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Nursing Guide to Hyperthyroidism, Thyroid Storm & Graves' Disease: Nursing Diagnosis, Interventions, & Care Plans

Updated On 7 Minute Read

Hyperthyroidism, Thyroid Storm, and Graves' Disease Etiology and Epidemiology

Hyperthyroidism, thyroid storm, and Graves' disease is a trio of disorders resulting from an excess of thyroid hormone.

Hyperthyroidism is the primary disease. Thyroid storm is a severe and acute state of untreated or undertreated hyperthyroidism (Wisse, 2020b).

Graves’ disease is an autoimmune disorder that is one of several forms of hyperthyroidism and is the most common cause of hyperthyroidism (Mayo Clinic, 2020). Symptoms may range from mild to severely life threatening.

Hyperthyroidism can occur in anyone at any age, however there are some groups with a higher prevalence of the disease including (Schraga, 2020):

  • White and Hispanic populations
  • Females
  • Populations between 20 and 40 years of age

The thyroid gland is one of the most important glands of the body. It is often described as a butterfly shaped gland that is located in the front of the throat and hugs the windpipe.

Thyroid hormones play a large role in many major functions of the human body, including but not limited to controlling metabolism on the cellular level and the body system level.

Thyroid hormones affects (Brady, 2021):

  • Body weight
  • Central and peripheral nervous system functions
  • Heart rate
  • Breathing
  • Muscle strength
  • Body temperature regulation
  • Cholesterol levels
  • Menstrual cycle regulation

Hyperthyroidism may present with numerous symptoms because of the many body systems that thyroid hormones affect.

Symptoms of hyperthyroidism may include (Schraga, 2020):

  • Dyspnea
  • Palpitations
  • Chest pain
  • Heat intolerance
  • Increased perspiration
  • Nervousness
  • Fatigue
  • Weakness
  • Edema
  • Menstrual cycle irregularity
  • Frequent bowel movements
  • Weight loss
  • Tremor
  • Anxiety
  • Psychosis
  • Disorientation
  • Mood swings

The thyroid gland uses iodine to produce thyroid hormones including (Brady, 2020):

  • Triiodothyronine (T3)
  • Thyroxine (T4)

This process is controlled by the pituitary and hypothalamus. The thyroid gland produces and releases T3 and T4 in response to the thyroid stimulating hormone (TSH), which is produced by the pituitary gland (Brady, 2021). The pituitary gland does this in response to TSH Releasing Hormone (TRH), which is produced by the hypothalamus (Brady, 2021).

Changes to this delicate cycle results in overproduction of thyroid hormones and leads to hyperthyroidism.

Causes of Hyperthyroidism:

One cause of hyperthyroidism includes ingested exogenous thyroid hormone, which causes Thyrotoxicosis factitial.

Other causes of hyperthyroidism include (Hershman, 2020):

  • Graves’ disease (most common)
  • Thyroiditis
  • Excessive iodine intake
  • Plummer disease (solitary or multinodular goiter)
  • Medications:
    • Amiodarone (Nexterone®)
    • Alemtuzumab (Campath®)
    • Interferon-alfa (Intron® A)
    • Levothyroxine sodium (Synthroid®)
  • Nonautoimmune autosomal dominant hyperthyroidism
  • Metastatic thyroid cancer
  • Pregnancy (usually caused by Graves’ disease)
  • Hyperemesis gravidarum
  • Molar pregnancy
  • Choriocarcinoma
  • Struma ovarii
  • Inappropriate TSH secretion

The most common cause of hyperthyroidism is Graves’ disease.

Graves’ disease occurs when the immune system has produced autoantibodies that work against the thyroid receptors for TSH, resulting in the thyroid’s being overly stimulated (Schraga, 2020). This overstimulation causes overproduction of thyroid hormone and gland enlargement.

Graves’ disease is characterized by a hallmark triad of symptoms including (Schraga, 2020):

  • Exophthalmos
  • Goiter
  • Infiltrative dermopathy/pretibial myxedema

Specific risk factors for Graves’ disease include (Mayo Clinic, 2020):

  • Individuals less than 40 years of age
  • Women (more likely than men)
  • Family history of Graves’ disease
  • Smoking
  • Stress (emotional and physical)
  • Excessive iodine intake
  • Comorbidities of other autoimmune disorders
  • Pregnancy

Complications of Graves’ disease include (Mayo Clinic, 2020):

  • Thyroid storm
  • Heart damage
    • Arrythmias
    • Heart structure and function changes
    • Heart failure
  • Osteoporosis
  • Pregnancy related:
    • Maternal heart failure
    • Preeclampsia miscarriage
    • Pre-term birth
    • Low birth weight
    • Fetal thyroid dysfunction

Thyroid storm is a rare complication that is caused by extremely high levels of thyroid hormone in an untreated or undertreated individual. It is brought on by a triggering event such as trauma, surgery, infection, embolism, preeclampsia, or diabetic ketoacidosis (Hershman, 2020).

Symptoms of thyroid storm are severe and acute. They include physical, psychological, and emotional symptoms such as (Hershman, 2020):

  • Fever
  • Sweating
  • Severe weakness
  • Muscle wasting
  • Nausea
  • Vomiting
  • Diarrhea
  • Hepatomegaly with mild jaundice
  • Tachycardia
  • Cardiovascular collapse
  • Shock
  • Extreme restlessness
  • Extreme emotional swings
  • Agitation
  • Confusion
  • Psychosis
  • Altered levels of consciousness (including coma)

Note: Thyroid storm is a medical emergency; prompt and appropriate treatment is required as this condition can be fatal (Hershman, 2020).

Diagnosis

Diagnostic tests may include (Wisse, 2020a):

  • Thyroid blood tests to evaluate the levels of free T4, T3, and TSH
  • Thyroid peroxidase (TPO) antibody
  • Thyroid stimulating immunoglobulin (TSI)
  • Anti-TSH receptor antibody (TRAb)
  • Radioactive iodine uptake and scan
  • Orbit computed tomography (CT) scan or ultrasound

Other diagnostics to evaluate cardiovascular, renal, and hepatic function may also be warranted.

Management

Management is determined by the severity and type of symptoms present. Treatment options include but are not limited to (Hershman, 2020):

  • Antithyroid medications:
    • Methimazole (Northyx®)
    • Propylthiouracil (Propacil®)  Note: Use only under strict circumstances due to the risk for acute liver failure, severe liver injury, and possible death.
  • Intravenous glucocorticoids such as dexamethasone (Decadron®)
  • Beta-blockers
  • Iodine
  • Radioactive iodine
  • Thyroidectomy

Treatment of any underlying cause that may have precipitated a thyroid storm such as infection, preeclampsia, diabetic ketoacidosis, and embolism should occur.

Hyperthyroidism, Thyroid Storm, and Graves' Disease Nursing Care Plan

Use the nursing process to develop a plan of care for individuals. The nursing assessment (with common findings listed), diagnoses, interventions, expected outcomes, and education for hyperthyroidism, thyroid storm, and Graves' disease are listed below.

Assessment

A thorough history should be taken. A wide range of symptoms may be discovered during a review of:

  • Past and present health conditions
  • Current symptomology
  • Medication history
  • Surgical history
  • Injury or trauma history to their throat
  • Family history
  • Activity habits

During the head to toe assessment there may be few to no symptoms. However, some symptoms that you may encounter include (Hershman, 2020):

  • Goiter
  • Exophthalmos
  • Infiltrative dermopathy, often in lower limbs
  • Arrythmias
  • Tachycardia
  • Dyspnea
  • Facial flushing
  • Fever
  • Sweating
  • Severe weakness
  • Muscle wasting

The individual may report:

  • Nausea
  • Vomiting
  • Weakness
  • Lethargy
  • Diarrhea
  • Chest pain
  • Difficulty breathing
  • Tremors
  • Weight loss
  • Moodiness
  • Concentration problems
  • Memory problems
  • Difficulty sleeping
  • Irregular menstrual cycles
  • Increased appetite
  • Eye symptoms (e.g., itching, irritation, tearing, double vision, or painful sensations)

During assessment, it is also important to assess the individual’s emotional and mental state. The individual may be disoriented, confused, agitated, restless, emotionally unstable, and suffering from psychosis due to hyperthyroidism.

Hyperthyroidism Nursing Diagnosis/Risk For

  • Deficient knowledge of disease and disease processes
  • Fatigue
  • Altered levels of consciousness
  • Coma
  • Shock
  • Unstable blood pressure
  • Diarrhea
  • Impaired gas exchange
  • Ineffective beathing pattern
  • Electrolyte imbalance
  • Ineffective cardiac output
  • Hyperthermia
  • Weakness
  • Falls
  • Injury
  • Anxiety
  • Psychosis
  • Acute confusion

Interventions

Interventions should ensure safety, comfort, and symptom management.

  • Maintain fall precautions.
  • Discuss procedures:
    • Pharmacological
    • Surgeries (thyroidectomy)
    • Expectations and outcomes
  • Monitor:
    • Cardiovascular, respiratory, renal, neurological, and hepatic function
    • Vital signs
    • Efficacy of treatment
    • Intake and output
    • Pulse oximetry readings
    • Arterial blood gas (ABG)
    • Electrolyte balance
    • Pain status
    • Levels of consciousness
  • Provide therapies as ordered:
    • Medications
    • Oxygen
    • Fluids
  • Provide comfort measures.
  • Provide fever reduction measures (e.g., remove heavy blankets, antipyretics as ordered, reduce room temperature).
  • Reduce stimulation.

Expected Outcomes

The individual will report and laboratory tests will confirm:

  • Achievement and maintenance of adequate thyroid hormone levels.
  • Reduction of cardiovascular, respiratory, renal, neurological, and hepatic symptoms.
  • Reduction of anxiety, restlessness, agitation, and mood swings.
  • Compliance with medication regimen.
  • No report of new falls and/or injuries.

Individual/Caregiver Education

  • Disease process: Various disease topics needed for adequate management
  • Recognizing the signs and symptoms of hyperthyroidism:
    • Heart palpitations
    • Fever
    • Flushing
    • Sweating
    • Mood changes
    • Restlessness
    • Confusion
    • Memory changes
    • Bulging eyes
    • Vision changes
  • Family and caregiver support to monitor changes in consciousness and behavior.
  • How to manage symptoms and when to contact provider.
  • Self-care measures:
    • Quiet space
    • Relaxation techniques
    • Deep breathing

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Additional Information

Content Release Date 

4/1/2022

Content Expiration

12/31/2026

Content Contributed by: Tameka N. Warren, MSN, RN, CLC

Tameka N. Warren, MSN, RN, CLC, earned her Bachelor and Master of Science in Nursing degrees from Indiana University School of Nursing at IUPUI, and her Associate of Science in Nursing from Ivy Tech College. She has over 19 years of nursing experience in public health, regulation, home health, leadership, education, maternal child community health, and long-term care environments. Tameka has served as a leader in home healthcare practices, quality improvement, and education as a community health nurse and a Public Health Nurse Surveyor (Home Health & Hospice) certified by CMS for a State Agency. She has served as a maternal and infant mortality advocate in managing home visiting services, supporting legislation to improve maternal child care in diverse communities, and as an ALPP Certified Lactation Counselor. She has also served as an Adjunct Clinical Professor to further awareness about the importance of community health nursing. Tameka’s passion is to serve the most vulnerable populations affected by health disparities and to inspire a new generation of nurses to do the same successfully.

Disclosures

Tameka N. Warren, MSN, RN, CLC has no relevant financial or non-financial relationship(s) with ineligible companies to disclose.

Reference herein to any specific commercial product, process, or service by trade name, trademark, service mark, manufacturer or otherwise does not constitute or imply any endorsement, recommendation, or favoring of, or affiliation with, Relias, LLC.

All characteristics and organizations referenced in the following training are fictional. Any resemblance to any actual organizations or persons living or dead, is purely coincidental.

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Tameka Warren, MSN, RN, CLC

Tameka N. Warren, MSN, RN, CLC, earned her Bachelor and Master of Science in Nursing degrees from Indiana University School of Nursing at IUPUI, and her Associate of Science in Nursing from Ivy Tech College. She has over 16 years of nursing experience in public health, regulation, home health, education, maternal child community health, and long-term care environments. Tameka served as a Public Health Nurse Surveyor (Home Health & Hospice) certified by the Centers for Medicare & Medicaid Services, or CMS, a maternal and infant mortality advocate, an ALPP Certified Lactation Counselor, and an Adjunct Clinical Professor. Tameka’s passion is to serve the most vulnerable populations affected by health disparities and to inspire a new generation of nurses to do the same successfully.