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Hypothyroidism

Jane is not fond of eating sea foods. She has been living in the city all her life and has grown accustomed to fast foods. At 34, she started noticing a growing lump in her neck area. She consulted her physician and her physician told her that her low iodine levels had lead to goiter, and this may further progress to hypothyroidism.

Description


Thyroid deficiency can affect all body functions and can range from mild, subclinical forms to advanced forms.
  • Hypothyroidism results from suboptimal levels of thyroid hormone.
  • Hypothyroidism also commonly occurs in patients with previous hypothyroidism that has been treated with radioiodine or antithyroid medications or thyroidectomy.
  • The term myxedema refers to the accumulation of mucopolysaccharides in subcutaneous and other interstitial tissues.

Classification


The types of hypothyroidism are classified according to their causes:
  • Central hypothyroidism. There is a failure of the pituitary gland, the hypothalamus, or both to stimulate production of thyroid hormones.
  • Secondary or pituitary hypothyroidism. The cause is entirely a pituitary disorder in secondary hypothyroidism.
  • Tertiary or hypothalamic hypothyroidism. This refers to the cause as a disorder of the hypothalamus resulting in inadequate secretion of TSH due to decreased stimulation of TRH.
  • The thyroid disorder is already present at birth in cretinism.

Hypothyroidism|Statistics and Epidemiology


Hypothyroidism occurs in specific individuals at different instances.
  • Hypothyroidism occurs most frequently in older women.
  • There is an increased incidence of thyroid cancer in men who have undergone radiation therapy for head and neck cancer.
  • More than 95% of patients with hypothyroidism have primary or thyroidal hypothyroidism.

Causes


Several diseases and factors could cause hypothyroidism.
  • The most common cause of hypothyroidism is inflammation of the thyroid gland, which damages the gland’s cells.
  • Autoimmune diseases. The most common cause of hypothyroidism in adults is autoimmune thyroiditis or Hashimoto’s disease.
  • Atrophy of the thyroid gland. The thyroid gland shrinks in size as a result of aging.
  • Therapy for hyperthyroidism. Therapies such as radioactive iodine and thyroidectomy could also cause hypothyroidism.
  • Medications such as lithium, iodine compounds, and antithyroid medications could decrease production of TSH.
  • Iodine deficiency or excess. Imbalance in the iodine levels in the body also affects the thyroid gland.
  • Autoimmune or Hashimoto’s thyroiditis, in which the immune system attacks the thyroid gland, is the most common example of this.
  • Some women develop hypothyroidism after pregnancy (often referred to as “postpartum thyroiditis”).

Clinical Manifestations


The signs and symptoms of hypothyroidism include: Hypothyroidism Signs and Symptoms
  • Extreme fatigue. Extreme fatigue makes it difficult for the person to complete a full day’s work or participate in usual activities.
  • Menstrual disturbances. Menorrhagia or amenorrhea may also occur.
  • Increase in weight. The patient usually begins to gain weight even without an increase in the food intake.
  • Cold intolerance. The patient often complains of being cold even in a warm environment.
  • Thick skin. The skin becomes thickened because of an accumulation of mucoplysaccharides in the subcutaneous tissues.

Prevention


Prevention of hypothyroidism can be achieved with the following:
  • Increase in iodine intake. Iodine intake is the foremost prevention strategy in hypothyroidism.
  • Early detection. Undergoing thyroid tests after a thyroid surgery or therapy could result in early detection and prompt treatment of hypothyroidism.

Complications


Hypothyroidism can be a life-threatening disease if left unchecked.
  • Myxedema coma. This is the decompensated state of severe hypothyroidism in which the patient is hypothermic and unconscious.

Assessment and Diagnostic Findings


Hypothyroidism can be detected in many ways.
  • Physical examination. The thyroid gland is inspected and palpated routinely in all patients.
  • Serum thyroid-stimulating tests. Measurement of the serum TSH concentration is the single best screening test of thyroid function because of its high sensitivity.
  • Serum T3 and T4. Measurement of total T3 or T4 includes protein-bound and free hormone levels that occur in response to TSH secretion.
  • Thyroid antibodies. Results of testing by immunoassay techniques for antithyroid antibodies are positive in Hashimoto’s thyroiditis (100%).

Medical Management


The primary objective in the management of hypothyroidism is to restore a normal metabolic state by replacing the missing hormone.
  • Pharmacologic therapy. Synthetic levothyroxine is the preferred preparation for treating hypothyroidism and suppressing nontoxic goiters.
  • Prevention of cardiac dysfunction. As long as metabolism is subnormal and the tissues require relatively little oxygen, a reduction in the blood supply is tolerated without overt symptoms of coronary artery disease.
  • Supportive therapy. Oxygen saturation levels should be monitored; fluids should be administered cautiously; application of external heat must be avoided, and oral thyroid hormone therapy should be continued.

Nursing Management


Nursing care for a patient with hypothyroidism includes the following:

Nursing Assessment

Assessment of the patient with hypothyroidism should include:
  • Assessment of the thyroid from an interior or posterior position.
  • Auscultation of the lobes of the thyroid gland using the diaphragm of the stethoscope if there are abnormalities palpated.
  • Assess thyroid gland for firmness (Hashimoto’s) or tenderness (thyroiditis).

Diagnosis

Based on the assessment data, the nursing diagnoses appropriate for a patient with hypothyroidism are:

Planning & Goals

To achieve a successful nursing care plan, the following goals should be realized:
  • Increase in participation in activities.
  • Increase in independence.
  • Maintenance of normal body temperature.
  • Return of normal bowel function.
  • Improve respiratory status.
  • Maintenance of normal breathing pattern.
  • Improve thought processes.

Nursing Interventions

Nursing interventions for a patient with hypothyroidism include the following:
  • Promote rest. Space activities to promote rest and exercise as tolerated.
  • Protect against coldness. Provide extra layer of clothing or extra blanket.
  • Avoid external heat exposure. Discourage and avoid the use of external heat source.
  • Mind the temperature. Monitor patient’s body temperature.
  • Increase fluid intake. Encourage increased fluid intake within the limits of fluid restriction.
  • Provide foods high in fiber.
  • Manage respiratory symptoms. Monitor respiratory depth, rate, pattern, pulse oximetry, and ABG.
  • Pulmonary exercises. Encourage deep breathing, coughing, and use of incentive spirometry.
  • Orient to present surroundings. Orient patient to time, place, date, and events around him or her.

Evaluation

A successful nursing care plan has achieved the following goals:
  • Increased participation in activities.
  • Increased independence.
  • Maintained normal body temperature.
  • Return of normal bowel function.
  • Improved respiratory status.
  • Maintained normal breathing pattern.
  • Improved thought processes.

Discharge and Home Care Guidelines

At the completion of the home care instruction, the patient or caregiver will be able to:
  • Medication compliance. State that compliance to medical regimen is life-long.
  • Cold intolerance. State the need to avoid extreme cold temperature until condition is stable.
  • Follow-up visits. State the importance of regular follow-up visits with health care provider.
  • Weight reduction. Identify strategies for weight reduction and prevention of constipation such as high-fiber, low-calorie intake and adequate fluid intake.

Hypothyroidism|Documentation Guidelines

The focus of documentation should include:
  • Level of activity.
  • Vital signs before, during, and after activity.
  • Record of core temperature, initially and prn.
  • Results of laboratory and diagnostic studies.
  • Usual and current bowel pattern, duration of the problem, and individual contributing factors.
  • Characteristics of stool.
  • Respiratory pattern, breath sounds, and use of accessory muscles.
  • Plan of care.
  • Teaching plan.
  • Response to interventions, teaching, and actions performed.
  • Attainment or progress toward desired outcomes.
  • Modifications to plan of care.
  • Long term needs.

Practice Quiz: Hypothyroidism


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1. The preferred medication for treating hypothyroidism is: A. Lithium. B. Propranolol. C. Propylthiouracil. D. Synthroid. 2. A clinical manifestation usually associated with hypothyroidism is: A. A pulse rate lower than 95 bpm but greater than 60 bpm. B. An elevated systolic blood pressure. C. Muscular fatigability. D. Weight loss. 3. Nursing care for a patient with hypothyroidism includes assessing for clinical manifestations associated with hypothyroidism. A manifestation not consistent with her diagnosis is a: A. Change in her menstrual pattern. B. Pulse rate of 58 bpm. C. Temperature of 95.88 ºF. D. Weight loss of 10 lbs over a 2-week period. 4. The principle objective of medical management is to: A. Irradiate the gland in an attempt to stimulate hormonal secretion. B. Replace the missing hormone. C. Remove the diseased gland. D. Withhold exogenous iodine to create a negative feedback response, which will force the gland to secrete hormones. 5. Nursing comfort measures for a patient with hypothyroidism should include: A. Encouraging frequent periods of rest throughout the day. B. Offering the patient additional blankets to help prevent chilling. C. Using a cleansing lotion instead of soap for the skin. D. All of the above. Answers and Rationale
1. Answer: D. Synthroid.
  • D: Synthetic levothyroxine is the preferred preparation for treating hypothyroidism and suppressing nontoxic goiters.
  • A: Lithium is not recommended for patients with hypothyroidism.
  • B: Propranolol is not recommended for patients with hypothyroidism.
  • C: Propylthiouracil is not recommended for patients with hypothyroidism.
2. Answer: C. Muscular fatigability.
  • C: Extreme fatigue makes it difficult for the person to complete a full day’s work or participate in usual activities.
  • A: A pulse rate lower than 95 bpm but greater than 60 bpm is considered normal.
  • B: An elevated systolic blood pressure is not a sign of hypothyroidism.
  • D: Weight loss is not a sign of hypothyroidism.
3. Answer: D. Weight loss of 10 lbs over a 2-week period.
  • D: Weight gain occurs in hypothyroidism.
  • A: A change in her menstrual pattern is a sign of hyperthyroidism.
  • B: A pulse rate of 58 bpm is a sign of hyperthyroidism.
  • C: A temperature of 95.88⁰F is a sign of hyperthyroidism.
4. Answer: B. Replace the missing hormone.
  • B: To balance the level of thyroid hormones, the principal objective of medical management should be to replace the missing hormone.
  • A: Irradiating the gland could worsen the disorder.
  • C: Removing the diseased gland could worsen the disorder.
  • D: Withholding exogenous iodine could worsen the disorder.
5. Answer: D. All of the above.
  • D: All of the interventions listed above are appropriate for a patient with hypothyroidism.
  • A: Promoting rest could avoid extreme fatigue.
  • B: Additional blankets could prevent chilling for the cold-intolerant patient.
  • C: Using a cleansing lotion could moisturize the dry skin instead of soap.

See Also


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