Focus On Hypothyroidism: (Relates To Chapter 50, "Nursing Management: Endocrine Problems," in The Textbook)

Focus on Hypothyroidism
(Relates to Chapter 50,

“Nursing Management: Endocrine Problems,”
in the textbook)
Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Hypothyroidism
 One of the most common medical

disorders in the United States
 Affects 10% of women and 3% of
men over 65 years of age
Etiology and Pathophysiology
 Results from insufficient circulating

thyroid hormone
 Result of a variety of abnormalities
Etiology and Pathophysiology (Cont’d)
 Can be primary or secondary

 Primary
 Related to destruction of thyroid tissue or
defective hormone synthesis
 Secondary
 Related to pituitary disease with ↓ TSH
secretion or hypothalamic dysfunction
 May be transient, related to

thyroiditis, or from discontinuing
thyroid hormone therapy
 Iodine deficiency
 Most common cause worldwide and
most prevalent in iodine-deficient
areas
 In places where iodine intake is
adequate, the primary cause is
atrophy of the gland
 Atrophy is the end result of

Hashimoto’s thyroiditis and Graves’
disease
 These autoimmune diseases destroy
the thyroid gland
 May also develop because of

treatment for hyperthyroidism
 Amiodarone and lithium can
produce hypothyroidism
 Cretinism is caused by thyroid

hormone deficiencies during fetal or
neonatal life
 All infants are screened at birth for
↓ thyroid function
Clinical Manifestations
 Vary depending on
 Severity
 Duration
 Age of onset
 Systemic effects characterized by

slowing of body processes
Clinical Manifestations (Cont’d)
 Ranges from no symptoms to classic

symptoms, and physical changes
easily detected on examination
 Onset of symptoms may occur over

months to years
 Unless occurs after thyroidectomy,
thyroid ablation, treatment with
antithyroid drugs
 Cardiovascular system
 ↓ Cardiac output
 ↓ Cardiac contractility
 Cardiovascular system (cont’d)

 Anemia
 Cobalamin, iron, folate deficiencies
 ↑ Serum cholesterol and triglycerides
 Respiratory system
 Low exercise tolerance
 Shortness of breath on exertion
 Neurologic system
 Fatigued and lethargic
 Personality and mood changes
 Impaired memory, slowed speech,
decreased initiative, and somnolence
 Gastrointestinal system
 ↓ Motility
 Achlorhydria common
 Constipation
 Integumentary system
 Cold intolerance
 Hair loss
 Dry/coarse skin
 Brittle nails
 Hoarseness
 Muscle weakness and swelling
 Weight gain
 Integumentary system (cont’d)

 Muscle weakness and swelling
 Weight gain
 Reproductive system
 Menorrhagia
 Those with severe, longstanding

hypothyroidism may display
myxedema
 Accumulation of hydrophilic
mucopolysaccharides in the dermis
and other tissues
 Causes puffiness, periorbital edema,
masklike effect
Common Features of Myxedema
Fig. 50-9
Complications
 Mental sluggishness
 Drowsiness
 Lethargy progressing gradually or
suddenly to impairment of
consciousness or coma
Complications (Cont’d)
 Myxedema coma
 Medical emergency
 Can be precipitated by infection,
drugs, cold, or trauma
 Characterized by subnormal
temperature, hypotension, and
hypoventilation
Complications (Cont’d)
 Myxedema coma (cont’d)

 Vital functions must be supported
 IV thyroid hormone replacement
administered
Diagnostic Studies
 History and physical examination

 Laboratory tests
 Serum TSH
 Determines cause of hypothyroidism
 Free T4
 Serum T3
 Serum T4
Diagnostic Studies (Cont’d)
 Laboratory tests (cont’d)

 Other abnormal findings are
↑ cholesterol and triglycerides,
anemia, and ↑ creatine kinase
Diagnostic Studies (Cont’d)
 TRH stimulation test

 ↑ in TSH after TRH injection suggests
hypothalamic dysfunction
 No change after TRH injection
suggests anterior pituitary dysfunction
Collaborative Care
 Restoration of euthyroid state as

safely and rapidly as possible
 Low-calorie diet
Collaborative Care (Cont’d)
 Drug therapy
 Levothyroxine (Synthroid)
 Must take regularly
 Monitor for angina and cardiac
dysrhythmias
 Monitor thyroid hormone levels and
adjust (as needed)
 Patient/family teaching
Nursing Management
Nursing Assessment
 Health history
 Weight gain
 Mental changes
 Fatigue
 Slowed/slurred speech
 Cold intolerance
 Skin changes
Nursing Management
Nursing Assessment (Cont’d)
 Health history (cont’d)

 Constipation
 Dyspnea
 Recent introduction of iodine
medications
Nursing Management
Nursing Assessment (Cont’d)
 Physical examination
 Bradycardia
 Distended abdomen
 Dry, thick, cold skin
 Thick, brittle nails
 Paresthesias
 Muscular aches and pains
Nursing Management
Nursing Diagnoses
 Imbalanced nutrition: More than
body requirements
 Activity intolerance
 Disturbed thought processes
Nursing Management
Planning
 Experience relief of symptoms
 Maintain a euthyroid state
 Maintain a positive self-image
 Comply with lifelong thyroid
replacement therapy
Nursing Management
Nursing Implementation
 Health Promotion
 No consensus for thyroid function
screening
 High-risk populations screened for
subclinical thyroid disease
 Family history of thyroid disease, history
of neck radiation, women over 50 years of
age, and postpartum
Nursing Management
Nursing Implementation (Cont’d)
 Acute Intervention
 Most individuals do not require acute
nursing care
 Managed on outpatient basis
Nursing Management
 Acute Intervention (cont’d)

 Individuals with myxedema coma
require acute nursing care
 Mechanical respiratory support
 Cardiac monitoring
 IV thyroid hormone replacement
 If hyponatremic, hypertonic saline may be
administered
 Monitor core temperature
Nursing Management
 Acute Intervention (cont’d)

 Individuals with myxedema coma
(cont’d)
 Vitals
 Weight
 I&O
 Visible edema
 Cardiovascular response to hormone
 Energy level
 Mental alertness
Nursing Management
 Ambulatory and Home Care

 Explain nature of thyroid hormone
deficiency and self-care practices to
prevent complications
 Patient and family must understand
replacement therapy and that it is lifelong
Nursing Management
 Ambulatory and Home Care (cont’d)

 Teach measures to prevent skin
breakdown
 Emphasize need for warm
environment
 Caution patient to avoid sedatives or
use lowest dose possible
Nursing Management

 Discuss measures to minimize
constipation
 Avoid enemas because of vagal
stimulation in cardiac patient
Nursing Management

 Teach patient to notify physician
immediately if signs of overdose
appear
 Orthopnea, dyspnea, rapid pulse,
palpitations, nervousness, insomnia
Nursing Management

 Patient with diabetes should test
capillary blood glucose at least daily as
return to euthyroid state frequently
↑ insulin requirements
Nursing Management

 Thyroid preparations potentiate the
effects of some common drug groups
 Teach patient toxic signs and symptoms
of these drugs
 Anticoagulants
 Digitalis compounds
Nursing Management

 Provide handouts for patients and
family members with verbal
instructions
Nursing Management
Evaluation
 Expected outcomes
 Have relief from symptoms
 Maintain euthyroid state as evidenced
by normal thyroid hormone and TSH
levels
 Adhere to lifelong therapy
Case Study
Case Study
 38-year-old female enters a

community outpatient clinic
 She is complaining of overwhelming

fatigue that is not relieved by rest
Case Study (Cont’d)
 She is attending graduate school

and is very sedentary
 She is so exhausted she has

difficulty waking for classes and
trouble concentrating when
studying
 Her face is puffy and her skin is dry

and pale
 She is dressed inappropriately for

warm weather
 She also complains of generalized

body aches and pains with frequent
muscle cramps and constipation
 Vital signs
 BP 142/84 mm Hg
 Heart rate 52 beats/min
 Respiratory rate 12 breaths/min
 Temperature 96.8° F
Discussion Questions
1. What are some possible causes of

her symptoms?
Discussion Questions (Cont’d)
2. No obvious irregularities are found

in her cardiopulmonary
assessment. Her TSH levels come
back 20.9 IU/L. She is diagnosed
with hypothyroidism. What can
you tell her about the treatment
and follow-up?
Discussion Questions (Cont’d)
3. What teaching will you need to do

with her before she leaves the
clinic?

Focus On Hypothyroidism: (Relates To Chapter 50, "Nursing Management: Endocrine Problems," in The Textbook)

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Focus on Hypothyroidism

(Relates to Chapter 50,

 One of the most common medical

 Results from insufficient circulating

 Can be primary or secondary

 May be transient, related to

 Atrophy is the end result of

 May also develop because of

 Cretinism is caused by thyroid

 Systemic effects characterized by

 Ranges from no symptoms to classic

 Onset of symptoms may occur over

 Cardiovascular system (cont’d)

 Integumentary system (cont’d)

 Those with severe, longstanding

 Myxedema coma (cont’d)

 History and physical examination

 Laboratory tests (cont’d)

 TRH stimulation test

 Restoration of euthyroid state as

 Health history (cont’d)

 Acute Intervention (cont’d)

 IV thyroid hormone replacement

 If hyponatremic, hypertonic saline may be

 Acute Intervention (cont’d)

 Cardiovascular response to hormone

 Ambulatory and Home Care

 Ambulatory and Home Care (cont’d)

 Ambulatory and Home Care (cont’d)

 Ambulatory and Home Care (cont’d)

 Ambulatory and Home Care (cont’d)

 Ambulatory and Home Care (cont’d)

 Ambulatory and Home Care (cont’d)

 38-year-old female enters a

 She is complaining of overwhelming

 She is attending graduate school

 She is so exhausted she has

 Her face is puffy and her skin is dry

 She is dressed inappropriately for

 She also complains of generalized

1. What are some possible causes of

2. No obvious irregularities are found

3. What teaching will you need to do

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