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.
CARE SETTING
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.
RELATED CONCERNS
Heart failure: chronic
Psychosocial aspects of care
Thyroidectomy
Patient Assessment Database
Data depend on the severity/duration of hormone imbalance and involvement of other organs.
ACTIVITY/REST
May report: Nervousness, increased irritability, insomnia
Muscle weakness, incoordination
Extreme fatigue
May exhibit: Muscle atrophy
CIRCULATION
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)
ELIMINATION
May report: Urinating in large amounts
Stool changes; diarrhea
EGO INTEGRITY
May report: Recent stressful experience, e.g., emotional/physical
May exhibit: Emotional lability (mild euphoria to delirium); anxiety/depression
FOOD/FLUID
May report: Recent/sudden weight loss
Increased appetite; large meals, frequent meals; thirst
Nausea/vomiting
May exhibit: Enlarged thyroid; goiter
Nonpitting edema, especially in pretibial area
NEUROSENSORY
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)
PAIN/DISCOMFORT
May report: Orbital pain, photophobia (eye movement)
RESPIRATION
May report: Difficulty breathing
May exhibit: Increased respiratory rate, tachypnea
Breath sounds: Crackles, wheezes (pulmonary edema associated with thyrotoxic crisis)
SAFETY
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
SEXUALITY
May report: Decreased libido
Hypomenorrhea, amenorrhea
Impotence
TEACHING/LEARNING
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.
DIAGNOSTIC STUDIES
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.
NURSING PRIORITIES
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.
DISCHARGE GOALS
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.
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.
CARE SETTING
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.
RELATED CONCERNS
Heart failure: chronic
Psychosocial aspects of care
Thyroidectomy
Patient Assessment Database
Data depend on the severity/duration of hormone imbalance and involvement of other organs.
ACTIVITY/REST
May report: Nervousness, increased irritability, insomnia
Muscle weakness, incoordination
Extreme fatigue
May exhibit: Muscle atrophy
CIRCULATION
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)
ELIMINATION
May report: Urinating in large amounts
Stool changes; diarrhea
EGO INTEGRITY
May report: Recent stressful experience, e.g., emotional/physical
May exhibit: Emotional lability (mild euphoria to delirium); anxiety/depression
FOOD/FLUID
May report: Recent/sudden weight loss
Increased appetite; large meals, frequent meals; thirst
Nausea/vomiting
May exhibit: Enlarged thyroid; goiter
Nonpitting edema, especially in pretibial area
NEUROSENSORY
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)
PAIN/DISCOMFORT
May report: Orbital pain, photophobia (eye movement)
RESPIRATION
May report: Difficulty breathing
May exhibit: Increased respiratory rate, tachypnea
Breath sounds: Crackles, wheezes (pulmonary edema associated with thyrotoxic crisis)
SAFETY
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
SEXUALITY
May report: Decreased libido
Hypomenorrhea, amenorrhea
Impotence
TEACHING/LEARNING
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.
DIAGNOSTIC STUDIES
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.
NURSING PRIORITIES
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.
DISCHARGE GOALS
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.
Chinese
French
German
Italian
Japanese
Korean
Russian
Spanish
