3/31/2020 Hyperthyroidism | Diseases and Disorders

Hyperthyroidism

General
DRG Category: 644

Mean LOS: 4.5 days

Description MEDICAL: Endocrine Disorders With CC

Classification Section

Nursing Type Primary: acute care

Nursing Type Secondary: not applicable

System Primary: endocrinologic

System Secondary: not applicable

Introduction
Hyperthyroidism is a condition caused by excessive overproduction of thyroid hormone by the thyroid gland. The
thyroid hormones (triiodothyronine [T3] and thyroxine [T4]), produced in the thyroid gland under the control of thyroid-
stimulating hormone (TSH), regulate the body's metabolism. Sustained thyroid hormone overproduction, therefore,
causes a hypermetabolic state that affects most of the body organs, such as the heart, gastrointestinal tract, brain,
muscles, eyes, and skin.

The seriousness of the disease depends on the degree of hypersecretion of the thyroid hormones. As the levels of
thyroid hormones rise, the risk of life-threatening cardiac problems becomes progressively greater. The most common
form of hyperthyroidism is called Graves disease or thyrotoxicosis. Graves disease is associated with
hyperthyroidism, eye disorders, and skin disorders, and when uncontrolled, vital organs are stressed to their capacity.
It is also associated with many autoimmune diseases such as diabetes mellitus, Addison disease, systemic lupus
erythematosus, rheumatoid arthritis, myasthenia gravis, and pernicious anemia. Risk factors include tobacco use,
high iodine intake, stress, and use of sex steroids.

Cardiac stress from increased myocardial oxygen requirements can lead to serious cardiovascular complications,
such as systolic hypertension, life-threatening dysrhythmias, myocardial infarction, or heart failure. Large goiters can
cause pressure on the neck and trachea, which can result in respiratory distress. Ophthalmopathy can result in
corneal ulceration and loss of vision. Metabolic hyperactivity can cause high levels of anxiety, insomnia, and
psychoses. The most severe form of hyperthyroidism is thyrotoxic crisis, known also as thyroid storm or
thyrotoxicosis. This condition, which occurs when the body can no longer tolerate the hypermetabolic state, is a
nursing and medical emergency and is fatal if not treated. Thyroid storm may be precipitated by a physiological
stressor such as diabetic ketoacidosis, infection, trauma, or surgery.

Causes
Graves disease has an autoimmune derivation and is caused by circulating anti-TSH autoantibodies that displace
TSH from the thyroid receptors and mimic TSH by activating the TSH receptor to release additional thyroid hormones.
Graves disease is also associated with Hashimoto disease, a chronic inflammation of the thyroid gland that usually
causes hypothyroidism but can also cause symptoms similar to those of Graves disease.

Thyrotoxicosis has several different pathophysiological causes, including autoimmune disease, functioning thyroid
adenoma, and infection.

Genetic Considerations
Hyperthyroidism has a strong genetic component, with heritability estimated at 40% to 60%. Mutations in the thyroid-
stimulating hormone receptor (TSHR) cause a nonautoimmune form of hyperthyroidism that is inherited in an

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autosomal dominant manner. The autoimmune form of hyperthyroidism, Graves disease, is caused by mutations in
several genes and follows either an autosomal recessive or x-linked inheritance pattern. Loci linked with Graves
disease include chromosome 6p11, CTKA4 on 2q33, AITD1, CTLA4, GRD1, GRD2, GRD3, HT1, and HT2. Other loci
and the human leukocyte antigen (HLA) region types are linked with Graves disease in people of other races and
ethnicities.

Gender, Ancestry, and Life Span Considerations

Hyperthyroidism is more frequently found in women than in men, and some experts suggest that the hormone cycles
of women may in some way affect the incidence of thyroid disease. Although it can affect all ages, it is most typically
diagnosed in 20- to 40-year-olds and is unusual in children, teenagers, and people over age 65. When
hyperthyroidism occurs in the elderly, their symptoms may be more subtle than those of younger persons, and the
classic signs may even be absent. Occasionally, an elderly person with hyperthyroidism has apathy or withdrawal
instead of the more typical hypermetabolic state. White/European American and Latino individuals have a slightly
higher prevalence of hyperthyroidism than do black/African American individuals.

Global Health Considerations

Hyperthyroidism is present in people of all nations. No data on global prevalence are available.

Assessment

History

Ask patients if they use tobacco products or have high levels of stress in their life. Often, patient report intolerance
to heat, excessive perspiration, and increased appetite accompanied by weight loss. Complaints of abdominal
cramping and frequent bowel movements are customary. Patients may also describe discomfort when wearing
clothing or jewelry that is close fitting at the neckline as well as generalized muscular weakness and increased
fatigue. Physical exertion may cause chest pain, shortness of breath, or both. They may have a history of heart
failure or cardiac dysrhythmias. A female patient may report oligomenorrhea (scanty or infrequent menses), and
both genders might experience decreased libido.

Take a drug history to determine the use of iodides (oral contraceptives, contrast media) that may cause falsely
elevated serum thyroid hormone levels. Similarly, severe illness, malnutrition, or the use of aspirin, corticosteroids,
and phenytoin sodium may cause a false decrease in serum thyroid hormone levels.

Physical Examination

The most common symptoms are due to hypermetabolism, such as anxiety, diaphoresis, nervousness, and
palpitations. The patient may have a short attention span and fine hand tremors or shaky handwriting. Note an
increased resting pulse, a widened pulse pressure, or hypertension. The skin may have a sheen of perspiration or
be salmon colored.

Stand behind the patient and palpate the thyroid gland at rest and during swallowing to note the size, tenderness,
and nodularity. Remember that excessive palpation of the thyroid gland can precipitate thyroid storm; therefore,
palpate gently and only when necessary. You may also hear a bruit when you auscultate the thyroid gland over the
lateral lobes. Exophthalmos, bulging of the eye resulting in larger amounts of visible sclera, is often quite noticeable;
a fixed stare because of the presence of fluid behind the eyeball and periorbital edema are also common. In
patients who have had Graves disease for several years, there may be changes in the skin, such as raised and
thickened areas over the legs or feet and hyperpigmentation and itchiness. Patients often exhibit fine, thin hair and
fragile nails. Patients with thyroid storm have a racing heart, high fever, profound diaphoresis, diarrhea, severe
dehydration, shaking, agitation, confusion, and coma.

Psychosocial
Well before a formal diagnosis, the patient may be aware that something is seriously wrong and report increased
anxiety or nervousness, insomnia, and early awakening from sleep. The anxiety is often heightened by symptoms of
the disease such as angina and the sense of loss of control over one's body.

Diagnostic Highlights

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Test Normal Result Abnormality Explanation

With Condition

TSH assay In most healthy patients, TSH values are Decreased so Elevation of thyroid hormones
0.4–4.2 mU/L that values may decreased TSH secretion by
be unmeasurable negative feedback

T4 4.6–12 mcg/dL Elevated Reflects overproduction of

radioimmunoassay thyroid hormones; monitors
response to therapy

T3 80–210 ng/dL; age-related normals: 16– Elevated Reflects overproduction of

radioimmunoassay 20 yr: 80–210 ng/dL; 20–50 yr: 70–204 thyroid hormones
ng/dL; >50 yr: 40–181 ng/dL

Other Tests: Tests include 24-hour radioactive iodine uptake, thyroid autoantibodies, antithyroglobulin, nuclear
thyroid scan, and electrocardiogram.

Primary Nursing Diagnosis

Diagnosis: Activity intolerance related to increased metabolism as evidenced by exhaustion, palpitations, and/or
fatigue

Outcomes: Energy conservation; Endurance; Self-care: Activities of daily living; Physiological; Mobility level;
Nutritional status: Energy; Symptom severity

Interventions: Energy management; Exercise promotion; Exercise therapy: Ambulation; Nutritional management;
Medication management; Surveillance; Vital signs monitoring

Planning Implementation

Collaborative

Most patients are diagnosed and treated on an outpatient basis. The goal of treatment is to return the patient to the
euthyroid (normal) state and to prevent complications. Graves disease is treated pharmacologically (see
Pharmacologic Highlights). Radioactive iodine (131I) is given for two purposes: for diagnosing imaging in low doses
and for therapeutic destruction of the thyroid gland in larger doses. Radioactive iodine is considered the definitive
and most common treatment, but it is not without risks. The principal disadvantage is the potential for
hypothyroidism because 40% to 70% of patients treated with 131I develop hypothyroidism within 10 years after
treatment. Other complications include parathyroid damage and exacerbation of hyperthyroidism. Surgical
treatment with thyroidectomy is no longer the preferred choice of therapy for Graves disease but is an alternative
therapeutic approach in some situations. In particular, it is used for patients who cannot tolerate antithyroid drugs,
have significant ophthalmopathy, have large goiters, or cannot undergo radioiodine therapy.

If thyroid storm is suspected, emergency treatment needs to be instituted immediately. Patients may need cardiac
monitoring, intubation and mechanical ventilation with supplemental oxygen, and IV fluids. The patient requires
antithyroid medications and may receive IV corticosteroids and beta-adrenergic medications.

Pharmacologic Highlights:

Medication or Dosage Description Rationale

Drug Class

Propylthiouracil Initial PTU: 300–400 mg/day PO divided
(PTU) tid; not to exceed 1,200 mg/day;
maintenance: 100–300 mg/day PO
Antithyroid Returns the patient to the euthyroid
agent (normal) state; inhibits use of iodine by
thyroid gland; blocks oxidation of
iodine and inhibits thyroid hormone
synthesis

Methimazole Initial: 15 mg/day for mild Antithyroid Returns the patient to the euthyroid
(Tapazole) hyperthyroidism; 30–40 mg/day for agent (normal) state; inhibits use of iodine by
moderately severe hyperthyroidism; 60 thyroid gland
mg/day for severe hyperthyroidism

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Other Drugs: Beta-adrenergic blockers, corticosteroids, radioactive iodine

Independent

Nursing interventions center on ongoing monitoring, protecting the patient from injury, reducing stress, and initiating
teaching. Patients with exophthalmos or other visual problems might be more comfortable wearing sunglasses or
eye patches to protect the eyes from light. Report any changes in visual acuity to the physician and use artificial
tears to lubricate the eyes.

Encourage the patient to follow the medication regimen and reassure him or her while waiting for it to take effect. To
determine the response to treatment and to prevent thyroid storm, assess the cardiovascular status, fluid and diet
intake and output, daily weights, bowel elimination, and the ability of the patient to perform activities of daily living
without excessive fatigue. Reassure the patient's family that the patient's mood swings, nervousness, or anxiety will
diminish as treatment continues. If the patient or family requires additional support, ask a clinical nurse specialist or
mental health counselor to see the patient or family. Note that extreme anxiety of the undiagnosed or uncontrolled
patient makes patient education difficult for all concerned. If you recognize the patient's inability to maintain long
cognitive or physical attention spans, you will have better success at patient education. One useful strategy is to
ensure that significant others are present during all teaching sessions.

Evidence Based Practice Health Policy

Langén, V., Niiranen, T., Puukka, P., Lehtonen, A., Hernesniemi, J., Sundvall, J., . . . Jula, A. (2018). Thyroid-
stimulating hormone and risk of sudden cardiac death, total mortality and cardiovascular morbidity. Clinical
Endocrinology, 88(1), 105–113.

The authors proposed to investigate the association of thyroid function and TSH with total mortality,
cardiovascular disease outcomes, and sudden cardiac death. They used a nationwide population-based study
in Finland with 5,211 patients 30 years of age and older, and they followed the patients for a median of 13
years.
The authors found that high TSH levels at baseline were related to a greater risk for total mortality as compared
to normal TSH levels. Low TSH was not associated with higher mortality or cardiovascular disease outcomes.
They suggested that more work needs to be done to study the effects of TSH on sudden cardiac death.

Documentation Guidelines
Physical findings: Cardiovascular status (resting pulse, blood pressure, presence of angina or palpitations),
bowel activity, edema, condition of skin, activity tolerance
Physical findings: Hypermetabolism, eye status, heat intolerance, activity level
Response to medications, skin care regimen, nutrition, body weight, comfort
Psychosocial response to changes in bodily function, including mental acuity, behavioral patterns, emotional
stability

Discharge and Home Healthcare Guidelines

DISEASE PROCESS. Provide a clear explanation of the role of the thyroid gland, the disease process, and the
treatment plan. Explain possible side effects of the treatment.

MEDICATIONS. Be sure the patient understands all medications, including the dosage, route, action, adverse effects,
and the need for any laboratory monitoring of thyroid medications. If the patient is taking propylthiouracil or
methimazole, encourage her or him to take the medications with meals to limit gastric irritation. If the patient is taking
an iodine solution, mix it with milk or juice to limit gastric irritation and have the patient use a straw to limit the risk of
teeth discoloration.

COMPLICATIONS. Have the patient report any signs and symptoms of thyrotoxicosis immediately: rapid heart rate,
palpitations, perspiration, shakiness, tremors, difficulty breathing, nausea, vomiting. Teach the patient to report
increased neck swelling, difficulty swallowing, or weight loss.

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