Hyperthyroidism Nursing Care

To continue our endocrine series, in this blog post we talk about the components of hyperthyroidism nursing care. Hyperthyroidism exists when the thyroid gland is producing too much thyroid hormone. Let’s go through a hyperthyroidism nursing care plan using the Straight A Nursing LATTE method (which you can read about here!).

Before we jump into it, here’s a quick overview. Graves disease, the most common form of hyperthyroidism, occurs when the thyroid gland produces too much thyroxine (T4). It can be an inherited disorder or the result of autoimmune factors. It often occurs in coordination with other endocrine disorders such as diabetes mellitus, hyperparathyroidism and thyroiditis.

The biggest complication of Graves disease is thyrotoxicosis, also known as thyroid storm. This is a life-threatening complication that can lead to renal, cardiac and liver failure. We’ll talk about both Graves disease and thyroid storm as we go through the LATTE acronym.

L: How will the patient LOOK?

The patient with hyperthyroidism can exhibit the following signs/symptoms:

• Goiter, which is an enlarged thyroid gland and appears as an area of localized swelling on the anterior neck (like this here!)
• Feelings of nervousness, may have a noticeable tremor
• Weight loss, with or without an increased appetite
• Heat intolerance and excessive sweating
• Fine or thinning hair; possibly premature graying
• Thin fingernails (though some sources say thick, ridged and brittle nails)
• Heart palpitations, tachycardia
• Diarrhea, nausea, vomiting
• Trouble concentrating, mood swings
• Menstrual irregularity
• Shortness of breath with exertion
• Difficulty climbing stairs
• Opthalmolgic abnormalities called Graves ophthalmopathy. This includes bulging eyes (a condition called exophthalmos), pressure in the eyes, swollen eyelids, inflammation in the eye, double vision, sensitivity to light, even a feeling of having sand or grit in the eye
• Thickened skin over the anterior tibia and dorsum of the feet, may be hyper pigmented and itchy

The patient with thyrotoxicosis (thyroid storm) will have even more signs/symptoms:

• Significant tachycardia
• Moist, warm and flushed skin
• High fever that rises rapidly and can reach lethal levels , often up to 106-degrees F (41.1-degrees C)
• Angina
• Vomiting
• Excessive irritability or nervousness, tremors often present
• Shortness of breath
• Cough
• Edema in the extremities

A: How will you assess the patient?

To assess the patient with Grave’s disease, you’ll want to monitor their weight, severity of symptoms and for the presence of a goiter. Examination of the eye can reveal the many optholmagic symptoms, including exophthalmos. Palpate the pulses…they may be fast and bounding (very strong). Listen to the patient’s heart as you may hear a systolic murmur; listening to the abdomen often reveals increased motility with hyperactive bowel sounds. Another important assessment is to osculate the thyroid gland…hearing a bruit means the patient could be experiencing a thyrotoxic crisis.

Speaking of thyrotoxic crisis, this patient can have life-threatening complications, so. you’ll want to assess:

• Temperature
• Heart rate; EKG
• Blood pressure
• Respiratory rate and effort
• Oxygenation

T: What TESTS will be ordered?

• Standard thyroid function tests include TSH, T4, T3 (high thyroxine with low or no TSH indicates hyperthyroidism)
• Thyroid scans will show increased iodine uptake
• Thyrotropin-releasing hormone simulation test…hyperthyroidism is present if TSH levels do not rise a half hour after administration of the test
• Serum cholesterol levels may be decreased (the opposite is often true in hypothyroidism)
• Serum calcium level to monitor for hypocalcemia when parathyroid gland is removed
• Opthalmolgic ultrasound may be needed to examine the eyes
• Radioimmunoassay will reveal increased T3 and T4 concentrations…this test is not done on pregnant patients due to the risks for the fetus
• A thyroid ultrasound can show images of the thyroid to detect the presence of nodules with the added benefit of no radiation exposure.
• In thyrotoxic crisis, an ABG can provide information about the patient’s pH and oxygenation.

T: What TREATMENTS will be provided?

The mainstays of treatment for hyperthyroidism/Graves are:

• Antithyroid medication: these medications antagonize thyroid hormone. Methimazole and propylthiouraci block the synthesis of thyroid hormone. Pregnant patients will take the lowest possible dose to prevent fetal hypothyroidism from developing. The usual course of therapy for these medications is 6 months to 2 years.
• A medications to manage tachycardia and prevent thyroid storm…propranolol is typically the drug used for this.
• Radioactive iodine is given as a single dose and typically only in patients who are not planning to reproduce since the radioactive iodine can collect in the gonads. Note that some patients may need a second dose, but symptoms typically begin to subside 6 to 8 weeks after the treatment.
• Surgical removal of the thyroid (or partial removal of the thyroid) is used for patients with goiter or who have not responded to medication therapy.
• Treatment for Graves ophthalmopathy include topical medications, corticosteroids and surgical decompression if the case is severe.
• If the parathyroid gland is removed, the patient may need calcium.

A patient having a thyrotoxic crisis will require a specialized and more intense approach. This patient will be in intensive care as the condition is very serious and can be fatal.

• Antithyroid medications
• An iodide to block the release of thyroid hormones
• Corticosteroid to inhibit T3 to T4 conversion; also replaces depleted cortisol that is used up during the crisis
• Propranolol to block SNS and keep tachycardia under control
• Antipyretics, ice packs to groin and axilla
• Oxygen as needed, intubation and mechanical ventilation in respiratory distress
• Patient may need sedation; psychosis can occur
• Plasmapharesis may be used when other therapies have not produced the desired result

E: How will you EDUCATE the patient/family?

• Patients with Graves’ ophthalmopathy should be advised to keep their eyes lubricated with eye drops or a lubricating gel. They should avoid head-down positions that can place extra pressure on the eyes. Also, wearing sunglasses when outdoors can protect the fragile eyes. Also, smoking exacerbates the condition, so these patients should be advised not to smoke or given resource for smoking cessation.
• Regular exercise can reduce anxiety, build bone density, increase muscle tone and benefit the cardiovascular system.
• Take antithyroid medication with meals to minimize GI distress.
• Frequent, small meals to optimize nutrition and prevent weight loss
• Advise patient to avoid excessive palpation of their thyroid gland; overstimulation can cause a thyroid crisis
• Balance rest with activity, avoid stress, get adequate sleep
• Teach patient undergoing total thyroidectomy they’ll need thyroid replacement hormones for life
• After radioactive iodine therapy, saliva is radioactive for 24 hours; patient should cover their mouth when coughing or expectorating.
• If patient has exophthalmos, he may need to wear eye patches with domed structure to avoid abrasion.

Hypothyroid vs Hyperthyroid

When you’re looking at endocrine disorders, you’ll see that some of them are oppositional…a great example of this is hypothyroidism and hyperthyroidism. Here’s a quick little reference sheet to help you keep the two conditions squared away.

Signs/Symptoms
Hypo: Swollen face, lethargy, weight gain, thinning outer third of eyebrows, slow thought processes, cold intolerance
Hyper: Nervousness, tachycardia, weight loss, mood swings, possible goiter, expothalmos, h eat intolerance

Diagnostics
Hypo: High TSH
Hyper: Low or no TSH with elevated T4

Treatments
Hypo: Thyroid hormone (levothyroxine is a common one)
Hyper: Antithyroid medication, iodides, radiated iodine, surgery

Complications
Hypo: Myxedema coma
Hyper: Thyrotoxic crisis (thyroid storm)

I hope this review of hyperthyroidism and the key differences between it and hypothyroidism helps! Best of luck with school!!

Get this on audio in episode 61 on the Straight A Nursing Podcast

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References

Ross, D. S. (2018, January 8). Thyroid storm. Retrieved from UpToDate website: https://www.uptodate.com/contents/thyroid-storm#H3

Hyperthyroidism – Symptoms and causes – Mayo Clinic. (n.d.). Retrieved July 15, 2019, from https://www.mayoclinic.org/diseases-conditions/hyperthyroidism/symptoms-causes/syc-20373659

Mills, E. (n.d.). Handbook of Medical-Surgical Nursing(Fourth). Lippincott Williams & Wilkins.