Nursing care in hypo- and hyperthyroidism, and the warning signs of a thyroid storm or myxoedema coma

Safe practice

The nurse watches heart rate, temperature and mental status, gives thyroid medicines correctly and knows the signs of the two thyroid emergencies.

Updated Nov 13, 2026

Key points

Levothyroxine: once a day, on an empty stomach, with water, 30–60 minutes before breakfast and at the same time each day.
Separate levothyroxine by at least 4 hours from iron, calcium, antacids and fibre supplements: they block its absorption.
Signs of too much thyroid hormone (fast heart rate, palpitations, chest pain, tremor, sweating): hold the dose and tell the doctor if they are cardiac.
Antithyroid drugs: fever or sore throat is reported at once (agranulocytosis); loss of appetite, itching or right upper abdominal pain can mean liver injury.
Thyroid storm: fever, very fast heart rate, agitation, confusion, diarrhoea. Myxoedema coma: low temperature, slow breathing, low blood pressure, drowsiness.
Myxoedema coma can be triggered by infection, cold, opioids or stopping the thyroid medicine.

What it is

In hypothyroidism everything slows down: tiredness, feeling cold, constipation, weight gain, slow heart rate. In hyperthyroidism everything speeds up: fast heart rate, heat intolerance, sweating, tremor, weight loss, diarrhoea. Nursing care centres on vital signs, giving the medicines correctly, watching for over- or under-treatment and teaching. Each disorder has a rare, life-threatening extreme. Thyroid storm is a sudden worsening of uncontrolled hyperthyroidism with fever, a very fast heart rate and agitation or confusion; it is often triggered by infection, trauma or a heart attack. Myxoedema coma is severe hypothyroidism with low temperature, slow breathing, low blood pressure, low glucose and reduced consciousness. Both are emergencies treated in intensive care.

What it requires

Levothyroxine treatment is usually lifelong and is not stopped when the person feels better.
Older adults and people with heart disease start with a low dose because of the risk of angina and arrhythmia.
Levothyroxine can change glucose control in diabetes and the effect of oral anticoagulants: glucose and INR are watched when it starts or changes.
TSH and thyroid hormones are checked to judge the effect of treatment.

How it is applied (and why)

Measure heart rate, rhythm, blood pressure and temperature every shift: they show over- or under-treatment.
Give levothyroxine on an empty stomach with water, before breakfast, away from iron, calcium and antacids.
Before each dose ask about palpitations, chest pain, tremor and heat intolerance: hold and report if they are cardiac.
With antithyroid drugs, weigh the patient 2–3 times a week: weight shows the response to treatment.
With antithyroid drugs, ask about fever, sore throat, yellow skin, itching and bruising: they are serious adverse effects.
In hypothyroidism, report drowsiness and review sedatives and opioids with the doctor: opioids can trigger myxoedema coma.
Watch for the triggers of a crisis (infection, surgery, trauma, a stopped medicine) and report them early.
Teach that treatment is lifelong, how to take the tablet, the signs of too much or too little hormone and the follow-up tests.

In nursing practice

Graves disease may bring bulging eyes; report irritated eyes, double vision or loss of vision (risk of corneal ulcer).
After radioactive iodine or surgery many people develop hypothyroidism and need replacement for life.
Thyroid storm can cause arrhythmias, heart failure and pulmonary oedema that develop rapidly.
In myxoedema coma, care in intensive care may include oxygen, ventilation and IV fluids.

Common mistakes

Giving levothyroxine with breakfast or with the iron and calcium tablets.
Missing a fever or sore throat in a patient on an antithyroid drug.
Treating new confusion with sedation in a patient with hypothyroidism without first reporting it.
Thinking that a thyroid storm is only anxiety: fever with a very fast heart rate in hyperthyroidism is an emergency.

Test yourself

Think of the answer, then tap the question to see it.

How is levothyroxine taken?

Once a day on an empty stomach with water, 30–60 minutes before breakfast, at the same time each day, and at least 4 hours apart from iron, calcium and antacids.

A patient on an antithyroid drug reports fever and a sore throat. Why is this urgent?

It can be agranulocytosis, a dangerous fall in white cells that usually appears in the first months. It is reported at once.

What are the signs of a thyroid storm?

Fever, a very fast pounding heart rate, agitation or confusion, sweating, tremor and diarrhoea in a person with uncontrolled hyperthyroidism. It is an emergency.

What can trigger myxoedema coma?

Infection or illness, cold exposure, some medicines such as opioids, and taking the thyroid medicine irregularly or not at all.

Add to my cards (4)

Elsewhere in DurgiPedia

Connections

In Pharmacology3

← All of nursing

Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.

Sources: Nursing Pharmacology, 9.5: Thyroid Medications (Open RN, Wisconsin Technical College System (CC BY 4.0), LibreTexts, 2023); Thyroid storm (MedlinePlus Medical Encyclopedia, U.S. National Library of Medicine, 2026); Hypothyroidism (MedlinePlus Medical Encyclopedia, U.S. National Library of Medicine, 2026); Hyperthyroidism (MedlinePlus Medical Encyclopedia, U.S. National Library of Medicine, 2026).

Spotted a mistake?We are always improving for the community. Tell us what is wrong and our team will review it.Report a mistake

Representative model, for educational purposes only.