Mamta Suryavanshi,MSc Nursing,PGIMER,CHD

1. HYPOTHYROIDISM
Presented by -
Mamta Suryavanshi
MSc. Nursing
NINE,PGI,CHD

2. Q-1
WHEN IS WORLD THYROID DAY CELEBRATED?

3. World Thyroid
Day May 25th
and International
Thyroid Awareness
Week May 25th to
31st, 2020.
THEME- “There are
still many people
living with some
kind
of thyroid disorder
without diagnosis.

4. Theme-2021
• “It’s not you. It‘s your thyroid” is the theme
of this year’s Thyroid Awareness Week. With
this theme, Thyroid Federation International
(TFI) – the initiator of Thyroid Awareness
Week – wants to make it clear that thyroid
disorders lead to symptoms that are often
misinterpreted by those affected.

5. • Curling (1850)- first case
of hypothyroidism in
children.
• Gull (1873) first to
identify adult
hypothyroidism
• Kocher(1883) -noticed
that the disorder occurs
after thyroidectomy.
• Ord(1878)-Myxedema
• Murray(1891)successful
treatment with
injections of sheep
thyroid extract for
myxedema.
• Kendall(1914)-thyroxin.
• Harrington elucidated
the precise constitution
of thyroxine in 1926.
HISTORY

6. INTRODUCTION-HYPOTHYROIDISM
• common endocrine disorder.
• deficiency of thyroid hormone
• a primary process -unable to produce
sufficient amounts of thyroid hormone.
• secondary—thyroid gland(normal)but
receives insufficient stimulation because of
low secretion of thyrotropin (ie, thyroid-
stimulating hormone [TSH]) from the pituitary
gland.

7. • tertiary hypothyroidism, inadequate secretion
of thyrotropin-releasing hormone (TRH) from
the hypothalamus leads to insufficient release
of TSH, which in turn causes inadequate
thyroid stimulation.
INTRODUCTION-HYPOTHYROIDISM

8. INTRODUCTION
• Worldwide, iodine deficiency remains the foremost cause
of hypothyroidism.
• In the United States and other areas of adequate iodine
intake, autoimmune thyroid disease (Hashimoto disease) is
the most common cause.
• Hypothyroidism may also be drug-induced or otherwise
iatrogenic.
• Some, but not all, studies have indicated that low vitamin
D levels can be linked to autoimmune thyroid diseases,
such as Hashimoto thyroiditis and Graves disease.
• No association has been found between vitamin D levels
and thyroid cancer.

9. EPIDEMIOLOGY
• NATIONAL
Prevalence
INDIA- 11%,
Aged 46–54 years-13·1%
Aged 18–35 years-7·5%
(Increases with age)
PAST- iodine was thought cause but
it is still prevalent despite its
promotion since 1983
• INTERNATIONAL
• Primary hypothyroidism –
worldwide(iodine-deficient
areas)
Prevalence
UK- 2% and USA- 4·6%
Gender- 2-8 times higher
in females.
(more common in women with
small body size at birth and low
body mass index during
childhood)

10. Studies
• A 2013 study showed that 42·2% of
households consumed inadequately iodised
salt and 10·5% consumed salt with no iodine.
• Across the world, with the advent of
iodisation, autoimmune thyroid disease has
become the most common cause of
hypothyroidism.

11. DEFINITION- HYPOTHYROIDISM
• Hypothyroidism is defined as a syndrome characterized
by the clinical and biochemical manifestations of
thyroid hormone deficiency in the target tissues of
thyroid hormone. Strictly speaking, hypothyroidism
denotes deficient thyroid gland production of thyroid
hormone. Hypothyroidism is diagnosed by an elevated
serum TSH in combination with a decreased serum
FT4.
• Hypothyroidism is seldom transient, and usually
requires lifelong treatment with daily levothyroxine
sodium tablets

12. Q-2
•Where does lie your
body’s butterfly?

14. THYROID GLAND-ANATOMY
 Shape-butterfly
 Location -in the front of
the neck just above the
trachea.
 Wt- 15-20 gm (adult)

15. Normal physiology of thyroid gland

17. Pathophysiology of Hypothyroidism

22. Additional signs specific to different
causes of hypothyroidism,
Diffuse or nodular goiter
and pituitary enlargement or tumor, can occur.

23. Man with myxedema or severe
hypothyroidism
showing an expressionless face,
puffiness around the eyes and pallor
Additional symptoms include swelling
of the arms and legs and ascites.

24. DIAGNOSTIC
EVALUATION

26. Diagnostic Evaluation
• Third-generation thyroid-
stimulating hormone (TSH)
assays-Most sensitive screening
tool for primary hypothyroidism.
• If TSH levels are above the
reference range, the next step is
measure free thyroxine (T4).
Another option is to measure
total T4 and binding proteins.
• Assays for anti–thyroid
peroxidase (anti-TPO) and
antithyroglobulin (anti-Tg)
antibodies may be helpful in
determining the etiology of
hypothyroidism or in predicting
future hypothyroidism.
• The generally accepted
reference range for normal
serum TSH is 0.40-4.2
mIU/L.
• In addition, anti-TPO
antibodies have been
associated with increased
risk of infertility and
miscarriage; levothyroxine
(LT4) treatment may lower
this risk.

27. Important points to know
 Patients who are critically ill include decreased TBG
levels and abnormalities in the hypothalamic-pituitary
axis.
 During recovery, some patients have transient elevations
in serum TSH concentrations (up to 20 mIU/L).
 Hence, thyroid function should not be evaluated in a
critically ill person unless thyroid dysfunction is strongly
suspected, and if evaluation is warranted, screening with
TSH alone is insufficient. When needed, however, multiple
thyroid hormone measurements over time may assist
with interpretation.

28. The complete blood count and metabolic profile may
show abnormalities in patients with hypothyroidism
• These include :
• Anemia
• dilutional hyponatremia
• hyperlipidemia,
• and reversible increases
in serum creatinine.
• Elevations in
transaminases and
creatinine kinase

29. Diagnostic evaluation contd...
• TRH--- prolactin along
with TSH.
• Prolactin levels in patients
with hypothyroidism tend
to be lower than those
usually seen with
prolactinomas (the latter
are usually 150-200 ng/mL
or higher).
• USG- neck and thyroid can
be used to detect nodules
and infiltrative disease.
• Serial images with fine-
needle aspiration (FNA) of
suspicious nodules may be
useful.

31. Screening
 Governmental bodies
frequently mandate
screening of neonates for
hypothyroidism so as to
prevent delay in the
recognition and treatment
of cretinism.
The American Thyroid
Association recommends
screening:
 at age 35 years and every 5
years thereafter, with closer
attention to patients who are
at high risk, such as the
following:
 Pregnant women
 Women older than 60 years
 Patients with type 1 diabetes
or other autoimmune disease.
 Patients with a history of neck
irradiation

32. Management
• Hypothyroidism can’t be
cured. But in almost every
patient, hypothyroidism can
be completely controlled.
Goal of treatment
• To reverse clinical
progression and correct
metabolic derangements, as
evidenced by normal blood
levels of thyroid-stimulating
hormone (TSH) and free
thyroxine (T4).

33. Medical Management
Correct Thyroid hormone
deficiency
• constant daily dose of
levothyroxine (LT4)(50-75
µg/day )
• All hypothyroid patients
except those with severe
myxedema (life-threatening
hypothyroidism) can be
treated as outpatients, not
having to be admitted to the
hospital.
• In elderly patients and those
with known ischemic heart
disease, treatment should
begin with one fourth to one
half the expected dosage, and
the dosage should be adjusted
in small increments after no
less than 4-6 weeks

34. Patients should be monitored for symptoms and signs
of overtreatment, which include the following
• Tachycardia
• Palpitations
• Atrial fibrillation
• Nervousness, Tiredness
• Headache
• Increased excitability
• Sleeplessness
• Tremors
• Possible angina.

35. Medical Management
• Medical Management for
Myxedema and Myxedema
Coma
• Supportive measures begin
immediately and include
maintaining a patient airway ,
giving oxygen and replace
fluids intravenously.
• Keep the client warm
• Closely monitor vital signs
until the client begins to
recover.
• Vasopresseors for maintaining
tissue perfusion.
• Levothyroxine sodium I/V with
glucose and corticosteroids.

36. Medical Management
• Goitre Suppression
 removing the stimulus causing the
decreased thyroid mass.
 Suppression of the increase in TSH is
necessary to correct the stimulus for
growth of thyroid gland.
 If goitrogenic foods are the cause
they should be eliminated.
 Rule out iodine deficiency and
institute replacement appropriately.
• Exogenous hormone to inhibit TSH
secretion if cause is unknown and if
goitre associated with Hashimoto’s
disease.
• Dosage should be verified by RAIU
TEST that should have value less than
5%
• Surgery if suppression is not
accomplished with therapy
• If Surgery is done, Life long therapy
is required to manage
hypothyroidism.

37. Surgical Management
• Thyroidectomy to treat large
goitre, particularly those
compressing adjacent tissues
The patient is prepared for surgery
physically and emotionally in the
following ways:
• A special effort to ensure that patient
has a good night’s rest preceding
surgery.
• Explain to patient that speaking is to
be minimized immediately
postoperatively and that oxygen may
be administered to facilitate
breathing.
• Explain that postoperatively, fluids
may be given via IV line to maintain
fluid, electrolyte, and nutritional
needs; IV glucose may also be given
in the hours before the
administration of anaesthetic agents.

38. Postoperative Management
Monitor for bleeding and respiratory distress that indicates
laryngeal edema, secondary to swelling in the area of
surgery.
 Watch for Signs of hypocalcemia i.e. irritability, twitching,
spasms of hands and feet.
monitorCalcium levels.
 If in 48 hours level falls below 7 mg/100 mL (3 mEq), IV
calcium (gluconate, lactate) replacement is given
IV calcium is used cautiously in patients who have renal
disease or who are taking digoxin.
Thyroid function is monitored after surgery.

39. Complications
• Hemorrhage, edema of the glottis, damage to
laryngeal nerve.
• Hypothyroidism following subtotal
thyroidectomy occurs in 5% of patients in first
postoperative year; increases at rate of 2% to 3%
per year.
• Hypoparathyroidism occurs in about 4% of
patients and is usually mild and transient;
requires calcium supplements via IV
administration and orally when more severe.

40. Diet and Activity
• No specific diets
• Adequate nutrition(well balanced)
• Prescribed caloric intake to achieve
goals of weight loss if indicated.
• Subclinical hypothyroidism has been
seen in increased frequency in
patients with greater iodine intake.
• The World Health Organization
(WHO) recommends a daily dietary
iodine intake of 150 µg for adults,
200 µg for pregnant and lactating
women, and 50-120 µg for children.
Activity
• Patients who have hypothyroidism
have generalized hypotonia and may
be at risk for ligamentous injury,
particularly from excessive force
across joints. Thus, patients should
exercise caution with certain
activities, such as contact sports and
heavy physical labor.
• Patients with uncontrolled
hypothyroidism may have difficulty
maintaining concentration in low-
stimulus activities and may have
slowed reaction times.
• Patients should use caution when
engaging in an activity that poses a
risk of injury (eg, operating presses
or heavy equipment and driving.

41. Nursing Management
• Assessment
• History
• Physical examination
• Need assessment
• Lab tests and interpretation

42. Nursing Diagnosis
• These are determined from analysis of
patient’s data

43. Activity intolerance R/T poor work capacity associated with
poor cardiac function, decreased breathing capacity and muscle
stiffness
Interventions :
Goal: To promote activity to the level of patient
tolerance
• Increased the activity of the patient gradually and as
per tolerance.
• e.g., ask the patient to move around in the room. Teach
patient to keep a record of physical activity, noting
duration, intensity, and level of fatigue.
• Monitor the cardiovascular response to new activities,
if the patient complains of chest pain or develops an
unacceptable heart rate, stop the activity and then
resume at slow rate.

44. Body image disturbance R/T change in appearance (weight
gain, hair and skin changes), changes in functioning (decreased
mental and physical function).
Interventions:
– Promote positive body image.
– Provide the information that helps patient and
significant others to understand the relationship
of body changes to hypothyroidism.
– Educate about reversible body changes.
– Stress the positive changes that have occurred.

45. Constipation R/T decreased peristaltic
action , decreased physical activity.
• Interventions:
• Promote normal bowel elimination
• Monitor bowel elimination
• Maintain adequate fluid intake
• Increase bulk in diet

46. Hypothermia R/T decreased heat production
associated with decreased metabolic rate.
• Interventions
• Treat hypothermia
• Monitor temperature every 2-4 hours
• Maintain an environmental temperature i.e.
comfortable for the patient
• Use blanket to increase body temperature if necessary

47. Knowledge deficit: disease, treatment, expected outcomes, self
–monitoring, follow up, R/T new interventions with no
previous exposure to information.
Interventions
• Teach the patient and his care givers about the nature of the
disorder, diagnostic tests and treatment, need for lifelong
replacement therapy.
• Provide information regarding medication, its dosage and
side-effects.
• Self monitoring of vital signs, weight, skin integrity and
bowel function.
• Teach them methods to prevent skin breakdown and
constipation.
• Educate them regarding the need for periods of rest
alternating with activity.
• Need for follow up care.

48. Pain R/T Headache and joint pain associate with chronic
thyroid problems.
Interventions:
• Promote comfort:
– Use non-medicinal comfort measures such as massage, cold
compress and distraction to promote pain control.
– If medication are used, monitor patient carefully, patient will
have lower tolerance for sedatives.

49. Impaired thought process R/T slowing of intellectual functions
associated with chronic deficits of thyroid hormone.
• Interventions:
• Facilitate a safe environment and orientation and monitor
neurological status every shift.
• Reorient the patient frequently, use resources such as
current events, clocks and newspapers.
• Maintain a safe environment remove any clutter, keep bed
rails up.
• Check on patient frequently, especially at night, and use
nightlights to prevent confusion.
• Inform significant others of relationship between mental
status and hypothyroidism.
• Involve patient, as possible in decision about care.[12]

50. Risk for Injury related to possible removal of
parathyroid glands.
• Nursing Interventions
• Observing for Hemorrhage and Airway Edema
• Administer humidified oxygen, as prescribed, to
reduce irritation of airway and to prevent edema.
• Move patient carefully; provide adequate support
to the head so that no tension is placed on the
sutures.
• Place patient in semi-Fowler’s position, with the
head elevated and supported by pillows; avoid
flexion of neck.

51. Risk for Injury related to possible
removal of parathyroid glands.
Interventions contd...
 Monitor vital signs frequently, watching for tachycardia and hypotension
that indicates hemorrhage (most likely between 12 and 24 hours
postoperatively).
 Observe for bleeding at sides and back of the neck, and anteriorly, when
patient is in dorsal position.
 Watch for repeated clearing of the throat or for complaint of smothering
or difficulty swallowing, which may be early signs of hemorrhage.
 Watch for irregular breathing, swelling of the neck, and choking— other
signs pointing to the possibility of hemorrhage and tracheal compression.
 Reinforce dressing, if indicated.
 Be alert for voice changes, which may indicate damage to laryngeal nerve.
 Keep a tracheostomy set in patient’s room for 48 hours for emergency use.

52. Preventing Tetany
• Watch for the development of tetany caused by removal or disturbance of
parathyroid glands through a progression of signs: Tingling of toes and
fingers and around the mouth; apprehension.
• Positive Chvostek’s sign—tapping on the cheek over the facial nerve
causes a twitch of the lip or facial muscles
• Positive Trousseau’s sign—carpopedal spasm induced by occluding
circulation in the arm with a BP cuff
• Be prepared to treat hypocalcemic tetany.
• Position patient for optimal ventilation; remove pillow to prevent head
from bending forward and compressing trachea.
• Keep side rails padded and elevated and position the patient to prevent
injury if a seizure occurs; do not use restraints because they only
aggravate the patient and may result in muscle strain or fractures.
• Have equipment available to treat respiratory difficulties that includes
airway suction equipment, tracheostomy, and cardiac arrest equipment.
• Administer IV calcium, as directed.

53. Preventing Tetany
• Positive Chvostek’s sign

54. Other Nursing diagnosis:
• Altered nutrition more than body requirement
R/T decreased metabolic rate
• Self care deficit, total(varies): bathing-hygiene;
dressing –grooming, feeding, toileting
• Sexual dysfunctioning R/T alterations in
menstrual cycle, sperm production and libido
• Impaired skin integrity R/T mucinous deposits in
skin, decreased circulation, immobility.
• Risk for Injury related to invasive procedure of
the neck.

55. Patient Education and Health
Maintenance
• Teach patient about complications to look for if
discharge occurs within a day or two of surgery.
• Advise patient to rest at home and to prevent
any strain on suture line, as directed by surgeon.
• Advise nutritious diet; report difficulty
swallowing.
• Encourage follow-up for monitoring and thyroid
hormone replacement after surgery[13]
•

56. Referrals
• Appropriate referrals might include home care
nursing, physical therapy ,and social services if
family /personal resources are limited.

57. Discharge education/Follow-up
Client will be instructed at the time of discharge /follow up
instructions as following:
• You’ll need to have your TSH checked 6 to 10 weeks after a
thyroxine dose change.
• You may need tests more often if you’re pregnant or you’re taking
a medicine that interferes with your body’s ability to use
thyroxine.
• The goal of treatment is to get and keep your TSH in the normal
range.
• Babies with hypothyroidism must get all their daily treatments
and have their TSH levels checked as they grow, to prevent mental
retardation and stunted growth.
• Once you’ve settled into a thyroxine dose, you can return for TSH
tests about once a year.

58. YOU NEED TO RETURN SOONER IF ANY OF THE
FOLLOWING APPLY TO YOU:
• Your symptoms return or get worse.
• You want to change your thyroxine dose or brand, or change
taking your pills with or without food.
• You gain or lose a lot of weight (as little as approx. 5 kg
difference for those who weren’t overweight to begin with).
• You start or stop taking a drug that can interfere with
absorbing thyroxine (such as certain antacids, calcium
supplements and iron tablets), or you change your dose of
such a drug.
• Medications containing estrogen also impact thyroxine doses,
so any change in such a medication should prompt a re-
evaluation of your thyroxine dose.

59. Contd..
• You start or stop taking certain medicines to control
seizures such as phenytoin or tegretol, as such medicines
increase the rate at which thyroxine is metabolized in your
body, and your dose of thyroxine may need to be adjusted.
• You’re not taking all your thyroxine pills. Tell your doctor
honestly how many pills you’ve missed.
• You want to try stopping thyroxine treatment. If ever you
think you’re doing well enough not to need thyroxine
treatment any longer, try it only under your doctor’s close
supervision. Rather than stopping your pills completely, you
might ask your doctor to try lowering your dose. If your TSH
goes up, you’ll know that you need to continue
treatment.[14]

60. Summary
• Hypothyroidism is a very common condition, also called an underactive
thyroid.
• It can happen due to damage to the thyroid gland from inflammation or
after certain treatments like surgery.
• If it is not treated it can lead to other illnesses such as heart disease and
may even be life threatening.
• It also causes symptoms like fatigue and weight gain.
• Patients with hypothyroidism need to take thyroid hormone which is
often a lifelong treatment.
• Client need to take well balanced diet and monitor weight, and need to
maintain weight in normal range.
• Client should be asked to resume physical activity as per tolerance.
• Client should be given discharge education and counselling for healthy
behaviour to manage hypothyroidism and prevent complication.
• Appropriate referrals might include home care nursing, physical therapy,
and social services if family /personal resources are limited. Follow up
instructions should be given to clients.

61. Conclusion
• We as health care professional should be aware about the
national health programme related to prevention of thyroid
disorders
(National Newborn Screening Programme including
congenital hypothyroidism, Rashtriya Bal Swasthya
Karyakram, National Guidelines for Screening of
Hypothyroidism during Pregnancy, National Iodine Deficiency
Disorders Control Programme and National Family Health
Survey 3 and 4.)
• and May 25th –world thyroid day, International Thyroid
awareness week: May25-May 31,and the theme for 2020-
Thyroid issue: Mother and baby...so as to make public aware
about prevention of thyroid disorders, screening of thyroid and
early diagnosis and treatment.

62. TAKE HOME MESSAGE
“Supplement the thyroid
hormones your gland can not
produce, regular follow
up...you can have a perfectly
normal life’’

63. •QUIZ -
SESSION

64. Q-1 )One of the symptoms of
hypothyroidism is:
A. Fatigue
B. Intolerance to cold
C. Weight gain
D. All of the above

65. Answer- 1
• D

66. Q-2.) In women, hypothyroidism can
affect pregnancy by:
A. Reducing the chance of getting pregnant
B. Boosting the chance of getting pregnant
C. Making miscarriage more likely
D. Making labor and delivery more difficult

67. Answer-2
• A- Reducing the chance of getting pregnant

68. Q-3.) A person with untreated
hypothyroidism may also have:
A. High cholesterol
B. Low blood pressure
C. Low blood sugar
D. None of the above

69. Answer-3
A- High cholesterol

70. Q-4.) How is hypothyroidism treated?
A. With radiation
B. With surgery
C. With a synthetic hormone
D. The condition can't be treated

71. Answer-5
C- With a synthetic hormone

72. Q-6.)Which of the following is the initial treatment indicated in
most cases of mild to moderate hypothyroidism?
A. Levothyroxine at a dose of 50-75 µg/day
B. Levothyroxine at a dose of 4 µg per kilogram of lean
body weight as an intravenous bolus, with 100 µg
administered 24 hours later
C. Desiccated thyroid at a dose of 15-30 mg orally per
day
D. Liothyronine at a dose of 25 µg orally per day

73. Answer-6
A- Levothyroxine at a dose of 50-75 µg/day

74. Q-7.) you are performing discharge teaching with a patient who is going
home on Synthroid. Which statement by the patient causes you to re-
educate the patient about this medication?
A. “I will take this medication at bedtime with a
snack.
B. “I will never stop taking the medication
abruptly.
C. “If I have palpitations, chest pain, intolerance to
heat, or feel restless, I will notify the doctor.”
D. “I will not take this medication at the same time
I take my Carafate.”

75. Answer-7
A- Synthroid is best taken in the MORNING on
an empty stomach. All the other statements
are correct about taking Synthroid

76. Q-8.) Myxedema coma is a severe form of hypothyroidism that
most commonly occurs in which of the following?
A. Male patients with hypothyroidism and excessive
weight gain
B. Female patients with galactorrhea and menstrual
disturbances secondary to hypothyroidism
C. Patients with hypothyroidism and decreased
appetite, sleepiness, hair loss, and dry skin
D. Patients with untreated hypothyroidism who are
subjected to an external stress

77. Answer-8
D- Patients with untreated hypothyroidism who are subjected
to an external stress.
Myxedema coma is a severe form of hypothyroidism that
results in an altered mental status, hypothermia,
bradycardia, hypercarbia, and hyponatremia. Cardiomegaly,
pericardial effusion, cardiogenic shock, and ascites may be
present. Myxedema coma most commonly occurs in
individuals with undiagnosed or untreated hypothyroidism
who are subjected to an external stress, such as low
temperature, infection, myocardial infarction, stroke, or
medical intervention (eg, surgery or hypnotic drugs)

78. Q-9.) A patient was recently discharged home for treatment of
hypothyroidism and was ordered to take Synthroid for
treatment. The patient is re-admitted with signs and symptoms
of the following: heart rate 42, blood pressure 70/56, blood
glucose 55, and body temperature of 96.8 ‘F.
The patient is very fatigued and drowsy. The family reports the
patient has not been taking Synthroid since being discharged
home from the hospital.
Which of the following conditions is this patient most likely
experiencing?
A. Thryoid Storm
B. Myxedema Coma
C. Iodism
D. Toxic Nodular Goiter

79. Answer-9
B- Myxedema Coma…The red flags in this
question are the patient’s signs/symptoms
and the report from the family the patient
hasn’t been taking the prescribed Synthroid.
The patient is showing signs and symptoms of
extreme hypothyroidism known as Myxedema
coma (which is life-threatening if not treated).

80. Q-10.) ___________ is an autoimmune disorder
where the body attacks the thyroid gland that causes
it to stop releasing T3 and T4. The patient is likely to
have the typical signs/symptoms of hypothyroidism,
however, they may present with what other sign as
well?
•
A. Myxedema coma; joint pain
B. Thyroid storm; memory loss
C. Hashimoto’s Thyroiditis; goiter
D. Toxic nodular goiter (TNG); goiter

81. Answer-10
• Hashimoto’s Thyroiditis; goiter

82. • THANK YOU

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84. Contd...
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