4 Thyroid Disorders and Nursing Care

Assessment and thyroid tests

Assess symptoms alongside medical and medication history, vital signs, weight changes, energy level, temperature tolerance, bowel pattern, skin and hair, mood, and cardiovascular status. Inspect the neck for thyroid enlargement and observe for eye changes associated with Graves’ disease.

Interpret thyroid-function tests in the context of the clinical presentation. In primary hypothyroidism, TSH is generally elevated and free T4 is low. In primary hyperthyroidism, TSH is usually low and free T4 and/or T3 is elevated. TSH may not follow these patterns in pituitary or hypothalamic disease, and symptoms alone do not establish a diagnosis.

Hypothyroidism and its care

Hypothyroidism is inadequate thyroid-hormone production. Common causes include autoimmune thyroiditis (Hashimoto’s disease), thyroid surgery, and radioiodine treatment. It may develop gradually, so early symptoms can be subtle.

Common findings include fatigue, cold intolerance, weight gain, constipation, dry skin, slowed heart rate, and difficulty concentrating. Some older adults may present mainly with reduced appetite, withdrawal, or cognitive changes.

Treatment and nursing care

Levothyroxine is commonly prescribed as long-term hormone replacement. Give it consistently as prescribed. Patients are generally advised to take it on an empty stomach and wait 30–60 minutes before eating; calcium and iron can reduce absorption, so follow instructions on separating these products from the dose.

Monitor symptoms, pulse, and thyroid-function tests as ordered. TSH is commonly used to guide dose adjustment in primary hypothyroidism, and reassessment is needed after a dose change. Explain that improvement may take time and that patients should not stop or change the dose without consulting the prescriber. They should report possible signs of excessive replacement, such as palpitations, tremor, or chest discomfort.

Support comfort and safety by providing warmth as needed, encouraging fluids and fiber when appropriate for constipation, and assessing fatigue-related fall risk.

Hyperthyroidism and its care

Hyperthyroidism is excessive thyroid-hormone production. Graves’ disease is a common cause; other causes include overactive thyroid nodules and thyroiditis. The condition accelerates body processes and can affect the heart, muscles, mood, and gastrointestinal system.

Common findings include heat intolerance, sweating, tremor, anxiety or irritability, weight loss despite normal or increased appetite, frequent bowel movements, muscle weakness, and a rapid or irregular heartbeat. Graves’ disease may also cause goiter and eye changes.

Treatment and nursing care

Treatment depends on the cause and may include antithyroid medication, radioactive iodine, or surgery. A beta blocker may be prescribed to control symptoms such as tremor and rapid heart rate while other treatment takes effect.

Monitor heart rate and rhythm, blood pressure, temperature, weight, hydration, bowel pattern, and mental status. Promptly report significant tachycardia, a new dysrhythmia, chest pain, or worsening agitation. Promote a calm, cool environment and allow rest periods. Support hydration and nutrition as appropriate, since frequent stools and increased metabolic demand can contribute to fluid and weight loss.

Reinforce the prescribed medication plan and follow-up testing. Teach patients to contact the care team promptly about concerning medication effects; do not advise stopping prescribed antithyroid medication without clinical direction.

Thyroid storm

Thyroid storm is a rare, life-threatening worsening of thyrotoxicosis with severe systemic effects. It can follow a trigger such as infection, surgery, trauma, or interruption of treatment. Findings may include high fever, marked tachycardia or dysrhythmia, agitation or delirium, vomiting or diarrhea, and cardiovascular instability. This is a clinical emergency; treatment should not wait for a particular thyroid-hormone level.

Priority nursing actions

1. Recognize rapid deterioration, activate the emergency response, and prepare for intensive-care management.

2. Support airway, breathing, and circulation. Apply continuous cardiac and oxygen-saturation monitoring, and obtain frequent vital signs and mental-status assessments.

3. Prepare to administer prescribed therapies and fluids, and monitor response and complications. Medical treatment may include a beta blocker, a thionamide to reduce hormone synthesis, iodine to reduce hormone release, and glucocorticoids. Administer iodine after the thionamide, not before. Beta blockade requires close clinical monitoring, particularly when cardiac function is compromised.

4. Use cooling measures as directed and administer prescribed antipyretics. Identify and help treat the precipitating cause, such as infection. Avoid aspirin unless specifically directed because it may increase free thyroid hormone.

Myxedema coma

Myxedema coma is decompensated, severe hypothyroidism with altered mental status and failure of multiple body systems. Despite its name, the patient may not be comatose. Possible triggers include infection, cold exposure, a cardiac or neurologic event, or sedating medications. Findings can include hypothermia, lethargy or reduced consciousness, bradycardia, hypotension, hypoventilation, hyponatremia, and hypoglycemia. Suspected myxedema coma requires immediate emergency and critical-care management.

Priority nursing actions

1. Support airway and breathing. Closely monitor respiratory effort, oxygenation, and level of consciousness, and prepare for ventilatory support if needed.

2. Monitor cardiac rhythm, temperature, blood pressure, glucose, electrolytes, and urine output. Report deterioration promptly.

3. Prepare to administer prescribed intravenous thyroid hormone and stress-dose glucocorticoids. Give glucocorticoids before thyroid hormone until coexisting adrenal insufficiency has been assessed or excluded.

4. Use passive warming, such as blankets, as directed; avoid aggressive peripheral rewarming. Give fluids and correct glucose or electrolyte abnormalities only as prescribed, with close monitoring.

5. Help identify and manage the precipitating illness, and avoid unnecessary sedatives or respiratory-depressing medications. Clinical improvement may take time, so monitor organ function and treatment response closely.

Applying priorities in care

A patient with known hypothyroidism becomes increasingly drowsy after an infection and has a low temperature and slow, shallow respirations. The priority is not simply to give a routine oral thyroid dose. Recognize possible myxedema coma, summon emergency support, and immediately prioritize airway, breathing, circulation, and close monitoring while preparing for prescribed critical-care treatment.

Hypothyroidism slows body processes, whereas hyperthyroidism speeds them up. Track trends in vital signs, mental status, temperature, weight, and thyroid-function tests, and reinforce safe medication use. Thyroid storm and myxedema coma are life-threatening emergencies: recognize deterioration early, support airway and circulation, monitor closely, and facilitate prompt prescribed treatment.