C.

Thyroid gland Thyroid Tests

1. Located in the anterior part of the neck Tests Normal Findings
Serum Thyroid-
Stimulating Hormone
(Blood test is used to
2–10 mcU/L (2–10
differentiate the diagnosis
mU/L).
of primary
hypothyroidism.)

0.9 to 1.7 ng/dL (11.5 to

Serum Free T4 21.8 pmol/L).

Normal range for T4 is

5.4 to 11.5 μg/dL (57 to
148 nmol/L)
Serum Free T3 and T4
Normal range for serum
T3 is 80 to 200 ng/dL
(1.2 to 3.1 nmol/L)

25% to 35% (relative

2. Controls the rate of body metabolism and growth, uptake fraction, 0.25 to
influence cell replication and are important in T3 Resin Uptake Test
0.35)
brain development, and produces thyroxine (T4),
triiodothyronine (T3), and thyrocalcitonin. Normal values vary from
one geographic region to
Radioactive Iodine
3. Thyroxine (T4) and triiodothyronine (T3) another and with the
Uptake
hormones accelerate metabolic processes by intake of iodine.
(Measures thyroid uptake
increasing the level of specific enzymes that patterns of iodine as a
contribute to oxygen consumption and altering Normal values are 3% to
whole or within specified
the responsiveness of tissues to other hormones. 10% at 2 to 4 hours, and
areas of the gland.)
5% to 30% in 24 hours.
4. Thyrocalcitonin is secreted in response to high
plasma levels of calcium, and it reduces the
plasma level of calcium by increasing its
Other thyroid tests include;
deposition in bone. It serves as a marker for
a) Thyroid Antibodies A blood test used to identify
sepsis, and is believed to be a mediator of
thyroid immune disease (Graves’ disease, chronic
inflammatory responses.
thyroiditis, Hashimoto’s thyroiditis).
Normal values:
Synthesis of Thyroid Hormone Antithyroglobulin: negative to titer < 1:20
Iodine is essential to the thyroid gland for synthesis of its
Antimicrosomal: negative to titer < 1:100
hormones. The major use of iodine in the body is by the
thyroid, and the major derangement in iodine deficiency
b) Fine-Needle Biopsy to detect malignancy.
is alteration of thyroid function.
Results are reported as (1) negative (benign), (2)
positive (malignant), (3) indeterminate
Iodide is ingested in the diet and absorbed into the blood
(suspicious), and (4) inadequate (nondiagnostic).
in the GI tract. The thyroid gland is extremely efficient at
c) Thyroid Scan, Radioscan, or Scintiscan to
taking up iodide from the blood and concentrating it
determine the location, size, shape, and anatomic
within the cells, where iodide ions are converted to iodine
function of the thyroid gland, particularly when
molecules, which react with tyrosine (an amino acid) to
thyroid tissue is substernal or large.
form the thyroid hormones.
d) Serum Thyroglobulin to detect persistence or
recurrence of thyroid carcinoma.
 (cretinism). In such instances, the mother may
Nursing Implications also have thyroid deficiency.
When thyroid tests are scheduled, it is necessary to g. The most common cause of hypothyroidism in
determine whether the patient has taken medications or adults is autoimmune thyroiditis (Hashimoto’s
agents that contain iodine, because these may alter the test disease), in which the immune system attacks the
results. Iodine-containing medications include contrast thyroid gland.
agents and those used to treat thyroid disorders.
Causes of Hypothyroidism
Partial List of Medications That May Alter Thyroid Autoimmune Disease (Hashimoto’s Thyroiditis, post-
Test Results Graves’ Disease)
Estrogen Opioids Atrophy for Thyroid gland with aging
Sulfonylureas Androgens Therapy for Hyperthyroidism (Radioactive iodine,
Corticosteroids Salicylates Thyroidectomy)
Iodine Lithium Medications (Lithium, Iodine Compounds,
Propranolol Amiodarone Antithyroid Medications)
Cimetidine Clofibrate
Radiation to head and neck for treatment of head and
5-Fluorouracil Furosemide
neck
Phenytoin Diazepam
Heparin Danazol cancers, lymphoma
Chloral hydrate Dopamine antagonist Infiltrative diseases of the thyroid (amyloidosis,
X-ray contrast Agents Propylthiouracil scleroderma, lymphoma)
Iodine deficiency and iodine excess

The nurse asks the patient about the use of these 2. Assessment
medications and notes their use on the laboratory a) Lethargy and Fatigue
requisition. b) Weakness, muscle aches, paresthesias
c) Cold Intolerance
THYROID GLAND DISORDERS d) Weight gain
1. Hypothyroidism e) Dry skin and hair and loss of body hair
2. Hyperthyroidism f) Bradycardia
g) Constipation
A. Hypothyroidism h) Generalized puffiness and edema around the
1. Description eyes and face (myxedema)
a. Hypothyroid state resulting from hyposecretion i) Forgetfulness and loss of memory
of thyroid hormones and characterized by a j) Menstrual Disturbances (menorrhagia and
decreased rate of body metabolism amenorrhea, loss of libido)
b. The T4 is low and the TSH is elevated. k) Goiter may or may not be present
c. In primary hypothyroidism, the source of l) Cardiac Enlargement, tendency to develop
dysfunction is the thyroid gland and the thyroid heart failure
cannot produce the necessary amount of m) Sleep Apnea
hormones. More than 95% of patients with
hypothyroidism have primary or thyroidal  Advanced hypothyroidism may produce personality
hypothyroidism. and cognitive changes characteristic of dementia.
d. In secondary or pituitary hypothyroidism, the Inadequate ventilation and sleep apnea can occur with
thyroid is not being stimulated by the pituitary to severe hypothyroidism. Pleural effusion, pericardial
produce hormones. effusion, and respiratory muscle weakness may also
e. If the cause is a disorder of the hypothalamus occur.
resulting in inadequate secretion of TSH due to
decreased stimulation of TRH, it is referred to as  Severe hypothyroidism is associated with an elevated
hypothalamic or tertiary hypothyroidism. serum cholesterol level, atherosclerosis, coronary
f. If thyroid deficiency is present at birth, it is artery disease, and poor left ventricular function.
referred to as congenital hypothyroidism
 The patient with advanced hypothyroidism is insufficiency; hence, steroid therapy may be
hypothermic and abnormally sensitive to sedatives, started.
opioids, and anesthetic agents, which must be  Mild symptoms in alert patient or asymptomatic
administered with extreme caution cases (with abnormal laboratory results only)
require only initiation of low-dose thyroid
3. Diagnostic Evaluation hormone given orally.
 Low T3 and T4 levels.
 Elevated TSH levels in primary hypothyroidism c. Instruct the client about thyroid replacement
because the negative hormonal feedback from TH therapy and about the clinical manifestations of
is lost. both hypothyroidism and hyperthyroidism related
 Elevation of serum cholesterol, triglycerides, and to underreplacement or overreplacement of the
lipoproteins. Anemia, hypoglycemia, and hormone.
hyponatremia are also common Anticipated treatment effects.
 Electrocardiogram (ECG)—sinus bradycardia,  Diuresis, decreased puffiness.
low voltage of QRS complexes, and flat or  Improved reflexes and muscle tone.
inverted T waves.  Accelerated pulse rate.
 Elevation of thyroid peroxidase antibodies and  A slightly higher level of total serum T4.
antithyroglobulin antibodies.  All signs of hypothyroidism should disappear in
3 to 12 weeks.
4. Interventions  Decreasing TSH level.
a. Monitor vital signs, including heart rate and
rhythm d. Instruct the client in a low-calorie, low-
b. Administer thyroid replacement; levothyroxine cholesterol, low–saturated fat diet; discuss a daily
sodium is most commonly prescribed and is the exercise program such as walking.
treatment of choice. e. Assess the client for constipation; provide
roughage and fluids to prevent constipation.
L E V O f. Provide a warm environment for the client.
Life Long Early Very Oh the g. Avoid sedatives and opioid analgesics because
*Long Morning Hyper Baby is of increased sensitivity to these medications; may
Slow (High HR, Fine precipitate myxedema coma.
Onset Empty BP, Temp) h. Monitor for overdose of thyroid medications,
Stomach (Pregnancy characterized by tachycardia, chest pain,
(3-4 weeks 1x Daily REPORT Safe) restlessness, nervousness, and insomnia.
till relief 1 hour Agitation/ i. Instruct the client to report episodes of chest pain
before Confusion
or other signs of overdose immediately.
breakfast (Thyroid
(NOT at Storm)
night) B. Myxedema coma
1. Description
a. Myxedema coma is a rare life-threatening
Thyroid Hormone: T4-levothyroxine; T3-liothyronine; condition. It is the decompensated state of severe
T3 and T4 mixed. hypothyroidism in which the patient is
 Because T3 acts more quickly than T4, it is given hypothermic and unconscious (Kwaku &
via nasogastric tube if patient is unconscious Burman, 2007).
(myxedema coma). b. Most common risk factors are post-
 Sodium levothyroxine is administered thyroidectomy and abrupt stop of Levothyroxine.
parenterally (until consciousness is restored) to c. This condition may develop with undiagnosed
restore T4 level. hypothyroidism and may be precipitated by
infection or other systemic disease or by use of
 Later, patient is continued on oral thyroid
sedatives or opioid analgesic agents.
hormone therapy.
d. The term reflects the characteristic accumulation
 With rapid administration of thyroid hormone,
of nonpitting edema in the connective tissues
plasma T4 levels may initiate adrenal
throughout the body. The edema is the result of
 water retention in mucoprotein (hydrophilic the sympathetic nervous system’s physiologic
proteoglycans) deposits in the interstitial spaces. response to stimulation.
The face of a patient with myxedema appears b. Characterized by an increased rate of body
puffy, the tongue is enlarged, and the voice is metabolism
hoarse and husky (Porth & Matfin, 2009). c. Hyperthyroidism results from many different
e. The condition occurs most often among elderly factors, including autoimmune stimulation (as in
women in the winter months and appears to be Graves’ disease), excess secretion of thyroid-
precipitated by cold. However, the disorder can stimulating hormone (TSH) by the pituitary
affect any age group. gland, thyroiditis, neoplasms (such as toxic
multinodular goiter), side effect of certain drugs,
2. Assessment and an excessive intake of thyroid medications.
a. Hypotension d. A common cause is Graves’ disease, also known
b. Bradycardia (Below 60bpm) as toxic diffuse goiter, including toxic
c. Hypothermia multinodular goiter, and toxic adenoma.
d. Hyponatremia e. Clinical manifestations are referred to as
e. Hypoglycemia thyrotoxicosis.
f. Lactic Acidosis
g. Generalized edema 2. Assessment
h. Respiratory failure (Low RR) a) Personality changes such as irritability, agitation,
i. Cardiovascular collapse and mood swings
j. Coma b) Nervousness and fine tremors of the hands
c) Heat intolerance
3. Interventions d) Weight Loss
a. Maintain a patent airway. Place tracheostomy kit e) Smooth, soft skin with a characteristic of salmon
by bedside. color, and hair
b. Institute aspiration precautions. f) Palpitations (Heart Rate is usually between 90
c. Administer IV fluids (normal or hypertonic and 160 bpm), cardiac dysrhythmias such as
saline) as prescribed. tachycardia or atrial fibrillation
d. Administer levothyroxine sodium intravenously g) Protruding eyeballs
as prescribed. (exophthalmos) may be
e. Administer glucose intravenously as prescribed. present. This produces the
f. Administer corticosteroids as prescribed. startled expression.
g. Assess the client’s temperature hourly. h) Diaphoresis
h. Monitor blood pressure frequently. i) Hypertension (Hypertensive
i. Keep the client warm. Crisis) 180/100 mmHg
j. Monitor for changes in mental status. j) Enlarged thyroid gland
k. Monitor electrolyte and glucose levels. (goiter)
k) Hypermotile bowels and diarrhea
NURSING ALERT l) Insomnia
The nurse must monitor for myocardial ischemia or
infarction, which can occur in response to therapy in 3. Assessment and Diagnosis Evaluation
patients with severe, long-standing hypothyroidism or The thyroid gland invariably is enlarged to some
myxedema coma. The nurse must also be alert for signs extent. It is soft and may pulsate; a thrill often can be
of angina, especially during the early phase of treatment; palpated, and a bruit is heard over the thyroid arteries.
if detected, it must be reported and treated at once to avoid These are signs of greatly increased blood flow through
a fatal myocardial infarction. the thyroid gland.
1. Elevated T3 and T4.
C. Hyperthyroidism 2. Elevated serum T3 resin uptake and free thyroid index.
1. Description 3. Low TSH levels.
a. Hyperthyroid state resulting from hypersecretion 4. Presence of TSI antibodies (if Graves’ disease is the
of thyroid hormones (T3 and T4). This hormonal cause).
excess increases the metabolic rate and heightens
5. 131I uptake scan may be elevated or below normal anticoagulants; iodine
depending on the underlying cause of the increases their effect.
hyperthyroidism.
Health Education for the
4. Interventions Patient and Family
a. Provide adequate rest. *The maximum effect of iodine
in large doses usually occurs in
b. Administer sedatives as prescribed.
10 to 15 days.
c. Provide a cool and quiet environment.
*Long-term iodine therapy is
d. Obtain weight daily. not effective in controlling
e. Provide a high-calorie diet. hyperthyroidism.
f. Avoid the administration of stimulants.
g. Administer antithyroid medications, such as Nursing Responsibilities
methimazole or propylthiouracil that block *Monitor for side effects:
thyroid synthesis as prescribed. agranulocytosis (reduction in
h. Administer iodine preparations that inhibit the neutrophils, eosinophils, or
release of thyroid hormone as prescribed. basophils), hypothyroidism,
i. Administer propranolol [Inderal], atenolol pruritus rash, elevated
[Tenormin], metoprolol [Lopressor] (beta- temperature, (for iodides)
blocker) as adjunctive therapy for symptomatic periorbital edema, anorexia,
relief, particularly in transient thyroiditis, as loss of taste, hair loss, changes
in menstruation.
prescribed.
*Administer drugs at the same
j. Prepare the client for radioactive iodine time each day with meals to
therapy, as prescribed, to destroy thyroid cells. maintain stable blood levels.
k. Prepare the client for subtotal thyroidectomy if *Monitor for manifestations of
prescribed. hypothyroidism: fatigue,
l. Elevate the head of the bed of a client ANTITHYROID weight gain.
experiencing exophthalmos; in addition, instruct DRUGS
on low-salt diet, administer artificial tears, Methimazole Health Education for the
encourage the use of dark glasses, and tape (Tapazole) Patient and Family
eyelids closed at night if necessary. Carbimazole *Watch for unusual bleeding,
m. Provide food with high calories (4,00 to 5,00 per (converted to redness, swelling, nausea, loss
day), High protein and Carbs, and frequent meals methimazole when of taste, or epigastric pain.
absorbed) *Report any such
and snacks (6-8/day). Avoid high fiber, caffeine
Propylthiouracil manifestations to the physician.
(coffee, soda, tea) and spicy food.
(PTU, Propyl- *Propylthiouracil is associated
n. Allow the client to express concerns about body Thyracil) with weight changes; check
image changes. weight daily when starting this
medication to determine effect.
Report significant changes to
Nursing Responsibilities physician.
*Assess for hypersensitivity to *If you are also taking
iodine before giving warfarin, report any signs of
Iodine Sources medication; for example, ask bleeding.
Strong Iodine patient about allergies to *If you are taking lithium, be
Solution (Lugol’s shellfish. aware of manifestations of
Solution) *Dilute liquid iodine sources in hypothyroidism.
Potassium iodide water or orange juice to *It may take up to 12 weeks
(SSKI, Thyro- disguise bitter taste, and use before you experience the full
Block, Pima) straw to prevent staining of the effects of the drugs. Take the
teeth. medication regularly and
*Monitor for increased exactly as prescribed. Do not
bleeding tendencies if the discontinue abruptly.
patient is also taking
D. Thyroid Storm (Thyroid Crisis) Radioactive iodine is contraindicated during
1. Description pregnancy because it crosses the placenta. Women
a. This acute and life-threatening condition occurs of childbearing age should be given a pregnancy
in a client with uncontrollable hyperthyroidism. test 48 hours before administration of radioactive
b. It can be caused by manipulation of the thyroid iodine. They should also be instructed to not
gland during surgery and the release of thyroid conceive for at least 6 months following treatment.
hormone into the bloodstream; it also can occur
from severe infection and stress. To ensure that radioactivity is no longer actively
c. Antithyroid medications, beta blockers, concentrated in breast tissue, radioactive iodine
glucocorticoids, and iodides may be administered should not be given until at least 6 weeks after
to the client before thyroid surgery to prevent its lactation stops.
occurrence.
The goal of radioactive iodine therapy (131I) is to
2. Assessment eliminate the hyperthyroid state with the
a. Agitation and Confusion (early sign) administration of sufficient radiation in a single
b. Elevated temperature (hyperpyrexia), >38.5°C dose.
(>101.3°F)
c. Extreme Tachycardia Chief advantage over thioamides is that a lasting
d. Systolic hypertension remission can be achieved. Chief disadvantage is
e. Nausea, vomiting, and diarrhea that permanent hypothyroidism can be produced.
f. tremors, anxiety
g. Irritability, restlessness, and seizures as the BEFORE AFTER
condition progresses Negative Pregnancy Test AVOID EVERYONE
h. Delirium psychosis, somnolence and coma Remove neck jewelry and
dentures No pregnant People
3. Interventions No Crowds
a. Maintain a patent airway and adequate 5-7 Days before: hold Not same restroom (flush
ventilation. Humidified oxygen is given to antithyroid Medications 3x)
improve tissue oxygenation and meet the high (3 days before in some Not same food utensils
reference) Not same laundry basket
metabolic demands. Arterial blood gas levels or
as the family
pulse oximetry may be used to monitor
Awake- NO anesthesia or No Physical Touch
respiratory status. Conscious Sedation (cuddling and kissing)
b. IV fluids containing dextrose are given to replace
liver glycogen stores that have been decreased in NPO: 2 to 4 hour Before
the patient who is hyperthyroid. & 1-2 hours After
c. Administer antithyroid medications, iodides,
propranolol combined with digitalis, and
glucocorticoids as prescribed.
d. Hydrocortisone is prescribed to treat shock or F. Thyroidectomy
adrenal insufficiency. 1. Description
e. Monitor vital signs. a. Removal of the thyroid gland
f. Monitor continually for cardiac dysrhythmias. b. Performed when persistent hyperthyroidism
g. Administer nonsalicylate antipyretics as exists
prescribed (salicylates increase free thyroid c. Subtotal thyroidectomy, removal of a portion
hormone levels). (five sixths) of the thyroid gland, is the preferred
h. Use a cooling blanket to decrease temperature as surgical intervention because it results in a
prescribed. prolonged remission in most patients with
exophthalmic goiter.
E. Radioactive Iodine Therapy
Radioactive iodine has been used to treat toxic 2. Preoperative Care
adenomas, toxic multinodular goiter, and most a. Administer ordered antithyroid medications and
varieties of thyrotoxicosis. iodine preparations, and monitor their effects.
 Antithyroid drugs are given before surgery to  Respiratory distress.
promote a euthyroid state. Iodine preparations are Assess respiratory rate, rhythm, depth, and
given to the patient before surgery to decrease effort. Maintain humidification as ordered.
vascularity of the gland, thereby decreasing the risk Assist the patient with coughing and deep
of hemorrhage. breathing.
Have suction equipment, oxygen, and a
b. Teach the patient to support the neck by placing tracheostomy set available for immediate
both hands behind the neck when sitting up in bed, use.
while moving about, and while coughing. Placing Respiratory distress may result from
the hands behind the neck eases tension on the hemorrhage and edema, which may compress
suture line in the front of the neck. the trachea; from tetany and laryngeal spasms
resulting from decreased hormones due to
c. Answer questions, and allow time for the patient to removal or damage to the parathyroid glands;
verbalize concerns. Because the incision is made at and from damage to the laryngeal nerve,
the base of the throat, patients (especially women) causing spasms of the vocal cords.
are often concerned about their appearance after Stridor is heard in acute obstructions. This is
surgery. Explain that the scar will eventually be a high-pitched, squeaky sound and is a sign
only a thin line and that jewelry or scarves may be of airway obstruction. Equipment must be
used to cover the scar. immediately available if the patient
experiences respiratory distress that requires
d. Teach the patient to expect hoarseness due to interventions and treatment.
generalized swelling at the suture line.
 Laryngeal nerve damage.
Assess for the ability to speak aloud, noting
3. Postoperative Care quality and tone of voice. The location of the
a. Provide comfort measures: Administer analgesic laryngeal nerve increases the risk of damage
pain medications as ordered, and monitor their during thyroid surgery.
effectiveness; place the patient in a semi-Fowler’s Although hoarseness may be due to edema or
position after recovery from anesthesia; support the endotracheal tube used during surgery
head and neck with pillows. Analgesic medications and will subside, permanent hoarseness or
reduce the perception of pain and reduce physical loss of vocal volume is a potential danger.
stress during the postoperative period. Positioning
the patient in a semi-Fowler’s position and  Tetany.
supporting the head and neck decrease strain on the Assess for manifestations of latent tetany due
suture line. to calcium deficiency, including tingling of
toes, fingers, and lips; muscular twitches;
b. Perform focused assessments to monitor for positive Chvostek’s and Trousseau’s signs;
complications: and decreased serum calcium levels.
 Hemorrhage. Serum calcium levels will be monitored in
Assess dressing (if present) and the area the postoperative period. Keep calcium
behind and under the patient’s neck and gluconate or calcium chloride available for
shoulders for drainage. immediate IV use, if necessary.
Monitor blood pressure and pulse for The parathyroid glands are located in and
manifestations of hypovolemic shock. near the thyroid gland; surgery of the thyroid
Assess tightness of dressing (if present). The gland may injure or remove parathyroid
vascularity of the gland increases the risk of glands, resulting in hypocalcemia and tetany.
hemorrhage. The location of the incision Tetany may occur in 1 to 7 days after
and the position of the patient may cause the thyroidectomy.
drainage to run back and under the patient.
The danger of hemorrhage is greatest in the
first 12 to 24 hours after surgery.