- The objective of this document is to present a standardized procedure that complies with the requirements of the California Board of Nursing (BRN) as well as with all the 11 components espoused in the BRN’s guidelines for nurse practitioners (NPs) for the performance of specific nursing functions in the absence of a physician.
II Development and Review
- As with all standardized procedures, this standardized procedure was developed through collaborative efforts of the interdisciplinary committee (IDC) in the organization. The IDC comprises nurse practitioners, registered nurses, physicians, as well as the organization’s administrative representatives.
- Once the IDC has approved the standardized procedure, it will be made publicly available. The approval process ends in the signing of the approval sheets by all the professionals represented in the IDC.
- The review of all standardized procedures will be conducted every three years. The period of the review can, however, be longer.
- Upon being hired, all the supervising physicians and the NPs will confirm their agreement with the standardized procedures through signing. This confirmation will also be done annually or semiannually, depending on the need for change, and will be signed on a dated approval sheet at all times.
- The signature on the approval sheet implies that: all the procedures in the document have been approved; there is an intention to comply with the procedures and deliberate willingness to maintain a collaborative and collegial relationship between all the IDC members. The signed approval sheet also serves as a record of the names of those NPs who have been authorized to perform various procedures in line with the management of hypothyroidism. The signature page will always be on file alongside the standardized procedures for reference.
III Scope and Setting
A The functions outlined in the standardized procedure will be managed by NPs within their areas of specialty and in consistency with their credentials and their experiences. The functions of NPs may include patient assessment for hypothyroidism, management and treatment of the chronic condition, health promotion, and evaluation of the overall patient health status. Additionally, NPs may also perform functions that entail ordering for various diagnostic procedures, performing occupational, physical, diet referrals, and specialty care as stipulated by the scope of service for NPs.
B NPs are mandated to comply with the standardized procedures in all the organization’s outpatient and inpatient clinics.
IV Education and Training/Qualifications
A NPs working with patients with hypothyroidism should have the following qualifications:
1 To be a Registered Nurse (RN) in California.
2 To be certified as an NP by the State of California, BRN.
3 Be certified by the board of the American Nurses Credentialing Center
4 To hold an NP furnishing number
5 To be registered by the DEA.
6 To have a Current Health Care Provider Card issued by the American Heart Association
7 Credentialed by the supervising physicians in the practice organization.
B Besides the required training and education, all nurse practitioners working with patients with chronic hypothyroidism will need to complete validations for competency during hiring as well as upon annual performance reviews. The supervising physicians are mandated to observe the NPs and document competency validation procedures. The checklist for the competency validation is maintained and managed by the Office of the Medical Staff as part of the employee privilege process and is made available upon request. It is also reviewed and updated by the IDC annually.
V Supervision and Evaluation
A The practicing NPs are authorized to implement the directions of the approved standardized procedure even in the absence of the physician unless there is a specific instruction that requires direct observation by the physician.
B The supervising physicians have to conduct weekly reviews of at least 10% of the NPs in the facility. The reviews are documented as part of the general electronic medical record and have to be completed within 30 days of the review visit. Case selection is made randomly unless there is a specific request received by a medical professional.
C Every physician is allowed to supervise a maximum of 4 NPs at a time.
A Physician consultation is accomplished in line with the general facility regulations regarding outpatient consultations for all patients.
VII Patient Records
A Documenting complete electronic medical records for patients is the responsibility of the NPs. Each NP documents the records of patients with whom they are in contact and in line with the policies guiding record-keeping by medical staff at the healthcare facility.
Hypothyroidism Initial Health Visit
To enable healthcare practitioners, particularly NPs to distinguish between hypothyroidism and other medical conditions during an initial patient visit, and to provide guidelines for managing the condition
Hypothyroidism is described as a condition in which the thyroid gland is unable to produce adequate amounts of the thyroid hormone. In adults, the condition is referred to as myxedema, while in children, it is referred to as cretinism.
A The condition occurs in both children and adults.
B Individuals with the condition often have symptoms that are associated with low metabolism since the thyroid gland is responsible for running body metabolism.
C The condition is likely to affect nearly 10 million Americans each year.
D Almost 10% of all women have this or other forms of thyroid hormone deficiencies.
E Additionally, many people across the world suffer from hypothyroidism unknowingly.
A The first fairly common cause of hypothyroidism is a previous inflammation of the thyroid gland, which results in the damage of thyroid cells and thus their inability to produce sufficient amounts of the thyroid hormones.
B Another common cause is the failure of the thyroid gland, in a process called autoimmune thyroiditis
C Medical treatments could also result in the removal of part of the thyroid gland, resulting in the inadequacy of the remaining sections to produce hormones.
D Problems in the pituitary glands that result in poor thyroid hormone production from normal thyroid glands could also cause the condition.
V Physical Exam
B General weakness
C Muscle cramps or frequent muscle aches
E Intolerance to cold
F Low libido
G Memory loss
H Dry, coarse hair
I Rough, pale skin
K Weight gain and difficulty in weight loss
VI Diagnostic tests
A Blood tests – to determine the levels of THS and thyroxine hormone
B Monitoring vital signs including blood pressure, EKG, and HR
VII Management – One of the outcomes of hypothyroidism is an increase in the patient’s cholesterol levels. Accordingly, any treatment provided for the condition is aimed at not only reducing the cholesterol levels but also boosting the levels of the produced thyroid hormones. The medications work gradually, resulting in better health outcomes over the long-term.
A Replacement of Thyroid Hormone
Where the cause of the condition has been established to be the inadequacy of the thyroid hormone, the most common treatment is the administration of Synthroid levothyroxine.
B Patient Education
To take their drugs continuously without ceasing to take the drugs consistently at the same time every day and with food, avoid taking drugs with four hours of taking multivitamins, avoid narcotics such as opioids, and watch for signs of toxicity, which are exhibited as signs of hyperthyroidism.
C Treatment Dosages
The patient’s TSH levels should be evaluated every 6 to 8 weeks. This would help in modifying treatment procedures where necessary. The condition is a lifelong illness, and consistent treatment is necessary for progress in health quality.
- The best treatment for hypothyroidism is the drug levothyroxine, which is a synthetic version of the T4 hormone, which mirrors the action of the natural thyroid hormone. Different dosages are administered at different times, depending on the patient’s LSH levels.
2 Patients sent home with the instructions to:
a take their drugs consistently at the same time every day; visit the practitioner for further monitoring at 6-8 weeks; and avoid consuming thyroid medications with other supplements.
b Avoid narcotics and sedatives as they are harmful to patients with hypothyroidism.
c Use iodized salt in case of iodine deficiency
d Eat a balanced diet and minimize soy intake
- Follow the patient guidelines provided in the first stage treatment
- Change drug dosage as advised by the physician based on the LSH content.
- Continue on-going treatment as hypothyroidism is a chronic illness.
If no improvement
a Continue conducting tests and close patient monitoring every 6 to 8 weeks
b Continuously monitor the patient for myxedema coma if an adult
c Recommend further treatment such as surgery to eliminate any underlying issues
d Evaluate the patient to determine the underlying causes of hypothyroidism, which could be an autoimmune disorder, iodine deficiency, or a pituitary gland tumor.
e Refer the patient for treatment of the underlying issues
f Recommend avoidance of sedatives or narcotics as patients with hypothyroidism are quite sensitive to them and may experience myxedema coma in case they continue using the drugs.
Interventions of NPs for Severe Hypothyroidism
a Monitor patient for the onset of myxedema coma – this is usually caused by very low thyroid hormone production as a result of abruptly stopping medication or thyroid failure.
b Patient presents with the imminent shut-down of all vital organs.
c Check for hypothermia
d Also check for extreme patient drowsiness
e Another check-up is to be done for the respiratory failure of bradycardia.
f Low blood sugar and sodium levels
g Keep patient warm, encourage the use of fluids, and assess for constipation
VIII Development and Approval of the Standardized Procedure
The organization’s Interdisciplinary Committee developed and approved this standardized procedure for application in the care for patients with hypothyroidism. Further review and approvals will be conducted biennially in line with progress in healthcare advancements.
Revision Date_____________ Review Date______________
IX The following members of the Interdisciplinary Committee approved the development and application of this standardized procedure.
Pediatric Department Chair
Director of Nursing Practice
X The list of nurse practitioners authorized to operate under this standardized procedure will be filed alongside the standardized procedure in the respective departments of application. They will work in collaboration with the hospital’s administration and in accordance with other hospital rules and regulations.
Gaitonde, D.Y., Rowley, K.D., & Sweeney, L.B. (2012). Hypothyroidism. American Family Physician, 86(3), 244-251. Retrieved from www.aafp.org/afp/2012/0801/p244.html
Mayo Clinic (2020). Hypothyroidism (underactive thyroid). Mayo Clinic. Retrieved from www.mayoclinic.org/diseases-conditions/hypothyroidism/diagnosis-treatment/drc-20350289
Orlander, P.R. (2019, November 5). Hypothyroidism. MedScape. Retrieved from emedicine.medscape.com/article/122393-overview
Williams, L., & Wilkins, Inc. (2005). Thyroid disorders. The Nurse Practitioner, 30(6), 51-52. Retrieved from journals.lww.com/tnpj/Citation/2005/06000/Thyroid_Disorders.9.aspx