THRYOID STORM AND THE AACN SYNERGY MODEL THRYOID STORM AND THE AACN SYNERGY MODEL
In the Eye of the Storm: Recognizing Thyroid Storm and
Applying the AACN Synergy Model
Deborah L. Bray, RN, BSN, CNS Graduate Student
Murray State University
Introduction
Thyroid storm, or thyrotoxic crisis is a rare, but critical hypermetabolic state requiring emergent treatment.
According to Dahlen (2002), the disease state results from the overproduction and release of thyroid hormones
triiodothyronine (T3) and thryroxine (T4) which increases cellular function systemically. Thyroid storm occurs most
often from Grave’s disease either undiagnosed or undertreated (Kaplow & Hardin, 2007). Other precipitants of
thyroid storm can include pregnancy, surgery, trauma, induction of anesthesia, diabetic ketoacidosis, infection,
myocardial infarction, and noncompliance with anti-thyroid medications (Belfort, 2006). Only 1-2% of persons with
hyperthyroidism will develop thyroid storm; however, the mortality rate can be as high as 50-90% if left untreated
(Dulak, 2005). Nurses should be aware of the signs and symptoms of thyroid storm, so that prompt intervention may
occur and mortality be decreased.
The American Association of Critical Care Nurses (AACN) Synergy Model provides a framework for nursing practice.
The model links patient characteristics with nursing competencies to provide optimal patient outcomes (Curley,
1998). According to Curley (1998), when patient characteristics match nursing skill sets, synergy occurs moving the
patient and nurse more successfully toward a common goal. The purpose of this article is to discuss and apply the
Synergy Model in the complex patient experiencing thyroid storm. A case study will illustrate how to match patient
characteristics during thyroid storm with nurse competencies for the best patient outcomes.
Pathophysiology of Hyperthyroidism
In order to understand the disease state of thyroid storm, one must understand the physiology of the thyroid gland
and hyperthyroidism. The thyroid hormones orchestrate the regulation of metabolism within nearly all areas of the
body. The thyroid gland is regulated by a negative feedback system. The hypothalamus secretes thyrotropic releasing
hormone (TRH) which stimulates the anterior pituitary to release thyroid stimulating hormone (TSH) into the
circulation. TSH in turn activates the thyroid gland to produce and release the thyroid hormones T3 and T4. Iodine
is also required to produce thyroid hormone. T4 is produced entirely by the thyroid gland while 80% of T3 is
produced in the peripheral tissues by the conversion of T4 to T3. The levels of thyroid hormone (T3 and T4) in the
circulation provide negative feedback to the hypothalamus and the anterior pituitary to inhibit further TRH and TSH
release (Andreoli, Carpenter, Griggs & Benjamin, 2007; Kumrow & Dahlen, 2002).
Hyperthyroidism is a result of excess circulating thyroid hormone. Hyperthyroidism occurs most often in young women
and is evidenced by an increase in cellular metabolism which may be manifested by weight loss, palpitations,
nervousness, loose stools, heat intolerance, hair loss, and insomnia. (Gittoes & Franklin, 1998; Kumrow &
Dahlen, 2002). The most severe expression of hyperthyroidism is thyrotoxocosis, otherwise known as thyroid storm,
which can be precipitated by various events as discussed earlier. Signs and symptoms of thyroid storm include
hypermetabolism with high fever and sweating; cardiovascular symptoms including tachycardia, atrial fibrillation,
or congestive heart failure; neurological symptoms such as agitation, tremor, and mental status change;
gastrointestinal symptoms with diarrhea, nausea, and vomiting; supporting laboratory evidence such as a low TSH,
high free T4 and or high T3. (Belfort, 2006; Kaplow & Hardin, 2007).
The thyroid hormones, T3 and T4, are bound to plasma protein in the circulation. The unbound or free thyroid
hormones actually regulate the negative feedback system; therefore, evaluating the free hormone levels is important
as well as evaluating the total hormone levels. Normal thyroid function test values include the following and may
vary slightly in different laboratories: total thyroxine (T4) 4.5-12.0 µg/dl, free T4 0.7-1.9 ng/dl, total
triiodothyronine (T3) 80-180ng/dl, free T3 230-619 pg/dl, and thyroid stimulating hormone (TSH) 0.5-6 µU/ml (Kumrow
& Dahlen, 2002).
Case Study
Rachel is a 22 year old white female found by her roommate to be confused, agitated, diaphoretic, and incontinent
of diarrhea stool. The patient was brought by her roommate to a local hospital emergency room for evaluation. The
roommate states she is concerned her friend has the flu because she has had fever, nausea, diarrhea, and
diaphoresis for the past 24 hours. Rachel had no known prior medical problems.
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