free T4
at mid to high range, and Free T3 at the top end of the range. Hypothyroidism generally
occurs with Free T4 in the low range, and Free T3 at mid-range or slightly high.
• Reverse T3 (RT3) Test
The RT3 test must be done at the same time as the Free T3 in order to calculate the
ratio with the results and measurements. According to Thyroid-Rt3.com, divide Free T3
by reverse T3. The amount should be 20 or greater. If it’s less then that you have a RT3
problem. If it’s vastly smaller or larger you may have to move the decimal point to get
the units right. FT3 should be twenty of more times higher than RT3.

4. Treatment Regimen
a. Medication/Supplement / Vaccines
Hypothyroidism
● Standard treatment for hypothyroidism involves daily use of the synthetic thyroid
hormone levothyroxine. The medication gradually lowers cholesterol levels
elevated by the disease and may reverse any weight gain. Treatment with
levothyroxine will likely be lifelong, but because the dosage you need may
change, your doctor is likely to check your TSH level every year.
● After delivery we need to reduce the dose of levothyroxine.

Hyperthyroidism
• Propylthiouracil (PTU) is the drug of choice because of low transplacental
transfer and decreased peripheral conversion of T4 to T3. Also carbimazole, and
methimazole have been associated with rare cases of aplasia cutis and choanal atresia.
• Radioactive iodine. Taken by mouth, radioactive iodine is absorbed by your
thyroid gland, where it causes the gland to shrink. Symptoms usually subside within
several months. Excess radioactive iodine disappears from the body in weeks to
months.
This treatment may cause thyroid activity to slow enough to be considered underactive
(hypothyroidism), and you may eventually need to take medication every day to replace
thyroxine.But it is not recommended for pregnant patient because it can lead to
miscarriage

• To avoid fetal hypothyroidism, the dosage should be adjusted to maintain free T4

at the upper limit of normal. It is often possible to stop treatment in the third trimester.
Resume drugs after delivery.

• Beta blockers. Although these drugs are usually used to treat high blood
pressure and don't affect thyroid levels, they can ease symptoms of hyperthyroidism,
such as a tremor, rapid heart rate and palpitations. For that reason, your doctor may
prescribe them to help you feel better until your thyroid levels are closer to normal.
These medications generally aren't recommended for people who have asthma, and
side effects may include fatigue and sexual dysfunction.

b. Surgery
Hypothyroidism and Hyperthyroidism
- Thyroidectomy is the removal of all or part of your thyroid gland. Your thyroid is a
butterfly-shaped gland located at the base of your neck. It produces hormones that
regulate every aspect of your metabolism, from your heart rate to how quickly you burn
calories.Thyroidectomy is used to treat thyroid disorders, such as cancer, noncancerous
enlargement of the thyroid (goiter) and overactive thyroid (hyperthyroidism).

c. Diet and Nutrition

Hypothyroidism
- The recommended minimum iodine intake for most adults is 150 micrograms a day,
according to the National Institutes of Health Office of Dietary Supplements. Good food
sources include milk, cheese, poultry, eggs, kelp, and other seaweeds, Kellman says.
“But you have to be careful with supplementing iodine because too much can be
problematic and actually cause hypothyroidism.
Hyperthyroidism
- Once you begin treatment, symptoms of hyperthyroidism should subside and you
should start feeling much better. However, your doctor may recommend that you watch
out for iodine in your diet because it can cause hyperthyroidism or make it worse. Kelp,
dulse and other types of seaweed contain a lot of iodine. Cough syrup and multivitamins
also may contain iodine.

d. Physical Therapy or Exercise

Hyperthyroidism
● Thyroid disease is sometimes linked to osteoporosis. To help fight osteoporosis,
which decreases the density of your bones, it's suggested that hyperthyroidism
patients eat a healthy diet, take a calcium supplement and do some weight-
bearing exercises.
● The Centers for Disease Control and Prevention offers general exercise
guidelines for people looking to maintain a healthy weight
- First on the list is aerobic exercise — a minimum of 150 minutes
of moderate intensity or 75 minutes of vigorous intensity aerobic
exercise per week. The best aerobic exercises engage the large
muscles of your body, which could include taking a dance class,
biking or swimming.
- Include strength training at least twice per week, with at least 48
hours between sessions that focus on the same muscles.
- Resistance exercises include using resistance bands, doing
heavy gardening or doing body-weight exercises such as push-ups
and sit-ups.
- Remember to include weight-bearing activities to help prevent
osteoporosis, such as walking and stair climbing.
Hypothyroidism
- After all, symptoms like fatigue, swelling, and joint and muscle pain don’t make
you want to get up and go. But experts say that physical activity can help you feel
better
- Low-impact aerobic exercise and strengthening moves. Low-impact exercise
doesn’t apply as much pressure since hypothyroidism can cause pain and
swelling in your muscles and joints.
- Walking
- Water aerobics
- Yoga
- Tai chi
- Strength training

e. IV Fluids or Blood Transfusion

Intravenous glucocorticoids are indicated if adrenal insufficiency is suspected. Large
doses of dexamethasone (2 mg q6h) inhibit hormone production and decrease
peripheral conversion from T4 to T3.
f. Palliative
Palliative care in endocrine diseases is similar to palliative care in any other disease.
The aim will be to reduce the symptoms, avoid short-term complications and improve or
maintain the quality of life by minimal interference and with least inconvenience to the
patient. Palliative care in thyroid disorders aims to help the patient remain asymptomatic
in both hypothyroidism and hyperthyroidism and not normalizing the TSH.

5. Preventing and Prognosis

Hyperthyroidism:
After normalization of thyroid function with antithyroid medications, radioactive iodine
ablation usually is recommended as the definitive therapy. Long-term, high-dose
antithyroid medication is not recommended. There are 3 definitive treatments of
hyperthyroidism, all of which predispose the patient to potential long-term
hypothyroidism: radioactive iodine therapy (RAI), thionamide therapy, and subtotal
thyroidectomy. Clinical assessment and monitoring of free T4 are imperative for patients
who undergo any of these treatments. TSH-monitoring status after definitive therapy is
of poor utility since TSH remains suppressed until the patient becomes euthyroid. Thus,
TSH monitoring for thyroid status is not recommended immediately following definitive
therapy. Women with Graves’ disease should be followed closely after delivery because
recurrence or aggravation of symptoms is not uncommon in the first few months
postpartum. Most asymptomatic women should have a TSH and free-T4 performed
approximately 6 weeks postpartum. Both PTU and methimazole are excreted in breast
milk but PTU is largely protein bound and does not seem to pose a significant risk to the
breastfed infant.

Methimazole has been found in breastfed infants of treated women in amounts sufficient
to cause thyroid dysfunction. However, at low doses (10-20 mg/day) it does not appear
to pose a major risk to the nursing infant. The American Academy of Pediatricians
considers both acceptable in breast feeding mothers.
Hypothyroidism:
Undertreatment of hypothyroidism leads to disease progression, with gradual worsening
of symptoms and further metabolic derangements. Ultimately, untreated hypothyroidism
can cause profound coma or even death. Untreated hypothyroidism in infants can cause
irreversible mental retardation. When it comes to preventing hypothyroidism, there really
isn't anything most people can do to stop the onset of the disorder.

6. Nursing Care Plan

- Risk for maternal and fetal injury related to preexisting thyroid disorder
during pregnancy
- Risk for Decreased Cardiac Output
- Risk for Impaired Tissue Integrity
- Imbalanced Nutrition: More Than Body Requirements
- Deficient Knowledge
- Fatigue
REFERENCES: APA FORMAT
Book:
Silbert-Flagg, J. & Pillitteri, A.(2018)MATERNAL AND CHILD HEALTH NURSING
(8th Edition). Wolters Kluwer
Internet:
Liao, S.(2017) Exercises for an Underactive Thyroid. Retrieved from:
https://www.webmd.com/women/features/exercises-underactive-thyroid
Schraga, E.D. (2020)Hyperthyroidism, Thyroid Storm, and Graves Disease
Treatment & Management. Retrieved from:
https://emedicine.medscape.com/article/767130-treatment
Wood, K.(2020) Everything You Need to Know About Hypothyroidism Retrieved
from:https://www.healthline.com/health/hypothyroidism/symptoms-treatments-
more
Miss Lizzy. (N/I)Lab Tests For Hypothyroidism. Retrieved from:
https://www.misslizzy.me/lab-tests-hypothyroidism/

Video/Film
Mouris, M. (2018)Hypothyroidism:What is it, Causes, Symptoms and Treatments.
Retrieved from: https://www.youtube.com/watch?v=h9WIzDa9big
RegisteredNursRN(2016)Hyperthyroidism | Hyperthyroid Endocrine Nursing
Symptoms Treatment Pathophysiology NCLEX. Retrieved
from:https://www.youtube.com/watch?v=EjaEUH_nJPw
RegisteredNursRN(2016)Hypothyroidism Nursing Lecture NCLEX
Pathophysiology & Medications.
Retrieved from: https://www.youtube.com/watch?v=MVCRGso6tKw