SUSAN SIMMONS HOLCOMB, PHD, ARNP,BCNurse Practitioner • Olathe Health System, Inc. • Olathe, Kan.Consultant, Continuing Nursing Education • Kansas City Kansas Community College • KansasCity, Kan.

The author has disclosed that she has no significant relationship with or financial interest in anycommercial companies that pertain to this educational activity.

EDNA COOK, 70, says she feels depressed and tired, but she doesn’thave any abnormal signs or symptoms. When an antidepressant pre-scribed by her primary care provider doesn’t help, she chalks her feel-ings up to old age.

But is that what’s really the matter? Maybe not: Mrs. Cook may actual-ly be suffering from hypothyroidism, a deficiency of thyroid hormone.

It wouldn’t be much of a surprise if that were the case. Thyroid dis-eases are common, and they’re becoming more so as the population ages.Yet overt signs and symptoms are often lacking, particularly in patientsover age 60 who may simply complain of feeling depressed. Once theyreceive thyroid hormone replacement medication, their depressionalmost “magically” disappears.

Hypothyroidism isn’t the only problem that can occur with an imbalanceof thyroid hormone. Hyperthyroidism, also known as Graves’ disease, ischaracterized by increased thyroid hormone levels, and it can also tip apatient’s normal physiologic balance and be missed as a diagnosis.

Consider Sam Connors, 12, who has a history of attention-deficithyperactivity disorder (ADHD). Lately, his mother says, he’s beenbouncing from one thing to another, he can’t sit still, and he’s losing

A delicate balance:Keeping

thyroidhormones

incheck

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2.5CONTACT HOURS

LPN2007 l Volume 3, Number 2

Patients withhypothyroidism orhyperthyroidism maynot know they havea thyroid disease.Left undetected, theproblem can causeneedless suffering—and possibly seriousconsequences. Learnmore about imbal-ances of thyroid hor-mone and how youcan help patientswith a thyroid diseasestay healthy.

JON

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LPN2007 l Volume 3, Number 2

weight. She’s taken him to the pedia-trician to see if his medication needsto be adjusted to get the ADHDunder better control. But thesesymptoms may not be related toADHD; they may indicate that Samhas hyperthyroidism.

Left unchecked, either form ofthyroid disease can lead to coma anddeath. So, you need to be suspiciouswhen subtle changes are noted inyour patients. Thyroid diseases tendto run in families, so be alert when itcrops up in a patient’s history.

In this article, I’ll discuss thediagnosis, management, and nursingcare for both hypothyroidism andhyperthyroidism. First, let’s take acloser look at that amazing gland,the thyroid.

Setting the furnace thermostatThe pituitary gland may be knownas the “master gland,” but the thy-roid gland ranks high in importancetoo. Think of it as the body’s fur-nace: It has to be burning justright—not too cold, not too hot—tokeep physiologic processes, such asprotein, fat, and carbohydrate me-tabolism, on track.

The thyroid gland may play a bigrole, but it’s relatively small in size. Itlies in front of the neck, wrapped oneither side of the trachea. A narrowpiece of tissue called the isthmusjoins the two lobes of the gland.

The thyroid gland produces threehormones: thyroxine (T4), triiodothy-ronine (T3), and calcitonin; T4 andT3 are known collectively as thyroidhormone. The hypothalamic-pituitary-thyroid (H-P-T) axis, ornegative feedback loop, controlsproduction of thyroid hormone. Ifthe H-P-T axis senses low thyroidhormone levels, the hypothalamusreleases thyroid-releasing hormone(TRH), which signals the pituitaryto release thyroid-stimulating hor-mone (TSH), which in turn signalsthe thyroid gland to produce andrelease more thyroid hormone.Once hormone levels are sufficient,the hypothalamus cuts off therelease of TRH, signaling the pitu-itary to stop releasing TSH.

If you think of the thyroid gland asthe body’s furnace, then TSH is thethermostat. When the furnace is toocold (meaning the thyroid isn’tsecreting enough thyroid hormone),TSH production and secretionincrease to turn up the temperature,or stimulate the thyroid to produce

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All about thyroid hormoneThe three hormones produced by the thyroid gland are thyroxine (T4), triiodothyronine(T3), and calcitonin.

Collectively, T3 and T4 are known as thyroid hormone. T3 is about four times morephysiologically active than T4; however, T4 can be converted into T3 in the peripheraltissues, providing a backup source. About 90% of T3 lies in the tissues, with 10% inthe circulation. Only 1% of thyroid hormone is free (unbound) and able to easily enterinto the tissue cells to carry out thyroid hormone functions. The bulk of thyroid hor-mone—99%—binds to serum proteins such as thyroxine-binding globulin.

Thyroid hormone is responsible for regulating cellular metabolic activity. T4 is rela-tively weak, and it maintains the body’s metabolism in a steady state. The more physi-ologically active T3 can accelerate metabolic processes. Let’s take a closer look at theeffects thyroid hormone has on metabolism, growth, and specific body mechanisms.

Metabolism• Increases the metabolic rate• Increases protein synthesis• Increases cellular enzyme activity• Increases the number and size of mitochondria, increasing the availability of adeno-sine triphosphate• Enhances ion transport across the cell membrane, especially the sodium-potassiumpump

Growth• Enhances growth and development

Specific body mechanisms• Increases carbohydrate metabolism• Increases fat metabolism• Influences body weight• Influences heart rate• Affects cardiac output• Affects the rate of respiration• Enhances gastrointestinal motility• Influences mood, affect, personality, cognitive functioning, and sleep• Enhances muscle tone and strength• Influences hormone secretion by other glands

The body must take in at least 1 mg of iodine a week from the diet to produce thy-roid hormone. If iodine is unavailable, production of thyroid-releasing hormone andthyroid-stimulating hormone (TSH) rises. Continued stimulation by TSH can causeproliferation of cells as the thyroid struggles to meet the demands from TSH. The thy-roid gland grows in size, causing what’s known as a goiter. In some countries whereiodine is not readily available, the incidence of thyroid goiter is much more prevalent,as it was in the United States before iodized salt was widely used.

Calcitonin, or thyrocalcitonin, is the third hormone produced by the thyroid gland.It’s secreted in response to a high blood level of calcium, and it reduces this level byincreasing the deposition of calcium in bone.

March/April l LPN2007

and release more hormone. Whenthe furnace is too hot (meaning thethyroid is secreting too much thyroidhormone), TSH production andsecretion slow in an attempt to turndown the furnace, or slow the releaseof thyroid hormone. As you wouldexpect, too much TSH (value higherthan normal) means the patient hashypothyroidism; too little TSH(value lower than normal) means thepatient has hyperthyroidism.

The effects of thyroid hormonefall into three categories: metabo-lism, growth, and specific bodymechanisms. For more on this, seeAll about thyroid hormone.

What’s out of balance?How does the health care providerdetermine that a patient has a thy-roid disorder? A key diagnostic testis the serum TSH level. IncreasedTSH indicates hypothyroidism,and decreased TSH indicates hy-perthyroidism (see Lab tests for thy-roid diseases).

However, the TSH level can bedeceptive. If it’s low but the patienthas no signs and symptoms, it isn’t

likely that he has athyroid disease. Onthe other hand,pregnancy, birthcontrol, hormonereplacement, severesystemic illness,corticosteroids, andpituitary dysfunctioncan lead to a falsely low TSH level inpatients who actually have hyperthy-roidism (see Drugs that can alter thy-roid test results).

If the TSH test results aren’tdefinitive, the health care providermay order T3 and T4 levels. Theamount of unbound hormonesdetermines the physiologic responsesin the body, so free levels of eachhormone may be drawn (FT3, FT4).The health care provider may orderan FT4 level only, however, becausethe amount of FT3 is scant andshort-lived.

Thyroid hormone levels are theopposite of what’s found with theTSH level: low in patients withhypothyroidism and elevated inpatients with hyperthyroidism.

Other lab tests that may beordered includethyroxine-bind-ing globulin andthyroid autoanti-bodies, such asTSH receptorantibodies, thy-roid-stimulatingimmunoglobulin,antithyroid per-oxide, and anti-thyroglobulinautoantibodies. Aradioactive iodineuptake test, fine-needle aspirationbiopsy, or thyroidscan may also beperformed.

If your patientis scheduled for

thyroid tests, find out if she’s takingany medications or agents that con-tain iodine, which can alter the testresults. Iodine-containing medica-tions include contrast agents andthose used to treat thyroid disor-ders. Less obvious sources of iodineare topical antiseptics, multivitaminpreparations, and food supplementsfrequently found in health foodstores; cough syrups; and amio-darone, an antiarrhythmic agent.Other medications that may affecttest results include estrogens, salicy-lates, amphetamines, chemothera-peutic agents, antibiotics, cortico-steroids, and mercurial diuretics. Ifthe patient is taking any of thesemedications, be sure to note it onthe lab requisition form.

Now that we know how thyroiddiseases are diagnosed, let’s turn tothe most common form: hypothy-roidism.

The lowdown on hypothyroidismHypothyroidism affects morewomen than men, by a ratio of 5 to10:1. Its most common cause is au-toimmune thyroiditis, also known asHashimoto’s disease or Hashimoto’sthyroiditis. Other potential causesare medications (such as lithium andinterferon), surgeries, radiation, andiodine deficiency. Less commoncauses include pituitary or hypothal-amic disorders (see What causes hypo-thyroidism?).

Let’s take a closer look at signsand symptoms, treatment, complica-tions, nursing considerations, and

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Lab tests for thyroid diseases

= decreased = increasedÝ

Ý

Thyroid-stimulatinghormone

Triiodothyronine (T3)Thyroxine (T4)

HypothyroidismÝ

Ý

Ý

Hyperthyroidism

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The hypothalamic-pituitary-thyroid axis

LPN2007 l Volume 3, Number 2

patient education for hypothy-roidism.• Signs and symptoms. The signsand symptoms of hypothyroidismare equivalent to turning a furnacedown or off just when you need itto keep you warm. The patient maycomplain of fatigue, feeling cold,weight gain, and depression. (For abreakdown of other signs and symp-toms by body system, see Signs andsymptoms of thyroid diseases.) Remem-ber that these changes are often in-correctly attributed to other factors,such as aging. • Treatment. The treatment of hy-pothyroidism is relatively simple.Patients take a synthetic version of

T4 called levothyroxine (Synthroid,Unithroid) to replace the missingthyroid hormone. The starting doseis based on the patient’s age, weight,and cardiac status (see Meds fortreating thyroid diseases). The healthcare provider may choose to start apatient younger than age 50 on ahigher dose or at the anticipatedmaintenance dose. The lower endof the dosing range is used for olderadult patients or those who havecardiovascular disease. • Complications. A serious complica-tion of hypothyroidism is myxedema,which occurs from a lack of or sub-optimal treatment. Signs and symp-toms of this life-threatening emer-gency include severe bradycardia,hypothermia, and delayed deep ten-don reflexes. Other signs are non-pitting edema, an enlarged tongue,

disorientation, seizure, and coma.Fortunately, myxedema is rare; itmost commonly occurs in patientsage 60 and older.

Treatment of myxedema comaconsists of providing clinical supportto return vital signs to normal.Measures may include warming,fluid and thyroid hormone replace-ment therapy, and correction of elec-trolytes and glucose imbalances.With prompt recognition and treat-ment of hypothyroidism plus thor-ough patient education, myxedemacoma shouldn’t occur.• Nursing considerations. Nursingcare for patients with hypothy-roidism includes monitoring for evi-dence of decreased cardiac output,such as edema, hypotension, and re-duced urine output. Be sure tomonitor for myocardial ischemia orinfarction, which can occur in re-sponse to therapy in patients withsevere, long-standing hypothy-roidism or myxedema coma. Also,be alert for signs of angina, espe-cially during the early phase oftreatment. If they’re present, reportthem immediately to the health careprovider so that treatment can be

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What causes hypothyroidism?• Autoimmune thyroiditis (Hashimoto’s thyroiditis)• Atrophy of the thyroid gland with aging• Therapy for hyperthyroidism (radioactive iodine therapy, surgery)• Medications, such as lithium, iodine compounds, and antithyroid medications • Radiation to the head and neck for treatment of head and neck cancers, lymphoma• Infiltrative diseases of the thyroid, such as amyloidosis and scleroderma• Iodine deficiency and iodine excess

Drugs that can alterthyroid test results• Estrogens• Sulfonylureas• Corticosteroids• Iodine• Propranolol• Cimetidine• 5-fluorouracil• Phenytoin• Heparin• Chloral hydrate• X-ray contrast media • Opioids• Androgens• Salicylates• Lithium• Amiodarone• Clofibrate• Furosemide• Diazepam• Danazol• Dopamine antagonists• Propylthiouracil

The thyroid gland and surrounding structures

March/April l LPN2007

initiated to prevent a fatal myocar-dial infarction.

In patients with hypothyroidism,the effects of analgesic agents, seda-tives, and anesthetic agents are pro-longed. Be especially cautious whenadministering these drugs to olderpatients with hypothyroidism becauseof concurrent age-related changes inliver and renal function. Keep inmind, too, that severe untreatedhypothyroidism is characterized byincreased susceptibility to the effectsof hypnotic and sedative agents.

Good nutrition can help patientsgain weight and feel warmer as theyadd subcutaneous fat. Give warmblankets to patients who are cold. Awarming blanket may be used if thetemperature falls too low.

Mentation may be compromised,so be sure to communicate clearlyand evaluate whether the patientcomprehends the information.• Patient education. A primary fo-cus of patient education is detailedmedication instructions to promotea good response to thyroid hor-mone replacement therapy. Tellpatients that it may take 2 to 3weeks before their symptoms re-solve. Dosages are adjusted every 4to 6 weeks based on symptoms andthe TSH level; more frequent ad-justments would simply make itmore difficult to hit the dosing tar-get. Once symptoms are undercontrol and the TSH level returnsto normal, patients will need bloodwork every 6 to 12 months. Stressthe importance of this follow-up,as well as clinic visits, even if pa-

tients have no symptoms.Many medications and supple-

ments, especially minerals, can inter-fere with the absorption of levothy-roxine, so teach patients to take theirreplacement therapy on an emptystomach and at the same time everyday, usually with a full glass of water30 minutes before breakfast.

Different brands of levothyroxineseem to be absorbed differently, soadvise patients to always buy thesame brand. If the brand changes,patients should ask their health careprovider to order a TSH level in 6weeks, and they should report anychanges in symptoms.

Don’t forget to teach patients thesigns and symptoms of hyperthy-roidism, since overzealous thyroidreplacement can occur.

Hyperthyroidism: Over the top Hyperthyroidism, or Graves’ disease,is usually caused by an autoimmunedisorder. Other common causesinclude excessive iodine intake andtoo aggressive replacement of thy-roid hormone in patients withhypothyroidism.

The first signs of hyperthyroidismtypically emerge when patients arebetween ages 20 and 40. Certaintriggers may activate the genetic pre-disposition to hyperthyroidism, suchas stress, smoking, medications, viralor bacterial illnesses, and pregnancy.Because hyperthyroidism most oftenaffects women and hits during their

childbearing years, some expertsbelieve in a female hormonal con-nection as the genetic trigger to thedisease.

Let’s take a closer look at signsand symptoms, treatment, complica-tions, nursing considerations, andpatient education for hyperthy-roidism.• Signs and symptoms. In general,the signs and symptoms of hyper-thyroidism are the opposite of thoseof hypothyroidism, as if the furnacethermostat were turned up. Patientsare often irritable, energetic, and ex-perience weight loss. (For a break-down of signs and symptoms bybody system, see Signs and symptomsof thyroid diseases.) Hyperthyroidismcan increase the body’s metabolicrate by 60% to 100%—much morethan you’d get with a cup of yourfavorite triple espresso!• Treatment. It’s more difficult totreat hyperthyroidism than hypothy-roidism, so an endocrinologist man-ages the care of these patients. Thefirst step is to stabilize vital signs,especially the heart rate and rhythm.Beta-blockers are the drug of choiceto slow the heart rate, control therhythm, and decrease the bloodpressure. These drugs should beused cautiously in older adult pa-tients to minimize adverse effects oncardiac function that may causeheart failure. If beta-blockers arecontraindicated, calcium channelblockers can be used instead.

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Meds for treating thyroid diseases

Hypothyroidism

Hyperthyroidism

MedicationLevothyroxine(Synthroid, Unithroid)

Methimazole(Tapazole)Propylthiouracil(PTU)

Starting dose25 to 50 mcg/day;dose may be higher(50 to 100 mcg/day) inpatients under age 50

10 to 60 mg/day

300 to 1,200 mg/day

Maintenance dose75 to 100 mcg/day(1.6 to 1.8mcg/kg/day)

5 to 15 mg/day

50 to 300 mg/day

Did you know?Thyroid disorders are classified as pri-mary, secondary, or tertiary dependingon what part of the hypothalamus-pituitary-thyroid axis is out of kilter.Primary dysfunction is at the level of thethyroid, secondary at the pituitary, andtertiary at the hypothalamus.

LPN2007 l Volume 3, Number 2

Fever is treated with acetamino-phen; aspirin or nonsteroidal anti-inflammatory drugs can worsenhyperthyroidism by increasing theT4 level. Patients should be kept wellhydrated.

Once vital signs are stable, it’stime to turn to treatment options,which fall into three groups: radio-active iodine, antithyroid medica-tions, and surgery.

Radioactive iodine treatment (RAI-

131 and RAI-123) is the gold stan-dard for treating hyperthyroidism(see Profile of radioactive iodinetherapy). It’s used to destroy theoveractive thyroid cells, and it’s themost common treatment of hyper-thyroidism in older adult patients.The hypermetabolic state of hyper-thyroidism must be controlled byantithyroid medications beforeradioactive iodine treatment beginsbecause the radiation may precipitate

thyroid storm (more on that later) byincreasing the release of thyroid hor-mone. If hypothyroidism occurspostablation, levothyroxine replace-ment is indicated.

This treatment is contraindicatedin women who are pregnant orbreastfeeding because it may ablatethe baby’s thyroid gland.

Antithyroid medications includemethimazole (Tapazole) and propyl-thiouracil (PTU) (see Meds for treat-

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Signs and symptoms of thyroid diseases

WeightCentral nervoussystem

Eyes, ears, nose,and throat

Musculoskeletalsystem

Skin and hair

Cardiac system

GastrointestinalsystemGenitourinarysystem

Hypothyroidism• Increased• Depression• Hypersomnia• Fatigue• Forgetfulness• Slow thinking• Inability to concentrate• Cold intolerance• Puffy eyes• Enlarged tongue• Impaired hearing• Goiter, which causes hoarseness, deepening ofthe voice; dry, sore throat; difficulty swallowing

• Muscle weakness, cramps• Myalgias and joint complaints• Hyporeflexia• Ataxia• Pretibial nonpitting edema• Dry, patchy skin• Thinning hair• Coarse hair• Loss of body hair, alopecia• Loss of lateral eyebrows• Looks older than stated age• Yellow skin• Myxedema fluid infiltration of tissues (late sign),leading to “doughy” skin• Decreased heart rate• Hypertension (related to fluid gain)• Increased triglycerides and low-density lipoproteinlevels• Potential cardiac enlargement, pleural effusion,and ascites• Constipation

• Infertility• Menstrual irregularities, heavy bleeding

Hyperthyroidism• Decreased• Nervousness, irritability• Insomnia• Heat intolerance

• Exophthalmus (bulging eyes)• Downward gaze• Unblinking stare• Lid lag and/or retraction• Goiter, which causes hoarseness, deepening of thevoice; dry, sore throat; difficulty swallowing• Tremors• Fatigue, muscle weakness with muscle wasting• Early or worsening osteoporosis• Hyperreflexia

• Increased sweating• Moist palms• Hyperpigmentation• Fine, silky hair• Thinning hair• Onycholysis (irregular separation of the nail plate fromthe distal nail bed)• Ridges and/or thickening of the nails

• Angina• Rapid heart rate• Onset of atrial fibrillation• Hypotension (related to fluid loss)• Potential heart failure

• Frequent bowel movements; may have diarrhea

• Infertility• Excessive vomiting in pregnancy• Increased incidence of first trimester miscarriage

March/April l LPN2007

ing thyroid diseases). Methimazole isusually preferred over PTU becauseit can be given daily, compared withthree times a day for PTU. Bothdrugs may induce agranulocytosis orhepatitis, so they should be used cau-tiously, with careful monitoring, inolder adults and pregnant women.

Surgery to remove the overactivethyroid used to be the treatment ofchoice before the availability of iodineablation and the refinement ofantithyroid medications. Now, it’sused only for patients who don’trespond to other interventions.Surgery carries many potential com-plications, but it remains an appropri-ate option for patients who can’t toler-ate antithyroid medications or aren’tcandidates for radioactive iodine.

Other management aspects ofhyperthyroidism include frequentevaluation of lab parameters, includ-ing TSH, FT4, and electrolyte levels;liver function tests (LFTs); and othertests as ordered by the health careprovider. • Complications. Thyroid storm is alife-threatening complication of hy-

perthyroidism. Staying alert for it sothat you can intervene proactivelywill go a long way toward protect-ing your patients.

Thyroid storm results from un-treated or undertreated hyper-thyroidism. Manifestations includetachycardia, leading to heart failureand shock; hyperthermia (the tem-perature can rise to more than 105o

F); restlessness; agitation; abdominalpain with nausea and vomiting; andcoma. Besides a decreased TSH leveland increased thyroid hormone lev-els, lab tests will show abnormallyhigh LFTs, alkaline phosphatase,and, possibly, bilirubin level.

Immediate treatment goals forthyroid storm are preventing cardio-vascular collapse, returning the tem-perature to normal, and restoring aeuthyroid state as soon as possible.

Stabilizing the cardiovascular sys-tem includes administering oxygen,fluids, beta-blockers, and antithyroidmedications. Calcium channel block-ers are substituted in patients whohave bronchospastic lung disease,such as asthma, emphysema, or

bronchitis, or other contraindica-tions for beta-blockers. If thepatient’s blood pressure falls too low,intravenous vasopressors may needto be added.

A cooling blanket and aceta-minophen will help reduce hyper-thermia. Don’t go overboard withcooling measures, though; it’simportant to avoid shivering, whichincreases temperature, heart rate,and metabolic demands of a bodyalready in high alert.

An antithyroid medication (methi-mazole or PTU) is given to induce aeuthyroid state. Massive doses ofiodine are administered as well; theyhave a paradoxical reaction ofdecreasing thyroid hormone produc-tion. Glucocorticoids decrease thy-roid hormone production by inter-fering with TSH secretion, sothey’re also given. Lithium carbon-ate may be used because it reducesproduction of the thyroid hormones.In difficult cases, patients may needplasmapheresis or dialysis to removeexcess thyroid hormone.• Nursing considerations. Nursingcare of patients with hyperthyroid-ism focuses on interventions relatedto the hyperactivity associated withthe disease. Provide a quiet, calmenvironment to encourage patientsto recuperate from the fatiguecaused by hyperactivity.

Patients also need to boost caloricintake to meet their high metabolicneeds. Encourage extra calories inthe form of healthy foods, ratherthan sweets and fats.

When checking vital signs, payparticular attention to the bloodpressure and heart rate, and watchfor other signs and symptoms of car-diac complications such as hyperten-sion and heart failure.

Closely monitor patients whoundergo surgery. Postoperatively,keep the head of the bed elevated,and give pain medication as needed.

53

Profile of radioactive iodine therapyDosing: Not exact and is based on the patient’s weight and the endocrinologist’sexperience.Goal: To give enough iodine to restore the patient to a euthyroid state without inducinghypothyroidism. If the patient is at risk for serious adverse outcomes from prolongedtreatment of hyperthyroidism, then rapid ablation with radioactive iodine may be chosen. Follow-up: Done every 4 to 6 weeks during treatment and includes measurement ofthe thyroid-stimulating hormone (TSH) level, assessment of vital signs, and evaluationof symptoms to determine the thyroid’s function. If hyperthyroidism caused atrial fibril-lation, an electrocardiogram is obtained to monitor the heart rate and determinewhether cardioversion is needed.Timing: If the target response has been overshot, signs and symptoms of hypothy-roidism (including an elevated TSH level) may not be apparent for at least 3 months intotreatment with radioactive iodine. The health care provider may order levothyroxine thy-roid hormone replacement therapy about 2 months before total ablation is achieved tohelp attain a normal TSH level before total ablation.Adverse effects: The adverse effects are minimal. The primary concerns are thyroidi-tis, inflammation of the thyroid gland, and release of stored thyroid hormone from thethyroid gland. If these problems occur, they can induce harmful cardiac effects, suchas increased blood pressure, rapid heart rate, and atrial fibrillation. Because of thesepotential adverse effects, patients at high risk for cardiac toxicity receive antithyroidhormones before starting radioactive ablation.

LPN2007 l Volume 3, Number 2

Watch for signs and symptoms ofcomplications, such as hemorrhage;respiratory distress; vocal cord paral-ysis; damage to the parathyroidgland, which can cause tetany; andthyroid storm.

The health care provider maymodify dosages of medications usedto treat chronic illnesses in older adultpatients because of the altered rate ofmetabolism in hyperthyroidism.• Patient education. Teach patientswith hyperthyroidism about theirmedications and the use of radioac-tive iodine as needed. Explain thesigns and symptoms of thyroidstorm and the importance of seek-ing help immediately. Many patientswith hyperthyroidism will eventuallydevelop hypothyroidism, so remem-ber to teach signs and symptoms ofhypothyroidism as well.

Vigilance countsBecause thyroid diseases affect manybody functions, their signs andsymptoms may be looked at individ-ually instead of together. Be alert tothe possibility that a patient’s “fur-nace” may need to be repaired if hisor her signs and symptoms includemore than one body system. Forinstance, a patient complaining ofcold intolerance, thinning hair,weight gain, depression, and men-strual irregularities may havehypothyroidism. Or, a patient who’sirritable and angry for no apparentreason and complains of insomniaand weight loss may have hyperthy-roidism. Looking deeper than justthe surface, or in this case, the fur-nace knob, may make all the differ-ence in your patient’s outcome, well-being…and thermostat. LPN

Selected referencesAACE Thyroid Task Force. American Associationof Clinical Endocrinologists medical guidelinesfor the treatment of hyperthyroidism and hy-pothyroidism. Endocrine Practice. 8(6):457-469,November/December 2002.

Dambro M. 5-Minute Clinical Consultant. Philadel-phia, Pa., Lippincott Williams & Wilkins, 2006.(Skyscape version 5.0.116/2006 8.22 for PDAs)

Drugs for hypothyroidism and hyperthyroidism.Treatment Guidelines from The Medical Letter.4(44):17-24, April 2006.

Holcomb SS. Detecting thyroid disease, part 1.Nursing2003. 33(8):32cc1-32cc4, August 2003.

Holcomb SS. Detecting thyroid disease, part 2.Nursing2003. 33(9):32cc1-32cc4, September 2003.

Holcomb SS. The lowdown on hypothyroidism.Nursing made Incredibly Easy! 1(1):44-48, Septem-ber/October 2003.

McPhee SJ, et al. Current Medical Diagnosis andTreatment 2007. New York, NY, McGraw-Hill,2007.

Smeltzer SC, Bare B. Brunner & Suddarth’s Textbookof Medical-Surgical Nursing, 11th edition. Philadel-phia, Pa., Lippincott Williams & Wilkins, 2007.

Weeks BH. Graves’ disease: The importance ofearly diagnosis. The Nurse Practitioner. 30(11):34-36, 41-42, 44-45, November 2005.

54

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A delicate balance: Keeping thyroid hormones in checkGENERAL PURPOSE: To provide the nurse with an overview of the diagnosis, management, and nursing care of hypothyroidism and hyper-thyroidism. LEARNING OBJECTIVES: After reading the preceding article and taking the following test, you should be able to: 1. Discuss thepathophysiology and diagnosis of hypothyroidism and hyperthyroidism. 2. Describe the management and nursing care of the patient with hy-pothyroidism and hyperthyroidism.

1. The production of thyroid hormone iscontrolled by thea. level of thyroxine only.b. pituitary gland only.c. hypothalamic-pituitary-thyroid axis. d. positive feedback loop.

2. Which of the following occurs when thethyroid is not secreting enough thyroid hor-mone?a. Thyroid-stimulating hormone (TSH) produc-

tion and secretion increase.b. The pituitary gland increases production of

thyroid-releasing hormone (TRH).c. The hypothalamus releases TSH.d. The thyroid releases TSH.

3. Which of the following can lead to afalsely low TSH level in the presence of hy-perthyroidism? a. high blood pressureb. low sodium levelsc. pregnancyd. being overweight

4. Which statement about the thyroid hor-mone level is correct?a. If the TSH level is elevated, the thyroid hor-

mone level is low.b. If the TSH level is increased, the thyroid

hormone level is increased.c. As the thyroid hormone level increases, the

hypothalamus releases TSH.d. As the thyroid hormone level increases, the

pituitary gland releases TSH.

5. Thyroid test results can be altered bymedications or agents containinga. iron.b. potassium.c. calcium.d. iodine.

6. Which of the following are signs andsymptoms of hypothyroidism?

a. muscle aches, headache, tiredness, andshortness of breath

b. feeling cold, fatigue, weight gain, and de-pression

c. sore throat, abdominal pain, weight loss,and constipation

d. weight loss, irritability, and feeling energetic

7. Which intervention is part of a hypothy-roidism treatment plan?a. administration of methimazoleb. administration of levothyroxinec. a low-salt diet d. a high-salt diet

8. Which of the following is a complicationof hypothyroidism?a. tachycardiab. hyperthermiac. thyroid stormd. myxedema

9. A patient with hypothyroidism should bemonitored for a. respiratory depression.b. decreased cardiac output.c. agranulocytosis.d. hyperactivity.

10. How long may it take the symptoms ofhypothyroidism to resolve? a. 2 to 3 weeksb. 4 to 6 weeksc. 3 monthsd. 6 months

11. Which instructions should you give apatient taking levothyroxine?a. Take with food.b. Take at the same time and on an empty

stomach.c. Take before bedtime.d. Take with a glass of milk.

12. When the patient’s usual brand of med-

ication changes, advise the patient to a. cut the dosage in half for the first week.b. double the dosage for the first week.c. ask his health care provider to order a TSH

level in 2 weeks.d. ask his health care provider to order a TSH

level in 6 weeks.

13. Which patient is most at risk for hyper-thyroidism?a. a male in his 60s who’s underweightb. a male in his 30s who has diabetesc. a female in her 60s who’s obesed. a female in her 30s who smokes

14. Which medication is the drug of choiceto slow heart rate and decrease bloodpressure in a patient with hyperthyroidism?a. digoxinb. an angiotensin-converting enzyme inhibitorc. a beta-blockerd. a calcium channel blocker

15. Which treatment is the gold standardfor treating hyperthyroidism?a. chemotherapyb. antithyroid drugsc. radioactive iodine treatmentd. surgery

16. Which of the following is an adverseeffect of antithyroid medications used totreat hyperthyroidism?a. respiratory depressionb. decreased cardiac outputc. acute renal failured. hepatitis

17. Which dietary instructions should yougive a patient with hyperthyroidism?a. Increase healthy caloric intake.b. Reduce fluid intake.c. Eat a high-fat diet.d. Eat a low-salt diet.

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$ENROLLMENT FORM LPN2007, March/April, A delicate balance: Keeping thyroid hormones in check