NCP Hyperthyroidism (Thyrotoxicosis, Graves' Disease)

Hyperthyroidism is a metabolic imbalance that results from overproduction of the thyroid hormones triiodothyronine (T3) and thyroxine (T4). The most common form is Graves’ disease, but other forms of hyperthyroidism include toxic adenoma, TSH-secreting pituitary tumor, subacute or silent thyroiditis, and some forms of thyroid cancer.

Thyroid storm is a rarely encountered manifestation of hyperthyroidism that can be precipitated by such events as thyroid ablation (surgical or radioiodine), medication overdosage, and trauma. This condition constitutes a medical emergency.


Most people with classic hyperthyroidism rarely need hospitalization. Critically ill patients, those with extreme manifestations of thyrotoxicosis plus a significant concurrent illness, require inpatient acute care on a medical unit.


Heart failure: chronic

Psychosocial aspects of care


Patient Assessment Database

Data depend on the severity/duration of hormone imbalance and involvement of other organs.


May report: Nervousness, increased irritability, insomnia

Muscle weakness, incoordination

Extreme fatigue

May exhibit: Muscle atrophy


May report: Palpitations

Chest pain (angina)

May exhibit: Dysrhythmias (atrial fibrillation); gallop rhythm, murmurs

Elevated BP with widened pulse pressure

Tachycardia at rest

Circulatory collapse, shock (thyrotoxic crisis)


May report: Urinating in large amounts

Stool changes; diarrhea


May report: Recent stressful experience, e.g., emotional/physical

May exhibit: Emotional lability (mild euphoria to delirium); anxiety/depression


May report: Recent/sudden weight loss

Increased appetite; large meals, frequent meals; thirst


May exhibit: Enlarged thyroid; goiter

Nonpitting edema, especially in pretibial area


May exhibit: Rapid and hoarse speech

Mental status and behavior alterations, e.g., confusion, disorientation, nervousness, irritability, delirium, frank psychosis, stupor, coma

Fine tremor in hands; purposeless, quick, jerky movements of body parts

Hyperactive DTRs

Paralysis (thyrotoxic hypokalemia)


May report: Orbital pain, photophobia (eye movement)


May report: Difficulty breathing

May exhibit: Increased respiratory rate, tachypnea

Breath sounds: Crackles, wheezes (pulmonary edema associated with thyrotoxic crisis)


May report: Heat intolerance, excessive sweating

Allergy to iodine (may be used in testing)

May exhibit: Elevated temperature (above 100°F), diaphoresis

Skin smooth, warm, and flushed; hair fine, silky, straight

Exophthalmos, lid retraction; conjunctival irritation, tearing

Pruritic, erythematous lesions (often in pretibial area) that become brawny


May report: Decreased libido

Hypomenorrhea, amenorrhea



May report: Family history of thyroid problems

History of hypothyroidism, thyroid hormone replacement therapy or antithyroid therapy, premature withdrawal of antithyroid drugs, recent partial thyroidectomy

History of insulin-induced hypoglycemia, cardiac disorders or surgery, recent illness

(pneumonia), trauma; x-ray contrast studies

Discharge plan

DRG projected mean length of inpatient stay: 4.3 days

May require assistance with treatment regimen, self-care activities, homemaker/maintenance tasks

Refer to section at end of plan for postdischarge considerations.


Radioactive iodine (RAI) uptake test: High in Graves’ disease and toxic nodular goiter; low in thyroiditis.

Serum T4 and T3: Increased in hyperthyroidism. Normal T4 with elevated T3 indicates thyrotoxicosis.

Thyroid-stimulating hormone (TSH): Suppressed (except when etiology is a TSH-secreting pituitary tumor or pituitary resistant to thyroid hormone). Does not respond to thyrotropin-releasing hormone (TRH).

Thyroglobulin: Increased.

TRH stimulation: Hyperthyroidism is indicated if TSH fails to rise after administration of TRH.

Thyroid T3 uptake: Normal to high.

Protein-bound iodine: Increased.

Serum glucose: Elevated (related to adrenal involvement).

Plasma cortisol: Low levels (less adrenal reserve).

Alkaline phosphatase and serum calcium: Increased.

Liver function tests: Abnormal.

Electrolytes: Hyponatremia may reflect adrenal response or dilutional effect in fluid replacement therapy.

Hypokalemia occurs because of GI losses and diuresis.

Serum catecholamines: Decreased.

Urine creatinine: Increased.

ECG: Atrial fibrillations; shorter systole time; cardiomegaly, heart enlarged with fibrosis and necrosis (late signs or in elderly with masked hyperthyroidism).

Needle or open biopsy: May be done to determine cause of hyperthyroidism, differentiate cysts or tumors, diagnose enlargement of thyroid gland.

Thyroid scan: Differentiates between Graves’ disease and Plummer’s disease, both of which result in hyperthyroidism.


1. Reduce metabolic demands and support cardiovascular function.
2. Provide psychological support.
3. Prevent complications.
4. Provide information about disease process/prognosis and therapy needs.


1. Homeostasis achieved.
2. Patient effectively dealing with current situation.
3. Complications prevented/minimized.
4. Disease process/prognosis and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.