Nursing Care Plan: Hypothyroidism

NANDA Diagnoses - Priority Order

Overview of Hypothyroidism (Clinical Context)

Priority 1 - Ineffective Breathing Pattern

• Subjective: Reports shortness of breath, fatigue on exertion, feeling of chest heaviness
• Objective: Slow respiratory rate (bradypnea), shallow breathing, decreased oxygen saturation (SpO2), possible pleural effusion, decreased breath sounds on auscultation, hypoventilation on ABG

• Patient will maintain SpO2 >95% throughout shift
• Respiratory rate will remain within normal limits (12-20 breaths/min)
• Patient will demonstrate effective coughing and deep breathing techniques

• Monitor respiratory status every 2-4 hours
• Assess for signs of myxedema coma (most dangerous complication - marked by hypoxia, bradycardia, hypotension, decreased LOC)
• Maintain airway patency at all times
• Have intubation equipment available at bedside for high-risk patients

1. Monitor respiratory rate, depth, and rhythm every 2-4 hours; report rate <12/min immediately
2. Position patient in semi-Fowler's (30-45 degrees) to maximize lung expansion
3. Encourage deep breathing exercises and incentive spirometry every 2 hours while awake
4. Apply supplemental oxygen as ordered; titrate to maintain SpO2 >95%
5. Monitor ABG values and pulse oximetry continuously in severe cases
6. Administer IV levothyroxine as ordered in acute/myxedema coma situations
7. Assist with intubation and mechanical ventilation if respiratory failure develops
8. Avoid sedatives and CNS depressants that further depress respiration

• Patient maintains SpO2 within normal limits
• Respiratory rate is 12-20 breaths/min
• No signs of respiratory distress or cyanosis
• ABG values within acceptable range

Priority 2 - Decreased Cardiac Output

• Subjective: Reports fatigue, dizziness, palpitations, decreased exercise tolerance
• Objective: Bradycardia (HR <60 bpm), hypotension, muffled heart sounds, distant heart sounds (pericardial effusion), decreased pulse pressure, peripheral edema, pale/cool skin, possible ECG changes (low voltage, flat/inverted T waves)

• Heart rate will remain between 60-100 bpm
• Blood pressure will remain within patient's normal range
• Patient will demonstrate improved activity tolerance
• Signs of pericardial effusion will be identified and managed early

• Continuous cardiac monitoring for patients with bradycardia or dysrhythmias
• Daily weight monitoring for fluid retention
• Electrolyte monitoring (especially sodium - hyponatremia is common)
• Collaborate with physician regarding levothyroxine dosing

1. Monitor vital signs every 2-4 hours; report HR <50 bpm or symptomatic bradycardia
2. Apply continuous cardiac monitoring; report dysrhythmias immediately
3. Assess for signs of pericardial effusion (muffled heart sounds, JVD, paradoxical pulse)
4. Monitor daily weight and fluid intake/output - report gain >2 kg/day
5. Administer levothyroxine (oral or IV) as ordered; note that drug interactions (calcium, antacids, iron) reduce absorption - give on empty stomach
6. Restrict sodium and fluid intake as prescribed to manage edema
7. Elevate lower extremities to reduce peripheral edema
8. Monitor serum electrolytes, especially sodium (hyponatremia worsens cardiac function)
9. Avoid administering medications that worsen bradycardia (beta-blockers, digoxin) without physician guidance

• Vital signs stable within acceptable parameters
• No new dysrhythmias on cardiac monitor
• No evidence of pericardial effusion
• Edema reduced; daily weight stable or decreasing

Priority 3 - Hypothermia / Risk for Imbalanced Body Temperature

• Subjective: Reports feeling cold even in warm environments, inability to tolerate cold, requesting extra blankets
• Objective: Core temperature <36°C, cold and pale skin, decreased metabolic rate, shivering (may be absent in severe cases), bradycardia contributing to poor perfusion

• Patient will maintain core body temperature between 36.1°C - 37.2°C
• Patient will verbalize understanding of strategies to prevent cold exposure
• Skin will be warm and dry without signs of frostbite or tissue injury

• Monitor body temperature every 4 hours or per protocol
• Adjust room temperature and bedding to patient comfort
• Avoid rapid rewarming (which can cause cardiovascular collapse in myxedema coma)

1. Monitor core temperature every 4 hours; use rectal or tympanic method for accuracy
2. Increase room temperature and provide extra blankets, warm socks
3. Use warm (not hot) IV fluids if administering IV therapy
4. Avoid exposing large areas of skin during care; cover immediately after procedures
5. In myxedema coma: use passive external warming only (warm blankets); avoid active warming devices which cause vasodilation and cardiovascular collapse
6. Educate patient to layer clothing, avoid cold environments, and report worsening cold intolerance
7. Monitor for skin breakdown in areas of poor circulation

• Core temperature maintained between 36-37.2°C
• Patient reports comfort with thermal management strategies
• No cold-related skin injury

Priority 4 - Activity Intolerance

• Subjective: Reports overwhelming fatigue, weakness, inability to complete ADLs, needing to rest frequently, muscle aches and joint stiffness
• Objective: Slowed movements, prolonged response time, inability to sustain activity, tachycardia or dyspnea on minimal exertion, decreased muscle strength on testing

• Patient will demonstrate increased tolerance for activity within 3-5 days
• Patient will participate in planned rest/activity schedule
• Patient will be able to perform ADLs with minimal assistance

• Assess baseline activity tolerance using a functional scale
• Plan activities during periods of highest energy (usually morning)
• Schedule care activities to allow uninterrupted rest periods
• Gradually increase activity levels as thyroid hormone replacement takes effect

1. Assess current level of activity tolerance and ability to perform ADLs at baseline
2. Plan care to allow for scheduled rest periods between activities; avoid clustering all procedures together
3. Encourage gradual, progressive activity increases - start with sitting up in bed, then ambulating short distances
4. Provide assistance with ADLs as needed; do not rush patient
5. Educate patient that fatigue will gradually improve with consistent levothyroxine therapy (2-3 weeks for initial effect; 6-8 weeks for full effect)
6. Monitor vital signs before and after activity; discontinue if HR increases >20 bpm or patient becomes symptomatic
7. Encourage adequate sleep hygiene; hypothyroidism can cause insomnia and excessive daytime sleepiness
8. Collaborate with physical therapy for a structured exercise program as condition improves

• Patient performs increasing levels of activity without excessive fatigue
• Vital signs remain stable with activity
• Patient reports improved energy levels over time
• Patient adheres to rest-activity schedule

Priority 5 - Constipation

• Subjective: Reports infrequent bowel movements (<3/week), hard/dry stools, straining, abdominal bloating, decreased appetite
• Objective: Hypoactive or absent bowel sounds, abdominal distension on palpation, hard stool on rectal exam, weight gain

• Patient will have a bowel movement at least every 2-3 days without straining
• Bowel sounds will be present in all four quadrants
• Patient will identify dietary and lifestyle modifications to prevent constipation

• Assess bowel habits daily including frequency, consistency, effort
• Monitor for paralytic ileus in severe hypothyroidism (serious complication)
• Ensure adequate hydration and fiber intake

1. Assess bowel function daily: frequency, consistency (Bristol Stool Scale), pain, and last bowel movement
2. Auscultate bowel sounds in all four quadrants every shift; report absent bowel sounds (possible ileus)
3. Encourage fluid intake of 2000-3000 mL/day unless contraindicated by cardiac status
4. Encourage a high-fiber diet (fruits, vegetables, whole grains) - aim for 25-35g fiber/day
5. Encourage physical activity as tolerated - even gentle ambulation stimulates bowel motility
6. Administer stool softeners or laxatives as prescribed; document response
7. Monitor abdominal girth for distension; report significant changes
8. Educate patient on signs of fecal impaction and when to notify healthcare provider

• Patient has bowel movement at least every 2-3 days
• Stools are soft and passed without excessive straining
• Bowel sounds present in all four quadrants
• Patient verbalizes understanding of dietary fiber and hydration strategies

Priority 6 - Imbalanced Nutrition: More Than Body Requirements

• Subjective: Reports weight gain despite not eating more, poor appetite, feeling full quickly
• Objective: Weight gain (5-10 lbs common), elevated BMI, elevated cholesterol/triglycerides on labs, myxedematous puffiness (face, periorbital, extremities)

• Patient will not gain additional weight during hospitalization
• Patient will identify appropriate dietary modifications for reduced metabolism
• Lipid levels will trend toward normal with treatment

• Consult with dietitian for individualized nutritional assessment and plan
• Monitor weight daily (same time, same scale, same clothing)
• Review lab values: cholesterol, triglycerides, glucose

1. Weigh patient daily under consistent conditions; track trends
2. Consult dietitian for low-calorie, high-fiber meal planning appropriate to metabolic rate
3. Monitor lipid panel and blood glucose levels; report abnormal values
4. Educate patient that iodine-rich foods (seafood, dairy, iodized salt) support thyroid function - but do not self-supplement with iodine without physician guidance
5. Advise avoiding goitrogens in large quantities (raw cabbage, broccoli, soy) which can further suppress thyroid function
6. Set realistic weight management goals - weight loss will occur gradually as levothyroxine normalizes metabolism
7. Collaborate with patient on a nutrition plan they can sustain long-term

• Patient's weight is stable or decreasing
• Patient demonstrates understanding of dietary modifications
• Patient reports adherence to nutritional plan
• Lipid levels trend toward normal values

Priority 7 - Disturbed Thought Processes / Chronic Confusion

• Subjective: Reports forgetfulness, difficulty concentrating, depression, slowed thinking, memory loss
• Objective: Slowed speech, flat affect, impaired short-term memory on assessment, depression screening positive (PHQ-9), decreased deep tendon reflexes (delayed relaxation - classic sign), possible psychosis in severe cases ("myxedema madness")

• Patient will demonstrate improved cognitive function as thyroid levels normalize
• Patient will be oriented to person, place, and time
• Patient will verbalize coping strategies for memory and mood changes

• Use validated tools to assess cognitive function (MMSE, MoCA) at baseline and periodically
• Screen for depression using PHQ-9 at admission
• Provide safe environment for patients with confusion

1. Assess level of orientation (person, place, time) and cognitive function at each interaction
2. Speak slowly and clearly; allow extra time for the patient to respond - do not rush
3. Use simple, direct language and written instructions for teaching (cognitive impairment affects learning)
4. Reorient patient as needed; use calendars, clocks, familiar objects
5. Provide a calm, low-stimulation environment
6. Implement fall precautions due to slowed reflexes and cognitive impairment
7. Communicate cognitive changes to the healthcare team; document mental status assessments
8. Support family/caregivers in understanding that cognitive changes are expected to improve with treatment
9. Monitor for signs of depression; refer to psychiatric services or social work if needed

• Patient is oriented x3 at time of evaluation
• Cognitive function improves as evidenced by MMSE/MoCA scores over time
• Patient and family report understanding of expected cognitive recovery
• No falls or injury related to confusion

Priority 8 - Deficient Knowledge

• Subjective: Patient states "I don't understand why I need to take this pill every day" or asks questions about the disease, expresses concern about side effects
• Objective: Unable to verbalize purpose of levothyroxine, does not know signs of over/under-treatment, history of medication non-compliance

• Patient will accurately describe hypothyroidism and the rationale for lifelong levothyroxine therapy
• Patient will demonstrate correct administration of levothyroxine
• Patient will identify signs/symptoms requiring medical attention (both hypothyroid and hyperthyroid)

• Assess health literacy and preferred learning style before teaching
• Involve family/caregivers in education
• Provide written discharge materials at appropriate reading level

1. Assess patient's current understanding of hypothyroidism, treatment goals, and barriers to adherence
2. Educate patient on: what hypothyroidism is, why lifelong medication is needed (thyroid cannot self-correct), and consequences of stopping medication
3. Teach correct levothyroxine administration:
   • Take on empty stomach, 30-60 minutes before breakfast
   • Take at the same time each day
   • Avoid taking with calcium, iron, antacids (reduce absorption)
   • Do not skip doses; if missed, take as soon as remembered but do not double dose
4. Teach signs of under-treatment (worsening fatigue, weight gain, cold intolerance, constipation)
5. Teach signs of over-treatment/levothyroxine toxicity (palpitations, insomnia, weight loss, tremors, heat intolerance) - instruct to notify provider
6. Educate about routine TSH monitoring every 6-12 months once stable
7. Advise on food-drug interactions (goitrogens, iodine, grapefruit)
8. Inform about myxedema coma - when to seek emergency care (sudden worsening confusion, hypothermia, reduced consciousness)
9. Encourage participation in care planning and ask-back method to confirm understanding

• Patient accurately explains purpose of levothyroxine therapy
• Patient demonstrates correct medication administration
• Patient correctly identifies 3+ signs of under- and over-treatment
• Patient verbalizes when to seek medical attention
• Patient expresses confidence in self-management

Quick Priority Summary

NANDA Diagnoses - Full PES Format with AEB

Priority 1 - Ineffective Breathing Pattern

Ineffective Breathing Pattern related to depressed ventilation and respiratory muscle weakness secondary to decreased metabolic rate as evidenced by bradypnea (respiratory rate <12/min), shallow breathing, reduced oxygen saturation (SpO2 <95%), and patient reports of shortness of breath and fatigue on exertion.

Priority 2 - Decreased Cardiac Output

Decreased Cardiac Output related to altered myocardial contractility and bradycardia secondary to thyroid hormone deficiency as evidenced by heart rate <60 bpm, hypotension, muffled heart sounds, peripheral edema, cool pale skin, decreased pulse pressure, and patient reports of dizziness and decreased exercise tolerance.

Priority 3 - Hypothermia

Hypothermia related to decreased metabolic rate and inability to regulate body temperature as evidenced by core body temperature <36°C, cold and pale skin, patient verbalization of constant cold sensation, shivering, and requests for extra blankets even in warm environments.

Priority 4 - Activity Intolerance

Activity Intolerance related to decreased metabolic energy production and generalized weakness as evidenced by patient reports of overwhelming fatigue, inability to complete ADLs independently, slowed movements, muscle weakness on examination, and exertional dyspnea on minimal activity.

Priority 5 - Constipation

Constipation related to decreased gastrointestinal motility secondary to reduced metabolic rate as evidenced by fewer than 3 bowel movements per week, patient reports of straining, hard and dry stools, hypoactive bowel sounds on auscultation, and abdominal distension.

Priority 6 - Imbalanced Nutrition: More Than Body Requirements

Imbalanced Nutrition: More Than Body Requirements related to decreased metabolic rate with caloric intake exceeding metabolic demands as evidenced by weight gain of 5-10 lbs, elevated BMI, elevated serum cholesterol and triglycerides, myxedematous puffiness of face and extremities, and patient reports of weight gain despite no increase in food intake.

Priority 7 - Disturbed Thought Processes

Disturbed Thought Processes related to decreased cerebral metabolism and altered cardiovascular/respiratory status as evidenced by impaired memory, slowed speech, flat affect, difficulty concentrating, delayed deep tendon reflexes, positive depression screening (PHQ-9), and patient reports of forgetfulness and inability to think clearly.

Priority 8 - Deficient Knowledge

Deficient Knowledge regarding hypothyroidism, medication regimen, and long-term self-management related to lack of exposure to information and unfamiliarity with disease process as evidenced by patient's inability to explain the purpose of levothyroxine, verbalization of misconceptions about the disease, history of medication non-compliance, and repeated questioning about treatment.

Important Note on "Risk For" Diagnoses

Risk for [Problem] related to [Risk Factors]

Risk for Decreased Cardiac Output related to bradycardia and thyroid hormone deficiency.

Full NANDA PES Format Reminder