Thyrotoxicosis (Thyroid Storm) Nursing Care Plan

 

Hyperthyroidism Nursing Care Plan
Nursing Diagnosis
  • Risk for Decreased Cardiac Output
Risk factors may include
  • Uncontrolled hyperthyroidism, hypermetabolic state
  • Increasing cardiac workload
  • Changes in venous return and systemic vascular resistance
  • Alterations in rate, rhythm, conduction
Possibly evidenced by
  • Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
Desired Outcomes
  • Maintain adequate cardiac output for tissue needs as evidenced by stable vital signs, palpable peripheral pulses, good capillary refill, usual mentation, and absence of dysrhythmias.
Nursing Interventions
  • Monitor BP lying, sitting, and standing, if able. Note widened pulse pressure.
    • Rationale: General or orthostatic hypotension may occur as a result of excessive peripheral vasodilation and decreased circulating volume. Widened pulse pressure reflects compensatory increase in stroke volume and decreased systemic vascular resistance (SVR).
  • Monitor central venous pressure (CVP), if available.
    • Rationale: Provides more direct measure of circulating volume and cardiac function.
  • Investigate reports of chest pain or angina.
    • Rationale: May reflect increased myocardial oxygen demands or ischemia.
  • Assess pulse and heart rate while patient is sleeping.
    • Rationale: Provides a more accurate assessment of tachycardia.
  • Auscultate heart sounds, note extra heart sounds, development of gallops and systolic murmurs.
    • Rationale: Prominent S1 and murmurs are associated with forceful cardiac output of hypermetabolic state; development of S3 may warn of impending cardiac failure.
  • Monitor ECG, noting rate and rhythm. Document dysrhythmias.
    • Rationale: Tachycardia (greater than normally expected with fever and/or increased circulatory demand) may reflect direct myocardial stimulation by thyroid hormone. Dysrhythmias often occur and may compromise cardiac output.
  • Auscultate breath sounds. Note adventitious sounds.
    • Rationale: Early sign of pulmonary congestion, reflecting developing cardiac failure.
  • Monitor temperature; provide cool environment, limit bed linens or clothes, administer tepid sponge baths.
    • Rationale: Fever (may exceed 104°F) may occur as a result of excessive hormone levels and can aggravate diuresis and/or dehydration and cause increased peripheral vasodilation, venous pooling, and hypotension.
  • Observe signs and symptoms of severe thirst, dry mucous membranes, weak or thready pulse, poor capillary refill, decreased urinary output, and hypotension.
    • Rationale: Rapid dehydration can occur, which reduces circulating volume and compromises cardiac output.
  • Record I&O. Note urine specific gravity.
    • Rationale: Significant fluid losses through vomiting, diarrhea, diuresis, and diaphoresis can lead to profound dehydration, concentrated urine, and weight loss.
  • Weigh daily. Encourage chair rest or bedrest. Limit unnecessary activities.
    • Rationale: Activity increases metabolic and circulatory demands, which may potentiate cardiac failure.
  • Note history of asthma and bronchoconstrictive disease, sinus bradycardia and heart blocks, advanced HF, or current pregnancy.
    • Rationale: Presence or potential recurrence of these conditions affects choice of therapy. For example: use of [beta]-adrenergic blocking agents is contraindicated.
  • Observe for adverse side effects of adrenergic antagonists: severe decrease in pulse, BP; signs of vascular congestion/HF; cardiac arrest.
    • Rationale: Indicates need for reduction or discontinuation of therapy.
  • Administer IV fluids as indicated.
    • Rationale: Rapid fluid replacement may be necessary to improve circulating volume but must be balanced against signs of cardiac failure and need for inotropic support.
Administer medications as indicated:
  • Thyroid hormone antagonists:propylthiouracil (PTU), methimazole (Tapazole)
    • Rationale: May be definitive treatment or used to prepare patient for surgery; but effect is slow and so may not relieve thyroid storm. Once PTU therapy is begun, abrupt withdrawal may precipitate thyroid crisis. Acts to prevent release of thyroid hormone into circulation by increasing the amount of thyroid hormone stored within the gland. May interfere with RAI treatment and may exacerbate the disease in some people.
  • [beta]-blockers:  propranolol (Inderal), atenolol (Tenormin), nadolol (Corgard), pindolol (Visken)
    • Rationale: Given to control thyrotoxic effects of tachycardia, tremors, and nervousness and is first drug of choice for acute storm. Decreases heart rate or cardiac work by blocking [beta]-adrenergic receptor sites and blocking conversion of T4 to T3. If severe bradycardia develops, atropine may be required. Blocks thyroid hormone synthesis and inhibits peripheral conversion of T4 to T3.
  • Strong iodine solution (Lugol’s solution) or supersaturated potassium iodide (SSKI) PO
    • Rationale: May be used as surgical preparation to decrease size and vascularity of the gland or to treat thyroid storm. Should be started 1–3 hr after initiation of antithyroid drug therapy to minimize hormone formation from the iodine. If iodide is part of treatment, mix with milk juice, or water to prevent GI distress and administer through a straw to prevent tooth discoloration.
  • RAI (Na131I or Na125I) following NRC regulations for radiopharmaceutical
    • Rationale: Radioactive iodine therapy is the treatment of choice for almost all patients with Graves’ disease because it destroys abnormally functioning gland tissue. Peak results take 6–12 wk (several treatments may be necessary); however, a single dose controls hyperthyroidism in about 90% of patients. This therapy is contraindicated during pregnancy. Also people preparing or administering the dose must have their own thyroid burden measured, and contaminated supplies and equipment must be monitored and stored until decayed.
  • Corticosteroids:  dexamethasone (Decadron)
    • Rationale: Provides glucocorticoid support. Decreases hyperthermia; relieves relative adrenal insufficiency; inhibits calcium absorption; and reduces peripheral conversion of T3 from T4. May be given before thyroidectomy and discontinued after surgery.
  • Digoxin (Lanoxin)
    • Rationale: Digitalization may be required in patients with HF before [beta]-adrenergic blocking therapy can be considered or safely initiated.
  • Potassium (KCl, K-Lyte)
    • Rationale: Increased losses of K+ through intestinal and/or renal routes may result in dysrhythmias if not corrected.
  • Acetaminophen (Tylenol)
    • Rationale: Drug of choice to reduce temperature and associated metabolic demands. Aspirin is contraindicated because it actually increases level of circulating thyroid hormones by blocking binding of T3 and T4 with thyroid-binding proteins.
  • Sedative, barbiturates
    • Rationale: Promotes rest, thereby reducing metabolic demands and cardiac workload.
  • Furosemide (Lasix)
    • Rationale: Diuresis may be necessary if HF occurs. It also may be effective in reducing calcium level if neuromuscular function is impaired.
  • Muscle relaxants.
    • Rationale: Reduces shivering associated with hyperthermia, which can further increase metabolic demands.
  • Provide supplemental O2 as indicated.
    • Rationale: May be necessary to support increased metabolic demands and/or O2 consumption.
  • Provide hypothermia blanket as indicated.
    • Rationale: Occasionally used to lower uncontrolled hyperthermia (104°F and higher) to reduce metabolic demands/O2  consumption and cardiac workload.
Monitor laboratory and diagnostic studies:
  • Serum potassium
    • Rationale: Hypokalemia resulting from intestinal losses, altered intake, or diuretic therapy may cause dysrhythmias and compromise cardiac function/output. In the presence of thyrotoxic paralysis (primarily occurring in Asian men), close monitoring and cautious replacement are indicated because rebound hyperkalemia can occur as condition abates releasing potassium from the cells.
  • Serum calcium
    • Rationale: Elevation may alter cardiac contractility.
  • Sputum culture
    • Rationale: Pulmonary infection is most frequent precipitating factor of crisis.
  • Serial ECGs
    • Rationale: May demonstrate effects of electrolyte imbalance or ischemic changes reflecting inadequate myocardial oxygen supply in presence of increased metabolic demands.
  • Chest x-rays
    • Rationale: Cardiac enlargement may occur in response to increased circulatory demands. Pulmonary congestion may be noted with cardiac decompensation.
  • Administer transfusions; assist with plasmapheresis, hemoperfusion, dialysis.
    • Rationale: May be done to achieve rapid depletion of extrathyroidal hormone pool in desperately ill or comatose patient.
  • Prepare for surgery.
    • Rationale: Subtotal thyroidectomy (removal of five-sixths of the gland) may be treatment of choice for hyperthyroidism once euthyroid state is achieved.
Nursing Diagnosis
  • Fatigue
May be related to
  • Hypermetabolic state with increased energy requirements
  • Irritability of central nervous system (CNS); altered body chemistry
Possibly evidenced by
  • Verbalization of overwhelming lack of energy to maintain usual routine, decreased performance
  • Emotional lability/irritability; nervousness, tension
  • Jittery behavior
  • Impaired ability to concentrate
Desired Outcomes
  • Verbalize increase in level of energy.
  • Display improved ability to participate in desired activities.
Nursing Interventions
  • Monitor vital signs, noting pulse rate at rest and when active.
    • Rationale: Pulse is typically elevated and, even at rest, tachycardia (up to 160 beats/min) may be noted.
  • Note development of tachypnea, dyspnea, pallor, and cyanosis.
    • Rationale: O2 demand and consumption are increased in hypermetabolic state, potentiating risk of hypoxia with activity.
  • Provide for quiet environment; cool room, decreased sensory stimuli, soothing colors, quiet music.
    • Rationale: Reduces stimuli that may aggravate agitation, hyperactivity, and insomnia.
  • Encourage patient to restrict activity and rest in bed as much as possible.
    • Rationale: Helps counteract effects of increased metabolism.
  • Provide comfort measures: touch therapy or massage, cool showers. Patient with dyspnea will be most comfortable sitting in high Fowler’s position.
    • Rationale: May decrease nervous energy, promoting relaxation.
  • Provide for diversional activities that are calming, e.g., reading, radio, television.
    • Rationale: Allows for use of nervous energy in a constructive manner and may reduce anxiety.
  • Avoid topics that irritate or upset patient. Discuss ways to respond to these feelings.
    • Rationale: Increased irritability of the CNS may cause patient to be easily excited, agitated, and prone to emotional outbursts.
  • Discuss with SO reasons for fatigue and emotional lability.
    • Rationale: Understanding that the behavior is physically based may enhance coping with current situation and encourage SO to respond positively and provide support for patient.
Administer medications as indicated:
  • Sedatives: phenobarbital (Luminal), antianxiety agents: chlordiazepoxide (Librium)
    • Rationale: Combats nervousness, hyperactivity, and insomnia.
Nursing Diagnosis
  • Risk for Disturbed Thought Processes
Risk factors may include
  • Physiological changes: increased CNS stimulation/accelerated mental activity
  • Altered sleep patterns
Possibly evidenced by
  • Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
Desired Outcomes
  • Maintain usual reality orientation.
  • Recognize changes in thinking/behavior and causative factors.
Nursing Interventions
  • Assess thinking process. Determine attention span, orientation to place, person, or time.
    • Rationale: Determines extent of interference with sensory processing
  • Note changes in behavior.
    • Rationale: May be hypervigilant, restless, extremely sensitive, or crying or may develop frank psychosis.
  • Assess level of anxiety.
    • Rationale: Anxiety may alter thought processes.
  • Provide quiet environment; decreased stimuli, cool room, dim lights. Limit procedures and/or personnel.
    • Rationale: Reduction of external stimuli may decrease hyperactivity or reflexia, CNS irritability, auditory and/or visual hallucinations.
  • Reorient to person, place, or time as indicated.
    • Rationale: Helps establish and maintain awareness of reality and environment.
  • Present reality concisely and briefly without challenging illogical thinking.
    • Rationale: Limits defensive reaction.
  • Provide clock, calendar, room with outside window; alter level of lighting to simulate day or night.
    • Rationale: Promotes continual orientation cues to assist patient in maintaining sense of normalcy.
  • Encourage visits by family and/or SO. Provide support as needed.
    • Rationale: Aids in maintaining socialization and orientation. Note: Patient’s agitation and/or psychotic behavior may precipitate family conflicts.
  • Provide safety measures. Pad side rails, close supervision, applying soft restraints as last resorts as necessary.
    • Rationale: Prevents injury to patient who may be hallucinating or disoriented.
  • Administer medication as indicated: sedatives, antianxiety agents, and/or antipsychotic drugs.
    • Rationale: Promotes relaxation, reduces CNS hyperactivity and agitation to enhance thinking ability.
Nursing Diagnosis
  • Risk for Imbalanced Nutrition: Less Than Body Requirements
Risk factors may include
  • Increased metabolism (increased appetite/intake with loss of weight)
  • Nausea/vomiting, diarrhea
  • Relative insulin insufficiency; hyperglycemia
Possibly evidenced by
  • Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
Desired Outcomes
  • Demonstrate stable weight with normal laboratory values and be free of signs of malnutrition.
Nursing Interventions
  • Monitor daily food intake. Weigh daily and report losses.
    • Rationale: Continued weight loss in face of adequate caloric intake may indicate failure of antithyroid therapy.
  • Encourage patient to eat and increase number of meals and snacks. Give or suggest high-calorie foods that are easily digested.
    • Rationale: Aids in keeping caloric intake high enough to keep up with rapid expenditure of calories caused by hypermetabolic state.
  • Provide a balance diet, with six meals per day.
    • Rationale: To promote weight gain. Note: If patient has edema, suggest a low-sodium diet.
  • Avoid foods that increase peristalsis and fluids that cause diarrhea.
    • Rationale: Increased motility of GI tract may result in diarrhea and impair absorption of needed nutrients.
  • Consult with dietitian to provide diet high in calories, protein, carbohydrates, and vitamins.
    • Rationale: May need assistance to ensure adequate intake of nutrients, identify appropriate supplements.
  • Administer medications as indicated: Glucose, vitamin B complex, Insulin (small doses).
    • Rationale: Given to meet energy requirements and prevent or correct hypoglycemia. Insulin aids in controlling serum glucose if elevated.
Nursing Diagnosis
  • Anxiety [specify level]
May be related to
  • Physiological factors: hypermetabolic state (CNS stimulation), pseudo catecholamine effect of thyroid hormones
Possibly evidenced by
  • Increased feelings of apprehension, shakiness, loss of control, panic
  • Changes in cognition, distortion of environmental stimuli
  • Extraneous movements, restlessness, tremors
Desired Outcomes
  • Appear relaxed.
  • Report anxiety reduced to a manageable level.
  • Identify healthy ways to deal with feelings.
Nursing Interventions
  • Observe behavior indicative of level of anxiety.
    • Rationale: Mild anxiety may be displayed by irritability and insomnia. Severe anxiety progressing to panic state may produce feelings of impending doom, terror, inability to speak or move, shouting or swearing.
  • Monitor physical responses, noting palpitations, repetitive movements, hyperventilation, insomnia.
    • Rationale: Increased number of [beta]-adrenergic receptor sites, coupled with effects of excess thyroid hormones, produces clinical manifestations of catecholamine excess even when normal levels of norepinephrine or epinephrine exist.
  • Stay with patient, maintaining calm manner. Acknowledge fear and allow patient’s behavior to belong to patient.
    • Rationale: Affirms to patient or SO that although patient feels out of control, environment is safe. Avoiding personal responses to inappropriate remarks or actions prevents conflicts or overreaction to stressful situation.
  • Describe and explain procedures, surrounding environment, or sounds that may be heard by patient.
    • Rationale: Provides accurate information, which reduces distortions and confusion that can contribute to anxiety and/or fear reactions.
  • Speak in brief statements. Use simple words.
    • Rationale: Attention span may be shortened, concentration reduced, limiting ability to assimilate information.
  •  Reduce external stimuli: Place in quiet room; provide soft, soothing music; reduce bright lights; reduce number of persons contacting patient.
    • Rationale: Creates a therapeutic environment; shows recognition that unit activity or personnel may increase patient’s anxiety.
  • Discuss with patient and/or SO reasons for emotional lability and/or psychotic reaction.
    • Rationale: Understanding that behavior is physically based enhances acceptance of situation and encourages different responses and approaches.
  • Reinforce expectation that emotional control should return as drug therapy progresses.
    • Rationale: Provides information and reassures patient that the situation is temporary and will improve with treatment.
  • Administer antianxiety agents or sedatives and monitor effects.
    • Rationale: May be used in conjunction with medical regimen to reduce effects of hyperthyroid secretion.
  • Refer to support systems as needed: counseling, social services, pastoral care.
    • Rationale: Ongoing therapy support may be desired or required by patient/SO if crisis precipitates lifestyle alterations
Nursing Diagnosis
  • Risk for Impaired Tissue Integrity
Risk factors may include
  • Alterations of protective mechanisms of eye: impaired closure of eyelid/exophthalmos
Possibly evidenced by
  • Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
Desired Outcomes
  • Maintain moist eye membranes, free of ulcerations.
  • Identify measures to provide protection for eyes and prevent complications.
Nursing Interventions
  • Encourage use of dark glasses when awake and taping the eyelids shut during sleep as needed. Suggest use of sunglasses or eyepatch. Moisten conjunctiva often with isotonic eye drops.
    • Rationale: Protects exposed cornea if patient is unable to close eyelids completely because of edema or fibrosis of fat pads and/or exophthalmos.
  • Elevate the head of the bed and restrict salt intake if indicated.
    • Rationale: Decreases tissue edema when appropriate: HF, which can aggravate existing exophthalmos.
  • Instruct patient in extraocular muscle exercises if appropriate.
    • Rationale: Improves circulation and maintains mobility of the eyelids.
  • Provide opportunity for patient to discuss feelings about altered appearance and measures to enhance self-image.
    • Rationale: Protruding eyes may be viewed as unattractive. Appearance can be enhanced with proper use of makeup, overall grooming, and use of shaded glasses.
Administer medications as indicated:
  • Methylcellulose drops
    • Rationale: Lubricates the eyes, reducing risk of lesion formation.
  • Adrenocorticotropic hormone (ACTH), prednisone
    • Rationale: Given to decrease rapidly progressive and marked inflammation.
  • Antithyroid drugs
    • Rationale: May decrease signs and symptoms or prevent worsening of the condition.
  • Diuretics
    • Rationale: Can decrease edema in mild involvement.
  • Prepare for surgery as indicated.
    • Rationale: Eyelids may need to be sutured shut temporarily to protect the corneas until edema resolves (rare) or increasing space within sinus cavity and adjusting musculature may return eye to a more normal position.
Nursing Diagnosis
  • Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs
May be related to
  • Lack of exposure/recall
  • Information misinterpretation
  • Unfamiliarity with information resources
Possibly evidenced by
  • Questions, request for information, statement of misconception
  • Inaccurate follow-through of instructions/development of preventable complications
Desired Outcomes
  • Verbalize understanding of disease process and potential complications.
  • Identify relationship of signs/symptoms to the disease process and correlate symptoms with causative factors.
  • Verbalize understanding of therapeutic needs.
  • Initiate necessary lifestyle changes and participate in treatment regimen.
Nursing Interventions
  • Review disease process and future expectations.
    • Rationale: Provides knowledge base from which patient can make informed choices.
  • Provide information appropriate to individual situation.
    • Rationale: Severity of condition, cause, age, and concurrent complications determine course of treatment.
  • Identify stressors and discuss precipitators to thyroid crises: personal or social and job concerns, infection, pregnancy.
    • Rationale: Psychogenic factors are often of prime importance in the occurrence and/or exacerbation of this disease.
  • Provide information about signs and symptoms of hypothyroidism and the need for continuing follow-up care.
    • Rationale: Patient who has been treated for hyperthyroidism needs to be aware of possible development of hypothyroidism, which can occur immediately after treatment or as long as 5 yr later.
  • After 131I therapy, tell the patient not to expectorate or cough freely. Stress need for repeated measurement of serum T4 levels.
    • Rationale: Saliva will be radioactive for 24 hours.
  • Monitor CBC periodically.
    • Rationale: To detect leukopenia, thrombocytopenia, and agranulocytosis if the patient is taking propylthiouracil and methimazole. Instruct to take medications with meals to minimize GI distress and to avoid OTC cough preparations because many contain iodine.
  • Discuss drug therapy, including need for adhering to regimen, and expected therapeutic and side effects.
    • Rationale: Antithyroid medication (either as primary therapy or in preparation for thyroidectomy) requires adherence to a medical regimen over an extended period to inhibit hormone production. Agranulocytosis is the most serious side effect that can occur, and alternative drugs may be given if problems arise.
  • Identify signs and symptoms requiring medical evaluation: fever, sore throat, and skin eruptions.
    • Rationale: Early identification of toxic reactions (thiourea therapy) and prompt intervention are important in preventing development of agranulocytosis.
  • Explain need to check with physician and/or pharmacist before taking other prescribed or OTC drugs.
    • Rationale: Antithyroid medications can affect or be affected by numerous other medications, requiring monitoring of medication levels, side effects, and interactions.
  • Emphasize importance of planned rest periods.
    • Rationale: Prevents undue fatigue; reduces metabolic demands. As euthyroid state is achieved, stamina and activity level will increase.
  • Review need for nutritious diet and periodic review of nutrient needs. Tell patient to avoid caffeine, red/yellow food dyes, artificial preservatives.
    • Rationale: Provides adequate nutrients to support hypermetabolic state. A hormonal imbalance is corrected, diet will need to be readjusted to prevent excessive weight gain. Irritants and stimulants should be limited to avoid cumulative systemic effects.
  • Stress necessity of continued medical follow-up.
    • Rationale: Necessary for monitoring effectiveness of therapy and prevention of potentially fatal complications.
Other Possible Nursing Care Plans
  • Imbalanced Nutrition: Less Than Body Requirements—may be related intake less than metabolic needs secondary to excessive metabolic rate.
  • Risk for Injury—related to tremors.
  • Risk for Hyperthermia—may be related to lack of metabolic compensatory mechanisms secondary to hyperthyroidism.
  • Activity Intolerance—may be related to fatigue, exhaustion secondary to excessive metabolic rate.
  • Diarrhea—may be related to increased peristalsis secondary to excessive metabolic rate.
  • Impaired Comfort—may be related to heat intolerance and profuse diaphoresis.
  • Risk for Impaired Tissue Integrity: Corneal—may be related to inability to close eyelids secondary to exophthalmos.
  • Risk for Ineffective Therapeutic Regimen Management—may be related to insufficient knowledge of condition, treatment regimen, pharmacologic therapy, eye care, dietary management, and signs and symptoms of complication.