HYPOTHYROIDISM

ANATOMY AND PHYSIOLOGY OF THYROID GLAND

 THYROID GLAND—the largest endocrine

gland—is a butterfly-shaped organ located in
the lower neck, anterior to the trachea.
 Isthmus connects the 2 lateral lobes.
 Size & weight: 5 cm long and 3 cm wide and
weighs about 30 g.
 Blood flow: about 5 mL/min per gram of
thyroid tissue, approximately 5x blood flow to
the liver.
Produces 3 hormones:
1. Thyroxine (T4)
2. Triiodothyronine (T3)
3. Calcitonin PATHOPHYSIOLOGY

TYPES OF HYPOTHYROIDISM

I. PRIMARY OR THYROIDAL - 95 %;
dysfunction of the thyroid gland itself
II. CENTRAL - failure of the pituitary gland,
the hypothalamus, or both
III. SECONDARY- entirely a pituitary disorder
IV. TERTIARY OR HYPOTHALAMIC - disorder of
the hypothalamus resulting in inadequate
secretion of TSH due to decreased
stimulation of TRH
V. NEONATAL - thyroid deficiency is present at
birth

CAUSES OF PRIMARY HYPOTHYROIDISM

1. Autoimmune disease (Hashimoto Thyroiditis,

Post-Graves Disease) – most common
2. Atrophy of thyroid gland with Aging
3. Infiltrative diseases of the thyroid (Amyloidosis,
REGULATION OF THYROID HORMONE Scleroderma, Lymphoma)
4. Iodine Deficiency
5. Medications
6. Radioactive Iodine (131I)
7. Therapy for hyperthyroidism
8. Thyroidectomy
9. Radiation to head and neck in treatment for
head and neck cancers, lymphoma

SELECT MEDICATIONS THAT MAY ALTER THYROID

TEST RESULTS

 Amiodarone (pt with myocardial –

arrthymias ,given as maintenance)
 Aspirin
GOAL: EUTHYROID
  Cimetidine – H2 blockers given GERD – given  Signs of Depression
long term  Diminished Cognitive Status
 Diazepam – antianxiety / sedative long term  Lethargy
people who are anxious  Somnolence
 Estrogens
 Furosemide – loop diuretics ; help patients with
ADVANCED HYPOTHYROIDISM
heart failure
 Glucocorticoids – ex. Prednisone ; problem with
autoimmune , asthma and organ transplant
 Heparin – anticoagulant with CAD
 Lithium – antipsychotic/antimanic
 Phenytoin (dilentin) and other anticonvulsants -
 propranolol

Later S/Sx:

 Stuporous
 Respiratory Depression (Alveolar
 Hypoventilation, Progressive CO2 Retention);
Hypoventilation
 Narcosis
 Hyponatremia
 Hypoglycemia
 Hypotension
 Bradycardia
 Cardiovascular Collapse/ Shock
Coma
ASSESSMENT FINDINGS: Precipitating factors:
CLINICAL MANIFESTATIONS:  Infection
 Systemic Diseases
 Use of Sedatives or Opioid analgesic agents
 Cold: winter season (old women)

INITIAL S/SX:
  Medication that can alter result:
estrogens, androgens, salicylates,
phenytoin, anticoagulants, or
corticosteroids
 Normal : 25% to 35% (relative uptake
fraction: 0.25 to 0.35
5. Thyroid Antibodies : Thyroid Peroxidase
Antibodies (TPOAb) & Thyroglobulin
Antibodies (TgAb)
 Results of testing by immunoassay
techniques for antithyroid antibodies
are positive in chronic autoimmune
thyroid disease (90%)
 Hashimoto’s Disease
 Thyroid Peroxidase (TPO) is an enzyme
involved in the production of thyroid
hormones.
 Thyroglobulin is a protein produced by
the thyroid gland that is involved in the
synthesis of thyroid hormones

6. Thyroid Scan, Radioscan, or Scintiscan

 A scintillation detector or gamma
camera moves back and forth across
the area to be studied in a series of
parallel tracks
LABORATORIES AND DIAGNOSTIC TESTS:  A visual image is made of the
distribution of radioactivity in the area
1. Serum Thyroid-Stimulating Hormone (TSH) :
being scanned.
 Most sensitive test for hypothyroidism
 Uses isotopes of iodine: 123I & 131I
 American Thyroid Association
7. Thyroid Scan, Radioscan, or Scintiscan
recommends that pregnant women be
screened for thyroid disease(Alexander,
 It identifies increased function (“hot”
Pearce, Brent, et al., 2017)
areas) or decreased function (“cold”
 Normal: 0.4 - 4.0 mIU/L
areas)
2. Serum Free Thyroxine 4 (T4) :
 It determines location, size, shape, and
 Measures (unbound) thyroxine
anatomic function of the thyroid gland
 Normal: 0.7 - 2.0 ng/dL (10 - 26 pmol/L)
(substernal or large)
3. Serum Total Thyroxine (T3 and T4):
 Includes protein-bound and free
8. Thyroid UTZ
hormone levels that occur in response
to TSH secretion.
 Serious systemic illnesses, medications
(e.g., oral contraceptives,
corticosteroids, carbamazepine,
salicylates), and protein wasting
because of nephrosis, or the use of
androgens may interfere with accurate
test results.
 T4 is 70% bound to TBG (Thyroxine-
Binding Globulin); Only 0.03% of T4 are
unbound
 Normal T4 : 5.4 - 11.5 .g/dL (57 - 148
nmol/L)
 T3 is bound less firmly; 0.3% of T3 are
unbound
 Normal T3 : 260 - 480 pg/dL (4.0 - 7.4
pmol/L) 9. Fine Needle Aspiration Biopsy
4. T3 Resin Uptake Test :
 Indirect measure of unsaturated TBG  It is a procedure used to collect a
 Determines the amount of thyroid sample of cells from thyroid nodules or
hormone bound to TBG and the masses for examination under a
number of available binding sites microscope.
  Detects benign, malignant (follicular
neoplasm or a follicular lesion).
Blood Thinners: to be stopped for few
days
NURSING DIAGNOSIS
ACTUAL PHYSIOLOGIC
1. Impaired Breathing associated with depressed
ventilation
2. Acute Confusion associated with altered
oxygenation in the blood
3. Activity Intolerance associated with insufficient
physiologic or psychological energy
4. Constipation associated with diminished
gastrointestinal peristalsis
5. Lack of Knowledge about the therapeutic
regimen for lifelong thyroid replacement
therapy
POTENTIAL PHYSIOLOGIC
1. Risk For Impaired Cardiac Function related to
the altered metabolism
2. Risk For Impaired Thermoregulation related to
the decreased metabolic rate
3. Risk For Ineffective Tissue Perfusion related to
decreased cardiac output
4. Risk For Altered Neurological Function related
to cerebral edema and decreased cerebral
perfusion
ACTUAL BEHAVIORAL
1. Anxiety related to uncertainty about health
status and symptom management
2. Ineffective Coping related to chronic illness
management
3. Disturbed Body Image related to weight
changes and other physical symptoms
POTENTIAL BEHAVIORAL
1. Risk For Impaired Self-esteem related to
changes in physical appearance
2. Risk For Impaired Social Interaction related to
cognitive impairment
3. Risk for Depression related to the effect to the
neurovascular system
INTERVENTIONS : FOCUS MEDICATION AND
SUPPORTIVE CARE
Objectives:
 To restore a normal metabolic state by
replacing the missing hormone.
 To prevent the disease progression and
complications.
1. Assessment & Monitoring:
 Signs and symptoms of hypothyroidism
 Monitor patients' thyroid function tests,
including thyroid-stimulating hormone (TSH)
and free thyroxine (FT4) levels
 Assess treatment effectiveness
2. Patient Education:
 Causes; Symptoms; & Treatment
Importance of adherence to medication
(Lifetime)
 Regular follow-up appointments
 Blood tests monitoring for thyroid function
 Self-care management/ strategies
 Seeking medical attention promptly if
symptoms worsen or new symptoms
develop
 Avoiding Infection
3. Emotional Support:
 Living with a chronic condition: provide
emotional support to patients and their
families
 Address patients' concerns and fears
 Encourage patients to be independent if
still able
4. Medication Administration:
 levothyroxine (Synthroid, Levoxyl) = primary
treatment for hypothyroidism is thyroid
hormone replacement therapy
 Dose: 75 to 150 mcg per day ; started at the
lower dose and titrated slowly until desired
levels of serum TSH concentration are
achieved
 Normal TSH levels are often achieved with
50 mcg per day
 Older adult patients generally require a
lower dose
 Taking it on an empty stomach on a full
glass of water , preferably in the morning,
at least 30 minutes to 1 hour before eating
or drinking.
 Do not take together with: calcium, iron,
magnesium, zinc, fiber, soy products,
walnut, PPI’s, cholestyramine, colestipol,
anti-seizure drugs, warfarin, insulin, & OHA.
5. Symptom Management: SUPPORTIVE CARE
 Monitoring Of The Following:
 Cardiac Rate &Rhythm : ECG
 ABG to check for CO2 Retention
 Oxygen Saturation Levels
 Cholesterol Levels
 Fluid Regulations to avoid Water
Intoxication
 Dietary Modifications: Increasing Fiber
 Intake to alleviate Constipation
 Managing Fatigue : balance of activity &
rest
 Passive Rewarming *** to manage Cold
Intolerance
6. Collaborative Care/ Referral (Individualized
Care Plans & SBAR) :
 Physicians/ Surgeons
 Endocrinologists
 Dietitians
 Pharmacists