Hypothyroidism Nursing Care Management and Study Guide

Hypothyroidism slows every system, so the floor picture is a cold, fatigued, constipated patient with depressed ventilation and slowed cognition. Your priorities are pacing activity against fatigue, keeping the patient warm without external heat, protecting the airway, and confirming lifelong levothyroxine adherence. The emergency to never miss is myxedema coma.

Hypothyroidism

Thyroid deficiency affects all body functions and ranges from mild, subclinical disease to advanced forms. It results from suboptimal thyroid hormone levels and commonly follows prior treatment with radioiodine, antithyroid medications, or thyroidectomy. Myxedema is the accumulation of mucopolysaccharides in subcutaneous and other interstitial tissues.

Classification

Hypothyroidism is classified by cause. Central hypothyroidism is failure of the pituitary, the hypothalamus, or both to stimulate thyroid hormone production. Secondary (pituitary) hypothyroidism is caused entirely by a pituitary disorder. Tertiary (hypothalamic) hypothyroidism stems from a hypothalamic disorder that drops TSH through reduced TRH stimulation. In cretinism the thyroid disorder is present at birth.

Statistics and Epidemiology

Hypothyroidism occurs most often in older women. Thyroid cancer incidence is increased in men who underwent radiation therapy for head and neck cancer. More than 95% of patients with hypothyroidism have primary, or thyroidal, hypothyroidism.

Causes

The most common cause is inflammation that damages the gland's cells. In adults the leading cause is autoimmune thyroiditis (Hashimoto's disease), in which the immune system attacks the thyroid. The gland also atrophies and shrinks with aging. Treatments for hyperthyroidism, including radioactive iodine and thyroidectomy, can produce it, as can lithium, iodine compounds, and antithyroid medications that reduce TSH production. Both iodine deficiency and excess affect the gland. Some women develop hypothyroidism after pregnancy (postpartum thyroiditis).

Clinical Manifestations

Extreme fatigue makes a full day's work or usual activity difficult. Menstrual disturbances such as menorrhagia or amenorrhea occur. The patient gains weight without eating more and feels cold even in a warm room. Skin thickens from mucopolysaccharide accumulation in the subcutaneous tissue.

Prevention

Adequate iodine intake is the foremost prevention strategy. Thyroid testing after thyroid surgery or therapy allows early detection and prompt treatment.

Complications

Myxedema coma is the decompensated state of severe hypothyroidism in which the patient is hypothermic and unconscious. It is life-threatening.

Assessment and Diagnostic Findings

Inspect and palpate the thyroid routinely. Serum TSH is the single best screening test because of its high sensitivity. Total T3 and T4 measure protein-bound and free hormone produced in response to TSH. Antithyroid antibody testing by immunoassay is positive in Hashimoto's thyroiditis (100%).

Medical Management

The objective is to restore a normal metabolic state by replacing the missing hormone. Synthetic levothyroxine is the preferred preparation for treating hypothyroidism and suppressing nontoxic goiters. Because subnormal metabolism means tissues need little oxygen, reduced blood supply is tolerated without overt coronary symptoms, so restore hormone carefully to protect the heart. Supportive care: monitor oxygen saturation, give fluids cautiously, avoid applying external heat, and continue oral thyroid hormone therapy.

Nursing Management

Nursing Assessment

Assess the thyroid from an anterior or posterior position. Auscultate the lobes with the diaphragm if abnormalities are palpated, and assess for firmness (Hashimoto's) or tenderness (thyroiditis).

Diagnosis

Common diagnoses include activity intolerance related to fatigue and depressed cognition, risk for imbalanced body temperature related to cold intolerance, constipation related to depressed GI function, ineffective breathing pattern related to depressed ventilation, and disturbed thought processes related to depressed metabolism and altered cardiovascular and respiratory status.

Planning & Goals

Goals: increased activity and independence, normal body temperature, return of normal bowel function, improved respiratory status and breathing pattern, and improved thought processes.

Nursing Interventions

Space activities to balance rest and tolerated exercise. Protect against cold with an extra layer of clothing or a blanket, and avoid external heat sources. Monitor body temperature. Encourage increased fluid intake within any fluid restriction and provide high-fiber foods. Monitor respiratory depth, rate, pattern, pulse oximetry, and ABG, and encourage deep breathing, coughing, and incentive spirometry. Orient the patient to time, place, date, and surrounding events.

Evaluation

Expected outcomes: increased participation and independence, maintained normal body temperature, return of normal bowel function, improved respiratory status and breathing pattern, and improved thought processes.

Discharge and Home Care Guidelines

Teach that medication compliance is lifelong. Have the patient avoid extreme cold until stable, keep regular followup visits, and use strategies for weight reduction and constipation prevention such as high-fiber, low-calorie intake and adequate fluids.

Documentation Guidelines

Document activity level; vital signs before, during, and after activity; core temperature initially and as needed; lab and diagnostic results; usual and current bowel pattern with duration and contributing factors; stool characteristics; respiratory pattern, breath sounds, and accessory muscle use; the plan and teaching plan; response to interventions; progress toward outcomes; modifications to the plan; and long-term needs.