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Hypothyroidism Nursing Guide

Overview: Hypothyroidism

This course is intended as a Quick Reference for hypothyroidism and will cover an overview as well as nursing considerations utilizing the nursing process.


Hypothyroidism Etiology and Epidemiology

The thyroid gland, which secretes thyroid hormones to regulate metabolism, is located in the anterior neck. When the thyroid produces lower than normal levels of thyroid hormones, the result is hypothyroidism. If left untreated, hypothyroidism increases an individual’s morbidity and mortality. There are three types of hypothyroidism overt primary hypothyroidism, subclinical hypothyroidism, and central hypothyroidism.

Overt primary hypothyroidism shows an elevated thyroid-stimulating hormone (TSH) and low free thyroxine (T4). Overt primary can develop because of:

  • Autoimmune-related
  • Congenital
  • Thyroid surgery
  • Radiotherapy of the neck
  • Endemic iodine deficiency

Subclinical hypothyroidism shows an elevated TSH with a normal FT4. Central hypothyroidism has a low to normal TSH with a low FT4 and can be caused by:

  • Hypopituitarism
  • A hypothalamic process
  • Severe illness

There is a higher incidence of primary hypothyroidism among women and older adults (DynaMed, 2018). Hypothyroidism is a global health problem, and older adults comprise approximately 7% of all hypothyroidism cases. According to the National Institute of Diabetes and Digestive and Kidney Diseases (2021), 5 out of every 100 people over the age of 12 have hypothyroidism.

Risk factors for developing hypothyroidism include:

  • Female gender
  • Over 65 years old
  • Family history
  • Postpartum thyroiditis
  • Radiation therapy of head or neck area
  • Down syndrome
  • Turner syndrome
  • Autoimmune disorders such as:
    • Pernicious anemia
    • Diabetes mellitus type 1
    • Vitiligo
    • Alopecia
    • Celiac disease
    • Addison disease
    • Systemic lupus erythematosus
    • Primary biliary cirrhosis

A deficiency in thyroid hormone causes primary hypothyroidism, which is often due to autoimmune thyroiditis or Hashimoto. Less common causes of primary hypothyroidism include:

  • Deficient iodine intake
  • Excess iodine consumption
    • Injury of the thyroid from radiation of head or neck or thyroid surgery
  • Transient thyroiditis:
    • Postpartum thyroiditis
    • Destructive thyroiditis
    • Viral infection
  • Medications
    • Iodine (J.Crow’s® Lugols’s Solution)
    • Amiodarone (Multaq®)
    • Lithium (Lithobid®)
    • Tyrosine kinase inhibitors such as sunitinib (Sutent®)
    • Interferon-alfa (Intron®)
    • Thalidomide (Thalomid®)
    • Monoclonal antibodies (Regkirona)
    • Antiepileptic drugs such as valproate (Depacon®)
    • Medicines for drug-resistant tuberculosis such as ethionamide (Trecator®)
  • Malignancy of the thyroid
  • Infections

Most cases of secondary hypothyroidism are caused by a compressive or invasive lesion near the pituitary region (DynaMed, 2018). Secondary hyperthyroidism can also be caused by medications such as:

  • Dopamine
  • Somatostatins
  • Glucocorticosteroids
  • Retinoid X
  • Oral bexarotene

Undiagnosed hypothyroidism can lead to severe complications such as:

  • Seizures
  • Nephrocalcinosis
  • Laryngospasm, stridor, or anoxia
  • Irreversible calcification of basal ganglia
  • Increased intracranial pressure
  • Cataracts
  • Cardiac arrhythmias
  • Cardiac arrest
  • Death

Hypothyroidism Diagnosis

Hypothyroidism has a varied presentation with nonspecific symptoms and should be suspected when individuals present with symptoms such as (DynaMed, 2018):

  • Dry skin
  • Poor concentration
  • Depression diffuse muscle pain or cramps
  • Cold sensitivity
  • Fatigue
  • Voice changes
  • Constipation
  • Menstrual irregularities
  • Lethargy
  • Weight gain
  • Decreased libido
  • Periorbital edema
  • Hair loss
  • Menstrual disturbances
  • Galactorrhea
  • Infertility

Diagnosis of hypothyroidism depends upon serum levels of TSH and T4 (Chiovato et al., 2019). These tests will also help to determine the type of hypothyroidism (Hershman, 2020). In primary hypothyroidism, TSH is consistently elevated, and the free T4 is low. In secondary hypothyroidism, free T4 is low and TSH is normal. Hypothyroid symptoms such as menstrual disturbances, galactorrhea, and infertility are specific to secondary hypothyroidism.

Because each laboratory has its normal values, this should be taken into consideration if TSH or T4 are borderline in the presence of symptoms.

Hypothyroidism should be differentiated from nonthyroidal illness syndrome, which also has TSH abnormalities such as:

  • Severe systemic illness
  • Use of glucocorticoids or high dose androgens
  • Acromegaly
  • Cushing syndrome
  • Nephrotic syndrome
  • Medications:
    • Nicotinic acid (Niacor®, Niaspan®)
    • L-asparaginase (Elspar®)
    • Danazol (Danatrol®)
  • Anemia
  • Pregnancy


The gold standard for treating hypothyroidism has always been synthetic thyroxine or levothyroxine (Synthroid® or Levoxyl®), an exogenous form of T4 (Chiovato et al., 2019). Levothyroxine has been the preferred treatment for more than 60 years.

Levothyroxine is one of the most often prescribed medications worldwide and one of the two most frequently prescribed in the U.S. Once levothyroxine is initiated, treatment usually is continued for life. Doses are generally started in small amounts and slowly increase over months to years depending upon laboratory levels of TSH. Serum TSH should be checked every 4 to 8 weeks until targets levels are reached. With each subclinical TSH level, levothyroxine should be increased. The goal of treatment is to reduce a person's symptoms along with preventing long-term complications.

Levothyroxine comes in many forms, including:

  • Intravenous (Fera pharm®)
  • Tablets (Synthroid®, Levoxyl®)
  • Soft gel capules (Tirosint®)
  • Liquid (Tirosint-SOL®)

After levothyroxine has reached a therapeutic level for the individual, doses may still need adjusting over a person's lifetime. Factors that can affect TSH metabolism include:

  • Poor medication adherence
  • Dietary supplements
  • Changes in body mass
  • Dietary habits
    • Substantial intake of shellfish or seafood
    • Iodized or non-iodized salt
    • Dairy products

It is recommended that older adults and individuals with heart disease start with lower doses that are increased slowly while monitoring for osteoporosis, atrial fibrillation, and angina (Nikita, 2021). Because elevated cholesterol often accompanies hypothyroidism, serum cholesterol levels should also be observed, especially in those who already have heart disease.

Hypothyroidism Nursing Care Plan

Nursing Considerations

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 hypothyroidism are listed below.


Assess signs and symptoms, such as (Patil et al., 2021):

  • Vital signs
  • Dry skin
  • Sleep disturbances
  • Loss of hair
  • Constipation
  • Fatigue
  • Intolerant to cold temperatures
  • Intolerance to cold
  • Menstrual cycle changes
  • Weight gain
  • Appetite changes
  • Energy level
  • Change in voice
  • Muscle strength and tone
  • Fluid intake
  • Family history of thyroid disease
  • Anxiety, depression, or psychosis
  • Memory difficulty or loss
  • Periorbital edema
  • Palpitations or racing heart
  • Neck for enlarged thyroid or nodules
  • Reflex time
  • Thyroid levels:
    • Thyroid-stimulating hormone
    • Free T4
    • Thyroid peroxidase antibodies
    • Anti-thyroglobulin antibodies
  • Laboratory results for:
    • Hyperlipidemia
    • Serum creatinine kinase
    • Hepatic enzymes
    • Hemoglobin
    • Blood urea nitrogen
    • Creatinine
    • Uric acid

Hypothyroidism Nursing Diagnosis/Risk For

  • Imbalanced nutrition: More than body requirements as evidenced by (Phelps, 2021a):
    • Change in appetite
    • Sedentary lifestyle
    • Weight gain
  • Activity intolerance related to impaired metabolic state as evidenced by (Phelps, 2021b):
    • Overwhelming lack of energy
    • Inability to complete desired activities
  • Deficient knowledge: Disease process as evidenced by: (Phelps, 2021c):
    • New disease process
    • Lack of compliance with medication


  • Monitor vital signs
  • Encourage six small meals daily
  • Encourage diet rich in fiber and low in cholesterol, calories, and saturated fats
  • Promote rest periods between activities
  • Adjust climate to a comfortable temperature for the individual
  • Administer medications as ordered, in the morning or on an empty stomach
  • Insert IV if admitted for monitoring
  • Monitor heart rhythm
  • Offer emotional support
  • Provide meticulous skincare
  • Seizure precautions
  • Monitor lab results
  • Monitor treatment response

Expected Outcomes

  • TSH levels return to normal
  • States improved feeling of wellbeing
  • Decrease in symptoms
  • Increased energy

Individual/Caregiver Education

  • Condition, treatment, and expected outcomes
  • Notify healthcare provider or seek immediate medical care for:
    • No improvement of symptoms
    • Worsening of symptoms
    • Palpitations or racing heart
    • Change in behavior or mental status
    • Slow breathing or shortness of breath
    • Increased swelling of hands, feet, or face
    • Increased appetite
    • Insomnia
    • Shakiness
  • Weight changes and body requirements with hypothyroidism
  • Thyroid hormones and compliance
  • Not to stop taking the medication without contacting a healthcare provider
  • Benefits, side effects, and interactions of medications
  • Follow-up visits with a healthcare provider

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Course Contributor

The content was created by Kathleen Koopmann, RN, BSN, PCCN. Kathleen earned her Associate Degree in nursing in 1987 at Mid-Michigan Community College and her Bachelor of Science in nursing in 2018 from Western Governor’s University. She has training from the North Carolina Statewide Program for Infection Control and Epidemiology through NCDHHS and the University of North Carolina. Kathleen has worked in long-term care, outpatient care, acute care, and nursing education. She has hospital experience in Med-Surg, OR/PACU, Critical Care, Telemetry, and outpatient experience in Occupational Health. Kathleen has experience as a clinical instructor for the LPN program at Susquehanna County Career and Technical Center in Pennsylvania. Most recently, she worked in long-term care as a Staff Development Coordinator and Infection Control Practitioner.




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