Syllabus on Hyperthyroidism & Hypothyroidism

Submitted to:
Asst. Prof. Osel Sherwin Melad

Submitted by:
Angel Clyla Amit
 COLLEGE OF NURSING
Silliman University
Dumaguete City

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Placement: NCM 106A, Level IV, Ward Class Report
Time Allotment: 1 hr.
Topic Description: This deal on what is hyperthyroidism & hypothyroidism and what could be the possible complications if not taken care of. This also talks on
how to manage hyperthyroidism and hypothyroidism and live a healthy lifestyle.
Central Objectives: At the end of 30-45 minutes, the students shall gain sufficient knowledge on what is hyperthyroidism and hypothyroidism and its
complications if not managed well, develop deeper understanding on the importance of managing hyperthyroidism & hypothyroidism
especially to those people who are of a great risk of having this, and apply the different learned nursing managements into action and in the
actual setting.

Specific Objectives Content T-L Time Assessment

Strategies/Activities Allotted

At the end of 30-45

minutes, the students will
be able to:

 Question and
I. Hyperthyroidisms answer
1. State accurately  Socialized
what is a. Definition of hyperthyroidism Discussion
Lecture with Power 3 minutes
hyperthyroidism,  is hyperactivity of the thyroid gland with
sustained increase in synthesis and release of Point Presentation
its different key
concepts and type thyroid hormones. Hyperthyroidism occurs in
and determine women more than men, with the highest
what causes it to frequency in persons 20 to 40 years old. The most
happen. common form of hyperthyroidism is Graves’
disease. Other causes include toxic nodular
2. Determine some goiter, thyroiditis, excess iodine intake, pituitary
clinical tumors, and thyroid cancer. The term
thyrotoxicosis refers to the physiologic effects or
 manifestation clinical syndrome of hypermetabolism that results
associated with from excess circulating levels of T4, T3, or both.
hyperthyroidism Hyperthyroidism and thyrotoxicosis usually occur
together, as seen in Graves’ disease.

b. Etiology and pathophysiology

3. Determine the  Grave’s Disease Video presentation 5 minutes
diagnostic studies  is an autoimmune disease of unknown
and examinations etiology characterized by diffuse thyroid
done associated enlargement and excessive thyroid
with hypertension. hormone secretion. Graves’ disease
4. Enumerate the accounts for up to 80% of the cases of
drugs used in hyperthyroidism. Women are five times
order to lower more likely than men to develop Graves’
hyperthyroidism disease. Precipitating factors such as
insufficient iodine supply, infection, and
stressful life events may interact with
genetic factors to cause Graves’ disease.
Cigarette smoking increases the risk of
Graves’ disease and the development of
eye problems associated with the disease.

 In Graves’ disease the patient develops

antibodies to the TSH receptor. These
antibodies attach to the receptors and
stimulate the thyroid gland to release T3,
T4, or both. The excessive release of
5. Identify one thyroid hormones leads to the clinical
nursing diagnosis manifestations associated with
and its nursing thyrotoxicosis. The disease is
interventions. characterized by remissions and
exacerbations, with or without treatment.
It may progress to destruction of the
 thyroid tissue, causing hypothyroidism.

c. Clinical manifestations
 Clinical manifestations of hyperthyroidism are Lecture with Power 10
related to the effect of excess circulating thyroid Point Presentation minutes
hormone. It directly increases metabolism and
tissue sensitivity to stimulation by the
6. State accurately sympathetic nervous system.
what is
hypothyroidism,  Palpation of the thyroid gland may reveal a
its different key goiter. When the thyroid gland is excessively
concepts and type large, a goiter may be noted on inspection.
and determine Auscultation of the thyroid gland may reveal
what causes it to bruits, a reflection of increased blood supply.
happen. Another common finding is ophthalmopathy, a
term used to describe abnormal eye appearance or
function. A classic finding in Graves’ disease is
exophthalmos, a protrusion of the eyeballs from
the orbits that is usually bilateral . Exophthalmos
results from increased fat deposits and fluid
(edema) in the orbital tissues and ocular muscles.
The increased pressure forces the eyeballs
7. Determine some outward. The upper lids are usually retracted and
clinical elevated, with the sclera visible above the iris.
manifestation When the eyelids do not close completely, the
associated with exposed corneal surfaces become dry and
hypothyroidism irritated. Serious consequences, such as corneal
ulcers and eventual loss of vision, can occur. The
changes in the ocular muscles result in muscle
weakness, causing diplopia.

 A patient in the early stages of hyperthyroidism

may exhibit only weight loss and increased
 nervousness. Acropachy (clubbing of the digits)
may occur with advanced disease. Manifestations
8. Enumerate the (e.g., palpitations, tremors, weight loss) in older
drugs used in adults with hyperthyroidism do not differ
order to treat significantly from those of younger adults. In
hypothyroidism older patients with reports of confusion and
9. Identify one agitation, dementia may be suspected and delay
nursing diagnosis the diagnosis.
and its nursing
interventions. d. Complications
 Thyrotoxicosis (also called thyrotoxic crisis or
thyroid storm) is an acute, severe, and rare
condition that occurs when excessive amounts of
thyroid hormones are released into the
circulation. Although it is considered a life-
threatening emergency, death is rare when
treatment is initiated early. Thyrotoxicosis is
thought to result from stressors (e.g., infection,
trauma, surgery) in a patient with preexisting
hyperthyroidism, either diagnosed or
undiagnosed. Patients particularly prone to
thyrotoxicosis are those having a thyroidectomy,
since manipulation of the hyperactive thyroid
gland results in an increase in hormones released.
In thyrotoxicosis, all the symptoms of
hyperthyroidism are prominent and severe.
Manifestations include severe tachycardia, heart
failure, shock, hyperthermia (up to 105.3° F
[40.7° C]), restlessness, irritability, seizures,
abdominal pain, vomiting, diarrhea, delirium, and
coma. Treatment is aimed at reducing circulating
thyroid hormone levels and the clinical
manifestations with appropriate drug therapy.
 Supportive therapy is directed at managing
respiratory distress, reducing fever, replacing
fluid, and eliminating or managing the initiating
stressor(s).

e. Diagnostic studies
 The two primary laboratory findings used to
confirm the diagnosis of hyperthyroidism are
decreased TSH levels and elevated free thyroxine
(free T4) levels. Total T3 and T4 levels may also
be assessed, but they are not as definitive. Total
T3 and T4 determine both free and bound (to
protein) hormone levels. The free hormone is the
only biologically active form of these hormones.
 The RAIU test is used to differentiate Graves’
disease from other forms of thyroiditis. The
patient with Graves’ disease shows a diffuse,
homogeneous uptake of 35% to 95%, whereas the
patient with thyroiditis shows an uptake of less
than 2%. The person with a nodular goiter has an
uptake in the high normal range.
f. Collaborative care
The goal of management of hyperthyroidism is to block
the adverse effects of excessive thyroid hormone,
suppress oversecretion of thyroid hormone, and prevent
complications. There are several treatment options,
including antithyroid medications, radioactive iodine
therapy, and surgical intervention. The choice of
treatment is influenced by the patient’s age and
preferences, coexistence of other diseases, and pregnancy
status.
 Drug herapy
Drugs used in the treatment of
hyperthyroidism include antithyroid drugs,
iodine, and β-adrenergic blockers. These
drugs are useful in the treatment of thyrotoxic
states, but they are not considered curative.
Radiation therapy or surgery may ultimately
be required.

 Antithyroid drugs
The first-line antithyroid drugs are
propylthiouracil (PTU) and methimazole
(Tapazole). These drugs inhibit the
synthesis of thyroid hormones. Indications
for the use of antithyroid drugs include
Graves’ disease in the young patient,
hyperthyroidism during pregnancy, and
the need to achieve a euthyroid state
before surgery or radiation therapy. PTU
is generally used for patients who are in
their first trimester of pregnancy, have an
adverse reaction to methimazole, or
require a rapid reduction in symptoms.
PTU is also considered first line in
thyrotoxicosis, since it also blocks the
peripheral conversion of T4 to T3. The
advantage of PTU is that it achieves the
therapeutic goal of being euthyroid more
quickly, but it must be taken three times
per day. In contrast, methimazole is given
in a single daily dose.

Individuals vary, but improvement usually

 begins 1 to 2 weeks after the start of drug
therapy. Good results are usually seen
within 4 to 8 weeks. Therapy is usually
continued for 6 to 15 months to allow for
spontaneous remission, which occurs in
20% to 40% of patients. Emphasize to the
patient the importance of adherence to the
drug regimen. Abrupt discontinuation of
drug therapy can result in a return of
hyperthyroidism.

 Iodine
Iodine is used with other antithyroid drugs
to prepare the patient for thyroidectomy or
for treatment of thyrotoxicosis. The
administration of iodine in large doses
rapidly inhibits synthesis of T3 and T4
and blocks the release of these hormones
into circulation. It also decreases the
vascularity of the thyroid gland, making
surgery safer and easier. The maximal
effect of iodine is usually seen within 1 to
2 weeks. Because of a reduction in the
therapeutic effect, long-term iodine
therapy is not effective in controlling
hyperthyroidism. Iodine is available in the
form of saturated solution of potassium
iodine (SSKI) and Lugol’s solution.

 B-adrenergic Blockers
β-Adrenergic blockers are used for
symptomatic relief of thyrotoxicosis.
These drugs block the effects of
 sympathetic nervous stimulation, thereby
decreasing tachycardia, nervousness,
irritability, and tremors. Propranolol is
usually administered with other
antithyroid agents. Atenolol is the
preferred β-adrenergic blocker for use in
the hyperthyroid patient with asthma or
heart disease.

 Radioactive iodine herapy

 Radioactive iodine (RAI) therapy is the
treatment of choice for most nonpregnant
adults. RAI damages or destroys thyroid
tissue, thus limiting thyroid hormone
secretion. RAI has a delayed response,
and the maximum effect may not be seen
for up to 3 months. For this reason, the
patient is usually treated with antithyroid
drugs and propranolol before and for 3
months after the initiation of RAI until the
effects of radiation become apparent.
Although RAI is usually effective, it has a
high incidence of posttreatment
hypothyroidism (80% of adequately
treated persons), resulting in the need for
lifelong thyroid hormone therapy. Teach
the patient and the family about the
symptoms of hypothyroidism and to seek
medical help if these symptoms occur.
 RAI therapy is usually administered on an
outpatient basis. A pregnancy test is done
before initiation of therapy on all women
who experience menstrual cycles. Instruct
 the patient that radiation thyroiditis and
parotiditis are possible and may cause
dryness and irritation of the mouth and
throat. Relief may be obtained with
frequent sips of water, ice chips, or a salt
and soda gargle three or four times per
day. This gargle is made by dissolving 1
tsp of salt and 1 tsp of baking soda in 2
cups of warm water. The discomfort
should subside in 3 to 4 days. A mixture
of antacid (Mylanta or Maalox),
diphenhydramine (Benadryl), and viscous
lidocaine can be used to swish and spit,
increasing patient comfort when eating.
To limit radiation exposure to others,
instruct the patient receiving RAI on the
importance of home precautions,
including (1) using private toilet facilities
if possible and flushing two or three times
after each use; (2) separately laundering
towels, bed linens, and clothes daily at
home; (3) not preparing food for others
that requires prolonged handling with bare
hands; and (4) avoiding being close to
pregnant women or children for 7 days
after therapy.

 Surgical therapy
 Thyroidectomy
is indicated for individuals who have (1) a
large goiter causing tracheal compression,
(2) been unresponsive to antithyroid
therapy, or (3) thyroid cancer.
 Additionally, surgery may be done when
an individual is not a candidate for RAI.
One advantage that thyroidectomy has
over RAI is a more rapid reduction in T3
and T4 levels.

 Subtotal thyroidectomy
is often the preferred surgical procedure
and involves the removal of a significant
portion (90%) of the thyroid gland.

 Endoscopic thyroidectomy
is a minimally invasive procedure. Several
small incisions are made, and a scope is
inserted. Instruments are passed through
the scope to remove thyroid tissue or
nodules. Endoscopic thyroidectomy is an
appropriate procedure for patients with
small nodules (less than 3 cm) and no
evidence of malignancy. Advantages of
endoscopic thyroidectomy over open
thyroidectomy include less scarring, less
pain, and a faster return to normal
activity.

 Nutritional therapy
With the increased metabolic rate in hyperthyroid
patients, there is a high potential for the patient to
have a nutritional deficit. A high-calorie diet
(4000 to 5000 cal/day) may be ordered to satisfy
hunger, prevent tissue breakdown, and decrease
weight loss. This can be accomplished with six
full meals a day and snacks high in protein,
 carbohydrates, minerals, and vitamins. The
protein content should be 1 to 2 g/kg of ideal
body weight. Increase carbohydrate intake to
compensate for increased metabolism.
Carbohydrates provide energy and decrease the
use of body-stored protein. Teach the patient to
avoid highly seasoned and high-fiber foods
because these foods can further stimulate the
already hyperactive GI tract. Instruct the patient
to avoid caffeine-containing liquids such as
coffee, tea, and cola to decrease the restlessness
and sleep disturbances associated with these
fluids. Refer the patient to a dietitian for help in
meeting individual nutritional needs. Socialized discussion 15
g. Nursing Management minutes

 Nursing Diagnosis
Nursing diagnoses for the patient with
hyperthyroidism include, but are not limited to,
the following:
 Activity intolerance related to fatigue and
heat intolerance
 Imbalanced nutrition: less than body
requirements related to hypermetabolism
and inadequate food intake

 Planning
The overall goals are that the patient with
hyperthyroidism will (1) experience relief of
symptoms, (2) have no serious complications
related to the disease or treatment, (3) maintain
nutritional balance, and (4) cooperate with the
therapeutic plan.
 Nursing implementation
Acute thyrotoxicosis is a systemic syndrome that
requires aggressive treatment, often in an
intensive care unit. Administer medications
(previously discussed) that block thyroid
hormone production and the sympathetic nervous
system. Provide supportive therapy, including
monitoring for cardiac dysrhythmias and
decompensation, ensuring adequate oxygenation,
and administering IV fluids to replace fluid and
electrolyte losses. This is especially important in
the patient who experiences fluid losses due to
vomiting and diarrhea. Ensuring adequate rest
may be a challenge because of the patient’s
irritability and restlessness. Provide a calm, quiet
room because increased metabolism and
sensitivity of the sympathetic nervous system
causes sleep disturbances. Other interventions
may include (1) placing the patient in a cool room
away from very ill patients and noisy, high-traffic
areas; (2) using light bed coverings and changing
the linen frequently if the patient is diaphoretic;
and (3) encouraging and assisting with exercise
involving large muscle groups (tremors can
interfere with small-muscle coordination) to
allow the release of nervous tension and
restlessness. It is important to establish a
supportive, trusting relationship to facilitate
coping by a patient who is irritable, restless, and
anxious. If exophthalmos is present, there is a
potential for corneal injury related to irritation
and dryness. The patient may have orbital pain.
 Nursing interventions to relieve eye discomfort
and prevent corneal ulceration include applying
artificial tears to soothe and moisten conjunctival
membranes. Salt restriction may help reduce
periorbital edema. Elevate the patient’s head to
promote fluid drainage from the periorbital area.
The patient should sit upright as much as
possible. Dark glasses reduce glare and prevent
irritation from smoke, air currents, dust, and dirt.
If the eyelids cannot be closed, lightly tape them
shut for sleep. To maintain flexibility, teach the
patient to exercise the intraocular muscles several
times a day by turning the eyes in the complete
range of motion. Good grooming can help reduce
the loss of self-esteem from an altered body
image. If the exophthalmos is severe, treatment
options include corticosteroids, radiation of
retroorbital tissues, orbital decompression, or
corrective lid or muscle surgery.

II. Hypothyroidism

a. Definition of Hypothyroidism Lecture with Power 3 minutes

is a deficiency of thyroid hormone that causes a general Point Presentation
slowing of the metabolic rate. About 4% of the U.S.
population has mild hypothyroidism, with about 0.3%
having more severe disease.Hypothyroidism is more
common in women than men.
Video presentation 5 minutes
b. Etiology and Pathophysiology

 Primary hypothyroidism
is caused by destruction of thyroid tissue or
 defective hormone synthesis.

 Secondary hypothyroidism
is caused by pituitary disease with decreased TSH
secretion or hypothalamic dysfunction with
decreased thyrotropinreleasing hormone (TRH)
secretion. Hypothyroidism may also be transient
and related to thyroiditis or discontinuance of
thyroid hormone therapy.

Iodine deficiency is the most common cause of

hypothyroidism worldwide. In the United States,
the most common cause of primary
hypothyroidism is atrophy of the thyroid gland.
This atrophy is the end result of Hashimoto’s
thyroiditis or Graves’ disease. These autoimmune
diseases destroy the thyroid gland.
Hypothyroidism may also develop due to
treatment for hyperthyroidism, specifically the
surgical removal of the thyroid gland or RAI
therapy. Drugs such as amiodarone (Cordarone)
(contains iodine) and lithium (blocks hormone
production) can cause hypothyroidism.

Hypothyroidism that develops in infancy

(cretinism) is caused by thyroid hormone
deficiencies during fetal or early neonatal life. All
infants in the United States are screened for
decreased thyroid function at birth.
c. Clinical manifestations
Regardless of the cause, hypothyroidism has common Lecture with Power 10 mins
features. It has systemic effects characterized by a Point Presentation
slowing of body processes. Manifestations vary
depending on the severity and the duration of thyroid
deficiency, as well as the patient’s age at the onset of the
deficiency. The onset of symptoms may occur over
months to years unless hypothyroidism occurs after a
thyroidectomy, after thyroid ablation, or during treatment
with antithyroid drugs

The patient is often fatigued and lethargic and

experiences personality and mental changes, including
impaired memory, slowed speech, decreased initiative,
and somnolence. Many individuals with hypothyroidism
appear depressed. Weight gain is most likely a result of a
decreased metabolic rate.

Hypothyroidism is associated with decreased cardiac

contractility and decreased cardiac output. Thus the
patient may experience low exercise tolerance and
shortness of breath on exertion. Hypothyroidism may
cause significant cardiovascular problems, especially in a
person with previous cardiovascular disorders.

Anemia is a common feature of hypothyroidism.

Erythropoietin levels may be low or normal. Because the
metabolic rate is lower, oxygen demand is reduced.
Other hematologic problems are related to cobalamin,
iron, and folate deficiencies. The patient may bruise
easily. Increased serum cholesterol and triglyceride
levels and the accumulation of mucopolysaccharides in
the intima of small blood vessels can result in coronary
 atherosclerosis.

Patients with severe, long-standing hypothyroidism may

display myxedema, which alters the physical appearance
of the skin and subcutaneous tissues with puffiness,
facial and periorbital edema, and a masklike affect.
Myxedema occurs due to the accumulation of
hydrophilic mucopolysaccharides in the dermis and other
tissues. Individuals with hypothyroidism may describe an
altered self-image related to their disabilities and altered
appearance.

In the older adult the typical manifestations of

hypothyroidism (including fatigue, cold and dry skin,
hoarseness, hair loss, constipation, and cold intolerance)
may be attributed to normal aging. For this reason, the
patient’s symptoms may not raise suspicion of an
underlying condition. Older adults who have confusion,
lethargy, and depression should be evaluated for thyroid
disease.

d. Complications
The mental sluggishness, drowsiness, and lethargy of
hypothyroidism may progress gradually or suddenly to a
notable impairment of consciousness or coma. This
situation, termed myxedema coma, is a medical
emergency. Myxedema coma can be precipitated by
infection, drugs (especially opioids, tranquilizers, and
barbiturates), exposure to cold, and trauma. It is
characterized by subnormal temperature, hypotension,
and hypoventilation. Cardiovascular collapse can result
from hypoventilation, hyponatremia, hypoglycemia, and
lactic acidosis. For the patient to survive a myxedema
 coma, vital functions must be supported and IV thyroid
hormone replacement administered.

e. Diagnostic studies
The most common and reliable laboratory tests for
thyroid function are TSH and free T4. These values,
correlated with symptoms gathered from the history and
physical examination, confirm the diagnosis of
hypothyroidism. Serum TSH levels help determine the
cause of hypothyroidism. Serum TSH is high when the
defect is in the thyroid and low when it is in the pituitary
or the hypothalamus. The presence of thyroid antibodies
suggests an autoimmune origin of the hypothyroidism.
Other abnormal laboratory findings are elevated
cholesterol and triglycerides, anemia, and increased
creatine kinase.

f. Collaborative Care
The treatment goal for a patient with hypothyroidism is
restoration of a euthyroid state as safely and rapidly as
possible with hormone therapy. A low-calorie diet is also
indicated to promote weight loss or prevent weight gain.

 Nutritional therapy
 Low-calorie diet
 Drug therapy
 Levothyroxine
Levothyroxine (Synthroid) is the drug of
choice to treat hypothyroidism. In the
young and otherwise healthy patient, the
maintenance replacement dosage is
adjusted according to the patient’s
 response and laboratory findings. When
thyroid hormone therapy is initiated, the
initial dosages are low to avoid increases
in resting heart rate and BP. In the patient
with compromised cardiac status, careful
monitoring is needed when starting and
adjusting the dosage because the usual
dose may increase myocardial oxygen
demand. The increased oxygen demand
may cause angina and cardiac
dysrhythmias.
 Liotrix
Liotrix is a synthetic mix of levothyroxine
(T4) and liothyronine (T3) in a 4 : 1
combination. Levothyroxine has a peak of
action of 1 to 3 weeks. In contrast, liotrix
has a faster onset of action with a peak of
2 to 3 days. Liotrix can be used in acutely
ill individuals with hypothyroidism

g. Nursing management Socialized discussion 15

minutes
 Nursing Assessment
Careful assessment may reveal early and subtle
changes in a patient suspected of having
hypothyroidism. Note any previous history of
hyperthyroidism and treatment with antithyroid
medications, radioactive iodine, or surgery. Ask
the patient about prescribed iodine-containing
medications and any changes in appetite, weight,
activity level, speech, memory, and skin such as
increased dryness or thickening. Assess for cold
intolerance, constipation, and signs of depression.
 Further assessment should focus on heart rate,
tenderness over the thyroid gland, and edema in
the extremities and face.

 Nursing Diagnosis
Nursing diagnoses for the patient with
hypothyroidism may include, but are not limited
to, the following:
 Imbalanced nutrition: more than body
requirements related to calorie intake in
excess of metabolic rate
 Constipation related to GI hypomotility
 Impaired memory related to
hypometabolism
 Planning
The overall goals are that the patient with
hypothyroidism will (1) experience relief of
symptoms, (2) maintain a euthyroid state, (3)
maintain a positive self-image, and (4) comply
with lifelong thyroid therapy.

 Nursing implementation
Administer thyroid hormone therapy and all other
medications IV because paralytic ileus may be
present in myxedema coma. Monitor the core
temperature because hypothermia often occurs in
myxedema coma. Use soap gently and moisturize
frequently to prevent skin breakdown. Frequent
changes in patient positioning and a low-pressure
mattress can also assist in maintaining skin
integrity.

Monitor the patient’s progress by assessing vital

 signs, body weight, fluid intake and output, and
visible edema. Cardiac assessment is especially
important because the cardiovascular response to
hormone therapy determines the medication
regimen. Note energy level and mental alertness,
which should increase within 2 to 14 days and
continue to improve steadily to normal levels.
The patient’s neurologic status and free T4 levels
are used to determine continuing treatment.

References:

Bucher, Dirksen, Heitkemper, & Lewis. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed.). Missouri, USA: Mosby,
Elsevier Inc.

Ignativicus, D., & Workman, L. (2010). Medical surgical nursing: Patient-centered collaborative care (6th ed.). Missouri, USA: Saunders Elseviers.

Bare, B., et al. (2010). Brunner & suddarth’s textbook of medical-surgical nursing(12th ed,vol 2). Philadelphia, PA: Lippincott Williams & Wilkins.

Burcher, Dirksen, Heitkemper, Lewis, O’Brien. (2008). Medical -surgical nursing. 7 t h ed. Vol. 1. Elsevier : Philippines.