HYPOTHYROIDISM

Definition
hypothyroidism also called underactive thyroid, is a common endocrine disorder in
which the thyroid gland does not produce enough thyroid hormone.
Thyroid deficiency can affect all body functions and can range from mild, subclinical forms
to myxedema, an advanced form.
The most common cause of hypothyroidism in adults is autoimmune thyroiditis
(Hashimoto’s disease), in which the immune system attacks the thyroid gland.
causes
1. Causes of Myxedema (the adult form of this condition): 

 Thyroiditis - an autoimmune inflammation of the thyroid gland

 Overtreatment for hyperthyroidism (overactive thyroid gland) - radiation or surgery
 Severe iodine deficiency - resulting in a reduction in the production of thyroid
hormones
 Pituitary gland disorder
 Lithium
 Pregnancy - during or after, may seriously affect the fetus

2. Causes of congenital hypothyroidism (present from birth): 

 Iodine deficiency in the mother's diet during pregnancy and in that of the child after
birth
 Defective or absent thyroid gland - for unknown reasons, it doesn't develop normally
Risk factors for hypothyroidism are:
 Being female and over 50 years of age; however anyone can develop hypothyroidism
 Being treated with radioactive iodine (or other anti-thyroid drugs)
 Age, people over 60 years of age have a higher risk of developing hypothyroidism
 A close relative having an autoimmune disease
 Radiation exposure
 Thyroidectomy - partial surgical removal of the thyroid
SIGN AND SYMPTOMS
The main symptoms of hypothyroidism are fatigue and lethargy. The slower the
metabolism gets, the more obvious the signs and symptoms will become. If hypothyroidism goes
untreated, the signs and symptoms could become severe, such as an inflamed thyroid (goiter),
slow thought processes, or depression.

 The patient usually begins to gain weight even without an increase in food intake
 Advanced hypothyroidism may produce personality and cognitive changes characteristic
of dementia
 Advanced hypothyroidism may produce personality and cognitive changes characteristic
of dementia
 Severe hypothyroidism is associated with an elevated serum cholesterol level,
atherosclerosis, coronary artery disease, and poor
  left ventricular function. The patient with advanced hypothyroidism
 is hypothermic and abnormally sensitive to sedatives,
 opioids, and anesthetic agents. Dry, pallid, flaky skin
 Hoarse voice
 Amplified sensitivity to cold
 Constipation
 Muscle weakness
 Menstrual disturbances such as menorrhagia or amenorrhea occur,
 loss of libido
 Swollen or stiff joints
 Stiff, weak, painful muscle aches
 Higher than usual blood cholesterol level
 Extreme fatigue makes it difficult for the person to complete a full day’s work or
participate in usual activities.
 Hair loss,
 brittle nails, and dry skin,
 numbness and tingling of the fingers may occur.
 Myxedema coma describes the most extreme, severe stage of hypothyroidism, in which the
patient is hypothermic and unconscious.
 Myxedema coma may follow increasing lethargy, progressing to stupor and then coma.
DIAGNOSTIC EVALUATION
1. Physical exam : find that thyroid gland is enlarged. Sometimes, the gland is normal size or
smaller-than-normal.
The exam may also reveal:
 Brittle nails
 Coarse features of the face
 Pale or dry skin, which may be cool to the touch
 Swelling of the arms and legs
 Thin and brittle hair
2. Blood tests are also ordered to measure thyroid hormones TSH and T4.   
3. Cholesterol levels
4. Complete blood count (CBC)
5. Liver enzymes
6. Prolactin
7. Sodium
MEDICAL MANAGEMENT
Treatment is aimed at replacing the thyroid hormone that you are lacking.
Levothyroxine is the most commonly used medicine:
 The lowest dose possible that relieves symptoms and brings the blood hormone levels back to
normal is prescribed.
 If patient has heart disease or he is older, t start you on a very small dose.
 Most people with an underactive thyroid will need to take this medicine for life.
Patient should be aware of the following:
 Ask the patient do not stop taking the medicine when he feels better. Continue taking it
exactly as prescribed.
 Change of brands of thyroid medicine, should be informed to doctor
 Thyroid medicine works best on an empty stomach and when taken 1 hour before any other
medications.
 Ask patent to wait at least 4 hours after taking thyroid hormone before taking fiber
supplements, calcium, iron, multivitamins, aluminum hydroxide antacids, colestipol, or
medicines that bind bile acids.

NURSING CARE
 1. Risk for decreased Cardiac Output, R/T Uncontrolled hyperthyroidism, hypermetabolic
state Increasing cardiac workload
Desired Outcomes
 Maintain adequate cardiac output for tissue needs as evidenced by stable vital signs, palpable
peripheral pulses, good capillary refill, usual mentation, and absence of dysrhythmias.
Nursing Interventions

 Monitor BP lying, sitting, and standing, if able. Note widened pulse pressure.

 Monitor central venous pressure (CVP), if available.

 Investigate reports of chest pain/angina.

 Assess pulse/heart rate while patient is sleeping.

Auscultate heart sounds, noting extra heart sounds, development of gallops and systolic murmurs.

Monitor ECG, noting rate/rhythm. Document dysrhythmias.

Auscultate breath sounds, noting adventitious sounds (e.g., crackles).

Monitor temperature; provide cool environment, limit bed linens/clothes, administer tepid sponge
baths.

Observe signs/symptoms of severe thirst, dry mucous membranes, weak/thready pulse, poor
capillary refill, decreased urinary output, and hypotension.

Record I&O. Note urine specific gravity.

Weigh daily. Encourage chair rest/bedrest; limit nonessential activity.

Note history of asthma/bronchoconstrictive disease, sinus bradycardia/heart blocks, advanced HF, or

current pregnancy.

Observe for adverse side effects of adrenergic antagonists, e.g., severe decrease in pulse, BP; signs
of vascular congestion/HF; cardiac arrest.

Administer IV fluids as indicated.

Administer medications as indicated:[beta]-blockers, e.g., propranolol (Inderal), atenolol

(Tenormin), nadolol (Corgard), pindolol (Visken);Thyroid hormone antagonists, e.g.,
propylthiouracil(PTU), methimazole (Tapazole);   Acetaminophen (Tylenol); Sedative,

Monitor laboratory/diagnostic studies, as indicated, e.g.:Serum potassium; 

  Serum calcium; Sputum culture; Serial ECGs; Chest x-rays.

 Provide supplemental O2 as indicated.

 Provide hypothermia blanket as indicated.

 Administer transfusions; assist with plasmapheresis, hemoperfusion, dialysis.

2. Fatigue related to Hypermetabolic state with increased energy requirementsas evidenced

by Verbalization of overwhelming lack of energy to maintain usual routine, decreased
performance
Desired Outcomes
 Verbalize increase in level of energy.
 Display improved ability to participate in desired activities.
 Nursing Interventions

 Monitor vital signs, noting pulse rate at rest and when active.

 Note development of tachypnea, dyspnea, pallor, and cyanosis.

 Provide for quiet environment; cool room, decreased sensory stimuli, soothing colors, quiet music.

 Encourage patient to restrict activity and rest in bed as much as possible.

 Provide comfort measures, e.g., judicious touch/massage, cool showers.

 Provide for diversional activities that are calming, e.g., reading, radio, television.

 Avoid topics that irritate or upset patient. Discuss ways to respond to these feelings.

 Discuss with SO reasons for fatigue and emotional lability.

Administer medications as indicated:Sedatives, e.g., phenobarbital (Luminal); antianxiety agents,

e.g., chlordiazepoxide (Librium).
3. Disturbed Thought ProcessesR/T increased CNS stimulation/accelerated mental activity
DESIRED OUTCOMES
 Maintain usual reality orientation.
 Recognize changes in thinking/behavior and causative factors.
Nursing Interventions

 Assess thinking processes, e.g., memory, attention span, orientation to person/place/time.

 Note changes in behavior.

Assess level of anxiety.

 Provide quiet environment; decreased stimuli, cool room, dim lights. Limit procedures/personnel.

Reorient to person/place/time as indicated.

Present reality concisely and briefly without challenging illogical thinking.

 Provide clock, calendar, room with outside window; alter level of lighting to simulate day/night.

 Encourage visits by family/SO. Provide support as needed.

 Provide safety measures, e.g., padded side rails, close supervision, or soft restraints as last resort as
necessary.

 Administer medication as indicated, e.g., sedatives/antianxiety agents/antipsychotic drugs.

4. Risk for Nutrition imbalanced, less than body requirements R/T Increased metabolism,
Nausea/vomiting, diarrhea
Desired Outcomes
 Demonstrate stable weight with normal laboratory values and be free of signs of malnutrition.
Nursing Interventions

 Monitor daily food intake. Weigh daily and report losses.

  Encourage patient to eat and increase number of meals and snacks, using high-calorie foods that
are easily digested.

 Avoid foods that increase peristalsis (e.g., tea, coffee, fibrous and highly seasoned foods) and
fluids that cause diarrhea (e.g., apple/prune juice).

 Consult with dietitian to provide diet high in calories, protein, carbohydrates, and vitamins.

Administer medications as indicated:Glucose, vitamin B complex;Insulin (small doses).

5. Anxiety [specify level]related to hypermetabolic state (CNS stimulation), as evidenced by

Increased feelings of apprehension, shakiness, loss of control,
Desired Outcomes
 Appear relaxed.
 Report anxiety reduced to a manageable level.
 Identify healthy ways to deal with feelings.
Nursing Interventions

 Observe behavior indicative of level of anxiety.

Monitor physical responses, noting palpitations, repetitive movements, hyperventilation,

insomnia.

Stay with patient, maintaining calm manner. Acknowledge fear and allow patient’s behavior to
belong to patient.

Describe/explain procedures, surrounding environment, or sounds that may be heard by patient.

Speak in brief statements, using simple words.

Reduce external stimuli: Place in quiet room; provide soft, soothing music; reduce bright lights;
reduce number of persons contacting patient.

Discuss with patient/SO reasons for emotional lability/psychotic reaction.

Reinforce expectation that emotional control should return as drug therapy progresses.

Administer antianxiety agents or sedatives and monitor effects.Refer to support systems as

needed, e.g., counseling, social services, pastoral care.

6.Impaired Tissue Integrity R/T Alterations of protective mechanisms

Desired Outcomes
 Maintain moist eye membranes, free of ulcerations.
 Identify measures to provide protection for eyes and prevent complications.
Nursing Interventions

 Encourage use of dark glasses when awake and taping the eyelids shut during sleep as needed.

 Elevate the head of the bed and restrict salt intake if indicated.

 Instruct patient in extraocular muscle exercises if appropriate.

  Provide opportunity for patient to discuss feelings about altered appearance and measures to
enhance self-image.

Administer medications as indicated:Methylcellulose drops;Adrenocorticotropic hormone

(ACTH), prednisone; 
 Antithyroid drugs; Diuretics.

 Prepare for surgery as indicated.

6. Knowledge, deficient regarding condition, prognosis, treatment, self-care, and discharge

needs related to Lack of exposure/recall, Information misinterpretation as evidenced by
Questions, request for information, statement of misconception
Desired Outcomes
 Verbalize understanding of disease process and potential complications.
 Identify relationship of signs/symptoms to the disease process and correlate symptoms with
causative factors.
 Verbalize understanding of therapeutic needs.
 Initiate necessary lifestyle changes and participate in treatment regimen.
Nursing Interventions

 Review disease process and future expectations.

Provide information appropriate to individual situation.

Identify stressors and discuss precipitators to thyroid crises, e.g., personal/social and job concerns,
infection, pregnancy.

Provide information about signs/symptoms of hypothyroidism and the need for continuing follow-
up care.

Discuss drug therapy, including need for adhering to regimen, and expected therapeutic and side
effects.

Identify signs/symptoms requiring medical evaluation, e.g., fever, sore throat, and skin eruptions.

Explain need to check with physician/pharmacist before taking other prescribed or OTC drugs.

 Emphasize importance of planned rest periods.

 Review need for nutritious diet and periodic review of nutrient needs; avoid caffeine, red/yellow
food dyes, artificial preservatives.